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Background The aim of this study was to determine associations between characteristics of arteriovenous access (AVA) flow volume (Qa; mL/min) and 4-year freedom from cardiovascular mortality (CVM) in haemodialysis (HD) patients. Methods HD patients who received a primary AVA between January 2010 and December 2017 in one centre were analysed. Initial Qa was defined as the first Qa value obtained in a well-functioning AVA by a two-needle dilution technique. Actual Qa was defined as access flow at a random point in time. Changes in actual Qa were expressed per 3-month period. CVM was assessed according to the European Renal Association–European Dialysis and Transplant Association classification. The optimal cut-off point for initial Qa was identified by a receiver operating characteristics curve. A joint modelling statistical technique determined longitudinal associations between Qa characteristics and 4-year CVM. Results A total of 5208 Qa measurements (165 patients; 103 male, age 70 ± 12 years, autologous AVA n = 146, graft n = 19) were analysed. During follow-up (December 2010–January 2018, median 36 months), 79 patients (48%) died. An initial Qa Conclusions Studying novel AVA Qa characteristics may contribute to understanding excess CVM in HD patients.

Introduction: The purpose of this study is to identify the role of diabetes mellitus in the effectiveness of intradialytic exercise intervention among haemodialysis patients.Methods: In this multicentre study 90 dialysed patients were allocated to the experimental (EXG, n = 57) or control group (CNG, n = 33). In EXG, we included 20 diabetic and 37 non-diabetic patients. In CNG, we enrolled 8 diabetic and 25 non-diabetic patients. EXG underwent a 12-week supervised, progressive, intradialytic resistance training programme, while CNG stayed inactive during dialysis. Baseline, post-interventional and post-follow-up assessments of maximal force during hip extension (HE), hip flexion (HF) and knee extension (KE) contractions were completed in both groups of patients.Results: HE increased in diabetic and non-diabetic EXG patients (diabetic EXG, change: +14.5 N; 95% CI = -5.5 to +34.5; non-diabetic EXG, +18.6 N; 95% CI = +3.4 to +33.8) and diabetic CNG patients (change: +17.9 N; 95% CI = -9.2 to +44.9). Only non-diabetic CNG patients experienced a decrease in HE (change: -22.8 N; 95% CI = -36.9 to -8.7, P < .05).Conclusions: Resistance training improved muscle function among dialysis patients regardless of the presence of diabetes mellitus. We found that non-diabetic patients lose their muscle function extensively during inactivity, while diabetic patients retain their muscle function. (c) 2021 The Author(s). Published by Elsevier Espana, S.L.U. on behalf of SEEN y SED. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).

Background Several guidelines recommend that patients with chronic kidney disease treated by haemodialysis (HD) take care of their own arteriovenous fistula (AVF). The dialysis nurse plays an important role in the development of such self-care behaviours. A very small number of instruments are available to assess self-care behaviours with AVF in Turkey. Objective Cultural adaptation and psychometric testing of the Turkish version of the scale of assessment of self-care behaviours with arteriovenous fistula in haemodialysis (ASBHD-AVF) patients. Design Cross-sectional validation study. Participants and measurements This study was conducted involving 160 patients in the Bolu region in Turkey. The guidelines provided by Sousa and Rojjanasrirat were taken into account in the scale translation, adaptation and validation process. Validity was analysed through content validity and construct validity. The latter was measured through principal component analysis with varimax rotation, considering only factor loadings of 0.30 or larger. Reliability analysis was based on internal consistency measured by Cronbach's α. Results A two-factor structure was extracted explaining 59.01% of the total variance. Cronbach's α was 0.91, 0.85 and 0.84 for the overall scale, the self-care in prevention of complications subscale and the self-care in management of signs and symptoms subscale, respectively. Conclusions The Turkish version of the scale of ASBHD-AVF patients is a reliable and valid instrument and can therefore be used.

Routine systems for monitoring vascular access (VA) performance are lacking. We developed a vascular access triage system to evaluate the monthly performance of the access, developed a specific score and assessed the association between score improvement and clinical outcomes. Vascular access was triaged (Green, Yellow or Red) according to a score generated by dialytic and clinical parameters in all patients who, from 1/1/2014 to 31/03/2014, had been receiving haemodialysis treatment for at least 3 consecutive months in our Unit and who were then followed up for 4 years. We enrolled 130 patients, 78 with arteriovenous fistula (AVF) and 52 with tunnelled central venous catheter (CVC). During a median of 29 ± 11 months of follow up (range 3–46 months), 28 deaths and 303 hospitalizations (lasting 16 ± 30 days) were recorded. Vascular access triage scores improved over time (2014 vs 2015 vs 2016 vs 2017) in the population with an AVF (Green from 25% to 58% to 77% to 79%, Yellow from 65% to 39% to 18% to 20% and Red from 10% to 3% to 5% to 1%, respectively; χ2 p

Background Intra-dialytic hypotension (IDH) is the most common serious adverse event in paediatric haemodialysis (HD). Repeated IDH results in chronic multi-organ damage and increased mortality. At the Hospital for Sick Children, Toronto, retrospective data from all in-centre HD sessions revealed frequently occurring IDH events (16.5 ± 5.6% of HD sessions per week). Based on literature review and clinical expertise, fluid volume management was selected as a potential modifiable risk factor to decrease IDH. Root causes identified as contributing to IDH were incorporated into a Paediatric haemodialysis fluid volume management (PedHDfluid) program using the Model for Improvement methodology including rapid cycles of change. Methods Multiple measures were evaluated including (i) Outcome: IDH events per number of HD sessions per week; (ii) Process: number of changes to estimated dry weight per number of HD sessions per week; (iii) Balancing: time spent on dry weight meeting per week. Data was analysed using statistical process control charts. We aimed to decrease IDH in our dialysis unit to

Aim To establish the responses to the Sinopharm HB02 COVID‐19 vaccination in the dialysis population, which are not well established. We examined the humoral responses to the Sinopharm COVID vaccine in haemodialysis patients. Methods Standard vaccinations (two doses at interval of ~21 days) were given to all consenting haemodialysis patients on dialysis (n = 1296). We measured the antibody responses at 14–21 days after the second vaccine to define the development of anti‐spike antibodies >15 AU/ml after vaccination and observed the clinical effects of vaccination. Results Vaccination was very well tolerated with few side‐effects. In those who consented to antibody measurements, (n = 446) baseline sampling showed 77 had positive antibodies, yet received full vaccination without any apparent adverse events. Positive anti‐spike antibodies developed in 50% of the 270 baseline negative patients who had full sampling, compared with 78.1% in the general population. COVID infection continues to occur in both vaccinated and unvaccinated individuals, but in the whole group vaccination appears to have been associated with a reduction in the case fatality rate. Conclusion The humoral immune responses to standard HB02 vaccination schedules are attenuated in a haemodialysis cohort, but likely the vaccine saves lives. We suggest that an enhanced HB02 vaccination course or antibody checking may be prudent to protect this vulnerable group of patients. We suggest a booster dose of this vaccine at 3 months should be given to all dialysis patients, on the grounds that it is well tolerated even in those with good antibody levels and there may be a survival advantage., SUMMARY AT A GLANCE In this analysis of humoral response to the Sinopharm COVID‐19 vaccine in over 400 haemodialysis patients in United Arab Emirates, positive anti‐spike antibodies (>15 AU/ml) developed in 50% of 270 COVID‐19 sero‐naive patients who had full sampling, compared with 78.1% in the general population. Side effects were remarkably few.

