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Objective Excess sodium intake is associated with volume overload and increased blood pressure. Therefore, to prevent future cardiovascular events, a sodium-restricted diet is strongly recommended for patients on maintenance hemodialysis (HD). However, only one formula for estimating dietary sodium intake in HD patients is available, and its validity has not been adequately evaluated. This study aimed to measure daily sodium intake using the duplicate portion method and provide a new formula for estimating dietary sodium intake. Design and Methods Nineteen Japanese patients undergoing HD were enrolled in this cross-sectional multicenter study. The daily sodium intake of these patients was measured directly using the duplicate portion method. Two formulas for estimating sodium intake were developed by stepwise regression analysis. Their validities were compared with the validity of the previous formula. Furthermore, using these new formulas, we estimated the daily consumption of sodium in a large number of Japanese HD patients. Results The previous formula underestimated true sodium intake using Bland-Altman diagrams. No significant correlation was noted between the measured sodium intake and the estimated intake (r = 0.30, P = .23, Fisher's Z-transformation). The new formulas 1 and 2, which included age, predialysis and postdialysis serum sodium levels, predialysis body weight, and interdialytic body weight gain, accurately estimated sodium consumption. The coefficients of correlation between the estimated values and the true sodium intake were r = 0.858 and r = 0.805, respectively. The simulation model using data from the Japanese Society for Dialysis Therapy showed that the distribution of the estimated sodium intake using the previous formula shifted left compared with that using the new formulas. Conclusions The new formulas accurately estimated the daily sodium consumption in HD patients. Further longitudinal studies are required to determine whether the estimated sodium intake level calculated using the new formulas would serve as a potential marker and/or therapeutic target to prevent cardiovascular events in HD patients.

Introduction Medium cut-off (MCO) dialyzers were designed to provide better clearance of uremic toxins. Methods We conducted a meta-analysis comparing MCO with high-flux (HF) dialyzers for the effect on uremic toxins in maintenance hemodialysis(HD) patients. Five databases were systematically searched for relevant studies and 9 studies were identified finally. Results Reduction ratio (RR) of urea, urea, creatinine, β2-macroglobulin(β2-MG), kappa free light chain(κFLC) and lambda FLC(λFLC) levels were not significantly different between MCO and HF dialyzers. But RR of β2-MG, κFLC and λFLC were greater for MCO than HF dialyzers. MCO dialyzers could better reduce tumor necrosis factor-α(TNF-α) levels. Subgroup analysis stratified by study design indicated that in randomized controlled trial(RCT) studies, albumin levels was lower in MCO than HF dialyzers group, but the two dialyzers treatments were equivalent in non-RCT subgroup. Conclusions Compared with HF dialyzers, MCO dialyzers provided higher middle-molecules uremic toxins clearance and obviously reduced TNF-α levels. This article is protected by copyright. All rights reserved.

