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Introduction: For end‐stage renal disease (ESRD) patients residing in skilled nursing facilities (SNFs), the logistics and physical exhaustion of life‐saving hemodialysis therapy often conflict with rehabilitation goals. Integration of dialysis care with rehabilitation programs in a scalable and cost‐efficient manner has been a significant challenge. SNF‐resident ESRD patients receiving onsite, more frequent hemodialysis (MFD) have reported rapid post‐dialysis recovery. We examined whether such patients have improved Physical Therapy (PT) participation. Methods: We conducted a retrospective electronic medical records review of SNF‐resident PT participation rates within a multistate provider of SNF rehabilitation care from January 1, 2022 to June 1, 2022. We compared three groups: ESRD patients receiving onsite MFD (Onsite‐MFD), ESRD patients receiving offsite, conventional 3×/week dialysis (Offsite‐Conventional‐HD), and the general non‐ESRD SNF rehabilitation population (Non‐ESRD). We evaluated physical therapy participation rates based on a predefined metric of missed or shortened (<15 min) therapy days. Baseline demographics and functional status were assessed. Findings: Ninety‐two Onsite‐MFD had 2084 PT sessions scheduled, 12,916 Non‐ESRD had 225,496 PT sessions scheduled, and 562 Offsite‐Conventional‐HD had 9082 PT sessions scheduled. In mixed model logistic regression, Onsite‐MFD achieved higher PT participation rates than Offsite‐Conventional‐HD (odds ratio: 1.8, CI: 1.1–3.0; p < 0.03), and Onsite‐MFD achieved equivalent PT participation rates to Non‐ESRD (odds ratio: 1.2, CI: 0.3–1.9; p < 0.46). Baseline mean ± SD Charlson Comorbidity score was significantly higher in Onsite‐MFD (4.9 ± 2.0) and Offsite‐Conventional‐HD (4.9 ± 1.8) versus Non‐ESRD (2.6 ± 2.0; p < 0.001). Baseline mean self‐care and mobility scores were significantly lower in Onsite‐MFD versus Non‐ESRD or Offsite‐Conventional‐HD. Discussion: SNF‐resident ESRD patients receiving MFD colocated with rehabilitation had higher PT participation rates than those conventionally dialyzed offsite and equivalent PT participation rates to the non‐ESRD SNF‐rehabilitation general population, despite being sicker, less independent, and less mobile. We report a scalable program integrating dialysis and rehabilitation care as a potential solution for ESRD patients recovering from acute hospitalization. [ABSTRACT FROM AUTHOR]

Introduction: The effects of denosumab on bone mineral density (BMD) and metabolism in patients with end‐stage renal disease (ESRD) remain controversial. Hence, we performed a systematic review and meta‐analysis of observational studies. Methods: The MEDLINE, EMBASE, and Cochrane Library databases were searched in June 2022 to identify studies that evaluated the risk of denosumab‐associated hypocalcemia and changes in bone metabolism, changes in BMD from baseline to post‐treatment in patients with ESRD. Findings: Twelve studies with 348 participants were included. The pooled incidence of hypocalcemia during denosumab treatment was 35.0% (95% confidence interval [CI], 25%–46%; I2 = 63.6%). There were no significant changes in either the serum calcium or phosphate levels from the baseline to post‐treatment period; the mean differences were 0.04 mg/dL (95% CI, −0.12 to 0.20 mg/dL) and −0.39 mg/dL (95% CI, −0.89 to 0.12 mg/dL). We found significant changes in the alkaline phosphatase and parathyroid hormone levels; the standardized mean differences were −2.98 (95% CI, −5.36 to –0.59) and −3.12 (95% CI: –4.94 to –1.29), respectively. Denosumab may increase BMD, with mean differences of 9.10% (95% CI: 4.07%–14.13%) and 9.00% (95% CI: 5.93%–12.07%) for the femoral neck and lumbar spine, respectively. Discussion: Denosumab increased the BMDs of the lumbar spine and femoral neck in patients with ESRD. The onset of hypocalcemia must be carefully monitored during denosumab administration. [ABSTRACT FROM AUTHOR]

Introduction: The impact of timing of hemodialysis (HD) for end‐stage renal disease (ESRD) patients treated with twice‐weekly HD remains unclear. We aimed to determine the effects of late initiation of HD on short‐term mortality and hospitalization. Methods: A multicenter cohort study was conducted in 11 HD centers in Northeastern Thailand (HEmodialysis Network of the NorthEastern Thailand study group). We recruited adult ESRD patients who were treated with twice‐weekly HD for more than 3 months and had data on eGFR at HD initiation. Clinical and laboratory values at the time of recruitment were recorded. Late and early (eGFR at start <5 and >5 ml/min/1.73 m2) initiations were defined. Outcomes were disease‐related death (excluding any accidental deaths) and first hospitalization. Data analysis was performed by multivariable cox‐regression analysis. Findings: A total of 407 patients who had data on eGFR at HD initiation (303 in late group and 104 in early group) were included for analysis. There were 56.8% male with a mean age of 55 years. During the 15.1 months of follow‐up, there were 27 (6.6%) disease‐related deaths. The 1‐year survival rate was similar among late and early initiation groups. The incidence density of first hospitalization in the late group was significantly lower than those in the early group (HR adjusted, 0.63; 95% CI, 0.40–0.99, p = 0.047). Among 303 patients who were in the late start group, patients with diabetes had a higher mortality rate (HR, 3.49; 95% CI, 1.40–8.70, p = 0.007) when compared to non‐diabetic patients. Discussion: Early initiation of HD at eGFR >5 ml/min/1.73 m2 had no short‐term survival benefit compared to the late group in ESRD patients treated with twice‐weekly HD for at least 3 months in a resource‐limited setting. A survival benefit from an early start of HD was found among diabetic patients. [ABSTRACT FROM AUTHOR]

Introduction: We lack cardiovascular (CV) markers for patients with end‐stage renal disease (ESRD), and left atrial (LA) strain has not been studied definitively in this population. We examined associations of LA reservoir, conduit, and booster strain with major adverse cardiovascular events (MACE) among stable patients with ESRD on dialysis. Methods: One hundred and ninety patients in the Cardiac, Endothelial and Arterial Stiffness in ESRD study underwent echocardiography, including strain imaging. The primary outcome was 2‐year composite non‐fatal MACE or CV death. We performed Cox proportional hazards regression for LA strain measures, adjusting for demographics, comorbidities, left ventricular global longitudinal strain (LV GLS), E/e′ and LA volume index. Findings: Mean ± SD LA reservoir strain was 24.1 ± 7.0%, and LA conduit strain 11.9 ± 5.1%. In age‐adjusted analyses, lower LA reservoir strain and LA conduit strain were associated with the primary outcome (HR per 1‐SD worsening LA strain parameter = 1.57 [95% CI 1.2–2.1], p = 0.003 and 1.68 [95% CI 1.2–2.3], p = 0.002, respectively). After adjusting for comorbidities, LA reservoir strain remained associated with the primary outcome and with deaths alone, and LA conduit strain with the primary outcome and hospitalizations alone (p < 0.05 for all). Associations of LA conduit strain were independent of LV GLS. Associations were stronger in participants with serum albumin <3.6 mg/dl (p for interaction 0.008). Discussion Left atrial reservoir strain and conduit strain were independently associated with MACE among patients with ESRD. Our study provides unique ascertainment of CV hospitalizations not attributed to missed dialysis, and LA conduit strain was a strong marker for this outcome. [ABSTRACT FROM AUTHOR]

