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Background and Aims At least 80% of children with steroid sensitive nephrotic syndrome (SSNS) have relapses and many are triggered by upper respiratory tract infections (URTIs). Previous small studies (4 studies, 232 patients in total), mostly in children already taking maintenance corticosteroid in countries where URTI epidemiology is different to Europe, showed that giving daily low-dose prednisolone for 5-7 days during an URTI reduces the risk of relapse. The objective of the PREDNOS 2 trial was to determine if these findings were replicated in a large UK population of children with relapsing SSNS on different background medication or none. Method A randomised, double-blind, placebo-controlled trial, including a model-based economic evaluation was carried out in 122 UK paediatric departments. Between February 2013 and January 2019, 365 children with relapsing SSNS (mean age: 7.6 ± 3.5 y) were recruited from 91 sites and randomised (1:1) according to a minimisation algorithm based on background treatment (no background treatment; low-dose prednisolone only; low-dose prednisolone and other immunosuppression; other immunosuppression only). At the start of an URTI, children received 6 days of prednisolone 15 mg/m2 or matching preparation of placebo. Those already taking alternate day prednisolone rounded their daily dose using trial medication to the equivalent of 15 mg/m2 or their alternate-day dose, whichever was the greater. The primary outcome was the incidence of first URTI-related relapse (URR) following any URTI over 12 months. Secondary outcomes were the overall rate of relapse, changes in background treatment, cumulative dose of prednisolone, rates of serious adverse events, incidence of corticosteroid adverse effects, change in Achenbach Child Behaviour Checklist score and quality of life. Analysis was by intention to treat. The economic evaluation used trial data and a decision-analytic model to estimate Quality-Adjusted-Life-Years (QALYs) and costs at 1-year, which were then extrapolated over 16 years. Results 80 children completed 12 m follow-up without an URTI. Consent was withdrawn for 32 children, 14 prior to an URTI, leaving a modified intention to treat analysis population of 271 children (134 and 137 in prednisolone and placebo arms respectively). There were 384 URTIs and 82 URRs in the prednisolone arm, and 407 URTIs and 82 URRs in the placebo arm. The number of patients experiencing a URR was 56 (42.7%) and 58 (44.3%) in the prednisolone and placebo arms respectively (adjusted risk difference: -0.024, 95% CI: -0.14 to 0.095; P=0.7). There was no evidence that the treatment effect differed when data were analysed according to background treatment. There were no significant differences in secondary outcomes between treatment arms. A post-hoc subgroup analysis assessing primary outcome in 58 children of South Asian ethnicity (RR 0.66, 95% CI: 0.396 to 1.105) versus 213 of other ethnicity (RR 1.11, 95% CI: 0.806 to 1.535) showed possible efficacy of intervention in those of South Asian ethnicity (test for interaction P=0.09). Giving daily prednisolone at the time of an URTI was found to increase QALYs and decrease overall costs, when compared to standard care, a finding that was robust to sensitivity analysis. Conclusion In a large and methodologically-robust study, PREDNOS 2 has shown that giving 6 days of daily low-dose prednisolone at the time of an URTI does not reduce the risk of relapse of nephrotic syndrome in UK children, but could offer a cost-effective use of health care resources. Further work is needed to investigate inter-ethnic differences in treatment response, and the pathogenesis of individual viral infections and their effect on nephrotic syndrome.

Background and Aims We are uncertain about whether dialysate sodium improves overall health and well-being for people on haemodialysis, since there are a mixture of probably good and bad effects. Dialysate sodium is one of the most easy changeable parameter which can influence hemodynamic stability, echocardiography and laboratory parameters. The aim of the study was to investigate whether dialysis patients will have some beneficial effects of dialysate sodium set up according to serum sodium. Method 77 nondiabetic subjects (41men; 36women) performed 12 months hemodialysis (HD) sessions with dialysate sodium concentration setup at 138 mmol/L, followed by additional 24 month ssessions wherein dialysate sodium was set up according to pre-HD serum sodium concentration. Interdialytic weight gain (IDWG), echocardiography, laboratory parameters and survival were analysed. Results Sodium individualization resulted in significantly lower IDWG by using individualized sodium according to pre HD serum sodium compared to standard dialysate sodium (2.17±0.79 vs 1.93±0.64 kg, p1,2, URR lower than 65% have 10,9 times higher risk compared to URR>65% and CRP higher than 10 mg/L have 10.2 times higher risk for death compared to patients with CRP lower than 10 mg/L Conclusion Individualization of dialysate sodium according to pre HD serum sodium concentration result in better IDWG control, improvement of fluid overload and regression of left ventricular hypertrophy, better dialysis adequacy and higher survival compared to standard dialysate sodium.