Kouichi Murakami,1 Emi Inayama,1 Yukiko Itoh,1 Shoji Tuchiya,1 Masashi Iwasaki,2 Nobuko Tamura,1 Toshihiko Suzuki,3 Noriko Iwai,1 Junji Utino,4 Motoyuki Masai,4 Daiji Nagayama,5,6 Kohji Shirai4,6 1Seijinaki Mihama Narita Clinic, Narita City, Chiba, 286-0041, Japan; 2Seijinkai Mihama Katori Clinic, Katori City, Chiba, 287-0041, Japan; 3Seijinkai Mihama Sakura Clinic, Sakura City, Chiba, 285-0841, Japan; 4Seijinkai Mihama Hospital, Chiba City, Chiba, 261-0013, Japan; 5Nagayama Clinic, Oyama City, Tochigi, 323-0032, Japan; 6Sakura Hospital, School of Medicine Toho University, Sakura City, Chiba, 285-8741, JapanCorrespondence: Daiji NagayamaNagayama Clinic, 2-12-22, Tenjin-Cho, Oyama City, Tochigi, 323-0032, JapanTel/Fax +81-285-22-0219Email deverlast96071@gmail.comAim: Mortality rate of maintenance hemodialysis patients is known to be high. Cardio-ankle vascular index (CAVI) is an index reflecting the proper stiffness of the arterial tree from the origin of the aorta to the ankle. We aimed to clarify the utility of CAVI as a predictor of mortality in hemodialysis patients. The roles of age and nutritional conditions on survival were also examined.Methods: We followed 242 patients undergoing hemodialysis for 6 consecutive years. Data from 209 patients (mean age was 60 ± 11 years) excluding those with ankle-brachial index < 0.90 were then analyzed. CAVI and heart to ankle pulse wave velocity (haPWV) were measured using Vasera 1500.Results: Thirty-eight hemodialysis patients who died during the 6-year period had higher age, cardiothoracic ratio (CTR), CAVI, and haPWV, and lower diastolic blood pressure, albumin, phosphate, and calcium phosphate product. The Kaplan–Meier curves for cumulative survival among the tertile groups showed that the mortality rate was higher in the highest tertile (T3) compared to T1/T2 for both CAVI and haPWV. Receiver operating characteristic (ROC) analysis revealed that CAVI had better discriminatory power for all-cause mortality compared to haPWV. In the Cox-proportional hazards analyses, 1 SD increase in both parameters contributed independently to all-cause mortality [CAVI: HR 1.595 (95% CI 1.108– 2.297), haPWV: HR 1.695 (95% CI 1.185– 2.425)], as well as age and CTR. Both parameters above the cut-offs estimated in the ROC analysis (CAVI ≥ 9.2, haPWV ≥ 8.9) also had independent contributions to mortality.Conclusion: Through the 6 consecutive years of follow-up in 209 HD patients, increased CAVI might represent a major modifiable risk factor for all-cause mortality. Further research is needed to examine whether CAVI-lowering interventions contribute to improved prognosis.Keywords: hemodialysis patient, mortality, cardio-ankle vascular index, phosphorus

Purpose Maintenance hemodialysis (MHD) patients are at high risk of sarcopenia. Gut microbiota affects host metabolic and may act in the occurrence of sarcopenia importantly. This study aimed to study the characterization of the gut microbiota in MHD patients with sarcopenia, and to further reveal the complex pathophysiology of sarcopenia in MHD patients. Methods Fecal samples and clinical data were collected from 30 MHD patients with sarcopenia, and 30 age-and-sex-matched MHD patients without sarcopenia in 1 general hospital of Jiangsu Province from December 2020 to March 2021. 16S rRNA sequencing technology was used to analyze the genetic sequence of the gut microbiota for evaluation of the diversity, species composition, and differential microbiota of the two groups. Results Compared to MHD patients without sarcopenia, the ACE index of patients with sarcopenia was lower (P = 0.014), and there was a structural difference in the β-diversity between the two groups (P = 0.001). At the genus level, the relative abundance of Tyzzerella_4 in the sarcopenia group was significantly higher than in the non-sarcopenia group (P = 0.039), and the relative abundance of Megamonas (P = 0.004), Coprococcus_2 (P = 0.038), and uncultured_bacterium_f_Muribaculaceae (P = 0.040) decreased significantly. Conclusion The diversity and structure of the gut microbiota of MHD patients with sarcopenia were altered. The occurrence of sarcopenia in MHD patients may be influenced by gut microbiota.

3-Methylhistidine (3MH) is an indicator of muscle catabolism. Subclinical protein malnutrition is an independent predictor of aortic stiffness (AS). We aimed to study the relationship between serum 3MH level and AS among patients undergoing maintenance hemodialysis (MHD). Carotid-femoral pulse wave velocity was applied to measure AS of 110 MHD patients. Serum 3MH levels were analyzed using high-performance liquid chromatography and mass spectrometry. AS was defined as cfPWV >10 m/s. Forty-five (40.9%) patients were categorized as having AS. Multivariable logistic (odds ratio: 0.792, p

