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Background: Most patients with end-stage kidney disease (ESKD) appreciate the importance of exercise and would like to increase their physical activity; however, they report a few key barriers, including (1) lack of physician advice to do so, (2) lack of safe and convenient programs (ie, appropriate for home or neighborhood), and (3) cost. Importantly, patients indicated in a previous survey that they would prefer an exercise program that improves muscle strength and symptoms, and are less interested in cardiovascular disease prevention., Objective: To test the feasibility of a simple, prescribed exercise program using Nordic walking poles in patients with ESKD treated with dialysis., Design: Randomized multicenter pilot trial of an exercise intervention that includes Nordic walking poles, personalized physician exercise prescriptions, pedometers, and access to exercise videos, compared with standard of care, in patients being treated with maintenance dialysis., Setting: Multicenter tertiary care centers in Canada., Patients: Ambulatory adult patients with ESKD treated with peritoneal dialysis or hemodialysis (HD) for at least 6 months at participating sites are potentially eligible. Inclusion criteria include ability to use Nordic walking poles (either de novo or in place of mobility aid) and to provide informed consent in English or in French. Exclusion criteria include (1) any absolute contraindication to exercise, (2) baseline step count >8000 steps/day, (3) planned living donor kidney transplant, and (4) participation in another interventional trial that may affect the results of this study., Methods: This is a randomized multicenter pilot trial of an exercise intervention that consists of a prescription to exercise using Nordic walking poles, a pedometer to track activity, and access to exercise videos, with the comparator of standard of care (dialysis unit staff encouragement to exercise) in patients being treated with maintenance dialysis. Randomization is concealed and uses a 1:1 ratio for group assignment. Our specific aims are to determine the feasibility of patient recruitment, adherence to the exercise program (verified by step counts), and efficacy of the intervention on patient-important outcomes that were assessed as a priority by patients in a prior survey-specifically strength, fatigue, and sleep. We record days spent in hospital and loss of independent living to inform sample size calculations for a definitive trial of exercise in patient with ESKD treated with dialysis. Adverse events are closely monitored., Outcomes: Primary: Our recruitment goal is 90 to 150 patients over 27 months; adherence success will be defined if >75% of randomized patients, excluding those who are transplanted or deceased, achieve >80% of their prescribed steps at 6 and 12 months. Secondary Efficacy Outcomes: (1) strength-hand grip strength and 5 times sit to stand, (2) energy-Short Form (SF)-36 vitality subscale, and (3) sleep-Pittsburg Sleep Quality Index will be assessed at baseline, 6, and 12 months., Results: Trial recruitment started before the COVID-19 pandemic and the pandemic led to many interruptions and delays. Online exercise Web sites and a tailored video were added to the protocol to encourage activity when participants were unable or reluctant to walk in public places., Limitations: This trial was designed to include ambulatory patients with ESKD and does not address the burden of disease in patients with very restricted mobility., Trial Registration: NCT03787589., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Living kidney donation is considered generally safe in healthy individuals; however, there is a need to better understand the long-term effects of donation on blood pressure and kidney function., Objectives: To determine the risk of hypertension in healthy, normotensive adults who donate a kidney compared with healthy, normotensive non-donors with similar indicators of baseline health. We will also compare the 2 groups on the rate of decline in kidney function, the risk of albuminuria, and changes in health-related quality of life., Design Participants and Setting: Prospective cohort study of 1042 living kidney donors recruited before surgery from 17 transplant centers (12 in Canada and 5 in Australia) between 2004 and 2014. Non-donor participants (n = 396) included relatives or friends of the donor, or donor candidates who were ineligible to donate due to blood group or cross-match incompatibility. Follow-up will continue until 2021, and the main analysis will be performed in 2022. The anticipated median (25th, 75th percentile, maximum) follow-up time after donation is 7 years (6, 8, 15)., Measurements: Donors and non-donors completed the same schedule of measurements at baseline and follow-up (non-donors were assigned a simulated nephrectomy date). Annual measurements were obtained for blood pressure, estimated glomerular filtration rate (eGFR), albuminuria, patient-reported health-related quality of life, and general health., Outcomes: Incident hypertension (a systolic/diastolic blood pressure ≥ 140/90 mm Hg or receipt of anti-hypertensive medication) will be adjudicated by a physician blinded to the participant's donation status. We will assess the rate of change in eGFR starting from 12 months after the nephrectomy date and the proportion who develop an albumin-to-creatinine ratio ≥3 mg/mmol (≥30 mg/g) in follow-up. Health-related quality of life will be assessed using the 36-item RAND health survey and the Beck Anxiety and Depression inventories., Limitations: Donation-attributable hypertension may not manifest until decades after donation., Conclusion: This prospective cohort study will estimate the attributable risk of hypertension and other health outcomes after living kidney donation., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: During the study period, Dr Garg was supported by the Dr Adam Linton Chair in Kidney Health Analytics and a Clinician Investigator Salary Award from the CIHR, and he was the joint Ontario Renal Network-Trillium Gift of Life Network Provincial Medical Lead for Access to Kidney Transplantation. Dr Boudville was supported by grants from the National Health and Medical Research Council and the Raine Foundation; he also received unrestricted educational grants and consulting fees from Baxter, Amgen, Astra Zeneca, Otsuka, and Vifor. Dr Feldman was supported by a grant from Theator and received speaker fees from Abbott and Merck. Dr Gill was supported by a Foundation Award from the CIHR and he received grant support from Astellas Canada and Canadian Blood Services, and he served as a consultant for Veloxis, Takeda. Dr Klarenbach was supported by a Kidney Health Research Chair and the Division of Nephrology at the University of Alberta, and he was the Director of the Real World Evidence Consortium., (© The Author(s) 2022.)

