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Bone mineral abnormalities (defined as Chronic Kidney Disease Mineral Bone Disorder; CKD-MBD) are prevalent and associated with a substantial risk burden and poor prognosis in CKD population. Several lines of evidence support the notion that a large proportion of patients receiving maintenance dialysis experience a suboptimal biochemical control of CKD-MBD. Although no study has ever demonstrated conclusively that CKD-MBD control is associated with improved survival, an expanding therapeutic armamentarium is available to correct bone mineral abnormalities. In this position paper of Lombardy Nephrologists, a summary of the state of art of CKD-MBD as well as a summary of the unmet clinical needs will be provided. Furthermore, this position paper will focus on the potential and drawbacks of a new injectable calcimimetic, etelcalcetide, a drug available in Italy since few months ago.

Chronic kidney disease (CKD) represents a major public health issue worldwide and entails a high burden of cardiovascular events and mortality. Dyslipidaemia is common in patients with CKD and it is characterized by a highly atherogenic profile with relatively low levels of HDL-cholesterol and high levels of triglyceride and oxidized LDL-cholesterol. Overall, current literature indicates that lowering LDL-cholesterol is beneficial for preventing major atherosclerotic events in patients with CKD and in kidney transplant recipients while the evidence is less clear in patients on dialysis. Lipid lowering treatment is recommended in all patients with stage 3 CKD or worse, independently of baseline LDL-cholesterol levels. Statin and ezetimibe are the cornerstones in the management of dyslipidaemia in patients with CKD, however alternative and emerging lipid-lowering therapies may acquire a central role in near future. This position paper endorsed by the Italian Society of Nephrology aims at providing useful information on the topic of dyslipidaemia in CKD and at assisting decision making in the management of these patients.

Brachiocephalic arteriovenous fistulas (AVF) makeup approximately one third of prevalent dialysis vascular accesses. The most common cause of malfunction with this access is cephalic arch stenosis (CAS). The accepted requirement for treatment of a venous stenosis lesion is ⩾50% stenosis associated with hemodynamically abnormalities. However, the correlation between percentage stenosis and a clinically significant decrease in access blood flow (Qa) is low. The critical parameter is the absolute minimal luminal diameter (MLD) of the lesion. This is the parameter that exerts the key restrictive effect on Qa and results in hemodynamic and functional implications for the access. CAS is the result of low wall shear stress (WSS) resulting from the effects of increased blood flow and the unique anatomical configuration of the CAS. Decrease in WSS has a linear relationship to increased blood flow velocity and neointimal hyperplasia exhibits an inverse relationship with WSS. The result is a stenotic lesion. The presence of downstream venous stenosis causes an inflow-outflow mismatch resulting in increased pressure within the access. Qa in this situation may be decreased, increased, or within a normal range. Over time, the increased intraluminal pressure can result in marked aneurysmal changes within the AVF, difficulties with cannulation and the dialysis treatment, and ultimately, increasing risk of access thrombosis. Complete characterization of the lesion both hemodynamically and anatomically should be the first step in developing a strategy for management. This requires both access flow measurement and angiographic imaging. Patients with CAS present a relatively broad spectrum as relates to both of these parameters. These data should be used to determine whether primary treatment of CAS should be directed toward the anatomical lesion (small MLD and low Qa) or the pathophysiology (large MLD and high Qa).

