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Kidney replacement therapy (KRT) is used to provide supportive therapy for critically ill patients with severe acute kidney injury and various other non-renal indications. Modalities of KRT include continuous KRT (CKRT), intermittent hemodialysis (HD), and sustained low efficiency daily dialysis (SLED). However, circuit clotting is a major complication that has been investigated extensively. Extracorporeal circuit clotting can cause reduction in solute clearances and can cause blood loss, leading to an upsurge in treatment costs and a rise in workload intensity. In this educational review, we discuss the pathophysiology of the clotting cascade within an extracorporeal circuit and the use of various types of anticoagulant methods in various pediatric KRT modalities., Author(s): Rupesh Raina [sup.1] [sup.2] , Ronith Chakraborty [sup.1] [sup.2] , Andrew Davenport [sup.3] , Patrick Brophy [sup.4] , Sidharth Sethi [sup.5] , Mignon McCulloch [sup.6] , Timothy Bunchman [sup.7] [...]

Background: Frequent hemodialysis provided more than three times per week may lower mortality and improve health-related quality of life. Yet, the evidence is inconclusive. We evaluated the benefits and harms of frequent hemodialysis in people with kidney failure compared with standard hemodialysis. Methods: We performed a systematic review of randomized controlled trials including adults on hemodialysis with highly sensitive searching in MEDLINE, Embase, CENTRAL, and Google Scholar on 3 January 2024. Data were pooled using random-effects meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. We adjudicated evidence certainty using GRADE. Results: From 11,142 unique citations, only seven studies involving 518 participants proved eligible. The effects of frequent hemodialysis on physical and mental health were imprecise due to few data. Frequent hemodialysis probably had uncertain effect on death from all cause compared with standard hemodialysis (relative risk 0.79, 95% confidence interval 0.33–1.91, low certainty evidence). Data were not reported for death from cardiovascular causes, major cardiovascular events, fatigue or vascular access. Conclusion: The evidentiary basis for frequent hemodialysis is incomplete due to clinical trials with few or no events reported for mortality and cardiovascular outcome measures and few participants in which patient-reported outcomes including health-related quality of life and symptoms were reported. [ABSTRACT FROM AUTHOR]

Background and objectives Dialysis disequilibrium syndrome (DDS) is a rare neurological complication, most commonly affecting patients undergoing new initiation of hemodialysis (HD), but can also be seen in patients receiving chronic dialysis who miss regular treatments, patients having acute kidney injury (AKI), and in those treated with continuous kidney replacement therapy (CKRT) or peritoneal dialysis (PD). Although the pathogenesis is not well understood, DDS is likely a result of multiple physiological abnormalities. In this systematic review, we provide a synopsis of the data available on DDS that allow for a clear picture of its pathogenesis, preventive measures, and focus on effective management strategies. Methods We conducted a literature search on PubMed/Medline and Embase from January 1960 to January 2021. Studies were included if the patient developed DDS irrespective of age and gender. A summary table was used to summarize the data from individual studies and included study type, population group, age group, sample size, patient characteristics, blood and dialysate flow rate, and overall outcome. A descriptive analysis calculating the frequency of population size, symptoms, and various treatments was performed using R software version 3.1.0. Results A total of 49 studies (321 samples) were identified and analyzed. Out of the included 49 studies, a total of 48 studies reported the presence of DSS among patients (1 study reported based on number of dialysis and therefore was not considered for analysis). Among these 48 studies, 74.3% (226/304) patients were reported to have DSS. The most common symptoms were nausea (25.2%), headache (24.8%), vomiting (23.9%), muscle cramps (18.1%), affected level of consciousness (8.8%), confusion (4.4%), and seizure (4.9%) among the 226 DDS patients. Furthermore, 12 studies decided to switch from HD to alternative dialysis modalities including continuous venovenous hemofiltration/hemodiafiltration (CVVH/CVVHDF) or PD which reported no DDS symptoms. Conclusion Early recognition and timely prevention are crucial for DDS patients. We have provided comprehensive clinical practice points for pediatric, adolescent, and young adult populations. However, it is essential to recognize that DDS was reported more frequently in the early dialysis era, as there was a lack of advanced dialysis technology and limited resources., Author(s): Rupesh Raina [sup.1] [sup.2] [sup.3] , Andrew Davenport [sup.4] , Bradley Warady [sup.5] , Prabhav Vasistha [sup.1] , Sidharth Kumar Sethi [sup.6] , Ronith Chakraborty [sup.1] [sup.2] , Prajit [...]