Background and Aims Cardiovascular disease is common in chronic and end stage kidney disease. Left ventricular hypertrophy (LVH) has been identified as contributor to cardiovascular risk in this population. The aim of the study was to assess whether the combined use of electrocardiography and echocardiography in assessing LVH in a haemodialysis population can provide improved risk stratification. Method Prospective study of 192 prevalent maintenance haemodialysis ( HD) patients 12 lead ECGs were performed on a mid week non –dialysis day. Electrocardiographic strain was defined as a down slopping convex ST segment with inverted T waves in leads V5 and / or V6. Transthoracic echocardiographic was performed immediately after ECG .LV mass was indexed to body surface area (LVMIBSA). LVH was determined if LVMI >116g/m2 for male patients, and >100g/m2 for female patients. The primary study endpoint was major cardiac events (MACE). A secondary endpoint was all cause mortality. Results 192 patients included in the final analysis, 137 (71.4%) male.. The mean ejection fraction (EF) was 60.6± 11.1 % and the mean LVMI (BSA) was 115.0± 36.8 g/m2. During a mean follow up period of 2.4 ± 1.0 years, 50 patients reached a MACE end point and 62 patients died. On univariate Cox regression analysis, the factors associated with MACE were the presence of ECG strain (HR 2.961, CI: 1.254 – 6.990, p= 0.013)) URR (HR 0.968, CI: 0.942 – 0.994, p=0.015) and history of CAD (HR: 2.397 CI: 1.363 -4.2515, p= 0.002). In multivariate Cox regression analysis adjusting for baseline cardiovascular phenotype and dialysis parameters ECG strain remained significantly associated with MACE. Conclusion The presence of electrocardiographic strain increases the risk for MACE independently of LVH in haemodialysis patients. ECG strain has potential to be a simple bedside prognostic biomarker and even therapeutic target in haemodialysis patients.

Background and Aims Approximately one-third of all dialysis patients have mild to moderate malnutrition, while 6-8% have severe malnutrition. In patienst receiving maintenance hemodialysis, a low serum prealbumin is an indicator of malnutrition. Depression and anxiety are the most common psychological disorders in patients undergoing hemodialysis. The aim of this study was to evaluate the nutrional status in our hemodialysis patients and its association with anxiety and depression. Method In our cross-sectional study, 61 hemodialysis patients were evaluated with mini nutrional assessment (MNA) form, Beck anxiety/depression scale, clinical and laboratory data. Results Of 61 hemodialysis patients; 37 were male (mean age 60,8±11.7). 11.5 % of patients were malnourished. Severe depression and anxiety rates were 14.8% and 21.3% respectively. The clinical parameters of hemodialysis patients are shown in Table-1 and clinical and laboratory findings of the hemodialysis patients according to MNA scores are shown in Table-2. Malnourished patients and patients who were at risk of malnutrition; had lower urea, creatinine and prealbumin levels. Conclusion Anxiety was more prevalant in malnourished hemodialysis patients with lower prealbumin levels. Figure-1 Clinical and laboratory findings of hemodialysis patients (n=61). Figure-2: Clinical and laboratory findings of the hemodialysis patients according to MNA scores.