Background: Cardiac magnetic resonance (CMR) imaging accurately and precisely measures left ventricular (LV) mass and function. Identifying mechanisms by which LV mass change and functional improvement occur in some end-stage kidney disease (ESKD) patients may help to appropriately target kidney transplant (KT) recipients for further investigation and intervention. The concentration of serum adiponectin, a cardiovascular biomarker, increases in cardiac failure, its production being enhanced by B-type natriuretic peptide (BNP), and both serum adiponectin and BNP concentrations decline posttransplantation., Objective: We tested the hypothesis that kidney transplantation alters LV characteristics that relate to serum adiponectin concentrations., Design: Prospective and observational cohort study., Setting: The study was performed at 3 adult kidney transplant and dialysis centers in Ontario, Canada., Patients: A total of 82 KT candidate subjects were recruited (39 to the KT group and 43 to the dialysis group). Predialysis patients were excluded., Measurements: Subjects underwent CMR with a 1.5-tesla whole-body magnetic resonance scanner using a phased-array cardiac coil and retrospective vectorographic gating. LV mass, LV ejection fraction (LVEF), LV end-systolic volume (LVESV), and LV end-diastolic volume (LVEDV) were measured by CMR pre-KT and again 12 months post-KT (N = 39), or 12 months later if still receiving dialysis (N = 43). LV mass, LVESV, and LVEDV were indexed for height (m 2.7 ) to calculate left ventricular mass index (LVMI), left ventricular end-systolic volume index (LVESVI), and left ventricular end-diastolic volume index (LVEDVI), respectively. Serum total adiponectin and N-terminal proBNP (NT-proBNP) concentrations were measured at baseline, 3 months, and 12 months., Methods: We performed a prospective 1:1 observational study comparing KT candidates with ESKD either receiving a living donor organ (KT group) or waiting for a deceased donor organ (dialysis group)., Results: Left ventricular mass index change was -1.98 ± 5.5 and -0.36 ± 5.7 g/m 2.7 for KT versus dialysis subjects ( P = .44). Left ventricular mass change was associated with systolic blood pressure (SBP) ( P = .0008) and average LV mass ( P = .0001). Left ventricular ejection fraction did not improve (2.9 ± 6.6 vs 0.7 ± 4.9 %, P = .09), while LVESVI and LVEDVI decreased more post-KT than with continued dialysis (-3.36 ± 5.6 vs -0.22 ± 4.4 mL/m 2.7 , P < .01 and -4.9 ± 8.5 vs -0.3 ± 9.2 mL/m 2.7 , P = .02). Both adiponectin (-7.1 ± 11.3 vs -0.11 ± 7.9 µg/mL, P < .0001) and NT-proBNP (-3811 ± 8130 vs 1665 ± 20013 pg/mL, P < .0001) declined post-KT. Post-KT adiponectin correlated with NT-proBNP ( P = .001), but not estimated glomerular filtration rate (eGFR) ( P = .13). Change in adiponectin did not correlate with change in LVEF in the KT group (Spearman ρ = 0.16, P = .31) or dialysis group (Spearman ρ = 0.19, P = .21)., Limitations: Few biomarkers of cardiac function were measured to fully contextualize their role during changing kidney function. Limited intrapatient biomarker sampling and CMR measurements precluded constructing dose-response curves of biomarkers to LV mass and function. The CMR timing in relation to dialysis was not standardized., Conclusions: The LVESVI and LVEDVI but not LVMI or LVEF improve post-KT. LVMI and LVEF change is independent of renal function and adiponectin. As adiponectin correlates with NT-proBNP post-KT, improved renal function through KT restores the normal heart-endocrine axis., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Noninfectious hemodialysis catheter complications include catheter dysfunction, catheter-related thrombus, and central vein stenosis. The definitions, causes, and treatment strategies for catheter dysfunction are reviewed below. Catheter-related thrombus is a less common but serious complication of catheters, requiring catheter removal and systemic anticoagulation. In addition, the risk factors, clinical manifestation, and treatment options for central vein stenosis are outlined., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

When making decisions regarding vascular access creation, the clinician and vascular access team must evaluate each patient individually with consideration of life expectancy, timelines for dialysis start, risks and benefits of access creation, referral wait times, as well as the risk for access complications. The role of the multidisciplinary team in facilitating access choice is reviewed, as well as the clinical evaluation of the patient., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Nontunneled hemodialysis catheters (NTHCs) are typically used when vascular access is required for urgent renal replacement therapy. The preferred site for NTHC insertion in acute kidney injury is the right internal jugular vein followed by the femoral vein. When aided by real-time ultrasound, mechanical complications related to NTHC insertion are significantly reduced. The preferred site for tunneled hemodialysis catheters placement is the right internal jugular vein followed by the left internal jugular vein. Ideally, the catheter should be inserted on the opposite side of a maturing or planned fistula/graft. Several dual-lumen, large-diameter catheters are available with multiple catheter tip designs, but no one catheter has shown significant superior performance., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Catheter-related bloodstream infections, exit-site infections, and tunnel infections are common complications related to hemodialysis central venous catheter use. The various definitions of catheter-related infections are reviewed, and various preventive strategies are discussed. Treatment options, for both empiric and definitive infections, including antibiotic locks and systemic antibiotics, are reviewed., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Vascular access-related complications can lead to patient morbidity and reduced patient quality of life. Some of the common arteriovenous access complications include failure to mature, stenosis formation, and thrombosis., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.