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Home hemodialysis (HDD) is implemented in the Valencian Community with a higher prevalence than to the rest of the national territory, with a prevalence of 13.4 patients' pmp in December 2018. We carried out an assessment of the patients' characteristics and the overall and technical survival in HDD depending on the historical moment of onset and its origin.We conducted a retrospective and descriptive study including patients of the Valencian Registry of Renal Patients from the beginning of data reported until December 2020. We calculated overall survival (combined event death-technical failure, censoring transplantation) and technical survival (event technical failure, censoring exitus and transplantation). Comparing technical survival according to the starting era: ancient (1976-2000) vs modern (2001-2020) and according to the modality of origin. We performed univariate and multivariate Cox regression in the total series for both overall and technical survivals.236 patients on HDD (611.4 patient-years of follow-up), mean age 49.7±16.3 years; median time of prior renal replacement therapy 0.2 years. The ratio of transplantation, death, and technical failure were 13.2, 4.4, and 7 events per 100 patient-years, respectively. In the comparison by ancient (n=57) vs modern (n=179) eras, age (37.5 vs 53.5 years), DM (3.5 vs 13.4%) and chronic tubuleinterstitial nephropathy (24.6 vs 8.9%) as a cause of chronic kidney disease were statistically significant. The probability of coming from outpatient consultation (33.3 vs 48.6%) and peritoneal dialysis (1.8 vs 12.8%) were higher in modern era with statistical significance. In the ancient era a single hospital centralized 57.9% of the patients, and in the modern era between two hospitals centralized 55.8% of the patients. Overall survival in the ancient era was 83.7% at 1 year, 77.4% at 2 years, and 61% at 5 years; and in the modern era 87.3% per year, 83% 2 years and 47.8% 5 years (Log Rank 0.521). Technical survival in the ancient era was 85.4% at 1 year, 79% 2 years, and 64.1% 5 years; and in the modern era 91.4% per year, 88.5% 2 years and 74.5% 5 years (Log Rank 0.195). There were no statistical differences in the comparison based on technical of provenance. In the Cox regression it was statistically significant for overall survival: the age and being diagnosed with heart disease, vascular disease or active neoplasia and for technical survival liver disease or social problem, both in univariate and multivariate.In the modern era there is a considerable increase in HDD patients in the Valencian Community. There was a center effect in the development of HDD programs, most of the patients depended on few healthcare centers. The patients were older and had greater comorbidity in the modern era, despite this without affecting the technical and overall survival of the HDD.