Low serum 1,25-dihydroxyvitamin D (1,25(OH)2D) in end-stage renal disease (ESRD) is considered a consequence of elevated fibroblast growth factor 23 (FGF23) and concomitant reduced activity of renal 1α-hydroxylase (CYP27B1). Current ESRD treatment strategies to increase serum calcium and suppress secondary hyperparathyroidism involve supplementation with vitamin D analogues that circumvent 1α-hydroxylase. This overlooks the potential importance of 25-hydroxyvitamin D (25(OH)D) deficiency as a contributor to low serum 1,25(OH)2D. We investigated the effects of vitamin D (cholecalciferol) supplementation (40,000 IU for 12 weeks and maintenance dose of 20,000 IU fortnightly), on multiple serum vitamin D metabolites (25(OH)D, 1,25(OH)2D3 and 24,25(OH)2D3) in 55 haemodialysis patients. Baseline and 12 month data were compared using related-samples Wilcoxon signed rank test. All patients remained on active vitamin D analogues as part of routine ESRD care. 1,25(OH)2D3 levels were low at baseline (normal range: 60–120 pmol/L). Cholecalciferol supplementation normalised both serum 25(OH)D and 1,25(OH)2D3. Median serum 25(OH)D increased from 35.1 nmol/L (IQR: 23.0–47.5 nmol/L) to 119.9 nmol/L (IQR: 99.5–143.3 nmol/L) (P < 0.001). Median serum 1,25(OH)2D3 and 24,25(OH)2D3 increased from 48.3 pmol/L (IQR: 35.9–57.9 pmol/L) and 3.8 nmol/L (IQR: 2.3–6.0 nmol/L) to 96.2 pmol/L (IQR: 77.1–130.6 pmol/L) and 12.3 nmol/L (IQR: 9–16.4 nmol/L), respectively (P < 0.001). A non-significant reduction in daily active vitamin D analogue dose occurred, 0.94 µmcg at baseline to 0.77 µmcg at 12 months (P = 0.73). The ability to synthesise 1,25(OH)2D3 in ESRD is maintained but is substrate dependent, and serum 25(OH)D was a limiting factor at baseline. Therefore, 1,25(OH)2D3 deficiency in ESRD is partly a consequence of 25(OH)D deficiency, rather than solely due to reduced 1α-hydroxylase activity as suggested by current treatment strategies.

Background. Contemporary methods to create primary arteriovenous fistula (AVF) for permanent vascular access (PVA) in haemodialysis continue to improve. The modified Brescia-Cimino operation is considered the main technique of forming native AVF. Various early PVA complications occur in 6–40 % patients entailing repeated surgical interventions.Materials and methods. The study was conducted at the vascular surgery unit of City Clinical Hospital No. 21 of Ufa. All patients had surgery for distal AVF formation in forearm. Native forearm AVF creation was aided by the hydraulic balloon dilation technique prior to forming anastomosis.Results. The PVA survival was 75.0 (n = 30), the median survival time corresponding to estimated time-to-rehospitalisation in at least 50 % patients (n = 30) was 4.0 ± 0.89 (95 % CI: 2.25–5.75) months. Mean time-to-relapse was 6.05 ± 1.15 (95 % CI: 3.8–8.3) months.Discussion. The results obtained suggest the accessory hydraulic balloon dilation method useful prior to forming anastomosis to provide for the vein mechanical expansion, outflow capacity assessment and prevent venous torsion at preparation steps. Preparing a certain vein length (10 cm) with ligation of putative tributaries is also of importance.Conclusion. The accessory technique of hydraulic balloon dilation of recipient vein in primary native AVF creation allows an intraoperative estimation of the vein state to exclude torsion and perform its mechanical dilation prior to forming anastomosis, which reduces the risk of postoperative thromboses.

A target Kt/V of > 1.4 and use of a high-flux dialyzer are recommended for patients on hemodialysis. However, there is little information on the relationship between the dialyzer surface area and mortality in these patients. In this nationwide cohort study, we aimed to clarify this relationship by analyzing data from the Japanese Society for Dialysis Therapy for 2010–2013. We enrolled 234,638 patients on hemodialysis who were divided according to quartile for dialyzer surface area into the S group (small, 2), M group (medium, 1.5 m2), L group (large, 1.6 to 2), or XL group (extra-large, ≥ 2.0 m2). We assessed the association of each group with 3-year mortality using Cox proportional hazards models and performed propensity score matching analysis. By the end of 2013, a total of 53,836 patients on dialysis (22.9%) had died. There was a significant decrease in mortality with larger dialyzer surface areas. The hazard ratio (95% confidence interval) was significantly higher in the S group (1.15 [1.12–1.19], P P P 2 is superior, even with the same Kt/V.

Background Intravenous iron sucrose is becoming a prevailing treatment for individuals undergoing maintenance haemodialysis, but comparisons of dosing regimens are lacking. The aim of this retrospective review was to evaluate the safety and efficacy of proactively administered high-dose iron sucrose versus reactively administered low-dose iron sucrose in patients undergoing maintenance haemodialysis. Methods We analysed the data of 1500 individuals with maintenance haemodialysis who were treated with either high-dose iron sucrose that was proactively administered (Group HD) or low-dose iron sucrose that was reactively administered (Group LD) at the First Affiliated Hospital of Chongqing Medical University from Jan 1, 2008, to Dec 31, 2020. The primary endpoints were the cumulative doses of iron and erythropoiesis-stimulating agent; the secondary endpoints were the events of nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, infection rate, and death from any cause. Results Of the 2124 individuals, 624 individuals were excluded because they met one or more of the exclusion criteria, thus resulting in 1500 individuals who were eligible for inclusion in the study (Group HD, n = 760 and Group LD, n = 740). The median follow-up for the two cohorts was 32 months (range: 25–36). A significant median difference was detected in the monthly iron dose between the groups (1121 mg [range: 800–1274] in the HD group vs. 366 mg [range: 310–690] in the LD group; p p = 0.000). A significant difference was detected in the secondary endpoints (266 events in 320 cases in the HD group vs. 344 events in 385 cases in the LD group) (HR: 0.62; 95% CI: 0.51–0.79; p p = 0.361). Conclusions For individuals undergoing maintenance haemodialysis, high-dose iron sucrose that was proactively administered may be superior to low-dose iron sucrose that was reactively administered with low doses of erythropoiesis-stimulating agent.

Vascular access is absolutely essential for haemodialysis due to its relationship with quality of dialysis and associated morbidity. Therefore, it must be monitored and continuously surveilled from the moment it is created to prevent failure in maturation and thrombosis. Multidisciplinary collaboration is necessary when the main aim is to achieve the adequate vascular access flow with the fewest possible complications. The starting point, and probably the main one, is vascular access planning. This planning requires both a deep understanding of the anatomy of the upper limb and enough skill to examine it by Doppler ultrasound. The aim of this article is to review the anatomical and haemodynamical concepts of the arterial and venous vascular tree and explain how to perform ultrasound mapping, optimising the technical resources provided by this tool. Likewise, adequate access creation criteria that minimise the risk of failure and associated complications will be discussed.

End‐stage renal disease (ESRD) patients are amongst the vulnerable groups and thus prioritized in the Coronavirus disease‐2019 vaccination programmes. However, this cohort was excluded from vaccine‐trials and yet shares the same vaccination scheme with the general population. Here, we explore trends of immune response‐proportions amongst ESRD patients on renal replacement therapy for up to 4 weeks post‐vaccination completion with Pfizer/Moderna vaccines. From inception to 10 July 2021, we searched six online‐databases for articles reporting humoral and cellular immune response proportions for up to 4 weeks post booster‐vaccination. We pooled the responders' proportions by meta‐analysis and conducted a meta‐regression stratifying outcomes by significant confounders. Twenty‐seven eligible studies reported 2789 ESRD patients. 1337, 1452 and 477 were on haemodialysis, received kidney transplantation, and healthy controls, respectively. Haemodialysis patients' proportions of humoral and cellular immune responses varied from 87.29% (80.77–93.81)–88.78% (86.76–90.80) and 62.86% (56.56, 69.17)–85.78% (78.99, 92.57), respectively, between first‐ and fourth‐weeks. Kidney transplant patients' proportions of humoral and cellular immune responses ranged from 2.6% (0.06–13.48)–29.87% (27.68, 32.07) and 5.13% (0.63–17.3)–59.84% (54.57–65.10), respectively, between first‐ and fourth‐weeks. All healthy controls maintained ≥93% proportions of both responses throughout the follow‐up. Study design and country of study influenced the pooled response proportions. Conclusively, haemodialysis and kidney transplant patients have lower proportions of humoral and cellular immune responses than healthy controls. However, haemodialysis patients' response proportions improve, reaching near healthy‐control levels by the fourth week. Kidney transplant patients' lower responses' proportions also improve but remain significantly lower than healthy controls throughout four‐weeks. The “one‐size‐fits‐all” vaccination scheme might be inadequate for kidney transplant patients., SUMMARY AT A GLANCE This meta‐regression analysis demonstrated varying humoral and cellular immune responses to mRNA coronavirus vaccination amongst haemodialysis and kidney transplant patients.

