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Background: Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients., Methods: An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m 2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients)., Discussion: Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers., Trial Registration: Clinicaltrials.gov NCT05828823. Registered on 25 April 2023., (© 2024. The Author(s).)

The physical exam is changing. Many have argued that the physical exam of the 21st century should include point-of-care ultrasound (POCUS). POCUS is being taught in medical schools and has been endorsed by the major professional societies of internal medicine. In this review we describe the trend toward using POCUS in medicine and describe where the practicing nephrologist fits in. We discuss what a nephrologist's POCUS exam should entail and we give special attention to what nephrologists can gain from learning POCUS. We suggest a 'nephro-centric' approach that includes not only ultrasound of the kidney and bladder, but of the heart, lungs and vascular access. We conclude by reviewing some of the sparse data available to guide training initiatives and give suggested next steps for advancing POCUS in nephrology., (© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.)

Physical examination (PE) of arteriovenous access remains of high clinical value and continues to be recommended by leading societies and guidelines. PE is easy to learn and perform. Once learned, examiners can provide a comprehensive arteriovenous (AV) access examination in 20 to 30 seconds. Therefore, we continue to advocate that AV access PE should be part of the training for all dialysis care providers. Similarly, ultrasound can provide important AV access evaluation and provide key information. It is relatively cheap and can be readily available at the bed side. Additionally, it is well accepted by patients, as it is not expected to be associated with pain or discomfort during the examination. We present in this review the key components of PE, signs and symptoms of AV access dysfunction, and the role of ultrasound in AV access evaluation as a complementary tool to PE., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Competing Interests: V.D. Niyyar reports receiving honoraria from Albert–Einstein Montefiore and KidneyCon (for being invited faculty); from the American Society of Diagnostic and Interventional Nephrology (ASDIN), American Society of Nephrology, American Society of Nephrology Highlights, National Kidney Foundation (for being for being an invited speaker); from Ardea Biosciences (for random surveys and questionnaires); from Ironwood Pharmaceuticals (for serving on the Renal Event Adjudication Committee); and from Lesinurad (as advisory board member). V.D. Niyyar also reports having previous consultancy agreements with Ardea Biosciences and Lesinurad, and with Ironwood Pharmaceuticals (finished in December 2018); serving as a scientific advisor for, or member of, American Society of Nephrology (continuous cycler assisted peritoneal dialysis; 2018), American Society of Nephrology (interventional nephrology advisory group), and on the graft committee of Kidney Health Initiative–American Society of Nephrology/Food and Drug Administration; serving as the president-elect, and previous secretary treasurer and councilor, of ASDIN, and chair of the ASDIN hemodialysis vascular access Certification Committee and ASDIN US Certification Committee; and having other interests in/relationships with Commdex Consulting. M.K. Sharma reports serving on the editorial board of Annals of Internal Medicine; serving as a medical review board member of ESRD Network 15; serving on a speakers bureau for Relypsa; and having other interests in/relationships with University of Arkansas for Medical Sciences (Little Rock, AR) as adjunct faculty.

Background: Performing catheter-care observations in outpatient hemodialysis facilities are one of the CDC's core interventions, which have been proven to reduce bloodstream infections. However, staff have many competing responsibilities. Efforts to increase and streamline the process of performing observations are needed. We developed an electronic catheter checklist, formatted for easy access with a mobile device, and conducted a pilot project to determine the feasibility of implementing it in outpatient dialysis facilities., Methods: The tool contained the following content: ( 1 ) patient education videos; ( 2 ) catheter-care checklists (connection, disconnection, and exit-site care); ( 3 ) prepilot and postpilot surveys; and ( 4 ) a pilot implementation guide. Participating hemodialysis facilities performed catheter-care observations on either a weekly or monthly schedule and provided feedback on implementation of the tool., Results: The pilot data were collected from January 6 through March 12, 2020, at seven participating facilities. A total of 954 individual observations were performed. The catheter-connection, disconnection, and exit-site steps were performed correctly for most individual steps; however, areas for improvement were ( 1 ) allowing for appropriate antiseptic dry time, ( 2 ) avoiding contact after antisepsis, and ( 3 ) applying antibiotic ointment to the exit site. Postpilot feedback from staff was mostly favorable. Use of the electronic checklists facilitated patient engagement with staff and was preferred over paper checklists, because data are easily downloaded and available for use in facility Quality Assurance and Performance Improvement (QAPI) meetings. The educational video content was a unique learning opportunity for both patients and staff., Conclusions: Converting the CDC's existing catheter checklists to electronic forms reduced paperwork and improved the ease of collating data for use during QAPI meetings. An additional benefit was the educational content provided on the tablet, which was readily available for viewing by patients and staff while in the hemodialysis facility., Competing Interests: L. Golestaneh reports receiving compensation from the Cardiovascular Research Foundation for fulfillment of duties as a member of the clinical events committee for the Spyral Hypertension trials, sponsored by Medtronic; and receiving honoraria from Horizon Pharmaceuticals. A. Kliger reports having consultancy agreements with ASN and National Institute of Diabetes and Digestive and Kidney Diseases; having other interests/relationships with ASN and Renal Physicians Association; being a scientific advisor for, or member of, Qualidigm (quality-improvement organization); and receiving honoraria for lectures, seminars, and webinars from several universities, medical schools, and professional organizations. M. Mokrzycki reports receiving compensation from the Cardiovascular Research Foundation for fulfillment of duties as a member of the Clinical Events Committee for the following clinical trials: Medtronic Global Simplicity Registry, Medtronic Spyral HTN On/Off Meds, RECOR MEDICAL/RADIANCE II, Medtronic Spyral Dystal trial, and BOA GARNET trial; and receiving honoraria from Spherix Global Insights. V. Niyyar reports receiving honoraria as invited faculty for Albert Einstein–Montefiore and KidneyCon; receiving honoraria for being an invited speaker for the American Society of Diagnostic and Interventional Nephrology (ASDIN), American Society of Nephrology (ASN), ASN Highlights, and National Kidney Foundation; receiving honoraria from Ardea Biosciences; having previous consultancy agreements with Ardea Biosciences, Ironwood Pharmaceuticals (finished December 2018), and Lesinurad; being a scientific advisor for, or member of, the ASDIN (as president elect, previously secretary treasurer and councilor, chair, US certification committee, Hemodialysis Vascular Access certification committee), ASN Committee of Continuing Professional Development – 2018, ASN Interventional Nephrology Advisory Group, and Kidney Health Initiative – ASN/Food and Drug Administration (as member of the graft committee); having other interests/relationships with Commdex Consulting; receiving honoraria for serving on the renal event adjudication committee for Ironwood Pharmaceuticals; receiving honoraria for being on the advisory board for Lesinurad. All remaining authors have nothing to disclose., (Copyright © 2021 by the American Society of Nephrology.)