Resumen Introduccion La hemodialisis domiciliaria (HDD) esta especialmente implementada en la Comunidad Valenciana en comparacion con el resto del territorio nacional, con una prevalencia de 13,4 pacientes pmp a diciembre de 2018. Realizamos una valoracion de las caracteristicas de los pacientes y de la supervivencia global y tecnica del paciente en HDD en funcion del momento historico de inicio y de su procedencia. Material y metodos Pacientes incluidos en el Registro de Enfermos Renales de la Comunidad Valenciana desde que se reportan datos al mismo hasta diciembre de 2020. Estudio descriptivo y retrospectivo, calculando supervivencia global (evento combinado muerte-fallo tecnico, censurando trasplante) y supervivencia tecnica (evento fallo tecnico, censurando muerte y trasplante). Comparamos la supervivencia de la tecnica en funcion de era de inicio: antigua (1976-2000) vs. moderna (2001-2020), y en funcion de la modalidad de procedencia. Realizamos regresion de Cox uni- y multivariante en el total de la serie tanto para supervivencia global como tecnica. Resultados Doscientos treinta y seis pacientes en HDD (611,4 pacientes-ano de seguimiento), edad media 49,7 ±16,3 anos; tiempo terapia renal sustitutiva previa 0,2 anos de mediana. Los ratios de trasplante, muerte y fallo tecnico fueron 13,2; 4,4 y 7 eventos por 100 pacientes-ano respectivamente. En la comparacion por eras segun inicio en HDD, antigua (n = 57) vs. moderna (n = 179) fue estadisticamente significativa la edad (37,5 vs. 53,5 anos), la DM (3,5 vs. 13,4%) y la nefropatia tubulointersiticial cronica (24,6 vs. 8,9%) como causa de enfermedad renal cronica. Hubo en la era moderna mayor probabilidad de provenir de consulta externa (33,3 vs. 48,6%) y de dialisis peritoneal (1,8 vs. 12,8%) con significacion estadistica. En era antigua un unico hospital centralizaba el 57,9% de los pacientes, y en era moderna entre 2 hospitales centralizaban el 55,8% de los pacientes. La supervivencia global en era antigua fue del 83,7% al ano, del 77,4% a 2 anos y del 61% a 5 anos; y en era moderna del 87,3% al ano, del 83% a 2 anos y del 47,8% a 5 anos (Log Rank: 0,521). La supervivencia tecnica en era antigua fue 85,4% al ano, 79% a 2 anos y 64,1% a 5 anos; y en era moderna 91,4% al ano, 88,5% a 2 anos y 74,5% a 5 anos (Log Rank: 0,195). No hubo diferencias estadisticas en la comparacion en funcion de la procedencia. En la regresion de Cox fueron estadisticamente significativos para supervivencia global la edad y estar diagnosticado de cardiopatia, enfermedad vascular o neoplasia activa, y para la supervivencia tecnica hepatopatia o problema social, tanto en analisis univariante como en multivariante. Conclusion En la era moderna existe un incremento considerable de pacientes en HDD en la Comunidad Valenciana. Hubo un efecto centro en el desarrollo de los programas de HDD, la mayoria de los pacientes dependian de pocos centros asistenciales. Los pacientes fueron de mayor edad y mayor comorbilidad en la era moderna, pese a ello sin afectar ni la supervivencia tecnica y ni global de la HDD.

Acetate is widely used as a dialysate buffer to avoid the precipitation of bicarbonate salts. However, even at low concentrations that wouldn’t surpass the metabolic capacity of the Krebs tricarboxylic acid (TCA) cycle, other metabolic routes are activated, leading to undesirable clinical consequences by poorly understood mechanisms. This study aims to add information that could biologically explain the clinical improvements found in patients using citrate dialysate. A unicentric, cross-over, prospective targeted metabolomics study was designed to analyze the differences between two dialysates, one containing 4 mmol/L of acetate (AD) and the other 1 mmol/L of citrate (CD). Fifteen metabolites were studied to investigate changes induced in the TCA cycle, glycolysis, anaerobic metabolism, ketone bodies, and triglyceride and aminoacidic metabolism. Twenty-one patients completed the study. Citrate increased during the dialysis sessions when CD was used, without surpassing normal values. Other differences found in the next TCA cycle steps showed an increased substrate accumulation when using AD. While lactate decreased, pyruvate remained stable, and ketogenesis was boosted during dialysis. Acetylcarnitine and myo-inositol were reduced during dialysis, while glycerol remained constant. Lastly, glutamate and glutarate decreased due to the inhibition of amino acidic degradation. This study raises new hypotheses that need further investigation to understand better the biochemical processes that dialysis and the different dialysate buffers induce in the patient’s metabolism.

Background: Currently, bicarbonate-based dialysate needs a buffer to prevent precipitation of bicarbonate salts with the bivalent cations, and acetate at 3–4 mmol/L is the most used. However, citrate is being postulated as a preferred option because of its association with better clinical results by poorly understood mechanisms. In that sense, this hypothesis-generating study aims to identify potential metabolites that could biologically explain these improvements found in patients using citrate dialysate.Methods: A unicentric, cross-over, prospective untargeted metabolomics study was designed to analyze the differences between two dialysates only differing in their buffer, one containing 4 mmol/L of acetate (AD) and the other 1 mmol/L of citrate (CD). Blood samples were collected in four moments (i.e., pre-, mid-, post-, and 30-min-post-dialysis) and analyzed in an untargeted metabolomics approach based on UPLC-Q-ToF mass spectrometry.Results: The 31 most discriminant metabolomic variables from the plasma samples of the 21 participants screened by their potential clinical implications show that, after dialysis with CD, some uremic toxins appear to be better cleared, the lysine degradation pathway is affected, and branched-chain amino acids post-dialysis levels are 9–10 times higher than with AD; and, on its part, dialysis with AD affects acylcarnitine clearance.Conclusion: Although most metabolic changes seen in this study could be attributable to the dialysis treatment itself, this study successfully identifies some metabolic variables that differ between CD and AD, which raise new hypotheses that may unveil the mechanisms involved in the clinical improvements observed with citrate in future research.