Purpose This prospective, observational first in human study evaluated the safety and effectiveness of WRAPSODYTM Cell-impermeable Endoprosthesis (Merit Medical Systems, Inc.) in the treatment of arteriovenous fistula and arteriovenous graft access circuit stenosis. Materials and Methods Investigators conducted a prospective analysis of 46 patients with access circuit stenosis from three centres. Treatment sites included the peripheral outflow veins (e.g. cephalic arch, basilic vein swing point; 16 fistula and 10 graft patients); the graft-vein anastomosis (9 patients); and the central veins (up to, but not including the SVC; 11 patients). Primary outcome measures included 30-day freedom from access circuit-related safety events and 30-day target lesion primary patency. Secondary outcome measures included procedural success; device- and procedure-related adverse events; target lesion primary patency; access circuit primary patency; and secondary patency. In-person follow-up was scheduled at 1, 3, 6, and 12 months. An independent data monitoring/clinical event committee adjudicated all reinterventions and device/procedure-relatedness for adverse events. Results All initial procedures were successful. All but one patient was free from safety events through the first 30 days (97.8% (45/46)). This event was not device-related. Over the remainder of the study, one adverse event was adjudicated as possibly device-related. Six- and 12-month target lesion primary patency rates were 97.7% (42/43) and 84.6.% (33/39), respectively. Six- and 12-month access circuit primary patency rates were 84.4% (38/45) and 65.9% (29/44), respectively. Conclusion Results suggest that the study device is safe and effective for treatment of stenoses in the peripheral and central veins of arteriovenous access circuits. Level of Evidence Level 2b, cohort study.

Haemodialysis Units adopt a Quality Management System to provide quality healthcare services, to promote reliability and to increase the patients’ contentment and faith they receive the best possible care. The purpose of this study was to ascertain whether the ELOT EN ISO 9001:2015 Quality Management System, “Provision of Dialysis Services in Patients with Renal Failure”, in a Haemodialysis Unit affected the patients’ satisfaction level. The Quality Management System stipulated the use of a questionnaire containing 11 questions to measure the patients’ satisfaction. The data were collected in July 2018 during the annual audit for the continuous compliance of the Haemodialysis Unit with the quality requirements. 35 patients undergoing Chronic Haemodialysis for at least the last 6 months participated. The Quality Management System enabled the identification of the patients’ individual needs and the areas that required more attention. More specifically, 97.1% of the patients stated that the services provided had been improved and that requests such as the installation of TVs and the collaboration with a dietologist have been met. 77.1% of the patients were satisfied by the healthcare provided and 88.6% were satisfied by the staff in general. Regarding the care provided by the medical staff 74.3% of the patients were satisfied, while 54.2% found the information given for their health to be adequate. All of the patients (100%) were satisfied by the care provided by the nursing staff and almost all (97.1%) felt that the nursing staff was easy to communicate with. Only 6.1% of the patients stated that specific areas required further improvement. A Quality Management System in a Haemodialysis Unit leads to a better understanding of the patients’ individual needs, allowing for higher satisfaction. Moreover, the evidence based documentation of the quality of the services provided and the emphasis put on continuous improvement further enhances the patients’ trust. Doi: 10.28991/SciMedJ-2021-0303-2 Full Text: PDF

Background Patients undergoing in-centre haemodialysis (HD) are particularly exposed to the dire consequences of COVID-19. The present systematic scoping review aims to identify the extent, range, and nature of articles related to COVID-19 and maintenance HD: it reports specifically the prevalence of the COVID-19 pandemic in the HD population, implementation of strategies for the prevention, mitigation and containment of the COVID-19 pandemic in HD centres, demographic and clinical characteristics, and outcomes of the pediatric and adult HD patients. Methods A multi-step systematic search of the literature in Pubmed, Scopus, Ovid Medline, Embase and Web of Science, published between December 1, 2019, and January 30, 2021 was performed. Two authors separately screened the titles and abstracts of the documents and ruled out irrelevant articles. A report of the papers that met inclusion criteria was performed; then, a descriptive analysis of the characteristics of the included articles and a narrative synthesis of the results were performed. Results The review process ended with the inclusion of 145 articles. Most of them were based on single-centre experiences, which spontaneously developed best practices. Most studies were conducted in high-income countries (69.7%) and a part of them (9.6%) were not in English. Prevalence of COVID-19 among dialysis patients accounted for 0%-37.6%. Preventive measures were reported in 54% of the included articles, with particular emphasis on education, triage, hygiene, and containment measures. Patients experienced a heterogeneous spectrum of symptoms that led 35%-88.2% of them to hospital admission. Median and mean hospital length of stay ranged from 8 to 28.5 and 16.2 to 22 days, respectively. Admission to intensive care units varied widely across studies (from 2.6% to 70.5%) and was associated with high mortality (42.8%–100%). Overall, prognosis was poor in 0%–47% of the hospitalized patients. Conclusions This systematic scoping review provides an overview of the current knowledge on the impact of COVID-19 on the frail world of HD patients. Furthermore, it may help to implement the existing strategies of COVID-19 prevention and provide a list of unmet needs (safe transport, testing, shelter). Finally, it may be a stimulus for performing systematic reviews and meta-analyses which will form the basis for evidence-based guidelines. Graphic abstract Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-01136-5.

BACKGROUND: Wasting is a common complication of kidney failure that leads to weight loss and poor outcomes. Recent experimental data identified parathyroid hormone (PTH) as a driver of adipose tissue browning and wasting, but little is known about the relations among secondary hyperparathyroidism, weight loss, and risk of mortality in dialysis patients. METHODS: We included 42,319 chronic in-centre haemodialysis patients from the Dialysis Outcomes and Practice Patterns Study phases 2-6 (2002-2018). Linear mixed models were used to estimate the association between baseline PTH and percent weight change over 12 months, adjusting for country, demographics, comorbidities, and labs. Accelerated failure time models were used to assess 12 month weight loss as a mediator between baseline high PTH and mortality after 12 months. RESULTS: Baseline PTH was inversely associated with 12 month weight change: 12 month weight loss >5% was observed in 21%, 18%, 18%, 17%, 15%, and 14% of patients for PTH ≥600 pg/mL, 450-600, 300-450, 150-300, 50-150, and

The importance of extracellular volume control and avoidance of volume overload has been well documented in relation to the management of patients with chronic haemodialysis. Chronic volume overload results in poorly controlled hypertension, increased cardiovascular events, and increased all-cause mortality. Traditional methods of dry weight assessment have relied on clinical assessment to guide volume status. The challenge of achieving the balance between dry weights and preventing intradialytic complications is a formidable one. In order to achieve this, reproducible and sensitive methods are desirable to aid objective quantification of volume status. One such method is by the use of blood volume monitoring, which is achieved by real-time calculation of changes in relative blood volume via a cuvette placed in the arterial blood-line, which can be used to guide ultrafiltration targets during the haemodialysis session. This review article examines the use of blood volume monitoring as a tool to guide ultrafiltration during dialysis and to examine the current evidence to supports its use in assessing dry weight and in preventing intradialytic hypotension events.

Background The increasing burden of kidney failure (KF) in India necessitates provision of cost-effective kidney replacement therapy (KRT). We assessed the comparative cost-effectiveness of initiating KRT with peritoneal dialysis (PD) or haemodialysis (HD) in the Indian context. Methods The cost and clinical effectiveness of starting KRT with either PD or HD were measured in terms of life years (LYs) and quality-adjusted life years (QALYs) using a mathematical Markov model. Complications such as peritonitis, vascular access–related complications and blood-borne infections were considered. Health system costs, out-of-pocket expenditures borne by patients and indirect costs were included. Two scenarios were considered: Scenario 1 (real-world scenario)—as per the current cost and utilization patterns; Scenario 2 (public programme scenario)—use in the public sector as per Pradhan Mantri National Dialysis Programme (PMNDP) guidelines. The lifetime costs and health outcomes among KF patients were assessed. Results The mean QALYs lived per KF person with PD and HD were estimated to be 3.3 and 1.6, respectively. From a societal perspective, a PD-first policy is cost-saving as compared with an HD-first policy in both Scenarios 1 and 2. If only the costs directly attributable to patient care (direct costs) are considered, the PD-first treatment policy is estimated to be cost-effective only if the price of PD consumables can be brought down to INR70/U. Conclusions PD as initial treatment is a cost-saving option for management of KF in India as compared with HD first. The government should negotiate the price of PD consumables under the PMNDP.