Background/objectives Peritoneal dialysis (PD) patients are at increased risk of malnutrition and cachexia, definitions of which include weight loss. However, PD patients can absorb glucose from the dialysate and loss of muscle mass may be overlooked by fat weight gain. As such, we wished to review changes in body composition in prevalent PD patients. Subjects/methods We compared changes in body composition measured by dual x-ray absorptiometry (DXA) in adult PD patients, and calculated glucose absorption based on 24-h collections of PD dialysate. Results Overall, 73 prevalent PD patients, 60.3% male, mean age 62.5 [plus or minus] 16.4 years, had DXA scans a median of 24 (15-27) months apart. Weight did not change (70.7 [plus or minus] 16.8 vs. 70.9 [plus or minus] 16.8 kg), with a median 198 (88-295) mmol glucose absorbed/day. Appendicular lean mass (ALM) decreased in most of the male (59%) and female (52%) patients, and the change in ALM was negatively associated with the change in percentage body fat mass (%BFM) r = -0.54, p < 0.001. Overall, 56 patients (76.7%) were admitted to hospital with intercurrent illnesses. Women who lost ALM and gained %BFM had more hospital admissions and those with an increase in %BFM had more admissions due to PD peritonitis while, in males, these outcomes were not seen. Conclusion Although overall weight did not change, the majority of PD patients lost ALM, and this loss of muscle mass was masked by a gain in fat mass. Definitions of malnutrition and cachexia, which include unintentional weight loss criteria will underestimate the prevalence of PD patients with loss of muscle mass., Author(s): Kornchanok Vareesangthip [sup.1] , Andrew Davenport [sup.2] Author Affiliations: (1) Renal Division, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (2) UCL Department of Nephrology, [...]

Introduction Methods Results Conclusion Dialysis adequacy is traditionally calculated from pre‐ and post‐hemodialysis session serum urea concentrations and expressed as the urea reduction ratio, or Kt/Vurea. However, with increasing hemodiafiltration usage, we wished to determine whether there were any differences between standard Kt/Vurea equations and directly measured spent dialysate urea clearance.Urea clearance was measured from collected effluent dialysate and compared with various other methods of Kt/Vurea calculation, including change in total body urea from measuring pre‐ and post‐total body water with bioimpedance and the Watson equation, by standard Kt/V equations, and online clearance measurements using effective ionic dialysance (OLC).We compared urea clearance in 41 patients, 56.1% male, mean age 69.3 ± 12.6 years with 87.8% treated by hemodiafiltration. Reduction in total body urea was greater when estimating changes in total body urea, compared to measured dialysate losses of 58.4% (48.5–67.6) vs 71.6% (62.1–78), p < 0.01. Sessional urea clearance (Kt/Vurea) was greater using the online Solute‐Solver program compared to OLC, median 1.45(1.13–1.75) vs 1.2 (0.93–1.4), and 2nd generation Kt/V equations 1.3 (1.02–1.66), p < 0.01, but not different from estimated total body urea clearance 1.36 (1.15–1.73) and dialysate clearance 1.36 (1.07–1.76). The mean bias compared to the Solute‐Solver program was greatest with OLC (−0.25), compared to second‐generation equations (−0.02), estimated total body clearance (−0.02) and measured dialysate clearance (−0.01).This study demonstrated that the result from equations estimating urea clearance indirectly from pre‐ and postblood samples from hemo‐ and hemodiafiltration treatments was highly correlated with direct measurements of dialysate urea clearance. [ABSTRACT FROM AUTHOR]