Background and Aims Sodium zirconium cyclosilicate (SZC) (Lokelma®) is a new oral potassium binder. In September 2019 the UK National Institute for Health and Care Excellence (NICE) did not recommend SZC for dialysis patients due to a lack of evidence. The recent DIALIZE phase 3b randomised controlled trial concluded that SZC is an effective and well-tolerated treatment for hyperkalemia in haemodialysis (HD) patients. We offer an insight into SZC treatment in HD patients with persistent hyperkalaemia in clinical practice. Method Adult prevalent HD patients prescribed SZC for persistent hyperkalaemia were included for analysis. The highest pre-dialysis serum potassium (sK+) values were recorded each month before (M-6 to M-1) and after (M1 to M5) SZC initiation. The primary efficacy measure was a reduction in sK+ with SZC treatment. Results Sixteen patients (mean age 53.5 years, 56.3% male) were included for analysis. 43.8% (n=7) were diabetic. At the time of SZC initiation 43.8% (n=7) received HD via arteriovenous fistula, 12.4% (n=2) via arteriovenous graft and 43.8% (n=7) via tunnelled central venous catheter. The mean Urea Reduction Ratio [SD] was 68.5% [10.8] and the mean [SD] pre-HD bicarbonate was 22.8mmol/L [2.7]. The dialysate potassium prescription was 2mmol/L for 93.8% of patients (n=15) and 1mmol/L for 6.2% of patients (n=1). The mean [SD] achievement of prescribed dialysis hours over the previous 4 weeks was 93.5% [12.2]. 68.8% (n=11) had previous treatment with calcium polystyrene sulfonate and 12.5% (n=2) with patiromer. 18.8% (n=3) were currently prescribed a renin-angiotensin-aldosterone system inhibitor. 93.8% (n=15) had received dietetic advice. SZC starting doses ranged from 5g four times a week on non-dialysis days to 10g three times a day. Mean [SD] sK+ at month-1 (M-1) (immediate pre-treatment period) was 7.38mmol/L [0.31]. Mean [SD] sK+ at month 1 (M1) was 6.37mmol/L [1.21]. The statistical difference between these groups was p=0.0023 (paired two-tailed T-test). Figure 1 includes mean maximum monthly pre-dialysis sK+ from M-6 to M5. SZC was stopped in two patients (after M1 with sK+ 5.0mmol/L and after M4 with sK+ 4.3mmol/L) as it was no longer clinically indicated. Two patients became non-compliant (clinician-suspected or confirmed by patient) with SZC after M2 (sK+ 6.7mmol/L and sK+ 6.4mmol/L). Subsequent sK+ values would not reflect treatment with SZC in these patients. Figure 2 includes mean maximum monthly sK+ for the 12 patients on SZC from M-3 to M5. ANOVA and post-hoc Dunnett’s tests were undertaken to compare SZC treatment months (M1, 2, 3, 4 and 5) to the immediate pre-treatment period (M-1). ANOVA was close to significance (p=0.058), with post-hoc corrected for multiple comparisons finding the data to be significant for M1 vs. M-1 (p=0.045) and M5 vs. M-1 (p=0.018). The same tests across M1 through M5 revealed no significant difference (p=0.968 ANOVA and p=0.555 Dunnett’s), demonstrating that continued treatment with SZC to M5 did not result in a further decline in sK+. Conclusion Sodium zirconium cyclosilicate is effective in reducing pre-dialysis sK+ in patients with moderate and severe hyperkalaemia undergoing haemodialysis in clinical practice.

Background and Aims Hyperphosphatemia is frequently encountered in hemodialysis patients and is an important risk factor of cardiovascular diseases. It is usually difficult to be managed by phosphate binders and hemodialysis. This study was carried out to assess the effect of nutritional education (NE) on the control of serum phosphorus level in hemodialysis patients. Method An open label, single center randomized controlled trial was conducted in the nephrology department, New Mansoura General Hospital, Egypt. One hundred hemodialysis patients were randomized into two groups; intervention Group (IG) (n=50) subjected to NE program for 3 months and Control group (CG) (n=50) received the usual care. Nutritional education was applied for the intervention group, by a trained renal dietitian, in the form of educational sessions, booklets, procures, audio visual teaching aids and patient-tailored counselling. Nutritional evaluation was done for all patients using dietary history, 24 hour diet recall sheet and malnutrition inflammation score (MIS) in addition to assessment of anthropometrics measurements and routine laboratory tests before randomization and at the end of the study. Results Three months after randomization, body mass index, waist circumference and midarm muscle circumference (MAMC) were significantly lower among IG versus the CG (p=0.04, 0.04 and 0.004 respectively). MIS score was significantly lower among the IG compared to the CG (p=0.02). Regarding laboratory tests, serum phosphorus level and calcium X phosphorus product were significantly lower among IG compared to the CG at the end of the study (p 5.5 mg/dl) were significantly lower in the IG at the end of study (p=0.04). Other laboratory tests including serum albumin, hemoglobin level, iron status and urea reduction ratio did not show any significant difference between both groups. Conclusion NE applied to dialysis patients added to the control of hyperphosphaemia without exposing the patients to the risk of malnutrition, resulting from injudicious dietary restrictions.