Background Fabry disease (FD), an X-linked lysosomal storage disorder caused by a deficiency in alfa-galactosidase A (α-Gal A) activity due to mutations in the GLA gene, has a prevalence of 0–1.69% in patients undergoing haemodialysis; however, its prevalence in patients with chronic kidney disease (CKD) Stages 1–5 is unknown. Methods Serum α-Gal A activity analysis and direct sequencing of GLA were used to screen for FD in 2122 male patients with CKD, including 1703 patients with CKD Stage 5D and 419 with CKD Stages 1–5. The correlation between serum α-Gal A activity and confounding factors in patients with CKD Stages 1–5 was evaluated. Results FD prevalence rates in patients with CKD Stage 5D and CKD Stages 1–5 were 0.06% (1/1703) and 0.48% (2/419), respectively. A patient with CKD Stage 5D exhibited a novel GLA mutation, p.Met208Arg, whereas two patients with CKD Stages 1–5 had c.370delG and p.Met296Ile. p. Met208Arg caused moderate structural changes in the molecular surface region near the substituted amino acid residue but did not affect the catalytic residues Asp170 and Asp231 in α-Gal A. Serum α-Gal A activity in patients with CKD Stages 1–5 was inversely correlated with age (P Conclusions FD prevalence was much higher in male patients with CKD Stages 1–5 than in those with CKD Stage 5D. FD screening in patients with CKD Stages 1–5 may improve patient survival, decreasing the number of patients with CKD Stage 5D.

Dialysis adequacy is an important survival indicator in patients with chronic hemodialysis. However, there are inconveniences and disadvantages to measuring dialysis adequacy by blood samples. This study used machine learning models to predict dialysis adequacy in chronic hemodialysis patients using repeatedly measured data during hemodialysis. This study included 1333 hemodialysis sessions corresponding to the monthly examination dates of 61 patients. Patient demographics and clinical parameters were continuously measured from the hemodialysis machine; 240 measurements were collected from each hemodialysis session. Machine learning models (random forest and extreme gradient boosting [XGBoost]) and deep learning models (convolutional neural network and gated recurrent unit) were compared with multivariable linear regression models. The mean absolute percentage error (MAPE), root mean square error (RMSE), and Spearman’s rank correlation coefficient (Corr) for each model using fivefold cross-validation were calculated as performance measurements. The XGBoost model had the best performance among all methods (MAPE = 2.500; RMSE = 2.906; Corr = 0.873). The deep learning models with convolutional neural network (MAPE = 2.835; RMSE = 3.125; Corr = 0.833) and gated recurrent unit (MAPE = 2.974; RMSE = 3.230; Corr = 0.824) had similar performances. The linear regression models had the lowest performance (MAPE = 3.284; RMSE = 3.586; Corr = 0.770) compared with other models. Machine learning methods can accurately infer hemodialysis adequacy using continuously measured data from hemodialysis machines.

Objective: To document overall adherence to haemodialysis, medications, fluid restriction and dietary prescription in patients with end-stage renal disease and to study factors that could predict poor adherence. Study Design: Cross-sectional analytical study. Place and Duration of Study: Department of Nephrology, Pak Emirates Military Hospital, Rawalpindi, from Jul to Sep 2018. Methodology: Adult patients on haemodialysis for at least three months were selected using consecutive sampling technique. Patients with acute kidney injury, patients on haemodialysis for less than 3 months, those on infrequent haemodialysis and unwilling patients were excluded. Demographic data was recorded. Adherence to management was assessed by administering End Stage Renal Disease Adherence Questionnaire in direct face- to-face interviews. Results: There were a total of 101 patients having a mean age of 51.05 ± 13.80 years. Median haemodialysis vintage was 9 months (interquartile range 3-24 months). Mean adherence scores were 970.54 ± 149.43. Mean perception scores were 7.22 ± 1.37. Only 49 (48.51%) patients had good adherence, whereas 52 (51.49%) had poor adherence to management. Increasing age was associated with poor adherence (β=-0.038; Odds Ratio=0.963, 95% CI 0.928- 1.000, p=0.048). No other demographic parameter could predict poor adherence. Conclusion: Non-adherence to different aspects of management plan was a significant problem, more so in younger patients.

Patients with end stage kidney disease receiving in-center hemodialysis (ICHD) have had high rates of SARS-CoV-2 infection. Following infection, patients receiving ICHD frequently develop circulating antibodies to SARS-CoV-2, even with asymptomatic infection. Here, we investigated the durability and functionality of the immune responses to SARS-CoV-2 infection in patients receiving ICHD. Three hundred and fifty-six such patients were longitudinally screened for SARS-CoV-2 antibodies and underwent routine PCR-testing for symptomatic and asymptomatic infection. Patients were regularly screened for nucleocapsid protein (anti-NP) and receptor binding domain (anti-RBD) antibodies, and those who became seronegative at six months were screened for SARS-CoV-2 specific T-cell responses. One hundred and twenty-nine (36.2%) patients had detectable antibody to anti-NP at time zero, of whom 127 also had detectable anti-RBD. Significantly, at six months, 71/111 (64.0%) and 99/116 (85.3%) remained anti-NP and anti-RBD seropositive, respectively. For patients who retained antibody, both anti-NP and anti-RBD levels were reduced significantly after six months. Eleven patients who were anti-NP seropositive at time zero, had no detectable antibody at six months; of whom eight were found to have SARS-CoV-2 antigen specific T cell responses. Independent of antibody status at six months, patients with baseline positive SARS-CoV-2 serology were significantly less likely to have PCR confirmed infection over the following six months. Thus, patients receiving ICHD mount durable immune responses six months post SARS-CoV-2 infection, with fewer than 3% of patients showing no evidence of humoral or cellular immunity., Graphical abstract

Introduction In this observational study, we describe the change in the clinical profile and outcome of Corona Virus Disease 2019 (COVID-19) over the course of the outbreak, among patients requiring dialysis, including chronic haemodialysis therapy. Methods This is a single-centre prospective observational study of patients with COVID-19 (as confirmed by RT-PCR) and renal failure requiring haemodialysis. Their clinical profiles and outcomes were analysed, vis-à-vis the changing disease severity. Findings A total of 483 patients were included, of whom 416 had end-stage renal disease and were on maintenance haemodialysis. Patients who were symptomatic at presentation had significantly higher levels of Neutrophil–lymphocyte ratio (NLR) (p

Introduction: The pandemic of coronavirus disease (COVID-19) has highly affected patients with comorbidities and frailty who cannot self-isolate, such as individuals undergoing haemodialysis. The aim of the study was to identify risk factors for mortality and hospitalisation, which may be useful in future disease spikes. Methods: We collected data retrospectively from the electronic medical records of all patients receiving a diagnosis of COVID-19 between 11th March and 10th May 2020 undergoing maintenance haemodialysis at four satellite dialysis units from the Royal Free London NHS Foundation Trust, London, UK. Mortality was the primary outcome, and the need for hospitalization was the secondary one. Results: Out of 746 patients undergoing regular haemodialysis, 148 symptomatic patients tested positive for SARS-CoV-2 by RT-PCR and were included in the analysis. The overall mortality rate was 24.3%. By univariate analysis, older age, ischaemic heart disease, lower systolic blood pressure, lower body mass index (BMI) and higher frailty scores were associated with higher rates of mortality (all p value < 0.05). The laboratory factors associated with mortality were higher values of WBC, neutrophil counts, neutrophil to lymphocyte ratios (NLR), C-reactive protein (CRP), bilirubin, ferritin, troponin, and lower serum albumin level (all p value < 0.05). In the logistic regression, mortality was associated with older age and higher CRP, while high levels of NLR and CRP were associated with the need for hospitalization. Discussion: Haemodialysis patients are susceptible to COVID-19 and have a high mortality rate. Our study identifies prognostic risk factors associated with poor outcome including age, frailty and markers of inflammation, which may support more informed clinical decision-making. Graphic abstract: [Figure not available: see fulltext.]