Introduction: Parathormone (PTH) and phosphorus, which are considered as uremic toxins, are associated with reduced red cell survival, yet with unproven mechanism. We aimed to assess the relation between PTH and phosphorus levels and eryptosis in patients with CKD5d treated by hemodialysis. Methods: In a cohort of 85 patients with CKD5d treated by conventional hemodialysis, the percent of annexin V‐binding RBCs was assessed by flow cytometry to indicate the percent of eryptotic RBCs. Findings The median percent of annexin V‐binding RBCs was 2.3 (1.4–4.7)%. On linear regression analysis, PTH was independently associated with the percent of annexin V‐binding RBCs (β = 0.003; 95% CI: 0.002–0.004; p < 0.001). The percent of annexin V‐binding RBCs differed significantly in patients with low PTH (<150 pg/mL; 27/85, 31.8%), target PTH (150–600 pg/mL; 32/85, 37.6%), and high PTH (>600 pg/mL; 26/85, 30.6%) groups (1.24 [0.65–1.85]; 2.46 [1.73–4.05]; and 4.82 [3.45–5.61]%, respectively; p < 0.001). Considering the tertiles of the percent of annexin V binding RBCs, PTH increased significantly from 85 (50.6–273) in the 1st to 298.3 (172.8–606.8) in the 2nd and 827.6 (357.4–1171.3) pg/mL in the 3rd tertiles (p < 0.001). Phosphorus and calcium levels as well as the CaxPh product were similar among the three tertiles (p > 0.05). Discussion: Patients with CKD5d express high rates of eryptosis. PTH excess in those patients may result in further eryptosis enhancement, and this represents a potential pathogenic mechanism linking hyperparathyroidism with the anemia of CKD. [ABSTRACT FROM AUTHOR]

Introduction: Numerous studies have demonstrated that end‐stage renal disease (ESRD) patients undergoing hemodialysis (HD) have high myocardial fibrosis (MF) levels. Circulating fibrocytes are bone marrow‐derived circulating mesenchymal progenitors, and new evidence suggests a vital role for fibrocytes in the development of MF. This study aimed to investigate whether fibrocyte levels are elevated in patients undergoing HD and its influence factors. Methods: We carried out a flow cytometry analysis to measure the proportion of peripheral blood circulating fibrocytes in a cohort of 126 healthy control individuals and 161 subjects with HD. Cardiac function and morphology were assessed by electrocardiogram and transthoracic echocardiogram. Findings Compared to healthy controls, individuals with ESRD had significantly higher levels of circulating fibrocytes. There was a strong correlation between the frequency of fragmented QRS (fQRS) and circulating fibrocytes in HD patients. Furthermore, higher fibrocytes correlated to increasing age, dialysis age, left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF), and hypertension complication. On multivariate analysis, the dialysis age [odds ratio (OR) 1.011, 95% confidence interval (CI) 1.003–1.019, p = 0.006], LVMI (OR 1.012, 95% CI 1.002–1.022, p = 0.016), hypertension (OR 4.303, 95% CI 1.129–16.406, p = 0.033), and fQRS (OR 2.439, 95% CI 1.049–5.262, p = 0.038) were significant independent predictors of fibrocytes percentage. Discussion We concluded that bone marrow‐derived circulating fibrocytes were significantly increased in ESRD patients with HD compared with controls. Our data suggested that these cells might play essential roles during MF in HD patients. [ABSTRACT FROM AUTHOR]

Background: In patients with end‐stage renal disease (ESRD) undergoing hemodialysis, cardiovascular diseases, and in particular chronic heart failure are the leading causes of morbidity and mortality. Nevertheless, few data are available about the impact of fluid optimization on echocardiographic parameters of cardiac function in patients with ESRD. Methods and Results: In five patients with ESRD undergoing hemodialysis who had developed nonischemic dilated cardiomyopathy, an optimal fluid volume management based on a strict bioelectrical impedance analysis‐assisted dry weight target and dietary sodium and water restriction led to left ventricular reverse remodeling and improvement in hemodynamic parameters. The reverse remodeling further improved after kidney transplantation. Conclusions: This case series supports the possible beneficial effect of volume status optimization on cardiac function and the potential reversibility of cardiac dysfunction after kidney transplantation. [ABSTRACT FROM AUTHOR]

Severe metabolic alkalosis is rarely seen in end stage renal disease (ESRD) patients on long‐term hemodialysis. This can be life threatening and mortality is exponentially increased when the pH exceeds 7.60. Persistent vomiting, ingestion of alkali for dyspepsia and pica behavior are all potential causes of such severe metabolic alkalosis. The prevalence of pica is increased in chronic kidney disease and ESRD patients, with ice being the most commonly ingested substance. It can cause a myriad of complications including death, but the diagnosis may be elusive unless the pica behavior is witnessed firsthand by others since patients do not typically disclose their behavior. We present the case of a hemodialysis patient with severe alkalemia, hypernatremia, and excessive interdialytic weight gains resulting in recurrent hospitalizations for fluid overload due to baking soda pica behavior. [ABSTRACT FROM AUTHOR]

Spontaneous spinal epidural hematoma (SEH) is extremely rare in patients with end‐stage renal disease (ESRD). We report a case of a 71‐year‐old man with ESRD presented with progressive left limb weakness. Magnetic resonance imaging (MRI) revealed spinal cervical SEH involving C3‐5 level. The patient received emergent decompression laminectomy with the evacuation of the epidural hematoma. [ABSTRACT FROM AUTHOR]

Objective: To investigate the correlation between serum ectonucleotide pyrophosphatase/phosphodiesterase‐1 (ENPP1) level and severity of abdominal vascular calcification in end‐stage renal disease (ESRD) patients receiving dialysis. Methods: A total of 124 patients were consecutively enrolled into the study in our local institution. Based on the Kidney Disease Improving Global Outcomes (KDIGO) guidelines and recommendations, abdomen lateral X‐ray was used to determine abdominal aortic calcification score (AACS) for each patient at enrollment. Patients were divided into three groups based on AACS: no or mild calcification group, moderate calcification group, and severe calcification group. The relationships between ENPP1 levels and AACS were assessed by Spearman analysis and the value of ENPP1 in predicting severity of abdominal aortic calcification was evaluated by receiver operating characteristic (ROC). Results: The level of ENPP1 in dialysis patients was (7.68 ± 1.67) ng/ml. There was no significant difference in serum ENPP1 level between peritoneal dialysis patients and hemodialysis patients (p > 0.05). The AACS of dialysis patients was negatively correlated with ENPP1 value (r = −0.70). Compared to no/mild calcification patients, the levels of serum ENPP1 in patients with moderate/severe calcification were decreased significantly (p < 0.01). The severity of vascular calcification was correlated with serum ENPP1 value, the severer the vascular calcification, the lower the serum ENPP1 level, and the difference was statistically significant (all p < 0.05). The area under ROC curve of ENPP1 was 0.90, the corresponding sensitivity was 0.86, and the specificity was 0.87. Conclusion: Levels of serum ENPP1 in non‐diabetic ESRD patients are negatively related to the severity of abdominal aortic vascular calcification. [ABSTRACT FROM AUTHOR]

Introduction: The use of Acuseal arteriovenous graft (AAVG) is spreading in end‐stage renal disease (ESRD) patients for its advantages in early cannulation. However, comparison of clinical outcomes between AAVGs and standard arteriovenous grafts (SAVGs) is limited. In this study, we compared the performance of AAVGs and SAVGs. Methods: Consecutive ESRD patients underwent prosthetic vascular access between October 2017 and May 2019 at a single center were identified. Patients were divided into AAVG group and SAVG group. Patients' demographics, perioperative characteristics, and clinical outcomes were collected. Primary, primary assisted, and secondary patency rates were compared using Kaplan‐Meier analyses. Postsurgery complications were compared using chi‐square test or the Fisher's exact test. Findings A total of 304 arteriovenous grafts (AVGs) were implanted in 145 males and 159 females (mean age, 60.1 years; range, 20–91 years), comprising 143 AAVGs and 161 SAVGs. Median time to first cannulation was 3 days (interquartile range [IQR], 1–15 days) in the AAVG group and 30 days (IQR, 20–52 days) in the SAVG group (P < 0.001). Adjusted primary, primary assisted, and secondary patency at 12 months were not significant different between AAVGs and SAVGs (P = 0.911, P = 0.945, and P = 0.640, respectively). There was no statistical significance in regards to thrombosis (AAVG, 34.3%; SAVG, 26.1%; P = 0.120) and infection (AAVG, 4.9%; SAVG, 2.5%; P = 0.261) between the groups. Discussion Acuseal grafts provide comparable patency, and complication rates to SAVGs, with less time to first cannulation from the graft implanted. [ABSTRACT FROM AUTHOR]

