ObjectivesThe increasing prevalence of end-stage renal disease (ESRD), especially in aging populations, presents significant challenges for healthcare systems. Dialysis centers must navigate growing demands for cost efficiency while maintaining high-quality care. This study aimed to evaluate the relationship between operational efficiency and clinical quality in dialysis centers, using a systems-based performance assessment framework.MethodsWe analyzed 578 dialysis centers in Taiwan using Data Envelopment Analysis (DEA) to estimate operational efficiency. Clinical quality was assessed using outcome indicators including mortality rate, dialysis adequacy (urea reduction ratio [URR], Kt/V), serum albumin and hemoglobin levels, calcium-phosphate (Ca × P) product, and cardiothoracic ratio. Multiple regression analyses were conducted to examine associations between efficiency scores, clinical outcomes, and organizational characteristics, including chain affiliation and ownership type.ResultsHigher efficiency scores were significantly associated with lower URR, Kt/V, and Ca × P values, suggesting potential trade-offs between operational efficiency and clinical quality. Centers affiliated with chains generally reported better clinical outcomes. For-profit centers exhibited higher URR, Kt/V, and albumin levels, as well as lower Ca × P values, compared to their non-profit counterparts.ConclusionsOperational efficiency in dialysis centers may come at the cost of certain clinical outcomes. However, organizational characteristics such as chain affiliation and for-profit ownership are linked to better quality indicators. These findings highlight the value of DEA as a tool for system-level performance evaluation and inform strategies to optimize dialysis care delivery.

The increasing prevalence of end-stage renal disease (ESRD), especially in aging populations, presents significant challenges for healthcare systems. Dialysis centers must navigate growing demands for cost efficiency while maintaining high-quality care. This study aimed to evaluate the relationship between operational efficiency and clinical quality in dialysis centers, using a systems-based performance assessment framework. We analyzed 578 dialysis centers in Taiwan using Data Envelopment Analysis (DEA) to estimate operational efficiency. Clinical quality was assessed using outcome indicators including mortality rate, dialysis adequacy (urea reduction ratio [URR], Kt/V), serum albumin and hemoglobin levels, calcium-phosphate (Ca × P) product, and cardiothoracic ratio. Multiple regression analyses were conducted to examine associations between efficiency scores, clinical outcomes, and organizational characteristics, including chain affiliation and ownership type. Higher efficiency scores were significantly associated with lower URR, Kt/V, and Ca × P values, suggesting potential trade-offs between operational efficiency and clinical quality. Centers affiliated with chains generally reported better clinical outcomes. For-profit centers exhibited higher URR, Kt/V, and albumin levels, as well as lower Ca × P values, compared to their non-profit counterparts. Operational efficiency in dialysis centers may come at the cost of certain clinical outcomes. However, organizational characteristics such as chain affiliation and for-profit ownership are linked to better quality indicators. These findings highlight the value of DEA as a tool for system-level performance evaluation and inform strategies to optimize dialysis care delivery.

Kidney Support Therapy (KST) is essential for addressing metabolic disturbances and enhancing outcomes in critically ill children with acute kidney injury (AKI). The comparative effectiveness of different KST modalities remains uncertain. This cross-sectional analytical study included children in a tertiary care center undergoing peritoneal dialysis (PD, n = 16), hemodialysis (HD, n = 17), or continuous renal replacement therapy (CRRT, n = 20). The urea and creatinine reduction ratios and survival were higher in CRRT compared to PD. Higher PRISM III scores and lower eGFR were found to be predictors of mortality.

Background: Pain is a common and clinically important symptom in hemodialysis, yet its functional impact and determinants remain insufficiently characterized. This study examined factors associated with pain interference using the Pain Effects Scale (PES) in maintenance hemodialysis patients. Methods: In a cross-sectional study, 73 adults receiving thrice-weekly hemodialysis completed the PES, assessing the four-week impact of pain on mood, sleep, mobility, work, recreation, and enjoyment of life. Demographic, clinical, and dialysis-related variables-including vascular access type, dialysis vintage, session duration, ultrafiltration volume, predialysis urea, Kt/V, urea reduction ratio, comorbidities, and transplant history-were extracted from medical records. Associations were evaluated using parametric and non-parametric tests. Results: PES scores indicated substantial pain interference. Older age was positively correlated with higher PES scores (r = 0.32, p = 0.006), and patients with ischemic heart disease had significantly higher PES values than those without (23.1 ± 6.7 vs. 17.3 ± 6.2; p = 0.012). Willingness to pursue transplantation showed a non-significant trend toward lower scores. Conclusions: Pain interference in hemodialysis appears largely independent of routine adequacy metrics and most comorbidities, with ischemic cardiovascular disease emerging as an exception. Findings underscore the need for a biopsychosocial approach integrating pain screening with assessment of mood, sleep, neuropathy, musculoskeletal factors, and ischemic symptoms.