Purpose The aim of this study is to describe the incidence of Acute Kidney Injury (AKI) amongst patients admitted to the Intensive Care Unit (ICU) with COVID-19. In addition we aim to detail the range of Renal Replacement Therapy (RRT) modalities offered to these patients (including peritoneal dialysis - PD - and intermittent haemodialysis - IHD) in order to meet demand during pandemic conditions. Materials and methods Single-centre retrospective case note review of adult patients with confirmed COVID-19 admitted to ICU. Results Amongst 136 patients without a prior history of End Stage Kidney Disease (ESKD), 108 (79%) developed AKI and 63% of admitted patients received RRT. Due to resource limitations the range of RRT options were expanded from solely Continuous Veno-Venous HaemoDiaFiltration (CVVHDF - our usual standard of care) to include PD (in 35 patients) and IHD (in 15 patients). During the study period the proportion of RRT provided within ICU as CVVHDF fell from 100% to a nadir of 39%. There were no significant complications of either PD or IHD. Conclusions During periods of resource limitations PD and IHD can safely be used to reduce dependence on CVVHDF in select patients with AKI secondary to COVID-19., Highlights • AKI frequently complicates COVID-19 in patients admitted to ICU. • Large numbers of patients and high rates of AKI leads to great demand for RRT. • In selected patients PD and IHD can supplement CRRT in meeting this demand. • PD and IHD can be implemented rapidly and safely through a collaborative approach.

Background Previous studies in patients on haemodialysis (HD) have shown an association of fibroblast growth factor 23 (FGF23) with all-cause mortality. As of yet, the result of FGF23 lowering on mortality is unknown in this population. Methods FGF23 was measured in a subset of 404 patients from the Dutch CONvective TRansport STudy (CONTRAST study) [a randomized trial in prevalent dialysis patients comparing HD and haemodiafiltration (HDF) with clinical outcome] at baseline and Months 6 and 12. A substantial decline of FGF23 change over time was anticipated in patients randomized to HDF since HDF induces higher dialytic clearance of FGF23. The associations of both baseline FGF23 and 6-months change in FGF23 with all-cause mortality were analysed. In addition, the difference in FGF23 change between HD and HDF was explored. Furthermore, the role of dialysis modality in the association between FGF23 change and outcome was analysed. Results No association was observed between quartiles of baseline FGF23 and all-cause mortality. Over 6 months, FGF23 declined in patients on HDF, whereas FGF23 remained stable in patients on HD. A decrease in FGF23 was not associated with improved survival compared with a stable FGF23 concentration. However, increasing FGF23 was associated with a significantly higher mortality risk, both in crude and fully adjusted models [hazard ratio 2.01 (95% confidence interval 1.30–3.09)]. Conclusion Whereas no association between a single value of FGF23 and all-cause mortality was found, increasing FGF23 concentrations did identify patients at risk for mortality. Since lowering FGF23 did not improve outcome, this study found no argument for therapeutically lowering FGF23.

Introduction Caring for a patient with end‐stage renal disease undergoing in‐centre haemodialysis can be a stressful experience, likely to involve significant burden. Within the context of the new coronavirus pandemic, these patients are highly vulnerable to infection by COVID‐19, which might increase the care demands and burden of family caregivers. Aim This study aimed to explore the subjective experiences of family caregivers of non‐COVID‐19 patients with end‐stage renal disease undergoing in‐centre haemodialysis during the COVID‐19 lockdown. Study design A qualitative study was performed with a purposive sample. Methods Semi‐structured telephone interviews were conducted with 19 family caregivers (50.7 ± 14 years old) of patients undergoing in‐centre haemodialysis in April 2020. Findings Four major themes were identified: (1) emotional distress; (2) changes in caregiving responsibilities; (3) educational and supportive needs; and (4) coping strategies to deal with the outbreak and with the lockdown. Discussion The findings suggest that family caregivers of patients undergoing in‐centre haemodialysis have to manage several additional care responsibilities due to COVID‐19 lockdown. The dialysis team should consider the development of educational and supportive interventions to meet family caregivers’ needs, mitigate emotional distress, fears and concerns, and prevent caregiver burden during the COVID‐19 pandemic.

Introduction: Haemodialysis requires recirculation, and it happens when dialysed blood returning through the venous needle re-enters the extracorporeal circuit through the arterial needle, rather than returning to the systemic circulation. Significant recirculation should be expected, when there is an inadequate reduction in the values of urea. During End-Stage Renal Disease (ESRD), adequate dialysis is of utmost importance because it influences the morbidity and mortality of the patients. Methods and materials: The study was carried out in 200 patients who underwent haemodialysis at the dialysis unit in Kalyani kidney care centre, Erode. Patients were actively evaluated from February 2018 till November 2018. Patients were randomized and accordingly 64 patients were enrolled in category I Arteriovenous fistula (AVF), 63 Patients in category II Internal Jugular Catheter (IJC) and category III Femoral Catheter (FC) each and 10 patients in category IV Perm Catheter (PC). Success recirculation was estimated and adequacy of haemodialysis was done virtually. Calculated Kt/V was done in almost all patients. For assessing vascular access recirculation, the technique that was used was urea-based measurement (Two needles with three samples of blood). The recirculation percentage was calculated as(S-A)/(S-V) X100. For assessing the adequacy of haemodialysis, Kt/V was used where K is estimated from (Cbi-Cbo)/ (CbixQb), time duration of dialysis (t) and urea distribution volume (V) is determined from the Watson equations for men and women. Kt/V was also measured with Online Clearance Monitoring (OCM) in Fresenius machine 4000S. Results: The mean access recirculation rate was 6.3+5.1% in those with AVF, while in IJC and FC groups were 6.7+4.5% and 24.4+11.7% respectively. When the two groups were compared, AVF vs FC groups, the difference was statistically significant (p value

Background Haemodialysis (HD) patients are extremely vulnerable to coronavirus disease 2019 (COVID-19). Their immune response after infection is unclear. We have found high seroconversion rates in this population, with 95% developing antibodies. It is unclear if and how long these antibodies persist. Here we investigate this with serial antibody (Ab) testing. Methods We identified HD patients who had confirmedsevere acute respiratory syndrome coronavirus 2 between March and May 2020 and measured monthly antibodies (immunoglobulin G/immunoglobulin M) in those who survived. We used a semiquantitative cut-off index to create a qualitative result and plotted optical density (OD) over time. We used linear regression to examine the slope, as well as noting peak OD and time to peak OD. We correlated these against baseline demographics, markers of illness severity and comorbidities. Results A total of 122 patients were analysed. All remained Ab positive during follow-up for a minimum of 148 days. Seventy-one percent had a positive gradient indicating increasing Ab positivity over time. We found that age (P = 0.01), duration of polymerase chain reaction positivity (P = 0.06) and the presence of symptoms (P = 0.05) were associated with a longer time to peak OD. Immunosuppression did not alter peak OD but did lead to a non-significant increase in time to peak OD, and more patients had a subsequent decrease in Ab levels (P = 0.02). Diabetic patients were more likely to have a positive slope (odds ratio 2.26). Conclusions These results indicate that HD patients have a robust and sustained Ab response after confirmed COVID-19 infection with no suggestion that immunosuppression weakens this response. Although it is unclear what protection these antibodies confer, this is encouraging that HD patients should respond to vaccination.

Introduction: End-Stage Renal Disease patients (ESRD) on maintenance Haemodialysis (HD) are at high risk of acquiring Cytomegalovirus (CMV). The aim of the study was to determine the prevalence and risk factors of CMV infection among HD patients from Nasser's medical complex and Abu Yousef Al Najjar Hospital Southern Gaza strip. Methods: This study was an analytical cross-sectional from March to September 2019. Serum samples were taken from 96 patients (51.1% of them from Nasser medical complex and 48.9% of them from Abu Yousef Al Najjar Hospital), analyzed for CMV-specific immunoglobulin G (IgG) by using the Chemiluminescence immunoassay (CLIA) techniques, questionnaire, and Virological identification. Results: CMV-IgG was detected in 80 patients (83.3%), were 16 patients (16.7%) were CMV IgG Negative. The prominent risk factors were HD duration time, Receiving Injection, and previous blood transfusion. Conclusion: The prevalence of CMV infection among HD patients in the Southern Gaza strip was very high. We recommend that HD patients should be vaccinated against CMV.