Introduction: Health‐related quality of life (HRQoL) studies demonstrate the impact of end‐stage renal disease (ESRD) on the physical and psychosocial development of children. While several instruments are used to measure HRQoL, few have standardized domains specific to pediatric ESRD. This review examines current evidence on self and proxy‐reported HRQoL among pediatric patients with ESRD, based on the Pediatric Quality of Life Inventory (PedsQL) questionnaires. Methods: Following PRISMA guidelines, we conducted a systematic review and meta‐analysis on HRQoL using the PedsQL 4.0 Generic Core Scale (GCS) and the PedsQL 3.0 ESRD Module among 5‐ to 18‐year‐old patients. We queried PubMed, Embase, Web of Science, CINAHL, and Cochrane databases. Retrospective, case‐controlled, and cross‐sectional studies using PedsQL were included. Findings: Of 435 identified studies, 14 met inclusion criteria administered in several countries. Meta‐analysis demonstrated a significantly higher total HRQoL for healthy patients over those with ESRD (SMD:1.44 [95% CI: 0.78–2.09]) across all dimensional scores. In addition, kidney transplant patients reported a significantly higher HRQoL than those on dialysis (PedsQL GCS, SMD: 0.33 [95% CI: 0.14–0.53]) and (PedsQL ESRD, SMD: 0.65 [95% CI: 0.39–0.90]) concordant with parent‐proxy reports. Discussion: Patients with ESRD reported lower HRQoL in physical and psychosocial domains compared with healthy controls, while transplant and peritoneal dialysis patients reported better HRQoL than those on hemodialysis. This analysis demonstrates the need to identify dimensions of impaired functioning and produce congruent clinical interventions. Further research on the impact of individual comorbidities in HRQoL is necessary for developing comprehensive, integrated, and holistic treatment programs. [ABSTRACT FROM AUTHOR]

In conclusion, fQRS may be useful to demonstrate the clinical and subclinical MF in patients with ESRD. Recently, Li et al.1 reported a significant association between fragmented QRS (fQRS) and circulating fibrocyte levels in patients with ESRD. Patients with hemodialysis-dependent end-stage renal disease (ESRD) are at increased risk for myocardial fibrosis (MF) and cardiovascular events. [Extracted from the article]

Introduction: Few studies have reported hepatic and cardiac iron overload in patients with end‐stage renal disease (ESRD), and the current evidence regarding the prevalence is still scarce. Aim: This review aims to estimate the prevalence of hepatic and/or cardiac iron overload quantified by magnetic resonance imaging (MRI) in patients with ESRD who receive hemodialysis (HD), peritoneal dialysis (PD), or have undergone a kidney transplant. Methods: A systematic review with meta‐analysis was conducted and reported in line with PRISMA (Preferred Reporting Items for Systematic Review and Meta‐Analysis) guidelines. MEDLINE and Embase bibliographic databases were searched using a comprehensive list of controlled vocabulary and keywords to identify relevant studies. All studies reporting the prevalence of hepatic and/or cardiac iron overload quantified by MRI in ESRD patients were considered. The Newcastle‐Ottawa scale was used to assess the methodological quality of included studies. To investigate the heterogeneity between studies, random‐effect meta‐analyses for proportions were used. Results: The review comprised seven studies that included 339 patients. Using meta‐analysis, the pooled prevalence of severe and mild to moderate hepatic iron overload quantified by MRI was 0.23 [95% CI: 0.08–0.43] and 0.52 [95% CI: 0.47–0.57], respectively. Only three studies included cardiac iron quantification, and none reported iron overload. Conclusions: This review has revealed a high prevalence of severe hepatic iron overload in patients with ESRD treated by HD. Further studies with a larger sample size are needed to determine the impact of iron overload on vital organs in patients with ESRD and guide future research in this understudied field. Proper use of iron chelation and continuous monitoring will help in the early detection of unsolicited complications; however, the low renal clearance of most iron chelators limits the options for treating iron excess in patients with ESRD. [ABSTRACT FROM AUTHOR]

A patient with end‐stage renal disease experienced severe headaches exclusively during dialysis that were bilateral and throbbing with photophobia, weakness, and lightheadedness. The patient had no history of headaches, and dialysis was determined to be the cause of the severe headaches. More than 10 treatments were attempted without success. Headaches were successfully treated and prevented by addition of 100% oxygen (2 L via nasal cannula) for over 12 months without recurrence at time of publication. This case study indicates that oxygen therapy may be a valuable intervention for headaches during dialysis. [ABSTRACT FROM AUTHOR]

Introduction: Metformin is widely considered a first‐line antiglycemic agent due to its cost‐effectiveness and favorable adverse effect profile. However, its use is prohibited in patients with an estimated glomerular filtration rate <30 mL/min/1.73 m2, due to the risk of potentially lethal metformin‐associated lactic acidosis (MALA). We sought to evaluate MALA cases and outcomes at our institution. Methods: In this observational, retrospective case series, we reviewed our EMR for all patients who had a metformin level drawn between January 2013 and May 2022 to identify individuals who met the diagnostic criteria for MALA. We evaluated risk factors for MALA, the relationship between metformin level, blood pH, serum bicarbonate, and lactate level and clinical outcomes of ventilator dependency, renal replacement therapy requirement, renal recovery in acute kidney injury (AKI) patients, and survival. Findings: A total of 107 patients had metformin levels drawn, of which 19 patients met the diagnostic criteria for MALA. In our case series, MALA was primarily seen in AKI (15 patients) secondary to dehydration and sepsis, followed by end‐stage renal disease (ESRD) (4 patients). Intubation was required in 17 patients, of whom 8 were successfully extubated after a mean duration of 14 days. Sixteen patients received renal replacement therapy (RRT). Intermittent hemodialysis (IHD) was performed in nine, continuous renal replacement therapy (CRRT) in four, and sequential therapy of IHD and CRRT in three patients. Seven patients, all in the AKI group (46.7%), died while all ESRD patients survived, accounting for an overall mortality rate of 36.8%. Among the eight surviving AKI patients, four had complete renal recovery with renal function returning to baseline, three had partial renal recovery, and one continued to require IHD at the time of discharge to a rehabilitation facility. Discussion: MALA may be an underrecognized entity. A high level of clinical suspicion leading to prompt and aggressive treatment with RRT may improve mortality rates. Provider and patient education is of paramount importance for safe use of metformin. [ABSTRACT FROM AUTHOR]

Introduction: Routine hemodialysis depends on well‐functioning vascular access. In the event of vascular access dysfunction, percutaneous transluminal balloon angioplasty (PTA) is conducted to restore patency. Although an angioplasty procedure can provide an excellent immediate result by opening the access to allow dialysis to continue, the long‐term patency rates are less than satisfactory. The goal of this study was to assess the outcomes of patients who underwent a novel vessel preparation via longitudinal, controlled‐depth micro‐incisions prior to PTA. Methods: This multicenter, prospective, observational registry enrolled hemodialysis patients scheduled to undergo PTA of their arteriovenous fistula or graft due to clinical or hemodynamic abnormalities. A primary endpoint was anatomic success, defined as angiographic confirmation of <30% residual stenosis post‐procedure without an adverse event. Additional assessments included device technical success, clinical success, freedom from target lesion revascularization, target lesion primary patency, and circuit primary patency at 6 months. Findings: A total of 148 lesions were treated with the FLEX Vessel Prep™ System (FLEX VP) prior to PTA in 114 subjects at eight clinical sites. Target lesions were 21 ± 25 mm in length with mean pre‐procedure stenosis of 75.2% ± 4.7%. Five procedural complications were recorded without serious adverse events. Two subjects did not complete the follow‐up evaluation. Target lesion primary patency across all subjects at 6‐months was 62.2% with mean freedom from target lesion revascularization of 202.7 days. Target lesion primary patency and freedom from target lesion revascularization for AVF cases (n = 72) were 67.5% and 212.9 days, respectively. Target lesion primary patency and freedom from target lesion revascularization for AVGs (n = 42) were 52.4% and 183.3 days, respectively. In cases treating AVF cephalic arch stenosis (n = 25), 6‐month target lesion primary patency was 70.6% and freedom from target lesion revascularization was 213.4 days. Discussion: This FLEX‐AV registry demonstrates safety and effectiveness, notably in the cephalic arch and AVGs, when FLEX VP is used prior to PTA for treatment of vascular access dysfunction in a population of end‐stage renal disease subjects. [ABSTRACT FROM AUTHOR]