Hyperkalemia (HK) is the most common electrolyte disturbance observed in patients with kidney disease, particularly in those in whom diabetes and heart failure are present or are on treatment with renin–angiotensin–aldosterone system inhibitors (RAASIs). HK is recognised as a major risk of potentially life threatening cardiac arrhythmic complications. When an acute reduction of renal function manifests, both in patients with chronic kidney disease (CKD) and in those with previously normal renal function, HK is the main indication for the execution of urgent medical treatment and the recourse to extracorporeal replacement therapies. In patients with end-stage renal disease, the presence of HK not responsive to medical therapy is an indication at the beginning of chronic renal replacement therapy. HK can also be associated indirectly with the progression of CKD, because the finding of high potassium values leads to withdrawal of treatment with RAASIs, which constitute the first choice nephro-protective treatment. It is therefore essential to identify patients at risk of developing HK, and to implement therapeutic interventions aimed at preventing and treating this dangerous complication of kidney disease. Current strategies aimed at the prevention and treatment of HK are still unsatisfactory, as evidenced by the relatively high prevalence of HK also in patients under stable nephrology care, and even in the ideal setting of randomized clinical trials where optimal treatment and monitoring are mandatory. This position paper will review the main therapeutic interventions to be implemented for the prevention, detection and treatment of HK in patients with CKD on conservative care, in those on dialysis, in patients in whom renal disease is associated with diabetes, heart failure, resistant hypertension and who are on treatment with RAASIs, and finally in those presenting with severe acute HK.

Vascular accesses for hemodialysis are considered the patient’s lifeline and their maintenance is essential for treatment continuity. Following the example of institutions in other countries affected by the Covid-19 pandemic, the Brazilian Society of Nephrology developed these guidelines for healthcare services, elaborating on the importance of carrying out procedures for the preparation and preservation of vascular accesses. Creating definitive accesses for hemodialysis, grafts and arteriovenous fistulas are non-elective procedures, as well as the transition from the use of non-tunneled catheters to tunneled catheters, which cause less morbidity. In the case of patients with suspected or confirmed coronavirus infection, one may postpone the procedures for the quarantine period, to avoid spreading the disease.

Background: We aimed to identify the 100 most cited articles published on peritoneal dialysis (PD) and analyze their characteristics to provide information on the achievements and developments of PD research over the past decades. Methods: The Science Citation Index Expanded (SCIE) in the Web of Science Core Collection was comprehensively searched from 2000 to 2018, using the keywords “Peritoneal dialysis” or “Dialyses, Peritoneal” or “Dialysis, Peritoneal” or “Peritoneal Dialyses”. The top 100 cited articles were retrieved by reading titles and abstracts. Significant information was further elicited, including the authors, journals, countries, institutions, and publication year. Results: The United States was the most productive country (n = 51), Li Pkt published the highest number of papers (n = 7), the Journal of the American Society of Nephrology produced the highest number of contributions (n = 28), and Baxter International Inc., the University of California System, and the University of Toronto were the institutions with the highest number of articles (n = 10). Conclusions: This is the first bibliometric study to identify the most influential papers in PD research. This report describes the major changes and advances in research regarding PD as a guide for writing a citable article.

Background Chronic kidney disease (CKD) is characterized by dysbiosis, elevated levels of uremic toxins, systemic inflammation, and increased markers of oxidative stress. These factors lead to an increased risk of cardiovascular disease (CVD) which is common among CKD patients. Supplementation with high amylose maize resistant starch type 2 (RS-2) can change the composition of the gut microbiota, and reduce markers of inflammation and oxidative stress in patients with end-stage renal disease. However, the impact of RS-2 supplementation has not been extensively studied in CKD patients not on dialysis. Aerobic exercise training lowers certain markers of inflammation in CKD patients. Whether combining aerobic training along with RS-2 supplementation has an additive effect on the aforementioned biomarkers in predialysis CKD patients has not been previously investigated. Methods The study is being conducted as a 16-week, double-blind, placebo controlled, parallel arm, randomized controlled trial. Sixty stage 3–4 CKD patients (ages of 30–75 years) are being randomized to one of four groups: RS-2 & usual care, RS-2 & aerobic exercise, placebo (cornstarch) & usual care and placebo & exercise. Patients attend four testing sessions: Two baseline (BL) sessions with follow up visits 8 (wk8) and 16 weeks (wk16) later. Fasting blood samples, resting brachial and central blood pressures, and arterial stiffness are collected at BL, wk8 and wk16. A stool sample is collected for analysis of microbial composition and peak oxygen uptake is assessed at BL and wk16. Blood samples will be assayed for p-cresyl sulphate and indoxyl sulphate, c-reactive protein, tumor necrosis factor α, interleukin 6, interleukin 10, monocyte chemoattractant protein 1, malondialdehyde, 8-isoprostanes F2a, endothelin-1 and nitrate/nitrite. Following BL, subjects are randomized to their group. Individuals randomized to conditions involving exercise will attend three supervised moderate intensity (55–65% peak oxygen uptake) aerobic training sessions (treadmills, bikes or elliptical machine) per week for 16 weeks. Discussion This study has the potential to yield information about the effect of RS-2 supplementation on key biomarkers believed to impact upon the development of CVD in patients with CKD. We are examining whether there is an additive effect of exercise training and RS-2 supplementation on these key variables. Trial registration Clinicaltrials.gov Trial registration#NCT03689569. 9/28/2018, retrospectively registered.

