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BACKGROUND AND AIMS Ambulatory blood pressure monitoring (ABPM), extended to 44h or 48h for the diagnosis of hypertension in end-stage kidney disease (ESKD) patients, is recommended by Consensus Documents of the American Society of Nephrology and the European Renal Association. About 10%–20% of individuals in the general population report sleeping problems and other symptoms during 24 h ABPM. Because the longer recording period (44 or 48 h versus 24 h), the notorious sleeping disturbances and the high symptom burden of the ESKD population, the feasibility of the technique may be limited in this population. However, the large-scale tolerability of ABPM in the haemodialysis population, has never been investigated. METHOD We performed an international survey of feasibility and tolerability of 48 h ABPM in six centres in three European countries. These centres are led by motivated clinical nephrologists, all members of the EURECA-m working group. 48 h ABPM recording was proposed to a large, representative sample of the whole dialysis population of these centres. Well validated instruments (AAMI/ESH/ISO) were applied in all centres. As recommended by the European Society of Hypertension guidelines, recordings were made at 15-min intervals during the day and 30 min during the night. Reasons for refusal to undergo the test were accurately registered. A tolerability (symptoms) questionnaire and a specific questionnaire for sleep evaluation were administered to all participants who underwent 48h ABPM. Reasons for not completing of the ABPM monitoring were systematically recorded. RESULTS In the whole haemodialysis population of participating centres including 735 patients, 440 (60%) were invited to participate in the study. Among these patients, 119 (27%) refused to undergo ABPM recording. Reasons for refusal were fear of discomfort (n = 30, 25%), measurement too long (n = 22, 18%), logistic problems (n = 17, 14%), previous negative experience (n = 13, 11%), clinical reasons (n = 12, 10%), other reasons (n = 25). Among the 321 patients who performed the 48h ABPM recording, 29 (9%) did not complete it and the main reason for interrupting the recording were discomfort [12 patients (41%)], followed by device failure [10 patients (34%)]. Among symptoms developed during the ABPM study, frequent interruption of sleeping because of noise or discomfort was reported by 32% of patients, followed by itching (24%) and pain during the measurements (20%). The detailed list of symptoms, is reported in the Table 1. CONCLUSION Overall, about 25% of haemodialysis patients consider 48h ABPM a laborious and discomforting test and prejudicially refuse to undergo it. Among patients who undergo 48h ABPM, itching and interruption of sleeping are complained by about 1/3 of patients. These figures are substantially higher than those reported in studies in the general population and in hypertensive patients and point to peculiar barriers at applying extended ABPM recordings in the haemodialysis population. Studies applying more tolerable instruments and a minimum set of measurements over a shorter time, with a reduced number of measurements overnight, are clinical research priority for extending the use of ABPM in the haemodialysis population.

Background and Aims Home dialysis (both extracorporeal and peritoneal) can improve the management and the quality of life of patients affected by end stage renal disease. Remote patient monitoring (RPM) can improve the care of Patients in home dialysis: RPM may detect early problems, ensure compliance and give both clinicians and patients a sense of reassurance regarding the clinical management. These advantages may translate into improved outcomes and increased uptake on home dialysis therapies. For these reasons, the Doctor Plus® NEPHRO program has been created. Clinical and social advantages derived from remote patient monitoring by the Doctor Plus® NEPHRO program versus the standard of care were evaluated. Method Patients included in the remote monitoring program, by the Nephrology Unit of ASL 3 in Rome (Italy), from July 2017 and April 2019, were analyzed. Each patient was observed for at least 4 months, up to 22 months. Patients received a Doctor Plus® NEPHRO KIT composed by clinical devices to measure systolic and diastolic pressure, heart rate, body weight and oximetry. Clinical data were automatically sent from electronic devices to the HUB included into the provided KIT and from the HUB to the Vree Platform operating at the Nephrology Unit. All devices, included HUB and Vree Platform, were classified as medical device class IIa. The SF-12 questionnaire was also administered by remote nurses and the level of satisfaction with the program Doctor Plus® NEPHRO was evaluated. Results We observed 16 patients (56,3% males, mean age 62 years), 14 in Peritoneal Dialysis and 2 in Home Hemodialysis. A total number of 35.720 clinical measures were collected during the observational period. During this length time, systolic pressure was reduced in 69% of patients and diastolic pressure was reduced in 62,5% of patients. Systolic pressure decreased from 137,8 to 130,2 mmHg (p0,0002). Mean heart rate decreased in 50% of patients from 69,4 bpm to 68,8 bpm (p During the same period, clinical monitoring generated 58 early clinical interventions: 11 non planned visits at Nephrological Centre and 47 calls from nephrologist to patients (0,5 visits per month and 2,2 calls per month). In 35 cases pharmacological therapy has been modified (in 80% of cases treatment modified was the hypertension therapy). Due to the increase of clinical monitoring, Patients accesses to ER are decreased of 29%. SF-12 questionnaire showed an improvement in the perceived health status in all patients. Reduction of 15% in workdays lost were registered in both patients and caregivers. Conclusion Doctor Plus® NEPHRO resulted as a useful tool for the Nephrology Center in order to monitor patients who performed home dialysis. Data collected by the remote monitoring program have shown an improvement in clinical outcomes and the possibility to prevent some clinical complications thus reducing clinical emergencies and the hospitalization rate. Moreover, the possibility for patients and caregivers to complain with morbidity remaining in a home setting, results in the improvement in quality of life. Finally, the possibility to avoid hospitalizations, emergency accesses and transfers to hemodialysis is important for cost saving with a more appropriate use of healthcare resources.