Introduction: The composition of the dialysate is a crucial feature in the dialysis treatment. Two of its most debated elements are the optimal calcium concentration and the use of acetate as a buffer. Moreover, among the different alternatives to achieve acetate-free dialysis, the use of citrate is postulated as the most suitable option. The objective of this study is to identify the potential beneficial effects of citrate when compared to acetate dialysate (AD) both in short-term effects (especially regarding intradialytic calcium balance and cardiac damage biomarkers) and in medium-term ones with CKD-mineral and bone disorder (CKD-MBD) and inflammatory biomarkers measured after twelve sessions performed with each dialysate. Methods: This is a unicentric, cross-over, prospective study. Each patient underwent 24 dialysis sessions, 12 with each dialysate buffer. Blood samples were taken in 2 different sessions with each acidifier. They include CKD-MBD and inflammatory biomarkers. The calcium concentration of both dialysates was 1.5 mmol/L, while all other dialysis parameters and patients’ treatment remained unchanged during the study period. Results: When comparing AD and citrate dialysate (CD), there were no differences in pre-dialysis ionized calcium (iCa) (1.11 vs. 1.08 mmol/L) in both groups. However, there was a significant increase in iCa with the use of AD in immediate and 30-min post-dialysis blood samples. In contrast, iCa levels remained stable with the use of citrate. Inflammatory biomarkers were also reduced after the use of CD. Conclusions: The use of citrate provides interesting advantages when compared to acetate. It maintains iCa levels stable during dialysis sessions with a neutral or negative effect on calcium balance, and it improves the chronic inflammatory condition that comes with long-time hemodialysis treatment. These beneficial effects may lead to an improvement in clinical outcomes.

BACKGROUND AND AIMS Chronic kidney disease (CKD) produces profound changes in lipid metabolism, and these associated lipid disorders, in turn, contribute to the progression of CKD and its cardiovascular complications. Patients on peritoneal dialysis have a more atherogenic lipid profile than non-dialysis-dependent CKD patients or on HD. In the general population, the reduction of total cholesterol and LDL levels is associated with improved clinical outcomes in terms of morbidity and mortality; however, several studies have failed to obtain these same results in patients on dialysis. The use of lipidomics to detect a broader panel of lipid species can improve the prediction of the different alterations that influence cardiovascular mortality. METHOD This is a single-center prospective observational study of a cohort of CKD patients who start renal replacement therapy with continuous ambulatory peritoneal dialysis (CAPD). Data from 39 patients were examined. All samples for routine laboratories and lipidomics studies were obtained the day before starting CAPD (T0) and 6 months after (T1). Samples were analysed on an Ultra-Performance Liquid Chromatography system. The differences in the lipid profile analytical variables between baseline and 6 months after the start of CAPD were analysed. For the lipidomic analysis, each compound was grouped with its possible adducts and compound class based on the International Lipid Classification. RESULTS Thirty-nine patients were enrolled the study. Their mean age was 57.9 ± 16.3 years. The underlying renal diseases were glomerular disease (15 patients), diabetic kidney disease (10), congenital kidney disease (4), hypertensive kidney disease (2), interstitial nephropathy (2) and others (6). Hypertension was present in 96.3% of the patients, diabetes mellitus in 30.8% and 30 of the 39 patients had dyslipidemia (76.9%). Of the group of patients with dyslipidemia, only one of them was not on statin treatment. Table 1 shows the results of the analytical variables of lipid profile, serum glucose and renal function before and 6 months after initiating CAPD. The levels of CT and LDL were lower 6 months after CAPD initiation, but these were not statistically significant. Using the plasma lipid profile, with a mass spectrometry approach, a significant increase (P CONCLUSION Our LC-QTOF/MS-based lipidomics approach to study the effect of starting renal replacement therapy with CAPD in patients with CKD shows that total FFAs increased after 6 months on this technique. Within this group of lipids, FA 16:1 (palmitoleic acid) and FA 18:0 (stearic acid) were the ones that increased the most. An earlier study demonstrated that FFA levels are increased in the plasma of CKD patients; moreover, they have reported that higher levels of saturated fatty acids in serum correlate with sudden cardiac death in patients starting HD. Likewise, monounsaturated fatty acids are the products of stearoyl-CoA desaturase (SCD) catalyzed reactions and act as substrates to synthesize phospholipids and triglycerides. The activity of SCD is very high in patients with cardiovascular disease, hypertension and diabetes.