Vascular accesses for hemodialysis are considered the patient’s lifeline and their maintenance is essential for treatment continuity. Following the example of institutions in other countries affected by the Covid-19 pandemic, the Brazilian Society of Nephrology developed these guidelines for healthcare services, elaborating on the importance of carrying out procedures for the preparation and preservation of vascular accesses. Creating definitive accesses for hemodialysis, grafts and arteriovenous fistulas are non-elective procedures, as well as the transition from the use of non-tunneled catheters to tunneled catheters, which cause less morbidity. In the case of patients with suspected or confirmed coronavirus infection, one may postpone the procedures for the quarantine period, to avoid spreading the disease. RESUMO Os acessos vasculares para hemodiálise são considerados a linha da vida do paciente, e sua manutenção é essencial para o seguimento do tratamento. A exemplo de instituições de outros países atingidos pela pandemia da Covid-19, a Sociedade Brasileira de Nefrologia elaborou estas orientações para os serviços de saúde, esclarecendo a importância da realização dos procedimentos de confecção e preservação de acessos vasculares. Consideramos como não eletivos os procedimentos de confecção de acessos definitivos para hemodiálise, próteses e fístulas arteriovenosas, bem como a transição do uso de cateteres não tunelizados para cateteres tunelizados, os quais acarretam menor morbidade. Nos casos de pacientes com infecção suspeita ou confirmada por coronavírus, é aceitável o adiamento dos procedimentos pelo período de quarentena, para evitar disseminação da doença.

Die Nierenersatztherapie ist neben der Beatmung eines der wichtigsten und am häufigsten angewendeten Organersatzverfahren in der täglichen Praxis in der Intensivmedizin. Im Gegensatz zur Beatmungstherapie sind Qualitätsstandards für die Nierenersatztherapie weniger gut definiert und bekannt. In diesem Positionspapier der Deutschen Interdisziplinären Vereinigung für Intensivmedizin (DIVI) beschreiben wir Qualitätsstandards zur Nierenersatztherapie mit dem Ziel die Behandlungsqualität der Patienten mit einem schweren akuten Nierenversagen zu verbessern.

The kidney exerts multiple functions, and pathophysiological interactions between the kidney and the heart have important clinical implications, but it has only recently become clear that these interactions should be studied across the whole spectrum of reduced kidney function and not only in cases with severe, end-stage renal disease (ESRD), as has been done for many years.1 The prevalence of chronic kidney disease (CKD), defined as a glomerular filtration rate (GFR) of 3 months, exceeds 10% in the adult population and reaches 47% in subjects older than 70 years, according to data from the USA, with a trend towards a recent increasing prevalence.1,2 Many interactions between kidney and cardiovascular functions have important implications for clinical management and health policy ( Figure 1 ), since even mild forms of kidney disease are associated with an increased risk of cardiovascular morbidity and overall mortality, and renal function may worsen over time.1,3 Figure 1 Stages of the development and progression of chronic kidney disease (CKD), including complications and strategies to improve outcomes. Modified from Eckardt et al. 1 GFR, glomerular filtration rate. Although cardiovascular disease (CVD) and cardiac disorders are more frequent and severe in CKD, they are often not recognized, or undertreated, in view of the complexity of patient management in this setting.4 On the other hand, the presence and evolution of CKD is often not evaluated and monitored in patients with various forms of heart diseases, including patients with cardiac rhythm disturbances, a setting where CKD is associated with challenging decision-making on the management of specific treatments and interventions. In patients with cardiac diseases, CKD predisposes to acute kidney injury and vice versa , and both may strongly influence clinical management of cardiac conditions. Considering the need for increasing the awareness of …