Background and Objectives: Eight states and Washington, DC have implemented regulations mandating a minimum ratio between treatment staff and patients receiving hemodialysis in a facility in an effort to improve the quality of hemodialysis treatment. Our investigation examines the association between minimum staffing regulations and patient mortality for four states and hospitalizations for two states that implemented these rules during our sample period. Design, Setting, Participants, and Measurements: We utilized a synthetic difference in differences estimation to analyze the effect of minimum staffing ratios on hemodialysis treatment quality, measured by deaths and hospitalizations for end‐stage renal disease patients. We used data gathered by the US Renal Data System and aggregated at the state level. Results: We are unable to find evidence that mandated dialysis staffing ratios area associated with a reduction in mortality or hospitalizations. We estimate a slight reduction in deaths per 1000 patient hours and a slight increase in hospitalizations, but neither are statistically significant. Conclusions: We were unable to find evidence that minimum staffing ratios for hemodialysis facilities are associated with improved patient outcomes. Our findings highlight the need for future work, studying the impact of these regulations at the facility level. [ABSTRACT FROM AUTHOR]

Complications of tunneled central venous catheters (CVCs) for hemodialysis are frequent, and most commonly include bacteremia, thrombosis, and stenosis. While bleeding is a relatively rare complication of dialysis lines overall, tunneled CVCs may present a unique bleeding risk given their ability to be displaced or damaged as patients have direct access to the equipment in place. Here, we describe the case of a 68‐year‐old man with end‐stage renal disease and neurocognitive disorder, who developed hemorrhagic shock following self‐inflicted laceration of his tunneled dialysis catheter proximal to the Y. Examination of the catheter tunnel revealed that the cuff was palpable proximal to the exit site, but the opening was well retracted. In such cases, hemorrhage is particularly difficult to control because the cuff is rigid and poorly amenable to compression, in addition to being difficult to access. This case demonstrates the risk of significant hemorrhage when a tunneled CVC is damaged at this location and the potential need for the urgent removal of the retained component to prevent recurrence of bleeding. It also highlights important patient safety considerations given the risk of self‐inflicted trauma in patients with a neurocognitive disorder and a language barrier affecting communication. [ABSTRACT FROM AUTHOR]

Crohn's disease is a relapsing chronic inflammatory condition of the intestine with increasing prevalence around the world. Biologic therapies are currently widely used and have proved safe and effective in treating moderate to severe Crohn's disease. However, contemporary bibliography contains little information about the use of these drugs in patients with end‐stage renal disease undergoing hemodialysis. Here we present a case of a 47‐year‐old female patient with treatment‐refractory Crohn's disease on hemodialysis. In this patient, treatment with the anti‐IL‐12/23 receptor antibody ustekinumab was effective in inducing and maintaining remission while being safe in administering throughout hemodialysis. [ABSTRACT FROM AUTHOR]

Introduction: Hemodiafiltration (HDF) and high‐flux hemodialysis (hf‐HD) are different methods of kidney replacement therapy (KRT) used for the treatment of kidney failure patients. A debate has raged over the last decade about the survival benefit of patients with the use of HDF compared with hf‐HD, but with divergent results from randomized controlled trials. Therefore, this study aimed to perform a meta‐analysis to compare HDF and hf‐HD regarding all‐cause and cardiovascular mortality. Methods: PubMed and Cochrane databases were searched until July 19, 2023, for randomized clinical trials comparing HDF and hf‐HD in patients on maintenance dialysis. A meta‐analysis was performed using Stata 16.1, applying fixed or random effect models according to the heterogeneity between studies. Findings: Of the 496 studies found, five met the inclusion criteria. Compared with the hf‐HD group, the risk ratio (RR) for all‐cause mortality with HDF use was 0.76 (95% CI: 0.67–0.88, I2 = 0%). HDF was associated with lower cardiovascular mortality, although the sensitivity analysis showed that the result differed between scenarios. Subgroup analysis showed lower all‐cause mortality among patients without diabetes in the HDF group compared with hf‐HD (RR 0.66, 95% CI: 0.51–0.81, I2 = 0%), but not in diabetic patients (RR = 0.89, 95% CI: 0.65–1.12, I2 = 0.0%). A subgroup analysis considering convection volumes was not performed, but the studies with the highest weight in the meta‐analysis described convection volume as more than 20 L/session. Discussion: More clinical studies considering critical risk factors, such as advanced age and preexisting cardiovascular disease, are needed to confirm the supremacy of HDF over hf‐HD on the survival of patients treated by these two forms of kidney replacement therapy. [ABSTRACT FROM AUTHOR]

Introduction: The present cross‐sectional study aimed to compare the prevalence, the characteristics of post‐dialysis fatigue and the length of recovery time after hemodialysis in prevalent end‐stage renal disease patients (ESRD) receiving bicarbonate hemodialysis (HD) or hemodiafiltration (HDF). Methods: Patients were suffering from post‐dialysis fatigue if they spontaneously offered this complaint when asked the open‐ended question: "Do you feel fatigued after dialysis?". Moreover, each patient was invited to rate the intensity, duration, and frequency of post‐dialysis fatigue from 1 to 5. In order to assess RECOVERY TIME AFTER DIALYSIS, patients were invited to answer to the following single open‐ended question: "How long does it take you to recover from a dialysis session?" Findings: We included 335 patients: 252 received HD and 83 received HDF. Post‐dialysis fatigue was present in 204 patients (60.9%). Prevalence of post‐dialysis fatigue did not differ significantly between patients on HD (62.3%) and on HDF (56.6%; p = 0.430). Median recovery time after dialysis was 180 min [180–240] and did not differ significantly between the two subgroups (180 min [130–240] and 240 min [120–332] p = 0.671, respectively). Median post‐dialysis fatigue intensity, duration, and frequency were 3 [1–5], 3 [1–5], and 4 [1–5] and did not differ significantly between patients on HD and on HDF. At the multivariate analysis, age, ADL and hemoglobin levels were the independent predictors of the HDF treatment. Discussion: Prevalence and characteristics of post‐dialysis fatigue do not differ significantly between patients receiving bicarbonate HD or HDF. [ABSTRACT FROM AUTHOR]

Introduction: People with end‐stage renal disease on hemodialysis are at increased risk for death due to arrhythmia associated with the prolonged interdialytic interval that typically spans the weekend, with bradycardia being the arrhythmia most closely associated with sudden death. In this prospective observational study we assessed whether predialysis fluid and electrolytes values including hyperkalemia are risk factors for the arrhythmias associated with the prolonged interdialytic interval. Methods: Sixty patients on hemodialysis with a history of hyperkalemia underwent cardiac monitoring for 1 week. Arrhythmia frequency, average QTc interval, and average root mean square of successive differences (rMSSD) per 4‐h period were reported. Predialysis electrolytes and electrocardiograms were collected prior to pre‐ and post‐weekend dialysis sessions. Clinical variables were assessed for correlation with arrhythmias. Findings: Predialysis hyperkalemia occurred in 29 subjects and was more common at the post‐weekend dialysis session. Bradycardia occurred in 11 subjects and increased before and during the post‐weekend dialysis session, but was not correlated with any electrolyte or clinical parameter. Ventricular ectopy occurred in 50 subjects with diurnal variation unrelated to dialysis. Pre‐dialysis prolonged QTc was common and not affected by interdialytic interval. Average QTc increased and rMSSD decreased during dialysis sessions and were not correlated with clinical parameters. Discussion: The results confirm that arrhythmias are prevalent in dialysis subjects with bradycardia particularly associated with the longer interdialytic interval; EKG markers of arrhythmia risk are increased during dialysis independent of interdialytic interval. Larger sample size and/or longer recording may be necessary to identify the clinical parameters responsible. [ABSTRACT FROM AUTHOR]