Patients undergoing maintenance hemodialysis (MHD) are susceptible to muscle wasting and decreased muscle function, resulting in shorter survival time. This study was aimed at evaluating the effect of radial extracorporeal shock wave therapy (rESWT) on muscle mass and function in patients on MHD. This single blind controlled study was conducted on patients on MHD from September 2018 to December 2019. Eighteen patients were enrolled in the rESWT and control groups. rESWT was performed once a week for 12 wk in both quadriceps femoris muscles of the ESWT group. Finally, 15 patients were assessed for body composition, handgrip strength, physical performance and blood chemistry before rESWT, after rESWT and at a 12-wk follow-up. Leg lean mass and appendicular skeletal muscle mass index increased significantly in the ESWT group compared with the control group (p = 0.001 and p = 0.017). The timed up-and-go test and sit-to-stand tests revealed greater significant improvement in the ESWT group (p = 0.023 and p = 0.046). This study is the first to report that rESWT can improve muscle mass and function in MHD patients. A subsequent study will be conducted to validate the clinical effects of rESWT in a larger sample of patients undergoing MHD.

Background Non-high-density lipoprotein cholesterol (non-HDL-C) may be an independent risk factor for cardio-cerebrovascular disease (CVD); however, the cutoff level in patients on maintenance hemodialysis (MHD) is unknown. Methods This was a retrospective multicenter study of MHD patients treated at 10 dialysis centers in Guangdong Province from July 1, 2016, to April 1, 2017. Laboratory test data were collected and CVD complications and outcomes recorded. Results In total, 1288 eligible patients were included in this study; the non-HDL-C interquartile range was 2.76 (2.24–3.45) mmol/L. Over a median follow-up time of 24 months, 141 patients developed CVD. The non-HDL-C level was a principal risk factor for such events (P 3.39 mmol/L. Conclusion Higher baseline non-HDL-C levels may increase the CVD risk in MHD patients. Thus, non-HDL-C effectively predicts CVD.

Kidney replacement therapy is required in up to one-third of patients after left ventricular assist device (LVAD) placement. A subset of these patients requires long-term maintenance hemodialysis and therefore needs durable vascular access but the ideal access in such patients has not been established. We present a series of 3 patients in whom arteriovenous grafts (AVGs) were successfully used for long-term kidney replacement therapy after LVAD placement. The maximum time from AVG placement to first successful AVG use was 40 days, and the longest AVG use duration was more than 2 years. 2 patients required AVG excision due to infection but both had successful placement of a second AVG. Total time on kidney replacement therapy was 993, 1,055, and 956 days for the 3 cases, of which dialysis catheter use was required for only 23%, 6.5%, and 27%, respectively. These cases suggest that AVG placement is a viable option for dialysis access in patients with LVADs.

Background and objectives Fat-based energy-dense nutritional supplements may offer benefits over protein- or carbohydrate-dense supplements for patients receiving dialysis because of the adverse metabolic consequences of the latter. We conducted a randomized controlled trial to assess the effects of the short-term use of a fat-based nutritional supplement on various measures of nutritional status in patients receiving maintenance hemodialysis who have low dietary energy intake. Design, setting, participants, & measurements We enrolled nondiabetic patients receiving hemodialysis for >3 months who had inadequate dietary energy intake ( Results The average age of the total population was 47 (SD: 12) years, and 55% were men. The median of dialysis vintage was 43.4 (22.5–76.3) months; 240 participants were randomly assigned to the intervention (n=120) or control group (n=120). In total, 228 (95%) participants completed the trial. The change in phase angle did not differ significantly between the intervention and control groups (estimate, 0.0; 95% confidence interval, −0.1 to 0.1 versus estimate, 0.0; 95% confidence interval, −0.1 to 0.1; estimated difference, 0.0; 95% confidence interval −0.2 to 0.2; P=0.99). None of the 19 domains of quality of life differed between the groups. Adverse events were reported in 23 (19%) participants in the control group and 40 (33%) participants in the intervention group. Conclusions In nondiabetic patients on maintenance hemodialysis, short-term administration of fat-based energy-dense nutritional supplement has no clinically significant effect on nutritional status as measured by phase angle. Podcast This article contains a podcast at https://https://www.asn-online.org/media/podcast/CJASN/2021_08_03_CJN16821020.mp3