Uremic toxins accumulate in the body due to kidney dysfunction and are classified by molecular weight into small, middle, and large solutes. Middle-sized molecules, such as myoglobin and interleukin-1 (IL-1), are implicated in chronic inflammation, cardiovascular complications, and dialysis-related issues. Conventional hemodialysis (HD) effectively removes small solutes but is less efficient at clearing middle molecules. To assess the removal efficiency of myoglobin and IL-1 using two different high-flux dialyzers (FX80 and Platinum H4, surface area 1.8 m²) in both high-flux hemodialysis (HF-HD) and hemodiafiltration (HDF) modalities. A crossover study was conducted on 30 prevalent ESRD patients undergoing thrice-weekly HD at Ain Shams Uni-versity Specialized Hospital. Patients received both HD and HDF treatments using FX80 and Platinum H4 dialyzers, with a two-week washout period between modalities. Each session was conducted with blood flow ≥300 mL/min and bicarbonate dialysate. Serum IL-1 and myoglobin were measured before and after sessions, and reduction ratios were calculated. The mean age of patients was 51.8 ± 12.9 years, and 80% were male. Baseline pre-dialysis IL-1 and myoglobin levels showed no significant differences across groups. Post-dialysis, the highest reduction ratios were observed with HDF-Platinum H4 for both IL-1 (81.6 ± 12.6%) and myoglobin (83.8 ± 10.6%), followed by HDF-FX80, HD-Platinum H4, and HD-FX80 (p < 0.001). Urea reduction ratio was also significantly higher with HDF compared to HD (75.2 ± 5.6% vs. 67.1 ± 8.3%, p < 0.001). No significant correlations were observed between transmembrane pressure and reduction ratios. IL-1 and myoglobin are reliable markers for dialysis adequacy. HDF demonstrates superior removal of these middle molecules compared to HF-HD. Among dialyzers, Platinum H4 outperformed FX80, showing greater clearance efficiency in both modalities.

IntroductionThe major neutrophilic peptide alpha-defensin plays a pivotal role in atherogenesis. Atherosclerosis is more frequent in dialysis patients, increasingly ascribed to chronic low-grade inflammation. We investigated the potential association between dialysis treatment and circulating alpha-defensin levels.MethodsIn a cohort of hemodialysis (HD) patients, plasma alpha-defensin concentrations were determined immediately before and after a dialysis session. Blood samples were also tested for CBC, CRP, lipid profile, and troponin levels. Body weight change, Urea Reduction Ratio and Kt/V were used to assess dialysis adequacy. Patients were divided into two groups based on alpha-defensin increase post dialysis. Groups were compared for dialysis adequacy, CBC, CRP, LDL levels, and the incidence of new documented coronary artery narrowing post HD initiation. The study was approved by the local IRB and all patients were consented.ResultsA total of 37 HD patients (55% males, median age 66.5 (60.3–78 years)) were recruited. There was a marked surge in median alpha-defensin levels after HD [11,571 vs. 16,661 ng/ml, p=0.009]. Overall, alpha-defensin levels increased in 65% of cases, whereas CRP levels showed no significant rise following dialysis. Similarly, platelet and neutrophil counts exhibited no significant change. Kt/V values were found favorable in HD patients with alpha-defensin decrease (1.48 vs. 1.37, P = 0.24), corresponding to a higher body weight decrease post dialysis (2.4% vs. 1.75%). Moreover, the HD group with alpha-defensin increase was more prone to sustain new cardiovascular events (12.5% vs. 0% at a median time of 5 (3.75-6.57) years), despite demonstrating a better blood lipid profile (LDL 63 vs. 87 mg/dl).ConclusionHD is an alpha-defensin generating procedure. Patients are potentially predisposed to atherosclerosis because of their enhanced alpha defensin secretion. alpha-defensin might evolve as a potential therapeutic target for atherosclerosis mitigation in this high-risk population. However, this remains to be validated in future research.