Background and aims Calciphylaxis is a rare condition associated with very high mortality in patients with end-stage kidney disease. Data from country-based registries have been an invaluable resource for a better understanding of the natural history and management for this condition. This study aimed to investigate the current management strategies and outcomes of patients enrolled in the United Kingdom Calciphylaxis study (UKCS). Methods The study was conducted on 89 patients registered in the UKCS since 2012. The initial analysis included a description of the baseline characteristics, management strategies and outcomes on follow-up until May 2020. Further analysis included a comparison of the mortality outcome of the UKCS patients who were receiving haemodialysis with a propensity score matched cohort of haemodialysis patients from the Chronic Renal Insufficiency Standards Implementation Study- Haemodialysis (CRISIS-HD). Results Median age of the cohort was 59 years, with a predominance of females (61%) and Caucasian (95%) ethnicity. About 54% of the patients were diabetic and 70% were receiving haemodialysis at study entry. The skin lesions were mostly distributed in the lower extremities (48%). Sodium thiosulphate and calcimimetic were the most widely used management strategies. The mortality rate was 72 deaths per hundred patient-years (50 deaths observed in 69.5 patient years). Complete wound healing was noted in 17% and bacteraemia was reported in 26% of patients. In a comparative analysis of the matched haemodialysis patients, the presence of calciphylaxis in 62 patients showed a strong association with all-cause mortality (HR 6.96; p Conclusions This UK wide study strengthens the evidence that calciphylaxis is a strong and independent risk factor associated with all-cause mortality; no significant benefit was shown with any individual treatment modality. Until further evidence becomes available, a multifaceted approach would be the appropriate treatment strategy in the management of this extremely serious condition. Graphic abstract

The novel coronavirus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic in March 2020 by the World Health Organization. Older individuals and patients with comorbid conditions such as hypertension, heart disease, diabetes, lung disease, chronic kidney disease (CKD) and immunologic diseases are at higher risk of contracting this severe infection. In particular, patients with advanced CKD constitute a vulnerable population and a challenge in the prevention and control of the disease. Home-based renal replacement therapies offer an opportunity to manage patients remotely, thus reducing the likelihood of infection due to direct human interaction. Patients are seen less frequently, limiting the close interaction between patients and healthcare workers who may contract and spread the disease. However, while home dialysis is a reasonable choice at this time due to the advantage of isolation of patients, measures must be assured to implement the program. Despite its logistical benefits, outpatient haemodialysis also presents certain challenges during times of crises such as the coronavirus disease 2019 (COVID-19) pandemic and potentially future ones.

Background Knowledge of arrhythmias in patients with end-stage renal disease (ESRD) is mainly based on ambulatory electrocardiography (ECG) studies and observations during haemodialysis (HD). We used insertable cardiac monitors (ICMs) to define the prevalence of arrhythmias, focusing on bradyarrhythmias, in ESRD patients treated with several dialysis modes including home therapies. Moreover, we assessed whether these arrhythmias were detected in baseline or ambulatory ECG recordings. Methods Seventy-one patients with a subcutaneous ICM were followed for up to 3 years. Asystole (≥4.0 s) and bradycardia (heart rate Results At recruitment, 44 patients were treated in in-centre HD, 12 in home HD and 15 in peritoneal dialysis. During a median follow-up of 34.4 months, 18 (25.4%) patients had either an asystolic or a bradycardic episode. The median length of each patient’s longest asystole was 6.6 s and that of a bradycardia 13.5 s. Ventricular tachyarrhythmias were detected in 16 (23%) patients, and AF in 34 (51%) patients. In-centre HD and Type II diabetes were significantly more frequent among those with bradyarrhythmias, whereas no bradyarrhythmias were found in home HD. No bradyarrhythmias were evident in baseline or ambulatory ECG recordings. Conclusions Remarkably many patients with ESRD had bradycardia or asystolic episodes, but these arrhythmias were not detected by baseline or ambulatory ECG.

Background Clinical practice guidelines of dietary management are designed to promote a balanced diet and maintain health in patients undergoing haemodialysis but they may not reflect patients’ preferences. We aimed to investigate the consistency between the dietary intake of patients on maintenance haemodialysis and guideline recommendations. Methods Cross-sectional analysis of the DIET-HD study, which included 6,906 adults undergoing haemodialysis in 10 European countries. Dietary intake was determined using the Global Allergy and Asthma European Network (GA2LEN) Food Frequency Questionnaire (FFQ), and compared with the European Best Practice Guidelines. Consistency with guidelines was defined as achieving the minimum daily recommended intake for energy (≥ 30 kcal/kg) and protein (≥ 1.1 g/kg), and not exceeding the maximum recommended daily intake for phosphate (≤ 1000 mg), potassium (≤ 2730 mg), sodium (≤ 2300 mg) and calcium (≤ 800 mg). Results Overall, patients’ dietary intakes of phosphate and potassium were infrequently consistent with guidelines (consistent in 25% and 25% of patients, respectively). Almost half of the patients reported that energy (45%) and calcium intake (53%) was consistent with the guidelines, while the recommended intake of sodium and protein was consistent in 85% and 67% of patients, respectively. Results were similar across all participating countries. Intake was consistent with all six guideline recommendations in only 1% of patients. Conclusion Patients on maintenance haemodialysis usually have a dietary intake which is inconsistent with current recommendations, especially for phosphate and potassium.

Background The efficacy and safety of sucroferric oxyhydroxide (SO) have been reported in clinical trials. However, real-life data are scarce. This study presents data on the use, efficacy and safety of SO in real clinical practice. Methods We performed a retrospective multicentre study, without any influence on the prescription decisions, that included 220 patients from 11 Spanish centres. Demographic, treatment, analytical and nutritional parameters and adherence, side effects and dropout rates were collected during 6 months. Results SO was initiated due to inadequate control of serum phosphate (P) in 70% of participants and in 24.5% to reduce the number of tablets. Monotherapy with SO increased from 44% to 74.1%, with a reduction in the average daily number of sachets/tablets from six to two. Serum P decreased by 20% (4.6 ± 1.2 versus 5.8 ± 1.3 mg/dL; P Conclusions The use of SO in real-life results in better control of serum P, a reduction in the number of tablets and an improvement in therapeutic adherence. In addition, it may be beneficial with regards to secondary hyperparathyroidism and nutritional status.

International audience; Introduction. - There is no feasible benchmark in daily routine to estimate the hydration status of haemodialysis patients, which is essential to their management. Objective. - We performed a study in haemodialysis patients to assess the diagnostic performance of pulmonary ultrasound and clinical examination for the evaluation of fluid overload using transthoracic echocardiography as a gold standard.Methods. - Thirty-one patients receiving chronic haemodialysis patients were included. Evaluation of hydration status was assessed weekly before haemodialysis sessions using clinical and Echo Comet Score from pulmonary ultrasound and transthoracic echocardiography (reference method).Results. - Five patients had a transthoracic echocardiography overload. Compared with transthoracic echocardiography, the diagnostic performance of the clinical overload score has a sensitivity of 100%, a specificity of 77%, a positive predictive value of 50% and a negative predictive value of 100% with a k of 0.79. Only orthopnoea (P = 0.008), jugular turgor (P = 0.005) and hepatic-jugular reflux (P = 0.008) were significantly associated with transthoracic echocardiography overload diagnosis. The diagnostic performance of Echo Comet Score by pulmonary ultrasound has a sensitivity of 80%, a specificity of 58%, a positive predictive value of 26% and a negative predictive value of 94%. Ten patients (32.3%) had an increase of extravascular pulmonary water without evidence of transthoracic echocardiography or clinical overload.Conclusions. - Our clinical score has a convincing diagnostic performance compared to transthoracic echocardiography and could be easily used in daily clinical routine to adjust dry weight. The evaluation of the overload using pulmonary ultrasound seems poorly correlated with the overload evaluated by transthoracic echocardiography. Extravascular pulmonary water undetected by clinical examination and transthoracic echocardiography remains a parameter that requires further investigation. (C) 2020 Societe francophone de nephrologie, dialyse et transplantation.