Objective: Hepatitis E virus (HEV) is one of the prevalent nosocomially transmitted agents among patients on maintenance hemodialysis due to parenteral transmission of HEV and immunocompromised condition of chronic hemodialysis patients. Therefore, this study aimed to investigate prevalence, risk factors, and genotypic pattern of HEV infection among hemodialysis patients in South of Iran. Methods: All patients on maintenance hemodialysis attending the hemodialysis centers of Bushehr, Borazjan, and Genaveh cities for regular hemodialysis were enrolled in this study. Serum samples were tested for the presence of anti-HEV antibodies using ELISA kit. The serum samples were further tested for detection of HEV RNA using nested RT-PCR. Results: Of 226 hemodialysis patients, 155 patients (68.6%, 95% CI: 62.3%–74.3%) were positive for anti-HEV IgG antibody, of which 33 patients (14.6%, 95% CI: 10.6%–19.8%) had anti-HEV IgM antibody. The prevalence of anti-HEV IgG and anti-IgM antibodies in non-hemodialysis controls were 65.1% and 9.6%, respectively. Although the hemodialysis patients had higher prevalence of HEV than the controls, the difference was not significant. All samples were negative for HEV RNA. HEV seroprevalence among hemodialysis patients was not significantly associated with place of residency, ethnicity, level of education, gender distribution, hemodialysis duration, and levels of liver enzymes. HEV seropositive patients had significantly higher mean age compared to seronegative patients. Conclusion: This study reports the highest seroprevalence of HEV among hemodialysis patients in Iran. Inapparent HEV infection in the dialysis setting calls for regular screening of hemodialysis patients regardless of the hemodialysis duration, clinical symptoms, and liver function parameters.

Cardiovascular disease is the leading cause of death in maintenance hemodialysis (MHD) patients. The aim of this study is to investigate the predictive value of coronary artery calcification score (CACs) combined with bone mineral density (BMD) for the risk of cardiovascular diseases in MHD patients. From January 2017 to January 2019, we enrolled 112 MHD patients and 112 controls in Ningbo First Hospital, and retrospectively counted the cardiovascular events in the next 2 years after enrollment. According to the occurrence of cardiovascular events, the MHD patients were divided into CVD group and non-CVD group. The differences of vertebral BMD and CACs between the two groups were compared. ROC curve, Kaplan–Meier curve and Cox regression analyses were used for assess the predictive value of 2-year cardiovascular events in MHD patients. Among 112 MHD patients, 49 (43.75%) patients had cardiovascular events. The results showed that the average value of BMD in MHD patients was significantly lower than that in the control group (99.88 ± 30.99 VS. 108.35 ± 23.98, P = 0.0231). The CACs in MHD patients were significantly higher than that in the control group (317.81 ± 211.53 VS. 190.03 ± 100.50, P

Background Maintenance hemodialysis (MHD) patients face disadvantages with higher risk of acquiring SARS‐CoV‐2 infection, atypical manifestations, and associated multiple comorbidities. We describe patients' outcomes with symptomatic COVID‐19 on MHD in a large cohort of patients from India. Methods Data were collected prospectively from hemodialysis units in 11 public and private hospitals between March 15, 2020, and July 31, 2020. The survival determinants were analyzed using stepwise backward elimination cox‐regression analysis. Results Of the 263 total patients (mean age 51.76 ± 13.63 years and males 173) on MHD with symptomatic COVID‐19, 35 (13.3%) died. Those who died were older (p = 0.01), had higher frequency of diabetic kidney disease (p = 0.001), comorbidities (p = 0.04), and severe COVID‐19 (p = 0.001). Mortality was higher among patients on twice‐weekly MHD than thrice‐weekly (p = 0.001) and dialysis through central venous catheter (CVC) as compared to arteriovenous fistula (p = 0.001). On multivariate analysis, CVC use (HR 2.53, 95% CI 1.26–5.07, p = 0.009), disease severity (HR = 3.54, 95% CI 1.52–8.26, p = 0.003), and noninvasive ventilatory support (HR 0.59, 95% CI 0.25–0.99, p = 0.049) had significant effect on mortality. Conclusion The adjusted mortality risk of COVID‐19 in MHD patients is high in patients associated with severe COVID‐19 and patients having CVC as vascular access.