Background: Debate continues as to the optimum hemodialysis (HD) dialysate calcium concentration. Although current guidelines advocate 1.25–1.5 mmol/L, some investigators have suggested these may cause calcium gains. As such we investigated whether using dialysate calcium of 1.25 mmol/L risked calcium gains, and whether there were differences between hemodiafiltration and high flux HD. Methods: We continuously collect an aliquot of effluent dialysate during dialysis sessions, and calculated dialysis calcium mass balance by the difference between the amount of calcium delivered as fresh dialysate and that lost in effluent dialysate. Results: We studied 106 stable outpatients, 64% male, mean age 64.4 ± 16.2 years, median dialysis vintage 32 (22–60) months. Most sessions (69%) used a 1.0 mmol/L calcium dialysate, with a median sessional loss of 13.7 (11.5–17.1) mmol, whereas using 1.25 mmol/L the median loss was 7.4 (4.9–10.1) mmol, but with 6.9% had a positive balance (p = 0.031 vs dialysate calcium 1.0 mmol/L). Most patients (85.8%) were treated by hemodiafiltration, but there was no difference in sessional losses (11.7 (8.4–15.8) vs 13.5 (8.1–16.8)) with high flux HD. Dialysis sessional calcium balance was associated with the use of lower dialysate calcium concentration (β −19.5, 95% confidence limits (95%CL) −27.7 to −11.3, p < 0.001), and sessional duration (β 0.07 (95% CL) 0.03–012, p = 0.002). Conclusion: Ideally, the choice of dialysate calcium should be individualized, but clinicians should be aware, that even when using a dialysate calcium of 1.25 mmol/L, some patients are at risk of a calcium gain during hemodiafiltration and high‐flux hemodialysis. [ABSTRACT FROM AUTHOR]

Introduction: Hemodialysis patient groups have advocated reducing dialysis fatigue and symptoms. We investigated whether compartmental fluid shifts were associated with peri‐dialytic fatigue and symptoms. Methods: Sessional dialysis records of patients reporting both a short and delayed recovery (<1 h and ≥1 h) with corresponding bioimpedance measurements were reviewed. Results: One hundred and twenty‐four patients reported both short and delayed recovery times, mean age 66.0 ± 14.8 years, 66.1% male. Differences between sessions included higher distress thermometer [4 (1–6) vs. 3 (0–5)], fatigue [4 (0–9) vs. 2 (0–7)], total symptom scores [20.5 (12.3–34.5) vs. 16 (7–28)], change in extracellular water to total body water ratios between body compartments [right leg/left arm 2.36 (1.23–4.19) vs. 1.28 (0.12–2.01), all p < 0.01] with delayed recovery, and more hemodialysis than hemodiafiltration sessions (χ2 4.6, p = 0.02). Conclusion: Sessions with prolonged recovery times were associated with more peri‐dialytic symptoms, psychological distress, and hemodialysis mode, and greater changes in compartmental fluid shifts. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) is one of the most serious non‐communicable diseases affecting the population. In the early‐stages patients have no obvious symptoms, until it becomes life‐threatening leading end‐stage kidney failure. Therefore, it is important to early diagnose CKD to allow therapeutic interventions and progression monitoring. Here, a point‐of‐care (POC) sensing platform is reported for the simultaneous detection of three CKD biomarkers, namely creatinine, urea, and human serum albumin (HSA), using reduced graphene oxide/polydopamine‐molecularly imprinted polymer (rGO/PDA‐MIP) fabricated with novel surface‐molecularly imprinting technology. A multi‐channel electrochemical POC readout system with differential pulse voltammetry (DPV) function is developed, allowing the simultaneous detection of the three biomarkers, in combination with the surface‐MIP electrodes. This sensing platform achieves the record low limit‐of‐detection (LoD) at a femtomolar level for all three analytes, with wide detection ranges covering their physiological concentrations. Clinical validation is performed by measuring these analytes in serum and urine from healthy controls and patients with CKD. The average recovery rate is 81.8–119.1% compared to the results obtained from the hospital, while this platform is more cost‐effective, user‐friendly, and requires less sample‐to‐result time, showing the potential to be deployed in resource‐limited settings for the early diagnosis and tracking progression of CKD. [ABSTRACT FROM AUTHOR]