Background and Aims Among hemodialysis patients, malnutrition is a common health problem, it is a marker of poor prognosis in these patients, associated with increased risk of hospitalization and mortality. NGAL is an iron transporting factor which increases in the serum in acute and chronic kidney disease. The aim of our study is to assess the use of NGAL as a marker of malnutrition in patients with stage 5 CKD maintained on hemodialysis. Method This is a cross-sectional study of 80 regular hemodialysis (HD) patients (51 males and 29 females). All cases of this study were subjected to: Anthropometric measurements . Biochemical measurements: Neutrophil Gelatinase-associated Lipocalin Level in blood using commercially available ELIZA kits, Serum albumin, Blood urea, Complete blood count, Serum electrolytes . Results According to the result we found in our study 100% of CKD having malnutrition according to SGA, MIS and our data however most of our patients are mild malnutrition. We found also a significant decrease in some anthropometric parameters including BMI, fat mass, TSF, MAC, MAMC and MAMA with advanced malnutrition in hemodialysis patients. In this study, we use Twenty-four hours dietary recall and we found most of patients were with low protein (96.2%) and calorie (68.8%) contents. Dialysis adequacy (Kt/V) can affect the nutritional status of patients Kt/V was adequate in all malnutrition groups. These findings are consistent with an earlier report in which HD patients with Kt/V>1.4 had a significantly higher rate of malnutrition than patients with Kt/V ≤1.4. in this study NGAL serum levels were significantly (P=0.018) reduced with the severity of malnutrition. In this study, Spearman correlation analysis revealed that NGAL serum levels were significantly correlated with SGA (r =o,247 P =0.027) and albumin serum levels (r =0.402, P NGAL serum levels were significantly (P=0.018) reduced with the severity of malnutrition. Using ROC curve analysis, NGAL serum levels had a good ability (AUC=0.845) to predict severe malnutrition with good sensitivity (83.3%) and specificity (78.4%). Conclusion NGAL is well correlated with other standard markers used routinely in assessment of nutritional status of hemodialysis patients. Patients with high NGAL levels were closely related to good nutritional status. Its serum levels had a good diagnostic power for severe-malnourished patients, as it helps us for early prediction to malnutrition.

Patient reported outcome measures (PROMs) can evaluate the quality of health in patients with established renal failure. There is limited experience of their use within national renal registries.To describe the Scottish Renal Registry's (SRR) experience of collecting PROMS in the haemodialysis population and correlate PROMS to demographic and clinical parameters.Retrospective observational cross-sectional study.Haemodialysis patients in Scotland were invited to complete the KDQOL™-36 questionnaire on the day of the annual SRR census in 2015 and 2016. Questionnaires were linked to census demographic and clinical variables.In 2016, 738 questionnaires were linked to census data (39% of prevalent haemodialysis population). Response rates differed with age (≥ 65 years 42%, 65 years 36%) [χ2P = 0.006]; duration of renal replacement therapy (1 year 46%, ≥1 5 years 38%, ≥ 5 years 33%) [χ2P = 0.002] and social class (Scottish Index of Multiple Deprivation (SIMD) Class 1 32%, Class 2 41%, Class 3 40%, Class 4 48%, Class 5 40%) [χ2P 0.001]. There were significant differences in PROMs with age, SIMD quintile and primary renal diagnosis. Achieving a urea reduction ratio of 65% and dialysing through arteriovenous access were associated with significantly higher PROMs. PROMs were not affected by haemoglobin or phosphate concentration.Routine collection of PROMs is feasible and can identify potentially under-recognized and treatable determinants to quality of life. The association between attaining recommended standards of care and improved PROMs is striking. Individual and population-wide strategies are required to improve PROMs.

OBJECTIVE: Data about the survival rate of lupus patients on dialysis is controversial. The objective of this controlled prospective study was to report the survival of SLE patients undergoing dialysis and to analyse factors associated with mortality. METHODS: Twenty dialysis centres were visited between May 2003 and February 2004. Disease activity was evaluated using the SLEDAI without the renal-related parameters [non-renal (nr)SLEDAI] data collection was performed at entrance to the study. The control group consisted of haemodialysis patients without SLE matched for gender, age, dialysis modality, time on dialysis and dialysis-associated HCV infection. Patients were prospectively followed for 60 months. The Kaplan-Meier method was used to estimate survival. Associations of risk factors with mortality were tested using the Cox proportional hazards model. RESULTS: Each group was composed of 57 patients. In the multivariate analysis, only nrSLEDAI > 8 [hazard ratio (HR) 6.368; 95% CI 1.798, 22.548; P = 0.004], and urea reduction ratio (HR 0.953; 95% CI 0.917, 0.990; P = 0.014) were independently associated with mortality in lupus patients. The 5-year survival rate of the control group and the one from SLE patients with nrSLEDAI ≤ 8 (n = 51) were similar (83% and 73%, respectively) but significantly better than the one for SLE patients with nrSLEDAI > 8 (n = 6, 17%), P < 0.001. CONCLUSION: A high nrSLEDAI was strongly associated with 5-year mortality in lupus patients on dialysis.