Background Current evidence suggests that the initiation of maintenance hemodialysis should not be based on a specific glomerular filtration rate (GFR) but on symptoms or signs attributable to kidney disease. However, it is difficult to predict the time point at which overt uremic syndrome develops in individuals. The estimated GFR is poorly correlated with occurrence of uremic symptoms, and some patients require dialysis at a higher eGFR than others. In this case, patients are more likely to be improperly prepared for dialysis. We investigated the predialysis characteristics of patients who require dialysis at a higher eGFR. Methods A total of 453 incident dialysis patients being monitored by a nephrologist from January 2013 to December 2018 were included. The predialysis characteristics when eGFR decreased to 20 mL/min/1.73 m2 were obtained. Results The mean age was 61 years, and 65.7% were men. Overall, the median eGFR at the first dialysis was 5.8 (interquartile range 4.6–7.3) mL/min/1.73 m2 and initiation of dialysis at the first quintile (≥7.8 mL/min/1.73 m2) was defined as ‘early initiation of dialysis’ Among the predialysis characteristics, heart failure (adjusted odds ratio 3.68; 95% confidence interval, 1.59–8.03), serum albumin 15 mg/mg (1.92, 1.16–3.18), and hyperuricemia (1.84; 1.05–3.23) were independent predictors of early initiation. Diabetes mellitus and the causes of kidney disease were not independent predictors of early initiation. The early initiation group was less likely to initiate dialysis with a permanent vascular access than the late initiation group. Conclusions For patients with heart failure, low serum albumin level, high BUN/Cr ratio, or hyperuricemia, clinicians can provide predialysis counseling in advance and consider early creation of vascular access.

In the United States, hemodialysis remains the most common treatment modality for kidney failure, chosen by almost 90% of incident patients. A functioning vascular access is key to providing adequate hemodialysis therapy. Recently, major innovations in devices and technology for hemodialysis vascular access care have rapidly changed the landscape. Novel endovascular devices for creation of arteriovenous fistulas may offer a solution to the barriers encountered in initiating maintenance hemodialysis with a permanent vascular access rather than a central venous catheter (CVC). Furthermore, in the prevalent hemodialysis population, the minimally invasive endovascular arteriovenous fistula procedure should help improve long wait times for vascular access creation, which remains a major barrier to reducing CVC dependence. Bioengineered grafts are being developed and may offer another option to polytetrafluoroethylene grafts. Early studies with these biocompatible grafts are promising, as additional studies continue to evaluate their clinical outcomes in comparison to cryopreserved or synthetic options. Prolonging the vascular access patency with appropriate use of devices such as drug-coated balloons and stent grafts may complement the novel techniques of creating arteriovenous access. Finally, innovative solutions to treat stenosed and occluded thoracic central veins can provide an approach to creating a vascular access and allow patients with exhausted vasculature to remain on hemodialysis. The robust developments in hemodialysis vascular access are likely to change practice patterns in the near future.

Background Transitioning to maintenance hemodialysis (HD) is a vulnerable period for persons with end-stage renal disease (ESRD), punctuated by high rates of depression, hospitalizations and death. Screening for depression during this time may help to improve patient outcomes but formal inquiry has yet to be conducted. Among a national Veteran cohort, we examined whether depression screening in the year prior to HD initiation led to improved outcomes in the year thereafter. Methods Associations between pre-ESRD depression screening and post-ESRD outcomes were examined with Cox proportional hazards models (mortality) and Poisson regression models (hospitalization). Hierarchal adjustment models accounted for sociodemographic, clinical, pre-ESRD care and dialysis characteristics. Results The final analytic cohort of the study was 30 013 Veterans of whom 64% underwent pre-ESRD depression screening. During the 12 months post-transition, the crude all-cause mortality rate was 0.32 person-year for those screened and 0.35 person-year for those not screened, while the median (interquartile range) hospitalizations were 2 (2, 2) per year for both groups. In fully adjusted models, pre-ESRD depression screening was associated with a lower risk of mortality [hazard ratio (95% confidence interval): 0.94 (0.90–0.99)] and hospitalization [incidence rate ratio (95% confidence interval): 0.97 (0.9–0.99)]. Conclusion Depression screening among adults prior to maintenance HD transition may be associated with better outcomes during the following year.