Polytrauma is often characterised by rhabdomyolysis, hyperkalaemia and renal failure, which is treated with acute haemodialysis. Transport and storage of dialysate are expensive and cumbersome and require space that may be unavailable in resource-limited scenarios. We examined a portable, powerless dialysate generator in a porcine model of continuous renal replacement therapy (CRRT). Anaesthetised swine (n=12) underwent bilateral nephrectomy and placement of a haemodialysis catheter. Intravenous potassium and urea were infused, and animals received CRRT with either a dialysate solution prepared with tap water through a novel portable dialysate generator (PDG) or commercially available dialysate (CAD, NxStage). Both groups were dialysed with a NxStage System One through an in-line haemodialysis filter at typical flow rates. Blood samples were drawn hourly during 6 hours of CRRT. There were no differences in conductivity between PDG and CAD (p=0.31), as well as no detected arsenic, lead, mercury or free chlorine in the PDG dialysate produced. After 6 hours of CRRT, total effluent fluid was 10.09±0.18 L and 10.04±0.30 L in the PDG and CAD groups, respectively (p=0.89). Urea reduction ratio was similar in the two groups (p=0.39), as were serum levels of potassium (p=0.87). All animals survived until the end of CRRT. A PDG machine using potable water created dialysate of similar efficacy as commercial prepackaged dialysate in a porcine CRRT model. The generated dialysate may obviate transport and storage of large quantities of dialysate in a resource-limited combat or natural disaster environments.

Dialysis adequacy is an important parameter with regards to morbidity and mortality in chronic haemodialysis (HD) patients. Measuring the adequacy of HD is not an easy task. There is no objective, reliable and universally accepted criteria for measuring the adequacy. Clinically, several parameters must be considered to provide adequate dialysis, such as control of fluid overload and electrolytes disturbance, correction of metabolic acidosis and dialysis dose. This cross-sectional study explores the assessment of the adequacy of haemodialysis by urea kinetic modeling (UKM), a vital method for determining the optimal dialysis dose. This study was conducted at the haemodialysis unit of the National Institute of Kidney Diseases and Urology (NIKDU), Dhaka, Bangladesh between the periods of 1st January 2012 and 30th June 2013. Purposive sampling of 120 end stage renal disease (ESRD) patients on maintenance haemodialysis (MHD) getting dialysis for at least one month through arterio-venous fistula (AVF) and at least 2 dialysis sessions per week. Out of 120 patients, 72 (60%) were male and the ratio was 1.5:1. The mean age of haemodialysis patients in this study was 51 years (range: 18-75 years). Approximately 62 (52%) patients were on an 8-hour per week haemodialysis session. Our study showed mean total clearance of urea normalized or corrected for distribution volume (Kt/V), urea reduction ratio (URR), time average concentration of urea (TACurea) and normalized protein catabolic rate (nPCR) of all study population was 1.21±0.40, 62±12, 83±26, and 1.29±0.46, respectively. In 12 hours per week haemodialysis group achieved target Kt/V &gt;1.2 was only 26 (45%), on the other hand, in 8 hours per week haemodialysis group achieved target Kt/V &gt;2 was only 3 (5%). Among the study population only 52 (43%) patients achieved URR &gt;65%, 13 (11%) patients TACurea was less than 52 mg/dl and 107 (89%) patients achieved nPCR &gt;1g/kg/day. The mean values of the URR was significantly higher for dialysis patients who achieved a Kt/V of &gt;1.2 than for those who did not achieve a Kt/V &gt; 1.2. To achieve haemodialysis adequacy of KDOQI 2006 recommendation needs to increase the frequency of HD that is 3 sessions per week (12 hours/week) and needs to give more attention to other factors that increase urea clearance. To improve patient management with end-stage kidney disease, needs of continuous research to enhance our understanding of haemodialysis adequacy and its dose calculation. Jalalabad Med J 2025; 22 (1): 17-22.