Lateral flow assays (LFAs) hold great promise for point-of-care testing, especially in resource-poor settings. However, the poor sensitivity of LFAs limits their widespread applications. To address this, we developed a novel device by integrating dialysis-based concentration method into LFAs. The device successfully achieved 10-fold signal enhancement in Human Immunodeficiency Virus (HIV) nucleic acid detection with a detection limit of 0.1 nM and 4-fold signal enhancement in myoglobin (MYO) detection with a detection limit of 1.56 ng/mL in less than 25 min. This simple, low-cost and portable integrated device holds great potential for highly sensitive detection of various target analytes for medical diagnostics, food safety analysis and environmental monitoring.

INTRODUCTION: Acute kidney injury is associated with high mortality in the perioperative period of liver transplantation. The aim of this position paper was to provide an up-to-date overview with special emphases on diagnosis, risk factors, and treatment. EVIDENCEACQUISITION: The Liver Intensive Care Group of Europe nominated a panel of recognized international experts who reviewed the available literature published from 1990 to January 2016 and produced clinical recommendations. The level of evidence and strength of recommendation were judged according to the Grading of Recommendations Assessment Development and Evaluation system. EVIDENCESYNTHESIS: Diagnosis of AKIshould be based on the KDIGOcriteria. The preoperative risk factors are more related to the patients predisposing factors and post-operative risk factors tend to be difficult to control. Therefore, focusing on intra-operative risk factors it would be important to maintain an adequate hemodynamics and to keep inferior vena cava clamping as short as possible. Biomarkers to identify AKIat an early stage are available; however, there is a lack of robust data that indicates their true beneficial effect. Intraoperative renal replacement therapy may be beneficial in some selective cases whereas its postoperative timing is still under debate. CONCLUSIONS: Perioperative liver transplant risk factors for acute kidney injury are difficult to control. Therefore, the focus should be on intra-operative hemodynamics and nephrotoxic drugs avoidance. Prospective randomized trials are needed to show the beneficial effect of early replacement therapy. In this context, the new biomarkers would be helpful in identifying kidney injury earlier OA embargo

Background: Frailty is known to be highly prevalent in older hemodialysis (HD) patients. We studied the prevalence of frailty and its associated factors in Chinese HD patients. We further studied if frailty could predict survival in HD patients. Methods: This is a prospective study involving patients receiving maintenance HD in the dialysis center of Xuanwu Hospital, Beijing. Study subjects were enrolled from October to December, 2017 and followed up for two years. Demographic data, comorbidities and biological parameters were collected. Frailty was assessed using the Fried frailty phenotype at baseline. Cox regression analysis was performed to identify the relationship between frailty and mortality in HD patients. Kaplan-Meier was plotted using the cutoff value obtained by ROC curve to evaluate survival rates in different frailty status. Results: Total of 208 HD patients were enrolled with a mean age of 60.5±12.7 years. According to the frailty criteria, at baseline the prevalence of robust, pre-frail and frail in HD patients was 28.7%, 45.9%, and 25.4%, respectively. The two-year all-cause mortality was 18.8% (39/207) and underlying causes of death included coronary artery disease (CAD), cerebrovascular disease (CVD), hyperkalemia, severe infection, malignant tumor and others. Survival curve showed the patients with frailty score ≥4 to have significantly shorter survival time as compared to patients with frailty score ≤ 3. Frailty predicted two-year mortality when frailty score ≥4 with a sensitivity of 70% and a specificity of 83.67% with an AUC of 0.819. Frailty score was positively associated with age and ratio of ultrafiltration volume to dry weight, while negatively associated with levels of serum albumin, uric acid and diastolic blood pressure after HD. Conclusions: Our results confirm frailty to be very common among HD patients and severity of frailty was a significant predictor of mortality for HD patients. Factors such as age, malnutrition and low blood pressure are the factors to be associated with frailty. Interdialytic weight gain inducing excessive ultrafiltration volume is an important risk factor.