We compared the effects on the nutritional condition and health-related quality of life (HR-QoL) of the treatment of patients with on-line hemodiafiltration (OL-HDF) and conventional hemodialysis (CHD) using a superflux dialyzer. In total, 47 maintenance (M) HD patients were treated by CHD with a high-flux dialyzer for the first 4 months (1st CHD) and were then switched to predilution OL-HDF for the next 4 months (OL-HDF), after which CHD was resumed for the last 4 months (2nd CHD). We assessed the clinical parameters, fat mass value, muscle mass value, and HR-QoL. In patients with low serum albumin levels, these levels significantly (p < 0.05) increased in the OL-HDF period. Moreover, the fat mass values significantly (p < 0.05) increased in patients with decreased fat mass values in the OL-HDF period. Although there was no significant difference in the patients with higher scores of physical functioning, role physical, vitality, and social functioning, patients with lower scores in the 1st CHD period had significantly increased (p < 0.05) in the OL-HDF period. In this crossover study, we revealed that OL-HDF treatment significantly improved the nutritional conditions and HR-QoL scores compared with the improvement observed after CHD with a superflux dialyzer, especially for maintenance hemodialysis patients with malnutrition and a low QoL.

Background: Nurses are the first to encounter a patient in pain. A nurse’s knowledge of pain management in patients receiving hemodialysis allows them to provide optimal pain management. Objective: The aim of this qualitative study is to explore the experiences, perceptions, and beliefs of nurses in the hemodialysis unit regarding pain management practices and identify nurses’ educational needs to improve nurses’ pain management in practice. Methods: A purposive sample of 16 nurses working in four out-patient hemodialysis units in Amman, Jordan, was recruited. The data was collected through semi-structured interviews. The interviews were audio-recorded and transcribed manually for the following content analysis scheme. Results: The five themes and fifteen sub-categories were extracted from the nurses' experiences regarding nurses’ knowledge of pain management. The five categories that emerged from the analysis were (1) nurses’ knowledge of pain management, (2) nurses’ self-learning pain management strategy, (3) nurses’ approach to pain management, (4) patients continue to suffer unrelieved pain, (5) nurses’ educational needs. Relevance to Clinical Practice: This data will prove to be useful for evaluating pain management practices for patients on maintenance hemodialysis, developing educational programs for nurses working in hemodialysis units with a focus on improving pain management, and providing knowledge regarding these issues. More research is recommended among nurses for understanding pain knowledge in patients on maintenance hemodialysis. Conclusion: This qualitative analysis indicated that nurses are not fully aware of various strategies for pain management. Nurses’ perception of pain and pain management was found to be limited to pain assessment and some non-pharmacological management strategies. It has been revealed that nurses require educational interventions regarding pain management in practice.

Patients undergoing maintenance hemodialysis dialysis (MHD) are at high risk of sarcopenia. Diagnosing sarcopenia requires measurement of both muscle mass and muscle function. However, few studies have rigorously evaluated the best timing for assessment. This study aimed to evaluate the changes in body composition following hemodialysis in an Asian population. Overall, 87 MHD patients were included. Body composition was estimated using bioelectrical impedance analysis. Handgrip strength was measured using a quantitative handgrip dynamometer, and physical performance was assessed using the 6-m usual gait speed. All measurements were performed pre and post dialysis. Blood samples were collected before and after the same dialysis session. The prevalence of sarcopenia ranged from 6.9% to 18.8% pre dialysis (40–59-year group, 6.9%; 60–80-year group, 16.7%; >80-year group, 18.8%) and from 13.8% to 62.5% post dialysis. The body weight decreased from 59.32 ± 11.20 kg pre dialysis to 57.71 ± 11.05 kg post dialysis. Both the extracellular and intracellular water levels decreased post dialysis (from 14.70 ± 3.81 to 13.6 ± 2.82 L, P