Background. The prevalence, determinants and prognosis of pulmonary hypertension among long-term hemodialysis patients in the USA are poorly understood. Methods. A cross-sectional survey of prevalence and determinants of pulmonary hypertension was performed, followed by longitudinal follow-up for all-cause mortality. Pulmonary hypertension was defined as an estimated systolic pulmonary artery pressure of >35 mmHg using echocardiograms performed within an hour after the end of dialysis. Results. Prevalent in 110/288 patients (38%), the independent determinants of pulmonary hypertension were the following: left atrial diameter (odds ratio 10.1 per cm/m 2 , P < 0.0001), urea reduction ratio (odds ratio 0.94 per %, P < 0.01) and vitamin D receptor activator use (odds ratio 0.41 for users, P < 0.01). Over a median follow-up of 2.15 years, 97 (34%) patients died yielding a crude mortality rate (CMR) of 114.2 per 1000 patient-years. Of these, 58 deaths occurred among 110 patients with pulmonary hypertension (53%, CMR 168.9/1000 patientyears) and 39 among 178 without pulmonary hypertension (22%, CMR 52.5/1000 patient-years) [unadjusted hazard ratio (HR) for death 2.12 (95% confidence interval 1.41–3.19), P < 0.001]. After multivariate adjustment, pulmonary hypertension remained an independent predictor for all-cause mortality [HR 2.17 (95% confidence interval 1.31–3.61), P < 0.01]. Conclusions. Among hemodialysis patients, pulmonary hypertension is common and is strongly associated with an enlarged left atrium and poor long-term survival. Reducing left atrial size such as through volume control may be an attractive target to improve pulmonary hypertension. Improving pulmonary hypertension in this group of patients may improve the dismal outcomes.

Data from 21 renal units was insufficient to allow analyses of the dose of dialysis in those units. Amongst the remainder, there is evidence of a progressive increase in the proportion of patients meeting the Renal Association audit standard for urea reduction ratio (URR). In the UK as a whole, 81% of prevalent haemodialysis patients met the standard for URR in 2005. Greater achievement of the standard in a given unit is associated with a higher median URR in that unit, although there is some evidence that some units have been able to narrow the distribution of achieved URR values. Achievement of the standard remains, as in previous years' Reports, less common amongst patients recently established on haemodialysis compared with those established on haemodialysis for longer. Correction of acidosis, as measured by serum bicarbonate concentration remains highly variable, although there is continued uncertainty about the interpretation of routine measurements of venous serum bicarbonate concentration in haemodialysis patients. Overall, approximately 64% of UK haemodialysis patients, and 50% of peritoneal dialysis patients met the Renal Association standard for serum bicarbonate in 2005.

Background. Interdialytic weight gain is used as a surrogate for volume expansion in haemodialysis patients and as an indicator of non-compliance. Increased weight gain is associated with both a greater mortality risk and better nutrition indices. This analysis characterizes the association between dialysis-related volume expansion and mortality in the context of its interaction with nutritional surrogates. Methods. All patients receiving haemodialysis through Fresenius Medical Care-North America during 1998 were included. The percentage reduction in weight or intradialytic weight loss (IDWL%) was defined as the difference between the average of pre- and post-dialysis weights from the last 3 months of 1997 expressed as a percentage of post-dialysis weight. Associations between IDWL% and clinical and demographic variables were estimated using linear regression. The association between mortality risk and IDWL% was estimated using Cox proportional hazards regression. Results. Younger age, male gender, the presence of diabetes mellitus, decreasing cholesterol, post-dialysis weight and pre-dialysis blood pressure (systolic and pulse pressure) were associated with increased IDWL%. Increasing IDWL% was associated with increasing phosphorus, creatinine, albumin, potassium and urea reduction ratio. Increasing IDWL% was significantly associated with mortality at 1 year [hazard ratio (HR)=1.07, P=0.003]. Among patients with diabetes mellitus, increasing IDWL% was associated with a mortality HR of 1.03 (P=0.02). Among patients without diabetes mellitus, increasing IDWL% was not associated with an increased mortality risk. Increasing IDWL% is associated with a greater mortality risk among patients with creatinine < 7.26, which failed to remain significant for patients whose creatinine was ≥7.26 mg/dl. Increasing IDWL% is associated with a greater mortality risk among patients with greater post-dialysis weight, greater body mass index and lower serum sodium measurements. Conclusions. This study confirms and extends the findings of the deleterious association between increasing IDWL% and mortality among patients with diabetes mellitus and among subgroups based on serum creatinine and body weight. The putative deleterious effect of dialysis-related volume expansion on mortality must be interpreted in the context of the patient's diabetic and nutritional status.