Background: Coronavirus disease (COVID-19) has spread rapidly since 2019. Approximately 15% of the patients will develop severe complications such as multiple organ disease syndrome related to cytokine release syndrome (CRS). Continuous renal replacement therapy (CRRT) can remove inflammatory cytokines through filtration or adsorption. We evaluated the effectiveness of CRRT in COVID-19 patients with CRS. Methods: This retrospective, multicenter, descriptive study included 83 patients with CRS from three hospitals in Wuhan. Results: In COVID-19 patients with CRS, the fatality rate was even higher in CRRT group (P=0.005). However, inflammatory markers such as C-reactive protein, neutrophil counts, and D-dimer decreased after CRRT (P

Our study aimed to explore the intercorrelations of brachial‐ankle pulse wave velocity (baPWV), ankle‐brachial index (ABI), ambulatory arterial stiffness index (AASI), 24‐hour mean pulse pressure (24‐h PP), and augmentation index (AIx, AIx@75, the AIx standardized to a heart rate of 75) and compare the effectiveness of these markers for predicting renal outcomes. A total of 117 patients with chronic kidney disease (CKD) who received noninvasive arterial stiffness examinations were enrolled. We used correlation analysis and linear regression to explore the correlations between these five arterial stiffness markers and the Cox proportional hazards model and receiver operator characteristic (ROC) curve to assess the associations of markers with kidney disease outcomes. The median (interquartile range) of age and eGFR were 61 (49‐65) years and 50.5 (35.5‐84.1) ml/min/1.73 m2, respectively. In Pearson correlation analysis, baPWV was significantly associated with 24‐h PP (r = .531, p

Purpose Patients on maintenance hemodialysis are vulnerable to viral infections like COVID-19 because of the low chance of obedience and complying with rules besides the need for transfer to distant dialysis facilities. We investigated the impact and clinical effect of treatment of COVID-19 in dialysis patients. Methods We included patients on maintenance hemodialysis at different healthcare facilities in Zonguldak city. With the diagnosis of the first infected HD case, all other patients who shared the same session were screened. Hospitalized and clinically confirmed cases were included. COVID-19 diagnosis was made based on clinical, biochemical along radiologic findings. Results 34 (F/M:19/15, mean age 62 ± 13.2 years, dialysis duration 66.9 ± 57.7 months, length of hospital stay 16.2 ± 7.9 days) were diagnosed with COVID-19 infection. The prevalence of COVID-19 was found to be 18.4% of our exposed population. 38.2% of our patients were initially diagnosed by CT screening while asymptomatic. 35.3% had a fever as the first presenting symptom. Lymphopenia was the most common laboratory finding. Except for one, all had at least one comorbidity. Out of 12 (35.3%) patients admitted to ICU 6(17.6%) died. The deceased patients were older, presented with lower serum albumin and lymphocyte count, and had higher CRP and fibrinogen levels. High CRP level on admission was the only significant predictor of mortality. Conclusion Early detection will lower mortality. In this study, with a low prevalence of COVID-19, the importance of early screening of both symptomatic and asymptomatic patients was shown to be highly important. Further studies are still needed to find out the most appropriate medical management.