The cannulation technique of a hemodialysis vascular access has remained controversial with differing viewpoints. The quality of dialysis, overall patient safety, and individual dialysis experience often dictate the type of cannulation technique used in clinical practice. The three commonly used techniques to access a hemodialysis vascular access are the rope ladder, area, and buttonhole. Although the buttonhole technique has been around since the mid-1970s, the dialysis community remains divided on its suitability for routine use to provide maintenance hemodialysis therapy. The proponents of this technique value the ease of cannulation with less pain and discomfort whereas the opponents highlight the increased risk of infection. The actual clinical evidence from the United States is limited and remains inconclusive. The current review provides an overview of the available experience from the United States, highlighting the correct technique of creating a buttonhole, summarizing the current evidence, and recommending a need for larger randomized controlled studies in both in-center and home hemodialysis populations., Competing Interests: K. Abreo, M. Mokrzycki, V. Niyyar, T. Vachharajani, and L. Wong have nothing to disclose., (Copyright © 2020 by the American Society of Nephrology.)

Sonography is increasingly being performed by clinicians and has applications throughout the spectrum of nephrology, including acute and chronic renal failure, urinary obstruction, cystic disease, pain, hematuria, transplantation, kidney biopsy, temporary and permanent vascular access, and assessment of fluid status. The skill is relatively easily acquired, expedites patient care, and enhances the practice of nephrology. However, the lack of exposure in most training programs remains a major obstacle., (Copyright © 2018 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

This paper is part of the Clinical Trial Endpoints for Dialysis Vascular Access Project of the American Society of Nephrology Kidney Health Initiative. The purpose of this project is to promote research in vascular access by clarifying trial end points which would be best suited to inform decisions in those situations in which supportive clinical data are required. The focus of a portion of the project is directed toward arteriovenous access. There is a potential for interventional studies to be directed toward any of the events that may be associated with an arteriovenous access' evolution throughout its life cycle, which has been divided into five distinct phases. Each one of these has the potential for relatively unique problems. The first three of these correspond to three distinct stages of arteriovenous access development, each one of which has been characterized by objective direct and/or indirect criteria. These are characterized as: stage 1-patent arteriovenous access, stage 2-physiologically mature arteriovenous access, and stage 3-clinically functional arteriovenous access. Once the requirements of a stage 3-clinically functional arteriovenous access have been met, the fourth phase of its life cycle begins. This is the phase of sustained clinical use from which the arteriovenous access may move back and forth between it and the fifth phase, dysfunction. From this phase of its life cycle, the arteriovenous access requires a maintenance procedure to preserve or restore sustained clinical use. Using these definitions, clinical trial end points appropriate to the various phases that characterize the evolution of the arteriovenous access life cycle have been identified. It is anticipated that by using these definitions and potential end points, clinical trials can be designed that more closely correlate with the goals of the intervention and provide appropriate supportive data for clinical, regulatory, and coverage decisions., (Copyright © 2018 by the American Society of Nephrology.)

Hemodialysis remains the most commonly used RRT option around the world. Technological advances, superior access to care, and better quality of care have led to overall improvement in survival of patients on long-term hemodialysis. Maintaining a functioning upper extremity vascular access for a prolonged duration continues to remain a challenge for dialysis providers. Frequently encountered difficulties in clinical practice include (1) a high incidence of central venous catheter-related central vein stenosis and (2) limited options for creating a functioning upper extremity permanent arteriovenous access. Lack of surgical skills, fear of complications, and limited involvement of the treating nephrologists in the decision-making process are some of the reasons why lower extremity permanent dialysis access remains an infrequently used option. Similar to upper extremity vascular access options, lower extremity arteriovenous fistula remains a preferred access over arteriovenous synthetic graft. The use of femoral tunneled catheter as a long-term access should be avoided as far as possible, especially with the availability of newer graft-catheter hybrid devices. Our review provides a summary of clinical evidence published in surgical, radiology, and nephrology literature highlighting the pros and cons of different types of lower extremity permanent dialysis access., (Copyright © 2016 by the American Society of Nephrology.)

Despite recommendations by various national guidelines advocating arteriovenous fistulae as the access of choice in patients undergoing hemodialysis (HD), the use of central venous catheters (CVCs) remains widespread among both incident and prevalent HD patients. Unfortunately, long-term use of CVCs is fraught with complications, which are a major cause of morbidity and death in this patient population. Complications include a high rate of infections, as well as thrombus and sheath-related mechanical dysfunction. This review addresses prevention and management of noninfectious catheter-related dysfunction.