Severe hyperlipidemia is a risk factor for cardiovascular disease. Children with chronic kidney disease and end stage renal disease are at risk for development of hyperlipidemia. In this report, we describe a 7‐month‐old male infant with Denys–Drash syndrome who was found to have a "milky‐layer" floating on the deaerator of the hemodialysis machine. Investigations showed severe hypertriglyceridemia of >1000 mg/dl. The patient had been on chronic continuous manual peritoneal dialysis until 6 months of age and recently had been switched to hemodialysis. Management included lowering of caloric intake and addition of medium chain triglyceride with reduction of the serum triglyceride levels to 300–400 mg/dl. Close monitoring of serum lipids and timely intervention is important to prevent serious complications associated with dyslipidemia. Observation of the "milky layer" in the deaerator of the hemodialysis machine may be an interesting visual clue of underlying severe hypertriglyceridemia. [ABSTRACT FROM AUTHOR]

Introduction: Chronic kidney disease‐associated pruritus is a common complication in patients with end‐stage renal disease. In this study, we have explored the outcome of omega‐3 supplementary intake for the treatment of this symptom. Methods: This double‐blinded, randomized, crossover study was conducted in two dialysis centers in which 40 hemodialysis patients suffering from pruritus were randomly assigned into two groups (Group A and Group B). Patients in Group A consumed omega‐3 capsules for 4 weeks and after a washout period (6 weeks), they took placebo for another 4 weeks. The same was performed in Group B but in the reverse order. Pruritus score was determined at the baseline, Week 4, 10, and 14. Serum levels of prostaglandin E2 were also recorded at the baseline and Week 4. Results: There was a statistically significant reduction of pruritus score in patients who took the omega‐3 fatty acid supplement. The mean pruritus score decreased significantly in both first (−3.41 ± 2.62, p < 0.001) and second (−1.00 ± 1.84, p = 0.04) treatment period after omega‐3 treatment; but no significant mean pruritus score difference in placebo group after both intervention periods was observed. The decrease in prostaglandin E2 amount was not statistically significant in the intervention (omega‐3) group compared to the placebo group (p = 0.204). Discussion Our observations indicate that omega‐3 fatty acids (3 grams per day) have decreasing effects on pruritus. Also, reduction in prostaglandin E2 levels in the omega‐3 group did not differ from the changes in the placebo group. [ABSTRACT FROM AUTHOR]

Patients with end‐stage renal disease require to establish vascular access for regular hemodialysis. The creation of arteriovenous fistula (AVF) is usually a safe procedure; however, there could be complications such as bleeding, hematoma, pseudoaneurysm, thrombosis, infection, and steal syndrome. A rare complication of such vascular manipulation could be formation of lymphocele. We present a case of a 67‐year‐old man who presented with a progressively enlarging mass 12 days after the surgery for AVF creation at the site of surgery in the right upper arm. Ultrasonographic examination revealed a fluid‐filled cystic structure measuring about 4.2 × 3.6 × 1.9 cm under the skin just above the anastomosis. The fluid was aspirated using ultrasound‐guided fluoroscopy that relieved the swelling. The analysis of aspirate suggested the cyst to be a lymphocele. The mass re‐enlarged to its previous size in the next 3 days. While under observation for signs of complication, regular intermittent compression and a low‐fat diet completely resolved the lymphocele over the subsequent 3 months. The less common occurrence of such lymphocele post AVF creation needs to be evaluated for its potential for complication, in the absence of which the lymphocele is amenable to conservative management using regular intermittent compression and low‐fat oral diet. [ABSTRACT FROM AUTHOR]

Background: The passive immunization of patients with SARS‐CoV2 with convalescent plasma (CP) is theoretically beneficial in patients with end‐stage renal disease who are immunosuppressed and unable to mount an adequate immune response. Hence, this study was conducted to evaluate the safety and efficacy of CP in patients with chronic kidney disease on hemodialysis with moderate‐to‐severe SARS‐CoV2 infection. Methods: A prospective observational cohort study was conducted in consecutive 68 moderate‐to‐severe SARS‐CoV2 infected patients who were on maintenance hemodialysis or with acute worsening of chronic kidney disease which required initiation of hemodialysis. Patients who received CP were compared with those who did not. The primary outcome was death during hospitalization. Clinical characteristics, duration of hospitalization and inflammatory parameters were compared between the two groups. A subgroup analysis was done to find whether early initiation of plasma was associated with better outcome. Results: Sixteen patients (44%) in the plasma group and 14 (45%) patients in the control group died during hospitalization (p = 0.95). The median duration of hospitalization was 9 (6–14) days in the plasma group and 9 (6–16) in the control group (p = 0.60). There was no difference in mortality or duration of hospitalization with respect to early initiation of CP (p = 0.29). Fistula thrombosis occurred in two patients (11.1%) in the plasma group. Conclusion: Therapy with CP does not appear to confer any clinical benefit in moderate‐to‐severe SARS‐CoV‐2 infected patients with chronic kidney disease on hemodialysis. [ABSTRACT FROM AUTHOR]

Introduction: Hemodialysis is the most common treatment used for end‐stage kidney disease (ESKD) patients and an arteriovenous fistula (AV) fistula is the preferred vascular access. The goal of our study was to investigate potential associations between vascular access type and depression. Methods: This was a cross‐sectional survey of 180 patients receiving maintenance hemodialysis. The Beck Depression Inventory was used to assess degree of depression. Demographic factors, treatment details, and laboratory values were obtained from the hospital medical record. Findings: Fifty‐two percent (n = 93) of the patients were being dialyzed using an AV fistula and 48% (n = 87) via a tunneled cuffed catheter. No significant differences were found between access type use in terms of gender (p = 0.266), presence of diabetes, hypertension, or peripheral artery disease (p = 0.409, p = 0.323, p = 0.317; respectively). The prevalence of Beck Depression Inventory scores greater than 14 (marking presence of depression) was significantly higher in the patients being dialyzed with a tunneled cuffed catheters (61%) compared to patients dialyzed with an AV fistula (36%) (p = 0.001). Discussion: We found statistically higher depression scores among patients receiving hemodialysis with a tunneled cuffed catheter. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence rates of hepatosteatosis and gallstones are increasing owing to the multifactorial causes of chronic kidney disease, and the prevalence may change with the availability of different forms of renal replacement therapy. We aimed to determine the incidence or prevalence rates of hepatosteatosis, cholelithiasis, and acute cholecystitis in patients with chronic kidney disease and compare them between renal replacement therapy modalities. Methods: A total of 270 patients (90 with chronic kidney disease stages III–V, 90 undergoing peritoneal dialysis, and 90 undergoing hemodialysis) were included and categorized into the pre‐dialysis, hemodialysis, and peritoneal dialysis groups. The patients were questioned about previous gallbladder surgeries and chronic diseases. The results of abdominal ultrasonography, tomography, and magnetic resonance imaging were retrospectively evaluated with respect to the findings on the hepatobiliary system. Hepatosteatosis and cholelithiasis were diagnosed by expert radiologists on the basis of abdominal ultrasonography, tomography, and magnetic resonance imaging findings. The prevalence rates of hepatosteatosis, cholelithiasis, and other liver findings were compared between the groups. Findings: Hepatosteatosis and cholelithiasis were detected in 16.7% and 21.5% of the 270 cases, respectively. Hepatosteatosis was present in 17.8%, 25.6%, and 6.7% of patients in the pre‐dialysis, hemodialysis, and peritoneal dialysis groups, respectively. The prevalence of hepatosteatosis was significantly higher in patients undergoing hemodialysis than in patients undergoing peritoneal dialysis (p = 0.002). However, no statistically significant difference was found between the peritoneal dialysis and pre‐dialysis groups or between the hemodialysis and pre‐dialysis groups (p >0.05). The prevalence rates of cholelithiasis were 15.6%, 28.9%, and 20.0%, in the pre‐dialysis, hemodialysis, and peritoneal dialysis groups, respectively, and there were no statistically significant differences among the groups. The incidence of acute cholecystitis was significantly higher in the hemodialysis group than in the pre‐dialysis group (p = 0.006). Discussion: Our study showed that the hepatobiliary system is frequently affected in chronic kidney disease and that the findings may differ depending on the renal replacement therapy modality. [ABSTRACT FROM AUTHOR]