PurposeThe aim of the study was to assess whether a history of dialysis is related to cardiopulmonary resuscitation (CPR) attempts and survival to hospital admission in patients with out-of-hospital cardiac arrest (OHCA).MethodsThe databases of the POL-OHCA registry and of emergency medical calls in the Command Support System of the State of Emergency Medicine (CSS) were searched to identify patients with OHCA and a history of dialysis. A total of 264 dialysis patient with OHCA were found: 126 were dead on arrival of emergency medical services (EMS), and 138 had OHCA with CPR attempts. Data from the POL-OHCA registry for patients with CPR attempts, including age, sex, place of residence, first recorded rhythm, defibrillation during CPR, and priority dispatch codes, were collected and compared between patients with and without dialysis.ResultsCPR attempts by EMS were undertaken in 138 dialyzed patients (52.3%). The analysis of POL-OHCA data revealed no differences in age, sex, place of residence, first recorded rhythm, and priority dispatch codes between patients with and without dialysis. Defibrillation was less frequent in dialysis patients (P = 0.04). A stepwise logistic regression analysis revealed no association between survival to hospital admission and a history of hemodialysis (odds ratio = 1.12; 95% CI 0.74–1.70,P = 0.60).ConclusionsA history of dialysis in patients with OHCA does not affect the rate of CPR attempts by EMS or a short-term outcome in comparison with patients without dialysis. Defibrillation during CPR is less common in patients on dialysis than in those without.

Background: Although mechanical thrombectomy is a standard endovascular therapy for patients with acute ischemic stroke (AIS), the incidence of and risk factors for contrast-induced nephropathy (CIN) following mechanical thrombectomy are infrequently reported. Objectives: The aim of this study was to investigate the incidence and risk factors for CIN following mechanical thrombectomy for AIS, and whether the incidence of CIN is related to a poor prognosis. Methods: We examined consecutive patients who underwent a mechanical thrombectomy in the period from January 2014 to March 2018. The patients’ clinical backgrounds, treatments, and clinical prognoses were analyzed. CIN was defined as an increase in the serum creatinine level of ≥44.2 μmol/L (0.5 mg/dL) or 25% above baseline within 72 h after exposure to the contrast medium. Results: In total, 80 patients (46 men and 34 women aged 74.5 ± 11.5 years) who met our inclusion criteria were analyzed. CIN occurred in 8.8% (7/80) of the patients following mechanical thrombectomy. Although no patients needed permanent dialysis, 1 required temporary dialysis. The median amount of contrast medium was 109 mL. A comparison between the groups with and without CIN showed a significant difference in white blood cell (WBC) count at the time of admission (11.6 ± 2.7 × 103/μL and 8.1 ± 2.7 × 103/μL; p < 0.01) and the cut-off value was 9.70 × 103/μL. In multivariate analysis, contrast volume/estimated glomerular filtration rate by creatinine and WBC count were significantly associated with the incidence of CIN, with odds ratios of 1.64 (95% CI 1.02–2.65; p = 0.04) and 1.61 (95% CI 1.15–2.25; p < 0.01), respectively. Conclusions: This study found that CIN occurred in 8.8% of patients with AIS following mechanical thrombectomy. High WBC count was associated with an increased risk of CIN and may be helpful for predicting CIN.

Measurement of oxalate in the blood is essential for monitoring primary hyperoxaluria patients with progressive renal impairment and on dialysis prior to transplantation. As no external quality assurance scheme is available for this analyte, we conducted a sample exchange scheme between six laboratories specifically involved with the investigation of primary hyperoxaluria to compare results. The methodologies compared were gas chromatography/mass spectrometry (GCMS), ion chromatography with mass spectrometry (ICMS), and enzymatic methods using oxalate oxidase and spectrophotometry. Although individual laboratories performed well in terms of reproducibility and linearity, there was poor agreement (absolute values) between centres as illustrated by a longer-term comparison of patient results from two of the participating laboratories. This situation was only partly related to differences in calibration and mainly reflected the lower recoveries seen with the ultrafiltration of samples. These findings lead us to conclude that longitudinal monitoring of primary hyperoxaluria patients with deteriorating kidney function should be performed by a single consistent laboratory and the methodology used should always be defined. In addition, plasma oxalate concentrations reported in registry studies and those associated with the risk of systemic oxalosis in published studies need to be interpreted in light of the methodology used. A reference method and external quality assurance scheme for plasma oxalate analysis would be beneficial.