Introduction: Chronic Kidney Disease causes sudden changes in the daily lives of patients and creates a great impact on their quality of life. Failure of adherence in Hemodialysis can lead to increased morbidity, mortality, cost, and burden on health care system. Objectives: This study was conducted to assess the quality of life and adherence to treatment of patients undergoing Hemodialysis. Methodology: A descriptive correlational study was carried out at Nobel Medical College Teaching Hospital, Biratnagar, among 96 patients who were under HD using convenience sampling technique. The data was collected through face to face interview for the period of 5 months. Quality of life and adherence to treatment were assessed using Kidney Disease Quality of Life Questionnaire (KDQOL) and End Stage Renal Disease Adherence Questionnaire (ESRD – AQ) respectively. The data was analyzed using t test, Spearman correlation statistics. Results In this study, the overall mean score of quality of life (QOL) of patients under HD was 48.9±13.7. More than half (54.1%) of the patients had moderate adherence to treatment while 31.2% had good adherence. Domains with the highest and lowest scores on quality of life and adherence to treatment were social domain and illness impact and adherence to HD treatment and diet restriction, respectively. There was statistically significant association between total score of quality of life and duration of HD (p≤0.05). Likewise, there was statistically significant association between adherence to treatment and marital status (p≤0.05), educational status (p≤0.05), ethnicity (p≤0.05), duration of illness (p≤0.05). Poor correlation (r= 0.273) was observed between quality of life and adherence to treatment. Conclusion: On average, the kidney disease component dimension of quality of life of patients under HD is higher and the overall level of adherence to treatment was moderate. Thus proper periodic counseling on illness and its long term impact, regular follow up as well as information on adherance to dietary measures are important to improve the quality of life and treatment adherance of patients under hemodialysis.

Key Points Increased risk of SARS-CoV-2 infection was associated with community prevalence. Increased risk of SARS-CoV-2 infection was associated with exposure to infected family members and personal infection prevention measures

BackgroundThe association between serum advanced oxidation protein products (AOPP) and mortality risk remains equivocal. We aimed to assess the correlation of serum AOPP levels with the risk of all-cause mortality in hemodialysis (HD) patients.MethodsA total of 1394 maintenance HD patients with complete data on AOPP and related parameters were included from China Collaborative Study on Dialysis (CCSD), a multi-center, prospective cohort study. The primary outcome was all-cause mortality, the secondary outcome was cardiovascular disease (CVD) mortality.ResultsDuring a median follow-up duration of 5.2 years (IQR, 2.1–5.4), all-cause mortality occurred in 492 (31.4%) participants. Overall, there was a reversed L-shaped association between serum AOPP and all-cause mortality in HD patients (Pfor nonlinearity = 0.04), with an inflection point at 87 µmol/L. Accordingly, there was no significant association between serum AOPP and all-cause mortality (per SD increment; HR, 0.94; 95%CI, 0.84, 1.05) in participants with AOPP ConclusionsElevated serum AOPP levels were associated with higher risk of all-cause mortality in Chinese maintenance HD patients.

A 24-year-old man on maintenance hemodialysis presented with bilateral cavitary consolidations and methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia following ulceration of the skin over his arteriovenous (AV) fistula cannulation site. A diagnosis of septic pulmonary embolism was made, which presumptively originated from a localized MSSA infection of his AV access. He had an excellent response to a 28-day course of cloxacillin, with the resolution of the pulmonary lesions.

Clostridioides difficile infections (CDIs) cause substantial morbidity and mortality. Patients on maintenance hemodialysis are 2 to 2.5 times more likely to develop CDI, with mortality rates 2-fold higher than the general population. Hospitalizations due to CDI among the maintenance hemodialysis population are high, and the frequency of antibiotic exposures and hospitalizations may contribute to CDI risk. In this report, a panel of experts in clinical nephrology, infectious diseases, and infection prevention provide guidance, based on expert opinion and published literature, aimed at preventing the spread of CDI in outpatient hemodialysis facilities.