Chronic kidney disease poses a growing global health concern and is linked to several complications with higher prevalence and intensity in the hemodialysis (HD) population. These complications contribute to high morbidity and mortality and are associated with poor physical function, and poor quality of life. Intradialytic exercise has emerged as a promising strategy to improve HD patients' clinically relevant outcomes. Assess the effect of intradialytic exercise on the functional and metabolic status of patients undergoing HD, and on their physical performance and evaluate its safety and feasibility. This was a pre-experimental clinical trial conducted between February and August 2024, including adult patients on maintenance HD at Sahloul University Hospital. Patients underwent a supervised intradialytic resistance training twice or three times a week, over a period of 12 weeks.. Dialysis adequacy parameters, physical function, cardiovascular parameters, as well as patients' nutritional status were assessed before and after the intervention. Our study included 21 patient with a female predominance (76.2%). The population's mean age was 44.5 ± 10.4 years. A total of five patients (23.8%) received hemodialysis twice a week, while the remaining 16 patients underwent dialysis three times a week. Over the three-month intervention, the six minutes walk test distance improved significantly with a mean paired difference of 26.4 m (p = 0.007). As for cardiovascular parameters we noted that intradialytic blood pressure decreased from 121.7 mmHg to 112 mmHg (p = 0.03). Dialysis adequacy markers also showed significant increases in creatinine reduction ratio (p = 0.04) and Urea Reduction Ratio (p = 0.04).Furthermorenutritional status showed fewer patients at risk of malnutrition and BMI shifted toward healthier ranges. Our study results suggest that three months of intradialytic resistance exercise safely improved HD patients' care including cardiovascular state, physical function and adequacy parameters. Further research especially combining resistance and aerobic exercise is needed to expand and generalize these results. The trial was retrospectively registered with the Pan African Clinical Trial Registry (PACTR202506776186443).

Sex Differences in Associations Between Measures of Hemodialysis Adequacy and Quality, Cardiovascular Outcomes, and Mortality: A Systematic Review

BACKGROUNDEnd-stage renal disease is the final stage of chronic kidney disease, with hemodialysis as the primary treatment in India. Despite its prevalence, limited studies have focused on patient-reported outcomes, such as symptom burden and health-related quality of life.AIMTo evaluate the symptom burden among adult hemodialysis patients and identify factors influencing their outcomes.METHODSA multi-center, cross-sectional study was conducted among 157 adult hemodialysis patients in Chennai from March 2024 to June 2024. The Dialysis Symptom Index tool was used to assess 30 physical and emotional symptoms. Correlations between symptom severity and clinical parameters, such as hemoglobin levels and urea reduction ratio (URR), were analyzed.RESULTSModerate symptoms were reported by 48% of participants, with worry, insomnia, and feeling unwell identified as the most severe. Psychological symptoms significantly correlated with lower hemoglobin levels, while shortness of breath was linked to suboptimal URR values. Approximately 38% of patients had URR < 65%, which was associated with increased symptom burden.CONCLUSIONHemodialysis patients experience a substantial psychological and sleep-related symptom burden, emphasizing the need for dialysis adequacy and better hemoglobin management. Enhanced strategies addressing these factors could significantly improve patient outcomes.

Background: Chronic Kidney Disease (CKD) is a condition of progressive kidney function impairment that requires renal replacement therapy such as hemodialysis. Uremic pruritus is one of the symptoms experienced by more than 40% CKD patients who require hemodialysis. Hemodialysis adequacy is measured by the clearance time/volume of distribution value (Kt/V) or urea reduction ratio and is a crucial determinant of clinical outcomes for chronic hemodialysis patients. The purpose of this study is to analyze the relationship between uremic pruritus and adequacy of hemodialysis in patients with CKD. Methods: This study is an observational analytical study using a case-control design conducted in the hemodialysis room and the medical record unit of RSUD NTB from January to October 2025. Respondents were hemodialysis patients who met several inclusion criteria. Data were collected from the 5D itch scale questionnaire and Kt/V value, and analyzed with the Chi-Square test. Results: There were 93 patients; pruritus was present in 40 and absent in 53. Two patients had adequate dialysis with pruritus, 12 had adequate dialysis without pruritus, 38 had inadequate dialysis with pruritus, and 41 had inadequate dialysis without pruritus. The Chi-square test showed a statistically significant association (p = 0.019; OR = 5.60; 95% CI = 1.17–26.43). Conclusion: There is a statistically significant association between hemodialysis adequacy and uremic pruritus in CKD patients at RSUD NTB.