Compliance mismatch between an arteriovenous dialysis graft (AVG) and the connected vein is believed to result in disturbed haemodynamics around the graft–vein anastomosis and increased mechanical loading of the vein. Both phenomena are associated with neointimal hyperplasia development, which is the main reason for AVG patency loss. In this study, we use a patient-specific fluid structure interaction AVG model to assess whether AVG haemodynamics and mechanical loading can be optimised by using novel electrospun polyurethane (ePU) grafts, since their compliance can be better tuned to match that of the native veins, compared to gold standard, expanded polytetrafluoroethylene (ePTFE) grafts. It was observed that the magnitude of flow disturbances in the vein and the size of anastomotic areas exposed to highly oscillatory shear ($$\hbox {OSI} >0.25$$OSI>0.25) and very high wall shear stress ($$>40 \hbox { Pa}$$>40Pa) were largest for the ePTFE graft. Median strain and von Mises stress in the vein were similar for both graft types, whereas highest stress and strain were observed in the anastomosis of the ePU graft. Since haemodynamics were most favourable for the ePU graft simulation, AVG longevity might be improved by the use of ePU grafts.

Background Dialysis patients are at increased risk of HF. However, diagnostic utility of NT-proBNP as a biomarker is decreased in patients on dialysis. GDF-15 and cNEP are biomarkers of distinct mechanisms that may contribute to HF pathophysiology in such cohorts. The aim of this study was to determine whether growth differentiation factor-15 (GDF-15) and circulating neprilysin (cNEP) improve the diagnosis of congestive heart failure (HF) in patients on dialysis. Methods and results We compared circulating concentrations of NT-proBNP, GDF-15, and cNEP along with cNEP activity in patients on chronic dialysis without (n = 80) and with HF (n = 73), as diagnosed by clinical parameters and post-dialysis echocardiography. We used correlation, linear and logistic regression as well as receiver operating characteristic (ROC) analyses. Compared to controls, patients with HF had higher median values of NT-proBNP (16,216 [interquartile range, IQR = 27739] vs. 2883 [5866] pg/mL, p p = 0.014), but not cNEP (315 [107] vs. 318 [124] pg/mL, p = 0.818). Median cNEP activity was significantly lower in HF vs. controls (0.189 [0.223] vs. 0.257 [0.166] nmol/mL/min, p p Conclusion We present novel comparative data on physiologically distinct circulating biomarkers for HF in patients on dialysis. cNEP activity but not concentration and GDF-15 provided incremental diagnostic information over clinical covariates and NT-proBNP and may aid in diagnosing HF in dialysis patients. Graphic abstract

Background: Occult hepatitis B virus infection (OBI) is defined as undetectable serum hepatitis B surface antigen (HBsAg) with detectable HBV-DNA in the serum or liver. Patients with maintenance hemodialysis (MHD) are at a high risk of OBI. The prevalence of OBI in MHD patients in China is not well evaluated. In this study, we aim to assess the prevalence of OBI in MHD patients in Sichuan Province, Southwest of China and investigate the mutations in the “a” determinant of HBsAg. Methods: A total of 330 patients undergoing MHD at Sichuan Provincial People's Hospital were enrolled. Serum samples were collected for ELISA assay to test the serological markers of HBV infection, real-time PCR assay to identify the presence of HBV-DNA, and nested PCR plus sequencing analysis to investigate the gene mutations. Results: In a total of 330 MHD patients, we found that the prevalence of OBI was 4.2% (7/165) in the test group, 2.1% (7/330) in the overall dialysis cohort. After a follow-up study of 7 MHD patients with OBI for 2 years, 2 (isolated HBcAb+) of them were still detectable for HBV-DNA. By sequencing analysis, we revealed mutations at the “a” determinant of HBsAg, including Q129R, T131N, M133S, F134L and D144E. The Q129R and M133S mutations were first reported. Conclusions: Our study clarifies the prevalence of OBI in MHD patients in Sichuan Province(4.2% in the test group, 2.1% in the overall dialysis cohort), and demonstrate the mutations of Q129R and M133S in the “a” determinant of HBsAg for the first time.