Knowledge that adequacy measures such as the urea reduction ratio (URR) or Kt/V(urea) are being measured on haemodialysis may influence the behaviour of patients or staff such that the treatment may be better on those days. This study therefore tested the hypothesis that mean volume of blood processed (VBP), utilized as a surrogate for adequacy, is higher on adequacy measurement days than non-measurement days.Patients were identified who had been on haemodialysis over the preceding 8 months. Primary outcome was the difference in the mean VBP (in litres) on URR measurement compared with non-URR measurement days (DeltaVBP(U)(-N)). Univariate and multivariate correlates of mean VBP and DeltaVBP(U)(-N) were also determined.Eighty-nine patients were identified who met inclusion and exclusion criteria. Linear regression demonstrated a weak relationship between VBP and URR (r=0.24, P0.02). This relationship was much stronger when VBP was adjusted for patient weight (mean VBP/weight; r=0.78, P0.0001). The overall mean VBP was 87.4 l (+/-1.2 l) and the average DeltaVBP(U)(-N) was 1.1 l (+/-0.3 l) (P=0.001). Twenty per cent of patients had a clinically relevant DeltaVBP(U)(-N) of3.6 l. Patients with a graft or fistula had a significantly higher DeltaVBP(U)(-N) than patients with a tunnelled catheter.This study demonstrates that the average VBP is less on non-URR than on URR measurement days; this difference was clinically important in20% of patients. Univariate analysis indicated that the use of a fistula or graft correlated with a higher DeltaVBP(U)(-N). This implies that our current method of assessing dialysis adequacy does systematically overestimate the average delivered dose of dialysis in a subset of patients.

Background. The incidence of end-stage renal disease (ESRD) among patients over the age of 80 has nearly tripled in the last decade, making the ‘old-old’ the fastest growing ESRD demographic group. Despite this, very little information is available on the characteristics and survival of patients who initiate haemodialysis (HD) after reaching this age. Methods. We performed a retrospective study on all patients who entered an outpatient HD programme after the age of 80, from January 1988 to September 1998. A total of 106 charts were reviewed from a single nephrology practice group. Eleven patients were excluded due to incomplete data. The survival probability was calculated using the Kaplan–Meier method. Results. The characteristics of 95 patients were as follows: mean age at initiation of dialysis, 83.7 years; female, 50.5%; Caucasian, 40.0%, African–American, 30.0%; Hispanic, 10.0%; Asian, 4.3%; polytetrafluorethylene grafts, 80.0%; primary fistulas, 5.6%; tunnelled catheters, 5.6%; mean established KtuV, 1.68; urea reduction ratio (URR), 0.74; estimated dry weight (EDW), 60.3 kg. ESRD was attributed to hypertension in 37%, diabetes in 22% and analgesic use in 8%. The 1-, 2- and 5-year survival probability of the entire group was 82.6"4.0%, 64.0"5.6%, and 19.6"6.0%, respectively. The median survival was 29 months. When comparing survival probability of patients who were in the highest quartiles of URR and EDW to those in the lowest quartile there was no discernible difference. However, the 2-year survival probability of patients initiated after January 1, 1995 (76.9"8.4) was significantly better than those initiated from 1988–1994 (47.8"6.5; P-0.05). Conclusions. From analysis of this cohort, we conclude that: (i) elderly patients selected for outpatient HD programmes have substantially better survival than previously reported; (ii) KtuV does not correlate with survival in this demographic group; and (iii) contemporary dialysis practice is associated with better likelihood of survival of elderly patients in outpatient HD programmes.