Background and Objectives: Sexual satisfaction is a distinct patient-centered outcome in hemodialysis. Yet its links to routine dialysis parameters remain unclear. To examine sexual satisfaction-assessed with the Sexual Satisfaction Scale (SSS)-in adults receiving maintenance hemodialysis in relation to demographic and dialysis parameters, and to compare SSS scores with healthy controls. Materials and Methods: Cross-sectional study of adults on maintenance hemodialysis (n = 72) and controls (n = 52). Sexual satisfaction was measured with the SSS (higher scores indicate greater dissatisfaction) among respondents with one primary partner. Demographic, clinical, and dialysis variables (shift, session duration, access, vintage, ultrafiltration, predialysis urea, Kt/V, urea reduction ratio), as well as transplant history/intent, were recorded. Group comparisons used t/Welch tests or ANOVA; correlations used Pearson's r. Results: The SSS did not differ by sex, marital status, education, vascular access, dialysis shift, session duration, or adequacy indices. Prior kidney transplantation was associated with significantly lower SSS scores (mean 9.73 vs. 14.49; p = 0.0047), indicating better sexual satisfaction. Conclusions: Sexual dissatisfaction is common yet largely independent of routine demographic and dialysis metrics. Only previous kidney transplantation showed a significant association with sexual satisfaction in our cohort (p = 0.0047). Findings support a biopsychosocial, patient-centered approach and routine attention to sexual health in hemodialysis care.

Chronic kidney disease is common among people living with human immunodeficiency viruses (PLWH). Effective volume management is crucial for patients undergoing hemodialysis. This study analyzed the clinical characteristics and treatment status of male PLWH on hemodialysis, investigated differences in volume control compared to non-HIV-infected male patients, and further investigated the association between fluid management adherence and depressive symptoms in this population. This analytical study included 37 non-HIV-infected and 20 PLWH male hemodialysis patients. Baseline data and health indicators, including hematological parameters, electrolyte levels, lipid profiles, inflammatory markers, Kt/V, and urea reduction ratio values, were assessed. Interdialytic weight gain (IDWG) was measured over 1-month to determine the mean IDWG and its percentage relative to the dry body weight. These patients were then invited to complete the hospital anxiety and depression scale (HADS). There were no significant differences in erythrocyte, albumin, blood glucose, lipid, urea, creatinine, uric acid, potassium, parathyroid hormone, hypersensitive C-reactive protein, and dialysis adequacy between the 2 groups. PLWH on hemodialysis had lower blood calcium levels (2.1 ± 0.2 vs 2.2 ± 0.1, P < .05) and higher phosphorus levels (2.2 ± 0.7 vs 1.8 ± 0.5, P < .05). The mean IDWG for non-HIV-infected patients was 2.1 ± 0.8 kg, while for PLWH it was 3.1 ± 0.9 kg (P < .001). As a percentage of dry body weight, mean IDWG was 4.9 ± 1.5% for PLWH compared to 3.3 ± 1.1% for non-HIV-infected patients (P < .001). PLWH receiving hemodialysis demonstrated significantly higher HADS-D scores (6.7 ± 2.6 vs 4.2 ± 2.4, P < .01) and total HADS scores (10.7 ± 5.3 vs 6.8 ± 3.6, P < .01). Patients with IDWG exceeding 4% of dry body weight demonstrated significantly higher HADS-D scores (6.6 ± 2.5 vs 3.9 ± 2.4, P < .01) and total HADS scores (10.1 ± 4.0 vs 6.7 ± 4.5, P < .01) compared to those with lower fluid gains. PLWH undergoing hemodialysis exhibited poorer weight management and more severe depressive symptoms. Depressive symptomatology may adversely influence adherence to fluid management in patients undergoing hemodialysis.

Hemodialysis (HD) technology, pivotal in managing end-stage kidney disease, has witnessed significant advancements. Yet, the high cost of novel equipment often restricts its usage in resource-limited settings. This study introduces a two-filter adaptation to conventional HD machines, aimed at enhancing toxin removal while maintaining cost-effectiveness. Using a benchtop experimental setup, the performance of the adapted system was compared with that of standard HD. The results demonstrated that the two-filter system improved urea clearance rates by 54% compared with standard HD, without increasing albumin loss or causing additional hemolysis. In a pilot study of four HD patients, the modified setup achieved a higher single-pool Kt/V (1.82) and urea-reduction ratio (80%). These findings underscore the potential of this adaptation to enhance HD machine efficiency without additional patient risks, thereby offering a feasible solution for improving access to advanced renal therapies in under-resourced areas. Further clinical trials with larger populations are warranted to validate these benefits and evaluate middle-molecule clearance for comparison with hemodiafiltration (HDF).