Adrenal insufficiency is an uncommon disorder and presents with non‐specific symptoms. Identifying adrenal insufficiency in patients with chronic kidney disease requiring dialysis is increasingly difficult as there is a significant overlap of the signs and symptoms of adrenal insufficiency with those seen in chronic kidney failure. We highlight this diagnostic uncertainty in a case series of three patients with chronic kidney disease requiring hemodialysis as renal replacement therapy from a single center identified as hypoadrenal. Steroid replacement improved symptoms and hemodynamic parameters. Increased vigilance for adrenal insufficiency in dialysis patients is necessary. It is likely under recognized in hemodialysis patients given their multi‐morbidity. [ABSTRACT FROM AUTHOR]

Value‐based primary care has reduced health care costs, improved the quality of rendered care, and enhanced the patient experience. Value‐based care emphasizes prevention, outreach, follow‐up, patient engagement, and comprehensive, whole‐person health. Primary care Accountable Care Organizations have leveraged technology‐enabled workflows, practice transformation, and cutting‐edge data and analytics to achieve success. These efforts are increasingly aided by predictive modeling used in the context of patient identification and prioritization algorithms. Value‐based kidney care programs can glean salient takeaways from successful value‐based primary care methods and models. The kidney care community is experiencing unprecedented transformation as novel payer programs and financial models burgeon. The authors contend these efforts can be accelerated by the adoption of techniques honed in value‐based primary care. To optimize value‐based kidney care, though, nephrology thought leaders must transcend the archetype of value‐based primary care. To do so, the nephrology community must: (1) impel behavioral change among fee‐for‐service adherents; (2) harness emerging policy, guidelines, and quality measures; (3) adopt innovative tools, technologies, and therapies. In aggregating lessons from value‐based primary care—and leveraging novel methodologies and approaches—the kidney care community will be better equipped to achieve the quadruple aim for kidney care. [ABSTRACT FROM AUTHOR]

Introduction: Roxadustat is an oral hypoxia‐inducible factor prolyl hydroxylase inhibitor approved in several regions for the treatment of anemia of chronic kidney disease (CKD). ASPEN evaluated the efficacy, safety, and feasibility of roxadustat in patients with anemia of CKD in US dialysis organizations. Methods: This open‐label, single‐arm study (NCT04484857) comprised a 6‐week screening period, followed by 24 weeks of treatment (with optional extension ≤1 year) and a 4‐week follow‐up. Patients aged ≥18 years, receiving chronic dialysis, with hemoglobin (Hb) 9.0–12.0 g/dL if converting from erythropoiesis‐stimulating agents (ESAs), or <10.0 g/dL if receiving ESAs for <6 weeks, received oral roxadustat three times weekly in‐center. Primary efficacy endpoints included proportion of patients with mean Hb ≥10 g/dL, averaged over weeks 16–24, and mean Hb change from baseline to the average over weeks 16–24. Safety was also assessed. Findings: Overall, 283 patients were enrolled and treated, 282 (99.6%) were included in the full analysis set, and 216 (76.3%) continued into the extension period. Most patients enrolled were from DaVita sites (71%), with the rest from US Renal Care sites (29%). Mean (standard deviation [SD]) baseline Hb was 10.6 (0.7) g/dL. Nearly all patients were prior ESA users (n = 274; 97.2%). The proportion of patients with mean Hb ≥10 g/dL during weeks 16–24 was 83.7% (95% confidence interval 78.9–88.6). Mean (SD) Hb increase from baseline to the average over weeks 16–24 was 0.2 (1.0) g/dL. During the treatment period, 82 (29.0%) patients reported treatment‐emergent serious adverse events (TESAEs). The most common TESAEs were COVID‐19 pneumonia (n = 10; 3.5%), acute respiratory failure (n = 9; 3.2%), COVID‐19 (n = 7; 2.5%), acute myocardial infarction (n = 7; 2.5%), and fluid overload (n = 6, 2.1%). Discussion: Roxadustat was effective in maintaining Hb in patients with anemia of CKD on dialysis in large, community‐based dialysis organizations. [ABSTRACT FROM AUTHOR]

Background: End‐stage kidney disease is an independent risk factor for stroke; however, the relationship between hemodialysis and stroke in Sub‐Saharan Africa has not been established. Objective: To evaluate the incidence, associated factors, and clinical outcome of stroke among patients undergoing maintenance hemodialysis in Cameroon. Methods: A hospital‐based retrospective study using data from the medical files of 1060 patients on maintenance hemodialysis (given twice a week) was conducted. Patients with stroke prior to starting hemodialysis were excluded. Socio‐demographic data, comorbidities, dialysis parameters, and data concerning the diagnosis of stroke were retrieved and analyzed. Results: The dialysis vintage (duration of time on dialysis) averaged 11.4 ± 9.2 months. The incidence of stroke was 6.1 events per 1000 patient‐years, with hemorrhagic stroke being most common (66%). Eighty percent of strokes occurred before the 30th month of dialysis. Sixty percent of strokes occurred within 24 h of a dialysis session. Predictive factors for stroke were diabetes mellitus (p = 0.026), heart failure (p = 0.045), poor dialysis compliance (p = 0.001), and short vintage (p = 0.001). The overall mortality rate was 52% and was higher for hemorrhagic stroke (60%). The leading causes of death were multiple organ failure and sepsis. Conclusion: The incidence of stroke is high among hemodialysis patients in Cameroon and hemorrhagic stroke is the commonest type. Diabetes and heart failure triple the risk of stroke. Mortality in patients who suffered a stroke was high. [ABSTRACT FROM AUTHOR]

Introduction: Epidemiologic studies of physical activity among pediatric hemodialysis (HD) patients are lacking. A sedentary lifestyle in End‐Stage Kidney Disease is associated with a higher cardiovascular mortality risk. In those patients receiving HD, time spent on dialysis and restrictions on physical activity due to access also contribute. No consensus exists regarding physical activity restrictions based on vascular access type. The aim of this study was to describe the patterns of physical activity restrictions imposed by pediatric nephrologists on pediatric HD patients and to understand the basis for these restrictions. Methods: We conducted a cross‐sectional study involving US pediatric nephrologists using an anonymized survey through Pediatric Nephrology Research Consortium. The survey consisted of 19 items, 6 questions detailed physician characteristics with the subsequent 13 addressing physical activity restrictions. Findings: A total of 35 responses (35% response rate) were received. The average years in practice after fellowship was 11.5 years. Significant restrictions were placed on physical activity and water exposure. None of the participants reported accesses damage or loss that was attributed to physical activity and sport participation. Physicians practice is based on their personal experience, standard practice at their HD center, and clinical practices they were taught. Discussion: There is no consensus among pediatric nephrologists about allowable physical activity in children receiving HD. Due to the lack of objective data, individual physician beliefs have been utilized to restrict activities in the absence of any deleterious effects to accesses. This survey clearly demonstrates the need for more prospective and detailed studies to develop guidelines regarding physical activity and dialysis access in order to optimize quality of care in these children. [ABSTRACT FROM AUTHOR]