Background. Malnutrition, a predictor of increased mortality in dialysis patients, can be estimated using the subjective global assessment (SGA), a semiquantitative scale with three severity levels. This semiquantitative feature restricts the SGA's reliability and precision. Methods. Using the components of the conventional SGA, we developed a fully quantitative scoring system (the dialysis malnutrition score) consisting of seven variables: weight change, dietary intake, gastrointestinal symptoms, functional capacity, comorbidity, subcutaneous fat and signs of muscle wasting. Each component was assigned a score from 1 (normal) to 5 (very severe). The sum of all seven components in this malnutrition score lies between 7 (normal) and 35 (severely malnourished). To evaluate nutritional status in chronic dialysis patients, anthropometric measurements including mid-arm circumference (MAC), triceps skin-fold thickness, calculated mid-arm muscle circumference (MAMC), body mass index (BMI, ratio of weight to square of height) and laboratory parameters were used. Forty-one patients (20 men and 21 women) were randomly selected from a pool of 120 haemodialysis patients. Patients were aged between 26 and 81 years (mean±SD, 57±12 years) and had undergone haemodialysis for between 7 months and 12 years (mean±SD, 3.0±2.1 years). Results. The malnutrition score of each patient was assessed by a dietitian within 5-20 min (12.0±3.5 min) with no knowledge of anthropometric findings. Pearson correlation coefficients between the malnutrition score and biceps skin-fold (r=-0.32) MAC (r= -0.55), MAMC (r= -0.66), BMI (r=-0.35), total iron-binding capacity (TIBC, r=-0.77), the serum albumin concentration (r=-0.36) and total protein (r= -0.33) were all significant, whereas the conventional SGA had significant correlation only with TIBC (r= -0.35) and MAMC (r= -0.37). Malnutrition score showed a significant correlation with age (r= +0.34) and years dialysed (r=+0.28). Multiple regression analysis showed a significant correlation between the malnutrition score and the combination of the MAMC, BMI, serum albumin concentration and TIBC (r=0.81, P

Sir, The incidence of severe chronic kidney disease is rising worldwide, and the poor nations suffer more. Haemodialysis is the predominant form of renal replacement therapy in our environment and is still very expensive and hardly available to the majority of those who need it. At present the few patients who commence dialysis in Nigeria do not achieve adequate dialysis because of paucity of funds to sustain the treatment. The result is progressive deterioration in their clinical situation [1]. Recent reports suggest that a more frequent haemodialysis strategy might be expected to increase life expectancy by between 2 and 24 months depending on the frequency (four, five or six times per week). However, more frequent haemodialysis is much more expensive [2]. In Europe and America, more frequent but shorter durations of sessions are being advocated [2]. The same cannot be advocated for the poor countries since it is certainly more expensive. When we reviewed the first 1-year experience of haemodialysis in Zaria, Kaduna State, Nigeria, it was observed that only 40% of those recommended for dialysis got started on the procedure and 80% of those who started could not continue maintenance haemodialysis beyond 3 months [1]. The situation was similar in other dialysis centres across the country. The major reasons were lack of financial resources to either commence or continue the treatment. Some of our patients who had initially done well on the standard 4-h sessions three times a week for the oliguric and 4 h two times a week for those who made up to 500 ml of urine a day had reduced the frequency of dialysis because of poor funding. This resulted in progressive deterioration in their clinical condition. A tailor-made programme [3] was designed for this group of patients with the hope of maximizing the benefits they get from the money available to them. The programme extended the duration of dialysis to 6 h a session and also maximized the blood flow rate without increasing complications or the quantity of consumables. The cost of consumables used is what is paid for directly by the patients in the setting of our practice. The urea reduction ratio (URR) was calculated as the ratio of the fall in blood urea divided by the predialysis blood urea. Equilibrated Kt/V was calculated directly from predialysis blood samples and postdialysis samples taken 30–60 min postdialysis with volume of distribution estimated as 0.5 times body weight [4]. The functional state of the patients was based on their subjective responses to the question ‘how do you cope at home and at work?’ and also on physical examination by the doctor. Our patients on the extended duration programme showed significant improvement in their overall clinical condition compared to when they were on four hourly sessions with the same frequency of attendance. This was shown in all six patients who had better URR, higher Kt/V and were more active both at home and at work while on the extended hours programme than before it. Our study, though limited to only six patients, has shown that prolonging the duration of dialysis for patients with inadequate treatment could improve the overall patient outcome without additional costs to the patient. Quality of life that concerns the well-being of the patient from his/her own perspective clearly improved. Conflict of interest statement. I confirm that none of the authors has any interest that could influence them to have bias in this work.