Abstract Background and Aims An increasing number of patients with chronic kidney disease (CKD) increased the need for hemodialysis. Inadequate hemodialysis affects morbidity and mortality of hemodialysis patients. KDOQI guidelines recommend that Kt/V should be kept above 1.2 or URR 65% for thrice weekly routine hemodialysis. The aim of this study was to compare the urea reduction ratio (URR), Kt/V estimation by Daugirdas formula with the results measured by an Online Clearance Monitor (OCM). Method Cross-sectional study was conducted on 15 patients on hemodiafiltration (HDF) with age 36–79 years, 4-hour hemodiafiltration sessions three times a week and hemodialysis experience ≥ 6 months, using highflux dialyzers. For every patient blood flow rate was ≥ 350 ml/min and dialysis flow rate was 500 ml/min. According to vascular access all had AVF. Kt/V was calculated by the OCM of the Nipro Surdial X machine (the hemodialysis machine automatically calculate the measured sodium ion clearance based on the plasma conductivity). Results A total of 80 sessions were assessed with a predominance of males 51% (8). The mean of URR was 78.4 ± 10. Mean Kt/V values obtained with the Daugirdas formula was 1.9 ± 0.19. Mean Kt/V delivered by machine (OCM) was 1.87 ± 0.2. There was no significant difference between age, sex, comorbidities with adequacy of hemodialysis. The study show that there was no significant difference between the URR and Kt/V calculated with the Daugirdas formula and the OCM in the evaluation adequacy of hemodialysis. Conclusion Online Clearance Monitor (OCM) can be used as noninvasive guide to the real-time adjustment of the dialysis dose.

Abstract Background and Aims Remote ischemic preconditioning (RIPC), characterized by transient cycles of ischemia-reperfusion, has demonstrated organ-protective effects against ischemic injury. Hemodialysis (HD) is associated with microcirculatory disturbances, endothelial dysfunction, oxidative stress, and systemic inflammation, which may exacerbate tissue ischemia. This study aimed to evaluate the impact of RIPC on dialysis adequacy, hematological parameters, and cardiovascular outcomes in HD patients. Method In this single-blind randomized controlled trial, 55 patients on maintenance HD (&amp;gt;1 year) were allocated to an intervention group (n = 30) receiving RIPC (three cycles of 5-minute ischemia at 200 mmHg via sphygmomanometer cuff on the non-access arm, followed by 5-minute reperfusion) prior to each HD session for 12 weeks, or a control group (n = 25). Dialysis adequacy was assessed via single-pool Kt/V and urea reduction ratio (URR). Hematological parameters (hemoglobin, hematocrit, neutrophil-lymphocyte ratio) and cardiovascular metrics (trans-thoracic echocardiography) were evaluated Results Baseline demographics (age: 41 ± 10 vs. 36 ± 12 years; sex, dialysis vintage) were comparable between groups (P &amp;gt; 0.05). Post-intervention, intragroup analysis revealed a significant increase in Kt/V within the RIPC group (1.24 ± 0.23 to 1.36 ± 0.23, P = 0.04), though between-group differences in Kt/V (P = 0.6) and URR (P = 0.5) were nonsignificant. Hemoglobin levels were higher in the RIPC group versus controls (11.7 ± 1.2 vs. 11.1 ± 1.0 g/dL, P &amp;lt; 0.05), with no significant changes in hematocrit, platelets, or inflammatory markers. Echocardiography demonstrated a reduction in intraventricular septal diameter post-HD in the RIPC group (1.39 ± 0.34 to 1.17 ± 0.30 cm) versus controls (1.33 ± 0.29 to 1.32 ± 0.26 cm; P = 0.01), suggesting cardioprotective effects. Conclusion RIPC may offer potential benefits in anemia management and cardiovascular remodeling in HD patients, though its impact on dialysis adequacy remains inconclusive. These findings warrant further investigation into RIPC as an adjunctive therapy to mitigate HD-associated complications.