Clinical kidney journal : CKJ 14(6), 1514-1523 (2021). doi:10.1093/ckj/sfab011, Published by Oxford Univ. Press, Oxford

Background Exercise interventions designed to improve physical function and reduce sedentary behaviour in haemodialysis (HD) patients might improve exercise capacity, reduce fatigue and lead to improved quality of life (QOL). The PrEscription of intraDialytic exercise to improve quAlity of Life study aimed to evaluate the effectiveness of a 6-month intradialytic exercise programme on QOL and physical function, compared with usual care for patients on HD in the UK. Methods We conducted a prospective, pragmatic multicentre randomized controlled trial in 335 HD patients and randomly (1:1) assigned them to either (i) intradialytic exercise training plus usual care maintenance HD or (ii) usual care maintenance HD. The primary outcome of the study was the change in Kidney Disease Quality of Life Short Form (KDQOL-SF 1.3) Physical Component Score between baseline and 6 months. Additional secondary outcomes included changes in peak aerobic capacity, physical fitness, habitual physical activity levels and falls (International Physical Activity Questionnaire, Duke’s Activity Status Index and Tinetti Falls Efficacy Scale), QOL and symptom burden assessments (EQ5D), arterial stiffness (pulse wave velocity), anthropometric measures, resting blood pressure, clinical chemistry, safety and harms associated with the intervention, hospitalizations and cost-effectiveness. A nested qualitative study investigated the experience and acceptability of the intervention for both participants and members of the renal health care team. Results At baseline assessment, 62.4% of the randomized cohort were male, the median age was 59.3 years and 50.4% were white. Prior cerebrovascular events and myocardial infarction were present in 8 and 12% of the cohort, respectively, 77.9% of patients had hypertension and 39.4% had diabetes. Baseline clinical characteristics and laboratory data for the randomized cohort were generally concordant with data from the UK Renal Registry. Conclusion The results from this study will address a significant knowledge gap in the prescription of exercise interventions for patients receiving maintenance HD therapy and inform the development of intradialytic exercise programmes both nationally and internationally. Trial Registration ISRCTN N83508514; registered on 17 December 2014., Graphical Abstract

The metabolic impact of circulating fatty acids (FAs) in patients requiring hemodialysis (HD) is unknown. We investigated the associations between plasma triglyceride (TG) FAs and markers of inflammation, insulin resistance, nutritional status and body composition. Plasma TG-FAs were measured using gas chromatography in 341 patients on HD (age = 55.2 ± 14.0 years and 54.3% males). Cross-sectional associations of TG-FAs with 13 markers were examined using multivariate linear regression adjusted for potential confounders. Higher levels of TG saturated fatty acids were associated with greater body mass index (BMI, r = 0.230), waist circumference (r = 0.203), triceps skinfold (r = 0.197), fat tissue index (r = 0.150), serum insulin (r = 0.280), and homeostatic model assessment of insulin resistance (r = 0.276), but lower malnutrition inflammation score (MIS, r = − 0.160). Greater TG monounsaturated fatty acid levels were associated with lower lean tissue index (r = − 0.197) and serum albumin (r = − 0.188), but higher MIS (r = 0.176). Higher levels of TG n-3 polyunsaturated fatty acids (PUFAs) were associated with lower MIS (r = − 0.168) and interleukin-6 concentrations (r = − 0.115). Higher levels of TG n-6 PUFAs were associated with lower BMI (r = − 0.149) but greater serum albumin (r = 0.112). In conclusion, TG monounsaturated fatty acids were associated with poor nutritional status, while TG n-3 PUFAs were associated with good nutritional status. On the other hand, TG saturated fatty acids and TG n-6 PUFAs had both favorable and unfavorable associations with nutritional parameters.

Background: Cardiovascular disease (CVD) is the leading cause of death in haemodialysis (HD) patients. Vascular calcification (VC) is dramatically accelerated and is strongly associated with CVD events and mortality in HD patients. VC coexists with osteoporosis in many studies. Fibroblast growth factor 21 (FGF21) as an adipocytokines is a new hypoglycemic strategy and is inversely related to bone mineral density.Methods: To evaluate the contribution of FGF21 to VC in HD patients, we preliminary sreened 802 HD patients of two large HD centers in China. At last 388 HD patients were entered this cross-sectional study. We detected circulating FGF21 levels and measured the whole thoracic aorta calcification scores (TACS) and calcification scores of the three segments of thoracic aorta (TA), including ascending thoracic aorta (ATACS), aortic arch (AoACS), and descending thoracic aorta (DTACS) of our 388 HD patients. In addition, we pre-incubated human aortic endothelial cells (HAECs) with FGF21 in the presence or absence of parathyroid hormone (PTH) in vitro.Results: The median serum FGF21 level in HD patients was 11-fold higher than that in healthy controls. Ln(FGF21) was positively correlated with Ln(TACS+1), Ln(ATACS+1), Ln(AoACS+1) and Ln(DTACS+1) respectively in HD patients. Serum FGF21 was independently associated with TACS and ATACS, AoACS, and DTACS. FGF21 combined with age, calcium and intact parathyroid hormone demonstrated a high area under the curve (AUC=0.84) with optimal sensitivity (84%) and specificity (71%) for the prediction of VC in HD patients. Our vitro results showed that FGF21 enhanced the calcification effect of PTH on HAECs by increasing calcium deposition and endothelial-to-mesenchymal transition (EndMT).Conclusions: Circulating FGF21 was notably higher and was a potential predictor and promoter of VC in HD patients.Trial registration Chinese Clinical Trial Registry, identifier: ChiCTR1900028249. Registered 16 December 2019-Retrospectively registered,http://www.medresman.org.cn/uc/project/projectedit.aspx?proj=5981

Highlights • Few studies have examined management of breast cancer patients on hemodialysis. • Dosage for anticancer drugs should be carefully adjusted based on adverse events. • Combined therapy improves survival and quality of life., Introduction Management of breast cancer patients undergoing hemodialysis (HD) is difficult because of a lack of evidence about drug selection, dose adjustment, and surgical procedures. We herein present a case of metastatic breast cancer in a patient undergoing HD. Presentation of case A 58-year-old Japanese woman with breast cancer undergoing HD underwent total mastectomy of the left breast and left axillary dissection. Histopathological examination revealed invasive ductal carcinoma, and the diagnosis was pT2N3cM0 Stage ⅢC. Immunostaining of the resected specimen indicated that the tumor was estrogen receptor-positive, progesterone receptor-negative, human epithelial growth factor receptor 2-positive, and the Ki-67 labeling index was 70%. A postoperative positron emission tomography/computed tomography (PET/CT) scan indicated fluorodeoxyglucose uptake in the supraclavicular nodes. She received adjuvant therapy of epirubicin and cyclophosphamide followed by docetaxel, trastuzumab (T-mab) and radiation therapy. However, she developed multiple liver metastases during adjuvant T-mab and hormone therapy. Therefore, her regimen was changed to trastuzumab emtansine (T-DM1) as first-line therapy, T-mab, pertuzumab (P-mab), and eribulin as second-line therapy, and T-mab, P-mab, and weekly paclitaxel as third-line therapy. Eventually, she was administered fourth-line treatment of T-mab, P-mab, and vinorelbine because of adverse events. She has survived more than 25 months after the initial detection of recurrence of breast cancer and maintained quality of life. Conclusion We report a case of breast cancer in a patient undergoing HD. It is very difficult to identify the appropriate drugs and dosages in patients undergoing HD to improve survival and quality of life.

Background: Patients on maintenance haemodialysis (MHD) often complain of fatigue and tiredness following haemodialysis sessions leading to poor compliance with the dialysis schedule. There is limited Indian data on dialysis recovery time (DRT). The present study was designed to assess the factors affecting DRT in our haemodialysis population. Methods: We recorded self-reported patient recovery times of 120 patients who satisfied the inclusion criteria, over three consecutive dialysis sessions by asking the question, 'How long does it take to recover from a dialysis session'? Data recorded included patient factors like age, sex, co-morbidities, Charlson comorbidity index score (CCI), dialysis vintage, duration of kidney disease, interdialytic weight gain (IDWG), treatment factors like ultrafiltration rate (UFR), SpKt/V, blood pump speed, dialysate sodium, session length, pre and post HD blood pressure and laboratory parameters. Health-related quality of life (HRQoL) was assessed with the KDQOL-SF v. 1.3 questionnaire. Results from the SF-36 score were summarised into the physical composite score (PCS), mental composite score (MCS) and kidney disease composite score (KDCS). Results: The mean age of the study population was 50.6 ± 12.6 years. Among the 120 patients, 77 (64.2%) were males. Thirty-nine patients (32.5%) were diabetic and 95 (79.1%) patients were hypertensive. The mean dialysis vintage of the study population was 26.1 ± 18.6 months, 41 (34.2%) patients reported DRT 6 h. On multivariate regression analysis, higher IDWG, CCI score and UFR were associated with prolonged DRT. Reported DRT also inversely correlated with PCS (r = - 0.66), MCS (r = - 0.65) and KDCS (r = - 0.59) scores which was statistically significant. Conclusion: The present study showed that higher CCI scores, IDWG and UFR were associated with prolonged DRT in Indian haemodialysis patients and patients with longer recovery time had poor HRQoL. Interventions to reduce DRT need to be assessed in further trials in Indian MHD patients.