Sir, Dr Thomson and his colleagues are to be commended for their recent work1 which examines catheter-related-sepsis (CRS) in dialysis patients, but I have a few concerns about their analysis and a few comments about their conclusions. While they clearly note that they have evaluated risk factors for CRS such as: age, gender, length of time on renal replacement, renal diagnosis, urea reduction ratio, serum albumin, CRP and serum ferritin, I could find no mention of some previously …

The first successful dialysis treatment was performed, as almost every nephrologist would know, by Dr Willem Kolff in 1945. When Dr Kolff designed the first artificial kidney, he had to determine the size of the dialysis membrane that he would be using. To solve the problem of how to effect a dialysis treatment, he took a piece of artificial sausage skin (it was cellophane material), about 40 cm in length, filled it with 25ml of blood and added 400mg/100ml of urea, shook it up and down in a bath with saline and found, to his surprise, that within 5min, almost all of the urea had been removed by dialysis. Multiplying the length of the tubing by 20 gave him the length of tubing that he would need for an effective artificial kidney. It is really surprising that 62 years on, we are still using urea as the only marker of the adequacy of dialysis. Everybody knows about the urea reduction ratio (URR), percentage reduction in urea (PRU), Kt/V and eKt/V, when we also know that there is no study that has demonstrated any real biological impact of urea as a toxin. In nature, some fishes build up very high levels of urea in their blood. Sharks, for instance, may have a blood urea level of 2.5%, in contrast to the level of 0.01–0.03% in other vertebrates; such high levels allow them to be in osmotic equilibrium with the sea environment. In humans, the addition of urea to dialysate at even higher concentrations than those usually encountered in dialysis patients failed to demonstrate any impact on the symptoms related to the uraemic syndrome. In the HEMO Study, no difference in survival was found between patients treated at standard Kt/V (1.3) vs high Kt/V (1.7) [1]. The French Study Group for Nutrition in Dialysis showed that the survival of dialysis patients was not influenced by the Kt/V value [2]. Patients on haemodialysis (HD) continue to have high mortality rates, a high incidence of cardiovascular morbidity and mortality, high prevalence of hypertension, inflammation and malnutrition, and we are still using urea Kt/V as a marker of the adequacy of dialysis, when it might only be a marker of the adequacy of the diffusive process during a dialysis session. Moreover, urea has a kinetic behaviour which is not representative of many other known uraemic toxins, even low-molecular weight water-soluble compounds. So, maybe the time has come for us to accept that urea is definitely not a uraemic toxin. When Babb and Scribner proposed the middle molecule hypothesis in the early 70s, they had no means of identifying the culprits. In recent years, however, considerable work has been done by the EUTox Group towards facilitating an understanding of what might be the true uraemic toxins [3,4]. Among these, the protein-bound uraemic toxins (PBUTs) have attracted great interest: it is essential to increase our knowledge about these compounds, in order to better understand the complexity of the uraemic syndrome and to improve the outcomes of therapy for end-stage renal disease (ESRD). PBUTs certainly play a key role in the morbidity associated with ESRD. They are now known to be more efficiently removed by the use of high-permeability membranes and convective processes. It is not surprising, therefore, that the mortality associated with high-efficiency haemodiafiltration has been reported to be significantly lower as compared with that associated with other dialysis strategies [5]. An interesting alternative, however, to convective removal of PBUT could be the use of the high adsorptive capacity of some dialysis membranes, which deserves thorough investigation [6]. Most of the papers included in this issue are based upon the ’06 ERA-EDTA Congress Glasgow Industry Symposium: ‘The multiple aspects of middle-large molecular weight uremic toxins: state of the art’. The first three papers are related to uraemic pruritus taken here as an example of how an old and still unresolved clinical problem may be considered from a new point Correspondence and offprint requests to: Bruno Perrone, MD, Centre Hospitalier de Saintes, F-17100 Saintes, France. Email: perrone.bruno@wanadoo.fr Nephrol Dial Transplant (2007) 22 [Suppl 5]: v1–v2