Abstract Background and Aims Protein-bound uremic toxins (PBUTs) are low-molecular-weight uremic toxins which encompass different molecules, with indoxyl sulfate (IS) and p-cresyl sulfate (pCS) being two of the most toxic. Both are related to increased cardiovascular disease and mortality among dialysis patients. The peculiarity of PBUTs is their high affinity for albumin, limiting their clearance by conventional hemodialysis techniques such as high-flux hemodialysis, post-dilutional hemodiafiltration or expanded hemodialysis. Reduction ratio (RR) varies among published studies, but their removal is generally less than 50% for pCS and 55% for IS. Extended dialysis techniques have shown an increase in their removal, up to 59% and 66%, respectively. Our aim was to analyze PBUTs clearance in our hemodialysis unit with post-dilutional hemodiafiltration with high convective volumes (OL-HDF). Method A transversal study was made in the hemodialysis unit of Hospital Clínic of Barcelona during October 2024. Total IS and pCS were measured before and after one OL-HDF session. Total IS and pCS were measured in serum using liquid chromatography-mass spectrometry and post-dialysis levels were corrected for the degree of hemoconcentration and the volume of distribution according to Bergström and Wehle. All sessions were with a Fresenius 5008 or 6008 dialysis monitor. A total of 130 patients were included with a mean age of 71.5 ± 15.9 years (34.6% women). 112 patients (86.3%) realize three-weekly daily sessions with a mean time of 283 ± 23.2 min and blood-flux (Qb) of 423 ± 29.5 mL/min and dialysis-flux (Qd) of 400. The remain 18 patients (13.7%) did nocturnal OL-HDF with a mean time of 423 ± 44.5 min, Qb of 406 ± 29.1 mL/min and Qd of 200. Results Mean IS and pCS RR were 53.9 ± 10.3% and 47.5 ± 12.7% respectively. When these values are divided between groups, RR were 54.1 ± 9.84% for IS and 47 ± 11.7% for pCS in the daily group while 52.2 ± 13.3% for IS and 51 ± 18% for pCS in the nocturnal group (Fig. 1). T-Student analysis for independent groups showed no difference between daily or nocturnal groups (p-value 0.457 and 0.209 for RR of IS and pCS, respectively). Mean convective volumes were 31.8 ± 8.7 with 30 ± 7.2 in the daily-group while 41.7 ± 0.09 in the nocturnal-group. IS and pCS were slightly directly correlated with RR of slow-molecular-weight molecules such as creatinine (r = 0.36 and r = 0.31, respectively) and urea (r = 0.37 and r = 0.25, respectively). In the multiple regression analysis, RR of urea is the only variable statistically significant correlated for IS and pCS (P &amp;lt; 0.001 and p = 0.014, respectively), while convective volume shows a positive tendency with IS and pCS but without significance (p = 0.052 and p = 0.066 respectively). Conclusion Protein-bound uremic toxins are related to cardiovascular morbidity and mortality among patients with chronic hemodialysis treatment. Their removal is one of the facings obstacles in dialysis due to their high affinity to albumin. Our results in PBUTs removal with online-hemodiafiltration are in concordance with the results published in the literature with RR about 55% for IS and 50% for pCS. Their clearance is related to other low-molecular-weight as diffusion is the major responsible. However, all these results, including ours, are insufficient and new strategies for IS and pCS removal are needed. Currently, the use of albumin displacer or adsorptive membranes are promising options under development.