Aims and objectives To develop a smartphone application-based dietary self-management program for haemodialysis patients and to examine its effects on biochemical indicators, self-efficacy and quality of life. Background Lack of dietary management in haemodialysis patients can lead to serious complications such as oedema, hyponatremia, hyperkalaemia, hypertension, uraemia and eventually death; however, studies using smartphone applications for dietary self-management in haemodialysis patients are rare. Design A prospective, single-blind, randomised, controlled design with repeated measures was followed with 75 haemodialysis patients at a haemodialysis centre. Data were collected from 10 January 2017-6 May 2018. The study applied the Consolidated Standards of Reporting Trials statement. Methods The 8-week smartphone application-based dietary self-management program was developed through collaboration with a haemodialysis equipment company. The experimental group took this program while the control group took an 8-week general program. Study variables were serum phosphorus, potassium and albumin, self-efficacy and quality of life. They were measured at pretest, and 8 weeks and 12 weeks after the programs, and analysed using two-way repeated measures analysis of variance. Findings The smartphone application-based program significantly improved serum phosphorus, potassium, self-efficacy and quality of life over time compared with the general program. There was no significant difference in albumin level changes between the groups. Conclusions The smartphone application-based dietary self-management program is an opportune and effective nursing intervention to lower serum phosphorus and potassium levels in haemodialysis patients over time. Trial registration was performed on www.cris.nih.go.kr (KCT0005366). Relevance to clinical practice Haemodialysis patients can easily use the smartphone application to manage their diet anytime and anywhere. They can get real-time feedback and solutions to prevent haemodialysis complications. Nurses can provide tailored high-quality care based on an individual's lifelog data from the smartphone application.

Background C-type natriuretic peptide (CNP) and its co-product N-terminal proCNP (NTproCNP) have been associated with beneficial effects on the cardiovascular system. In prevalent dialysis patients, however, a relation between NTproCNP and mortality has not yet been investigated. Furthermore, as a middle molecular weight substance, its concentration might be influenced by dialysis modality. Methods In a cohort of patients treated with haemodialysis (HD) or haemodiafiltration (HDF), levels of NTproCNP were measured at baseline and 6, 12, 24 and 36 months. The relation between serum NTproCNP and mortality and the relation between the 6-month rate of change of NTproCNP and mortality were analysed using Cox regression models. For the longitudinal analyses, linear mixed models were used. Results In total, 406 subjects were studied. The median baseline serum NTproCNP was 93 pmol/L and the median follow-up was 2.97 years. No relation between baseline NTproCNP or its rate of change over 6 months and mortality was found. NTproCNP levels remained stable in HD patients, whereas NTproCNP decreased significantly in HDF patients. The relative decline depended on the magnitude of the convection volume. Conclusions In our study, levels of NTproCNP appear strongly elevated in prevalent dialysis patients. Second, while NTproCNP remains unaltered in HD patients, its levels decline in individuals treated with HDF, with the decline dependent on the magnitude of the convection volume. Third, NTproCNP is not related to mortality in this population. Thus NTproCNP does not seem to be a useful marker for mortality risk in dialysis patients.

Background Literature on recovery of kidney function (RKF) in patients with end-stage kidney disease treated with maintenance dialysis (i.e. >90 days) is limited. We assessed the incidence of RKF and its associated characteristics in a European cohort of dialysis patients. Methods We included adult patients from the European Renal Association–European Dialysis and Transplant Association Registry who started maintenance dialysis in 1997–2016. Sustained RKF was defined as permanent discontinuation of dialysis. Temporary discontinuation of ≥30 days (non-sustained RKF) was also evaluated. Factors associated with RKF adjusted for potential confounders were studied using Cox regression analyses. Results RKF occurred in 7657 (1.8%) of 440 996 patients, of whom 71% experienced sustained RKF. Approximately 90% of all recoveries occurred within the first 2 years after Day 91 of dialysis. Of patients with non-sustained RKF, 39% restarted kidney replacement therapy within 1 year. Sustained RKF was strongly associated with the following underlying kidney diseases (as registered by the treating physician): tubular necrosis (irreversible) or cortical necrosis {adjusted hazard ratio [aHR] 20.4 [95% confidence interval (CI) 17.9–23.1]}, systemic sclerosis [aHR 18.5 (95% CI 13.8–24.7)] and haemolytic uremic syndrome [aHR 17.3 (95% CI 13.9–21.6)]. Weaker associations were found for haemodialysis as a first dialysis modality [aHR 1.5 (95% CI 1.4–1.6)] and dialysis initiation at an older age [aHR 1.8 (95% CI 1.6–2.0)] or in a more recent time period [aHR 2.4 (95% CI 2.1–2.7)]. Conclusions Definitive discontinuation of maintenance dialysis is a rare and not necessarily an early event. Certain clinical characteristics, but mostly the type of underlying kidney disease, are associated with a higher likelihood of RKF.

Background While systemic anticoagulation is most widely used in haemodialysis (HD), contraindications to its use might occur in particular settings. The Solacea™ haemodialyser with an asymmetric triacetate membrane claims improved biocompatibility and has already shown promising results when used in combination with only half dose of anticoagulation. To quantify the performance of the Solacea™ when further decreasing anticoagulation to zero, fibre blocking was assessed by micro-computed tomography (micro-CT). Methods Ten maintenance HD patients underwent six dialysis sessions at midweek using a Solacea™ 19H dialyser, consecutively in pre-dilution haemodiafiltration (pre-HDF), HD and post-dilution HDF (post-HDF). After the first three sessions with only a quarter of their regular anticoagulation dose (one-quarter), the last three sessions were performed without anticoagulation (zero). Dialyser fibre blocking was quantified in the dialyser outlet potting using a 3D micro-CT scanning technique post-dialysis. Results Even in case of reduced (one-quarter) anticoagulation, the relative number of open fibres post-dialysis was almost optimal, i.e. 0.96 (0.87–0.99) with pre-HDF, 0.99 (0.97–0.99) with HD and 0.97 (0.92–0.99) with post-HDF. Fibre patency was mildly decreased for pre-HDF and HD when anticoagulation was decreased from one-quarter to zero, i.e. to 0.76 (0.61–0.85) with pre-HDF (P = 0.004) and to 0.80 (0.77–0.89) with HD (P = 0.013). Comparing the results for zero anticoagulation, post-HDF [i.e. 0.94 (0.82–0.97)] performed as well as HD and pre-HDF. Conclusions The Solacea™ dialyser provides promising results for use in conditions where systemic anticoagulation is contraindicated. Post-HDF, although inducing haemoconcentration in the dialyser, is equally effective for fibre patency in case of zero anticoagulation as pre-HDF and HD when using Solacea™.

Background The aim of this study was to evaluate the midterm results of a brachio-axillary arteriovenous graft (BA-AVG) for the provision of vascular access haemodialysis patients. Materials and methods A cohort retrospective consecutive single-centre study of 46 patients undergoing BA-AVG using the Gore Acuseal, from November 2015 to October 2019 was conducted. Data on patient demographics, comorbidities, medical therapy, and complications were collated for the initial endpoints of primary patency, primary assisted patency, and secondary patency. A subgroup analysis included outcomes in patients over 70 years old and events (complications) per AVG per year. Data were subjected to Kaplan-Meier survival estimator with log-rank analysis and test of probability. Results The mean age of the cohort was 63.5 years with male predominance (male, n = 27, 59%). A total of 37 (80%) patient procedures were conducted with elective settings as well as on an emergency basis with a 91.3% technical success rate. The most common complication was grade I steal syndrome (8.7%), followed by graft infections (4.3%), median nerve neuropraxia (4.3%), and postoperative bleeding (2%), demonstrating a 0.1 per AVG complication per 2 years. Median primary patency, primary assisted patency, and secondary patency over a mean follow-up period of 28 months was 5.5, 12.5, and 18 months, respectively, with no associated 30-day mortality. Conclusion BA-AVG with midterm longevity and low complications may serve as an alternative access type when a suitable site is not identified. The AVG patency rate in the elderly or patients with limited life expectancy is promising. However, more robust data are needed to confirm the benefit of AVG in this cohort., Highlights • This series showed that Gore® Acuseal graft can be used as vascular access option in ESRD patients on chronic haemodialysis. • It has reasonable technical success rate comparable to other synthetic access grafts and low complications rates in mid to long-term follow up. • Sub-groups analysis included outcome in patients over 70 years old and events (complications) per AVG per year. • AVG patency rate in elderly or patients with limited life expectancy is promising. However, more robust data needed.