Background. Lipids are molecules that constitute a fundamental part of the plasma. Chronic kidney disease (CKD) produces profound changes in lipid metabolism, and associated lipid disorders, in turn, contribute to the progression of CKD. Patients on peritoneal dialysis (PD) have more atherogenic lipid profiles than non-dialysis-dependent CKD patients. Methods. Single-center prospective observational study of a cohort of CKD patients who started renal replacement therapy with continuous ambulatory peritoneal dialysis. The differences in the lipid profile and analytical variables before and six months after the start of peritoneal dialysis were analyzed. Samples were analyzed on an Ultra-Performance Liquid Chromatography system. Results. Thirty-nine patients were enrolled in this study. Their mean age was 57.9 ± 16.3 years. A total of 157 endogenous lipid species of 11 lipid subclasses were identified. There were significant increases in total free fatty acids (p< 0.05), diacylglycerides (p Conclusions. Patients on PD present changes in the lipidomic profile beyond the classic markers of dyslipidemia, that suggest an increased cardiovascular risk in them.

Resumen: Se describe la experiencia de un hospital terciario y cuatro centros concertados de hemodiálisis adscritos al mismo durante la epidemia de COVID-19. Se resume la organización asistencial que se ha llevado a cabo y el curso clínico de los 16 casos de COVID-19 en pacientes en hemodiálisis. La aplicación conjunta de medidas que incluyen el cribado de pacientes, la investigación precoz de casos posibles, el aislamiento de los casos confirmados, en investigación o en contactos, así como la utilización de medidas de protección individuales, han permitido controlar la epidemia. Se compara el curso clínico de estos 16 pacientes con la serie publicada por el Hospital Universitario de Wuhan y con los datos del registro de infecciones COVID-19 de la Sociedad Española de Nefrología. En nuestra experiencia, y a diferencia de lo comunicado por el centro de Wuhan, la enfermedad COVID-19 en los pacientes en hemodiálisis es grave en un porcentaje importante de los casos y la letalidad, elevada, es mayormente causada por la propia infección. Las medidas de contención de la epidemia son eficaces. Abstract: The experience of a tertiary hospital and four hemodialysis centers attached to it during the COVID-19 epidemic is described. The organization of care that has been carried out and the clinical course of the 16 cases of COVID-19 in hemodialysis patients are summarized. The joint application of measures, including patient screening, the early investigation of possible cases, the isolation of confirmed, investigational or contact cases, as well as the use of individual protection measures, has enabled the epidemic to be controlled. The clinical course of these 16 patients is compared with the series published by the Wuhan University Hospital and with the data from the COVID-19 infection registry of the Spanish Society of Nephrology. In our experience, and unlike what was reported by the Wuhan Center, COVID-19 disease in hemodialysis patients is severe in a significant percentage of cases, and high lethality is mostly caused by the infection itself. Measures to contain the epidemic are effective.