Purpose: Successful pregnancy rates on dialysis are increasing with the advent of intensive hemodialysis and advances in medical management. Summary: Data support the use of intensive hemodialysis in pregnant women with end‐stage kidney disease (ESKD). This paper provides an overview of common pharmacotherapeutic changes in management when caring for a pregnant woman receiving intensive hemodialysis. Pregnant patients on peritoneal dialysis were excluded from this analysis due to insufficient data. Topics covered include those related to anemia (iron and erythropoietin stimulating agents), blood pressure agents, monitoring of phosphorus, as well as nutrition and anticoagulation. Conclusion: When patients on hemodialysis become pregnant, medication adjustments are needed regarding antihypertensives, anemia management, and mineral‐bone disease management as many agents require dose adjustment, switching agents due to teratogenicity, or cessation due to fetal complications. There are minimal data in this population; however, successful and healthy infants have been delivered in this patient population with the medication changes discussed. [ABSTRACT FROM AUTHOR]

In end‐stage kidney disease (ESKD), patient engagement and empowerment are associated with improved survival and complications. However, patients lack education and confidence to participate in self‐care. The development of in center self‐care hemodialysis can enable motivated patients to allocate autonomy, increase satisfaction and engagement, reduce human resource intensiveness, and cultivate a curiosity about home dialysis. In this review, we emphasize the role of education to overcome barriers to home dialysis, strategies of improving home dialysis utilization in the COVID 19 era, the significance of in‐center self‐care dialysis (e.g., cost containment and empowering patients), and implementation of an in‐center self‐care dialysis as a bridge to home hemodialysis (HHD). [ABSTRACT FROM AUTHOR]

Introduction: BTB and CNC homology 1 (Bach1) is a protein that antagonizes some actions of nuclear factor erythroid 2‐related factor‐2 (Nrf2), the master regulator of cytoprotective responses. Bach1 binds to genomic DNA and inhibits the synthesis of antioxidant enzymes, thereby increasing inflammation. Bach1 may be a therapeutic target for mitigating inflammation in chronic kidney disease (CKD) patients. However, no clinical study has been reported on Bach1 in this population. This study aimed to evaluate Bach1 mRNA expression with different treatments for CKD, including conservative treatment (nondialysis), hemodialysis (HD), and peritoneal dialysis (PD). Methods: Twenty patients undergoing HD (56.5 [19] years), 15 on PD (54 [24] years) and 13 nondialysis patients (63 [10] years, with an estimated glomerular filtration rate of 41 [14] mL/min/1.73 m2) were enrolled in the study. The mRNA expression of Nrf2, NF‐kB, heme oxygenase 1 (HO‐1), and Bach1 was evaluated in peripheral blood mononuclear cells using quantitative real‐time polymerase chain reaction. Malondialdehyde (MDA) was evaluated as a lipid peroxidation marker. Routine biochemical parameters were also evaluated. Findings: As expected, patients on dialysis were more inflamed. Bach1 mRNA expression was significantly higher in patients undergoing HD than in PD and nondialysis patients (p < 0.007). The mRNA expression of HO‐1, NF‐kB, and Nrf2 was not different in the groups. Conclusion: In conclusion, CKD patients on HD exhibited an upregulation of Bach1 mRNA expression compared to patients on PD treatment and nondialysis CKD patients. The association between Nrf2 and Bach1 expression in these patients warrants further investigation. [ABSTRACT FROM AUTHOR]

Compared to women with normal kidney function, women with end‐stage kidney disease (ESKD) are much less likely to become pregnant, but more likely to have a complicated pregnancy. While renal transplantation remains the best option for women who desire to have a child, pregnancy on dialysis should be considered an option for those who may not receive a transplant during their reproductive years. Many physicians do not encounter a pregnant patient with ESKD during their nephrology training, and may not feel prepared to provide care for such patients in a busy practice. In this paper, we briefly provide an overview of the most significant practical points related to management of a pregnant patient with ESKD through a real‐life case with twin pregnancy. The two key elements in management of these patients would be an intensified hemodialysis regimen and a multidisciplinary team that can provide frequent, regular, and multifaceted assessments. [ABSTRACT FROM AUTHOR]

Introduction: Post‐dialysis recovery time (DRT) has an important relationship to quality of life and survival, as identified in studies of ESRD patients on conventional dialysis. ESRD patients are often discharged from hospitals to skilled nursing facilities (SNFs) where on‐site treatment using home hemodialysis technology is increasingly offered, but nothing is known about DRT in this patient population. Methods: From November 4, 2019 to June 11, 2021, within a dialysis organization providing service across 12 states and 154 SNFs, patients receiving in‐SNF, more frequent dialysis (MFD) (modeled to deliver 14 treatment hours minimum per week and stdKt/V ≥2.0) were asked to describe their post‐dialysis recovery time following their previous treatment, within predefined categoric choices: 0–½, ½–1, 1–2, 2–4, 4–8, 8–12 h, by next morning, or not even by next morning. Patients reporting DRT following at least one full‐week treatment opportunity were included in a mixed model logistic regression of rapid recovery (DRT ≤2 h). Findings: Two thousand three hundred and nine patients met the statistical modeling inclusion criteria, providing DRT on 108,876 dialysis sessions, while receiving mean (SD) 4.3 (0.96) weekly dialysis treatments. 2118 (92%) reported DRT ≤2 h. Results appeared biologically plausible, as lower odds of rapid DRT were observed for patients who were older, missed their previous treatment, or experienced intradialytic hypotension. Greater odds of rapid DRT were observed in patients receiving five dialyses in the previous week or having 160–179 mmHg pre‐hemodialysis systolic blood pressure. Rapid recovery was associated with reduced mortality or hospitalization. Discussion: SNF dialysis patients receiving 5x per week MFD report rapid recovery time ≤2 h in 92% of dialyses despite advanced age, frailty, and comorbidities. Future studies will assess the practical ramifications of rapid DRT perception/experience on nursing home rehabilitation programs, which could impact patient health beyond the nursing home stay. [ABSTRACT FROM AUTHOR]

Background and objectives: In patients with chronic kidney disease the risk of developing Tuberculosis is increased, while the presentation is often atypical making the diagnosis more difficult. The aim of this study is to describe the presentation of Tuberculosis in dialysis and kidney transplant patients, including the range of diagnostic approaches and the utility of different sample types. Design, setting, participants, and measurements: In this retrospective study, case records of dialysis and kidney transplant patients were reviewed, including all those treated for Tuberculosis between January 2009 and December 2020. Results: Over 12 years, there were 143 cases of Tuberculosis in 141 patients (aged 17–86, 50.4% male). Tuberculosis was most common in Asian patients (64%) and those receiving hemodialysis (82%), particularly during the first year after dialysis initiation (54% of dialysis cases). Non‐pleural/pulmonary disease accounted 40% of cases, and non‐organ‐specific presenting features were prominent including fever, lymphadenopathy, and weight loss. The diagnosis was confirmed microbiologically or histologically in 87 cases (61%), with low sensitivity observed for many types of samples including sputum (18%) and pleural fluid (12%). Higher sensitivity was observed with tissue samples including bronchoscopic lymph node aspiration (75%) and other lymph node sampling (92%). In the 52 cases where drug sensitivities were available, resistance to a first line treatment, most commonly isoniazid, was seen in 12 cases (23%). Furthermore, 1‐ and 5‐year survival from diagnosis were 78% and 61%, respectively. Baseline variables independently associated with poorer survival were age (OR 1.8 per decade, 95% CI 1.4–2.3), weight loss over 10% (OR 1.9, 95% CI 1.0–3.5), and a non‐confirmed diagnosis (OR 1.6, 95% CI 1.2–2.1). Conclusions: Tuberculosis is common in dialysis and kidney transplant patients, particularly during the first year of dialysis. Short‐term mortality is high, but the diagnostic sensitivity of many types of samples is low, so that diagnosis is difficult, with treatment often initiated without confirmation. These data highlight the importance of judgment and clinical experience with this complex patient group. [ABSTRACT FROM AUTHOR]