Background: Several parasites are responsible for life threatening infections in immunocompromisedpatients including those with chronic renal diseases. Determination of enteroparasitosis prevalence inpatients with end stage renal disease (ESRD) experiencing hemodialysis (HD) showed elevated rates ofinfection, primarily by protozoa.Objectives: To investigate the common intestinal parasites among patients with ESRD undergoing HD inBenha University Hospital.Subjects and Methods: This case-control research was performed on 57 patients subjected to HDand 60 apparently healthy people as control group with no history of kidney disorders or otherimmunosuppressive conditions in the control group. Age of participants ranged from 20-70 years in bothgroups. Three consecutive fresh fecal samples from all participants were obtained after completion of thequestionnaire and examined macroscopically and microscopically to identify various stages of commonpathogenic intestinal parasites using iodine and modified Ziehl-Neelsen stains to detect protozoa.Results: The total rate of parasite infection was 68.4% and 48.3% in ESRD patients and control group,respectively. The discrepancies between the two groups were statistically significant. E. histolytica/E.dispar was the commonest parasite compared to other parasites in the two groups.Conclusion: In ESRD patients, a high detection rate of intestinal parasites was reported which can lead tosevere complications in these patients being immunocompromissed individuals. Hence, stool examintionshould also be integrated into the standard clinical care of these patients.

BACKGROUND: Restless legs syndrome (RLS) is a common complication in maintenance hemodialysis (MHD) patients. Current study was conducted to analysis the effectiveness and safety of electroacupuncture on 3 acupuncture points from lower limb meridians in the treatment of RLS. METHODS: A total of 7 MHD patients (5 Male and 2 Female) in our center with severe RLS symptom were enrolled. After one month of pharmacological washout period, patients received 12 sessions of electroacupuncture on three acupoints (Zusanli (ST36), Sanyinjiao (SP6) and Taichong (LR-3)) during HD. Severity of RLS symptoms and the sleep quality were evaluated by IRLSSG and ISI scores for 3 times (before, after and 1 month later of the electroacupuncture treatment). RESULTS: The average age of enrolled patients was 52.6±8.9 years, with median dialysis duration of 3.0 years. The hemoglobin level was 125.9±22.9 g/l. The IRLSSG score was significantly lower after electroacupuncture treatment (9.4±3.9) than that before treatment (17.3±4.7) (P CONCLUSION: Electroacupuncture on three lower limbs acupoints during MHD was as a safe and effective treatment for attenuating the symptoms of RLS and improvement of sleep quality in hemodialysis patients, and the therapeutic effect maintain for at least one month.

Background Maintenance hemodialysis (MHD) patients are particularly vulnerable to coronavirus disease 2019 (COVID-19), a viral disease that may cause interstitial pneumonia, impaired alveolar gas exchange and hypoxemia. We ascertained the time course of intradialytic arterial oxygen saturation (SaO2) in MHD patients between 4 weeks pre-diagnosis and the week post-diagnosis of COVID-19. Methods We conducted a quality improvement project in confirmed COVID-19 in-center MHD patients from 11 dialysis facilities. In patients with an arterio-venous access, SaO2 was measured 1×/min during dialysis using the Crit-Line monitor (Fresenius Medical Care, Waltham, MA, USA). We extracted demographic, clinical, treatment and laboratory data, and COVID-19-related symptoms from the patients’ electronic health records. Results Intradialytic SaO2 was available in 52 patients (29 males; mean ± standard deviation age 66.5 ± 15.7 years) contributing 338 HD treatments. Mean time between onset of symptoms indicative of COVID-19 and diagnosis was 1.1 days (median 0; range 0–9). Prior to COVID-19 diagnosis the rate of HD treatments with hypoxemia, defined as treatment-level average SaO2 Conclusions In HD patients, hypoxemia may precede the onset of clinical symptoms and the diagnosis of COVID-19. A steep decline of SaO2 is associated with poor patient outcomes. Measurements of SaO2 may aid the pre-symptomatic identification of patients with COVID-19.

Hyperkalemia is a frequent abnormality in patients treated with thrice weekly maintenance hemodialysis (MHD) ([1][1]). Its clinical relevance is underscored by potassium’s physiologic effects on the membrane potential and the acute arrhythmogenicity of its excursions (both hypo- and hyperkalemia