Abstract Background and Aims Anemia is common in patients under regular hemodialysis therapy. Despite treatment with erythropoiesis-stimulating agents (ESA), hypo-responsiveness to this therapy can occur (refractory cases). We studied the association between ESA resistance in hemodialysis patients and potential causes of ineffective treatment, including nutritional, iron metabolism, and inflammatory variables, and dialysis related parameters. Method We performed a cross-sectional study involving 289 hemodialysis patients. Ultrafiltration rate adjusted to weight (UFR/W), urea reduction ratio (URR) and Kt/V were obtained for the session where blood samples were collected. Blood analyses were performed by using automated technology or by enzyme-linked commercialized immunoassays, as previously described [1]. Erythropoietin (EPO) resistance index (ERI) was calculated by the formula: EPO dose per week (IU)/body weight (kg) /hemoglobin (g/dL). Results The mean age of patients was 68.7 years (±13.6), 240 patients (83%) were under ESA prescription and 186 (64.4%) were receiving intravenous iron. The median (interquartile range) for ERI was 7.1 (3.7–11.7) IU/kg/g/dL, and for median transferrin saturation (TSAT) was 21.9 (16.8–28.5) %. ERI was positively correlated with levels of soluble transferrin receptor (sTfR, r = 0.556, P = 7.8×10−21; Fig. 1), interleukin (IL)-6 (r = 0.196, P = 0.002), pentraxin 3 (r = 0.192, P = 0.003), C-reactive protein (r = 0.130, P = 0.043) and UFR/W values (r = 0.135, P = 0.037) and inversely correlated with body mass index (r = −0.179, P = 0.005) and levels of iron (r = −0.382, P = 9.2×10−10), TSAT (r = −0.340, P = 6.8×10−8), hepcidin (r = −0.197, P = 0.002) and albumin (r = −0.166, P = 0.010). By performing multivariate linear regression analysis (after normalization of non-normally distributed data), levels of sTfR (β = 0.487, P &amp;lt; 0.001), iron (β = −0.176, P = 0.003), and IL-6 (β = 0.111, P = 0.035), and UFR/W values (β = 0.168, P = 0.001) were independent predictors of ERI. When iron repleted patients (ferritin ≥ 100 µg/L and TSAT ≥ 20%) receiving EPO therapy were analyzed separately (n = 138), sTfR and UFR/W were kept in the regression model as predictors of ERI (β = 0.504, P &amp;lt; 0.001 and β = 0.207, P = 0.006, respectively); within these patients, those with UFR/W &amp;gt; 10 ml/h/kg presented higher ERI than those below 10 ml/h/kg (Fig. 2). Conclusion Besides lower iron, raised UFR/W and IL-6 are independently associated with hypo-responsiveness to ESA. sTFR seems to be a valuable tool to access ESA-driven erythropoiesis in hemodialysis patients, particularly in iron repleted patients. Our results support the idea that the modulation of inflammation and UFR prescription can improve anemia management.

Introduction: The standard dialysate flow (Qd) for hemodialysis (HD) is currently set at 500 mL/min. One potential, sustainable, and cost-effective solution for eco-friendly HD may involve reducing Qd to limit wastewater. However, the effect of reduced Qd on small molecule and middle molecule (MM) removal remains to be investigated. Methods: In this prospective observational study, 74 patients on different maintenance dialysis modalities with Qd set at 500 mL/min (Qd500) were assigned to receive Qd at 400 mL/min (Qd400) for 3 months. Dialysis adequacy, including small solute removal and MM reduction ratio (RR), was evaluated at enrollment and after 3 months. Results: Compared to Qd500, Qd400 after 3 months achieved similar single-pool Kt/V (1.41 ± 0.30 vs. 1.43 ± 0.33, p = 0.58), equilibrated KT/V, urea RR, creatinine RR, and phosphate RR. Qd400 vs. Qd500 provided significantly higher beta2-microglobulin RR (77.0 [71.4–81.7] vs. 74.7 [68.4–79.4] %, p = 0.009) and lower kappa free light chain (FLC) RR (54.2 [42.1–64.4] vs. 57.6 [41.6–65.0] %, p = 0.03), whereas myoglobin and lambda FLC RR were similar. Qd400 resulted in higher pre-dialysis urea (20.2 ± 5.5 vs. 18.2 ± 6.2 mmol/L, p = 0.002), creatinine (694.0 ± 179.5 vs. 665.6 ± 220.4 µmol/L, p = 0.029), beta2-microglobulin (26.5 [23.0–30.0] vs. 23.5 [20.0–28.0] mg/L, p = 0.0001), and myoglobin (174.0 [122.0–251.0] vs. 159.5 [119.0–195.0] µg/L, p = 0.033) levels. Pre-dialysis levels of albumin, potassium, bicarbonate, phosphate, and calcium were similar between Qd400 and Qd500. Conclusion: Three months of Qd at 400 mL/min appears to provide similar small molecule and MM removal, but with an increase in pre-dialysis urea, creatinine, beta2-microglobulin, and myoglobin levels. Although this strategy could help preserve water, its potential impact on long-term clinical outcomes deserves further evaluation.