Background and Aims Abnormalities of bone mineral parameters are associated with increased mortality in patients on dialysis, but their effects and the optimal range of these biomarkers are less well characterized in non-dialysis chronic kidney disease (CKD). Method PECERA (Collaborative Study Project in Patients with Advanced Chronic Kidney Disease) is a 3-year, multicentre, open-cohort, prospective study carried out in 995 adult patients with CKD stages 4-5 not on dialysis enrolled in 2007-09 from 12 centres in Spain. Associations between levels of serum calcium (corrected for serum albumin), phosphate, and intact parathyroid hormone (iPTH) and all-cause mortality were examined using time-dependent Cox proportional hazards models and penalized splines analysis adjusted by demographics and comorbidities, treatments and biochemical collected at baseline and every 6 months for 3 years. Results After a median follow-up of 30 months (IQR:14-37 months) there were 180 deaths (18%). The association of calcium and phosphate with all-cause mortality was U-shaped (Figure). The serum values associated with the minimum risk of mortality were 9.35 mg/dL for calcium and 3.56 mg/dL for phosphate, being the lowest risk ranges between 7.4 to 10.7 mg/dL and between 2.3 to 4.6 mg/dL for calcium and phosphate, respectively. For iPTH levels, the association was J-shaped, with an increased risk for all-cause mortality at levels > 110 pg/mL. Conclusion As previously reported in dialysis patients, PECERA provided evidence on the association of serum calcium, phosphate and iPTH levels with all-cause mortality in stage 4 and 5 CKD patients, suggesting potential survival benefits of controlling bone mineral parameters in this population. Whereas the ranges of calcium and phosphate associated with the lowest mortality in the study were consistent with the current K-DIGO guidelines, our results suggested that the threshold for considering anti-parathyroid treatment might be lower than is currently recommended.

Resumen Se describe la experiencia de un hospital terciario y cuatro centros concertados de hemodiálisis adscritos al mismo durante la epidemia de COVID-19. Se resume la organización asistencial que se ha llevado a cabo y el curso clínico de los 16 casos de COVID-19 en pacientes en hemodiálisis. La aplicación conjunta de medidas que incluyen el cribado de pacientes, la investigación precoz de casos posibles, el aislamiento de los casos confirmados, en investigación o en contactos, así como la utilización de medidas de protección individuales, han permitido controlar la epidemia. Se compara el curso clínico de estos 16 pacientes con la serie publicada por el Hospital Universitario de Wuhan y con los datos del registro de infecciones COVID-19 de la Sociedad Española de Nefrología. En nuestra experiencia, y a diferencia de lo comunicado por el centro de Wuhan, la enfermedad COVID-19 en los pacientes en hemodiálisis es grave en un porcentaje importante de los casos y la letalidad, elevada, es mayormente causada por la propia infección. Las medidas de contención de la epidemia son eficaces.

Objectives To assess the cost-effectiveness of methoxy polyethylene glycol-epoetin β (CERA) used in routine clinical practice for maintenance of Hb levels in patients with chronic kidney disease in predialysis and previous stabilised treatment with conventional epoetin. As secondary objective, we analyse the use of CERA in clinical practice. Methods Retrospective observational study including all patients receiving conventional epoetin who were switched to CERA over a period of 2 years. Demographic, clinical and therapeutic variables were collected. The main effectiveness outcome chosen was the difference between the haemoglobin level with conventional epoetin versus CERA after 24 weeks of treatment. Economic analysis was performed taking into account only the direct drug acquisition cost, the main cost outcome was the difference of patient/month cost with conventional epoetin versus CERA. Results Sixty-nine patients with a mean age of 68 years (35% male) were enrolled in the study. In 92.8% of cases, the starting dose used was lower than that recommended in the summary of product characteristics. Mean haemoglobin at 0 and 24 weeks was 11.9 and 11.7 g/dL, with no statistically significant difference (−0.2, 95% CI −0.6 to 0.1). With CERA, a lower proportion of patients exceeded the haemoglobin limit of 13 g/dL. The patient/month cost was 159.6€ and 169.9€ at weeks 0 and 24, with a difference of 10.3€ (95% CI −6.8 to 27.5). Conclusions CERA was as effective as conventional epoetin for the maintenance of haemoglobin levels after 24 weeks of follow-up. Conversion to CERA has led to an increase of 10.3€ the patient/month cost.