Introduction: Increased patient activation is associated with improved health outcomes; however, little is known about patient activation in people with end‐stage kidney disease at the start of their dialysis journey. This study aimed to measure activation status changes over the first 4 months of dialysis. Methods: Prospective, longitudinal, and observational study. Incident patients initiating dialysis at 25 in‐center hemodialysis and 17 home dialysis programs across three US states managed by the same dialysis provider completed the 13‐item Patient Activation Measure (PAM‐13) survey at baseline (month 1 after commencement of dialysis) and follow‐up (month 4). The survey yields a score (0–100) that corresponds to four levels (1–4), with higher scores or levels indicating higher activation. Findings: One hundred eighty‐two participants (139 center, 43 home) completed both baseline and follow‐up surveys. Mean age was 60 ± 15 years, 40% female. Mean PAM‐13 scores were 65.1 ± 16.8 and 64.8 ± 17.8 at baseline and follow‐up, respectively; mean intraindividual change: −0.3 ± 17.3. The proportions of patients at levels 1–4 at baseline were 11%, 23%, 35%, and 31% respectively. At follow‐up, 50%, 64%, 52%, and 37% of participants at levels 1–4, respectively, changed to a different PAM level (Spearman correlation = 0.47; p < 0.001). Home dialysis was associated with higher PAM scores when compared to in‐center hemodialysis in multivariable analyses, adjusted for sociodemographic variables, comorbidities, and predialysis nephrology care (β = 5.74, 95% confidence intervals [CI]: 0.11–11.37 and 9.02, 95% CI: 3.03–15.02, at baseline and follow–up, respectively). Discussion Although aggregated group scores and levels remained stable, intra‐individual patient activation changed significantly during the first 4 months of dialysis. This novel finding is foundational to future projects aiming to design interventions to improve patient activation. [ABSTRACT FROM AUTHOR]

Introduction: This study described control of parathyroid hormone (PTH), phosphorus, and corrected calcium in adults initiating calcimimetics in small dialysis organizations after the introduction of etelcalcetide. Methods: This retrospective study using Visonex Clarity electronic health records between October 1, 2017, and December 31, 2019, identified adults ≥ 18 years of age receiving in‐center hemodialysis as either a cinacalcet or etelcalcetide initiator based on their first calcimimetic use in 2018 (index date) with no prior calcimimetic use in the 3 months preindex date. Patients were stratified by PTH at index date and were followed for 15 months. Subcohorts of patients who were persistent on a single calcimimetic for 15 months and of patients who had their calcimimetic changed from cinacalcet to etelcalcetide were also analyzed. Findings A total of 677 patients initiated cinacalcet and 711 initiated etelcalcetide. Mean PTH (pg/ml), phosphorus, and corrected calcium (mg/dl) at baseline were 864, 5.9, and 9.3 for cinacalcet and 804, 5.9, and 9.4 for etelcalcetide, respectively. During follow‐up, the proportion of initiators considered in‐target (monthly average PTH < 600) increased from 48% to 62% with cinacalcet and from 56% to 86% with etelcalcetide in the baseline PTH 600 to < 800 subgroup; increased from 30% to 64% with cinacalcet and 31% to 59% with etelcalcetide among those with baseline PTH 800 to < 1000; and increased from 14% to 41% with cinacalcet and 12% to 58% with etelcalcetide among those with baseline PTH ≥1000. A similar pattern was observed for persistent users (n = 646). For patients changed from cinacalcet to etelcalcetide (n = 183), the proportion of patients considered in‐target increased from 22% in the month prior to the treatment change to 51% in Month 6 postchange. Discussion Patients initiating calcimimetics at lower baseline PTH had better biochemical control than patients starting at higher PTH. Patients changed from cinacalcet to etelcalcetide had improvements in PTH control postchange. [ABSTRACT FROM AUTHOR]

The triglyceride/high‐density cholesterol‐lipoprotein (TG/HDL‐c) is a biomarker of cardiovascular events and mortality. In hemodialysis patients, the evidence is controversial. A systematic review was carried out in the Medline, Scopus, Embase, Web of Science, and Pubmed databases to identify the relevant cohort studies on cardiovascular events and mortality in hemodialysis patients the role of TG/HDL‐c as a risk factor. Four cohort‐type studies were evaluated, with a total of 52,579 hemodialysis patients. Three studies conducted in Asian populations and one study in the United States had the highest percentage of the sample (50,673 patients). The elevated TG/HDL‐c ratio is associated with better survival, and there is a consistent gradual inverse association between TG/HDL‐c and mortality in all analysis subgroups. In the decile categorization of the exposure variable, a 21% decrease in the risk of cardiovascular mortality and a 15% decrease in all‐cause mortality in the highest decile compared to the reference group (D10 aHR = 0.79; 95% CI: 0.69–0.91 and D10 aHR = 0.85; 95%CI: 0.78–0.92). Our results show that the TG/HDL‐c ratio is a protective factor for cardiovascular outcomes and mortality in the American population and a risk factor for them in the population from Asia. [ABSTRACT FROM AUTHOR]

Gastrointestinal manifestations are common among patients with advanced kidney disease. Common symptoms include poor appetite, nausea, and vomiting. Prevalent lesions include esophagitis, gastritis, and duodenitis. Uremia‐associated colitis is extremely rare. In this case report we present a young patient who present with end‐stage kidney disease of unknown origin accompanied by abdominal pain and vomiting. Computed tomography showed severe bowel wall thickening of the colon. Due to extreme uremic state uremia‐associated colitis was suspected and hemodialysis was initiated immediately, resulted in clinical and radiology improvement. [ABSTRACT FROM AUTHOR]

Introduction: End‐stage kidney disease causes significant morbidity, mortality, and reduced quality of life. Despite improvements in conventional hemodialysis, these problems persist. In‐center nocturnal hemodialysis (INHD) has been shown to be beneficial in observational studies. This report outlines a 4‐year renal network experience of INHD from the patient and frontline staff perspective. Methods: Staff and patients' experiences of INHD were evaluated through two work streams. Work stream one: 12 patients who chose to stop INHD and 24 patients who chose to continue with INHD completed an anonymous survey. Work stream two: one‐to‐one interviews with 20 patients receiving INHD and seven staff working INHD shifts were conducted. Clinical incident reporting for conventional hemodialysis and INHD from April 2014 to December 2018 was reviewed. Findings Work stream one: Five themes were identified; facilities, time, health and well‐being, sleep, and transport. A patient "starter pack" was developed and improvements to the dialysis unit were completed. Work stream two: Patient interviews demonstrated starter packs to aid sleep were well received; sleep itself was not a single reason to discontinue INHD. Staff indicated that their greatest concern was staffing levels; although staff‐to‐patient ratio remains unchanged, total numbers on INHD shifts were fewer, causing concern around less colleague availability for support during an emergency. Safety: 363 clinical incidents were reported across all dialysis shifts; for conventional hemodialysis, a larger proportion were due to medical interventions, infection control, and transport; for INHD, most incidents centered around communication with patients and relatives, delays in patient transfer, and issues with medical equipment or facilities. Discussion Patients continue with INHD due to increased social time and perceived health benefits. Patient starter packs and adjustments to the dialysis unit may enhance sleep. This experience has optimized the design of the NightLife study; a randomized controlled trial evaluated the effect of INHD on quality of life. [ABSTRACT FROM AUTHOR]

An increasing demand for in‐center dialysis services has been largely driven by a rapid growth of the older population progressing to end‐stage kidney disease. Since the onset of the COVID‐19 pandemic, efforts to encourage home‐based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center‐based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population. [ABSTRACT FROM AUTHOR]