Background. Cardiac calcifications are a frequent occurrence in uraemic subjects and are probably connected to the increased cardiovascular mortality of haemodialysis patients. There is substantial support to the hypothesis that low levels of serum PTH in haemodialysis patients are associated with increased vascular and cardiac calcium deposits, due to decreased buffering capacity of bone in low turnover osteodystrophy. The present study has been carried out on a cohort of patients on haemodialysis, with exclusion of previously parathyroidectomized patients, with the aim to evaluate the association between PTH serum levels and coronary calcifications. Methods. The study has been carried out in a cohort of 197 haemodialysis patients. There were 133 males and 64 females. Twenty-two patients had diabetes mellitus. Average age was 58.6 � 12.9 years. Patients were divided into groups of intact PTH levels, 0–150 (A), 150–300 (B), 300–600 (C) and >600 (D) pg/ml. Results. The values of coronary scores in the PTH groups were as follows: (A) 624.7 � 939, (B) 866.4 � 1080, (C) 1202.8 � 1742.3 and (D) 1872.7 � 2961.9. The difference between coronary calcium scores was significant (P < 0.01). A general linear model identified serum calcium and dialysis age as independent factors of calcium deposits in the high PTH group. Conclusions. No prominent association between low PTH serum levels and the severity of coronary calcium deposits in haemodialysis patients was found while increased levels of PTH, with special regard to very elevated levels, associated with more frequent hypercalcaemia and hyperphosphataemia, should be considered a major risk factor of coronary calcifications and cardiac events.

Background. Numerous growth factors and cytokines are known to modulate bone turnover. An important, recently discovered complex involved in osteoclastogenesis is the osteoprotegerinuosteoprotegerin-ligand (OPGuOPGL) cytokine complex, which is produced by osteoblasts. Many factors, including parathyroid hormone (PTH), appear to affect bone turnover through this pathway. In this disorder, the role of the OPGu OPGL system in the pathogenesis of renal osteodystrophy, a disease with either low or high bone turnover, has not been investigated so far. Methods. Thirty-nine chronic haemodialysis patients had bone biopsies, including histomorphometric and histodynamic examinations. In addition, the following serum biochemistry parameters were measured: serum OPG, intact PTH, PTH 1–84, total PTH, osteocalcin, total and bone alkaline phosphatases, 25-hydroxycholecalciferol and 1,25-dihydroxycholecalciferol. Results. On average, serum OPG levels were above the normal range. They were lower in adynamic bone disease (ABD) patients, than in patients with predominant hyperparathyroidism (HP) or mixed osteodystrophy (MO). Significant negative correlations were found between serum OPG and PTH levels, and between serum OPG and parameters of bone resorption (ESuBS) and bone formation (ObSuBS and BFRuBS) in HP and MO patients with PTH values O1000 pguml. For intact PTH levels O300 pguml, serum OPG was significantly lower in the group with ABD than in those with HP or MO (P-0.05). Conclusion. In renal osteodystrophy the OPGuOPGL system is involved in the regulation of bone turnover induced by PTH. The determination of serum OPG levels could be of use in the diagnosis of low turnover bone disease, at least in association with PTH levels O300 pguml.