Background: Patients with chronic kidney disease (CKD) are associated with high prevalence rates of proteinuria, vascular calcification and cardiomegaly. In this study, we investigated relationships among proteinuria, aortic arch calcification (AoAC) and cardio-thoracic ratio (CTR) in patients with CKD stage 3A-5. In addition, we investigated correlations among proteinuria and decline in renal function, overall and cardiovascular (CV) mortality. Methods: We enrolled 482 pre-dialysis patients with CKD stage 3A-5, and determined AoAC and CTR using chest radiography at enrollment. The patients were stratified into four groups according to quartiles of urine protein-to-creatinine ratio (UPCR). Results: The patients in quartile 4 had a lower estimated glomerular filtration rate (eGFR) slope, and higher prevalence rates of rapid renal progression, progression to commencement of dialysis, overall and CV mortality. Multivariable analysis showed that a high UPCR was associated with high AoAC (unstandardized coefficient β: 0.315; p = 0.002), high CTR (unstandardized coefficient β: 1.186; p = 0.028) and larger negative eGFR slope (unstandardized coefficient β: -2.398; p < 0.001). With regards to clinical outcomes, a high UPCR was significantly correlated with progression to dialysis (log per 1 mg/g; hazard ratio [HR], 2.538; p = 0.003), increased overall mortality (log per 1 mg/g; HR, 2.292; p = 0.003) and increased CV mortality (log per 1 mg/g; HR, 3.195; p = 0.006). Conclusions: Assessing proteinuria may allow for the early identification of high-risk patients and initiate interventions to prevent vascular calcification, cardiomegaly, and poor clinical outcomes.

Objective: Increased cancer risk after dialysis or transplantation has been recognized, but studies of cancer in pre-dialysis chronic kidney disease (CKD) are extremely limited. Therefore, we aim to investigate the risk of cancer in individuals with reduced kidney function. Methods: This study was based on China Health and Retirement Longitudinal Study (CHARLS), a nationally representative population aged ≥ 45 years old. We included 11 508 (5364 male) individuals with measurement of serum creatinine and without history of cancer at baseline. Incident cancer cases were documented in the biennial questionnaire. Results: The mean age was 58.7 ± 9.8 years. Participants with estimated glomerular filtration rate (eGFR) ≥ 90 ml/min/1.73m2, 60 to 89 ml/min/1.73m2, and eGFR < 60 ml/min/1.73m2 accounted for 62.9%, 33.7% and 3.4%, respectively. During 42 895 person-years' follow-up, 217 new cases of cancer were recorded. In participants with eGFR < 90 ml/min/1.73m2, cubic spline showed linear relationship between the risk of cancer and eGFR, while remained stable and no association in participants with eGFR > 90 ml/min/1.73m2. Compared to participants with eGFR ≥ 90 ml/min/1.73m2, those with eGFR < 60 ml/min/1.73m2 was associated with the increased risk of cancer in the fully adjusted model (hazard ratio 2.08; 95% confidence interval 1.22-3.53); and the risk for kidney and lung cancers was higher among those with eGFR < 60 ml/min/1.73m2. Conclusion: Reduced kidney function is associated with a higher risk of cancer and should be integrated into risk-stratification of cancer screening and management.

Introduction Anemia in patients with chronic kidney disease (CKD) is present in about 50% in pre-dialysis and over 90% of patients on hemodialysis. Erythropoiesis-stimulating agent (ESA) is a standard therapy for renal anemia, but management of anemia in CKD still remains a challenge from the treatment point of view. Aim To evaluate safety and efficacy of methoxy polyethylene glycol-epoetin beta as continuous erythropoietin receptor activator (C.E.R.A.) in maintenance of haemoglobin (Hb) concentrations in patients with chronic renal anemia in the routine clinical practice. Methods National, multicenter, observational, prospective study in patients with CKD on hemodialysis for maintenance of Hb levels with once-monthly therapy with C.E.R.A. In 8 dialysis centers 184 adult patients were observed and followed up every month during one year. Total number of enrolled patients was 185 from whom 184 patients were observed and 147 patients were followed for 12 months as 37 dropped out from the study earlier. Results Overall mean dose of C.E.R.A. was 115.2 μg with average 4.99 dose modifications per patient. Among 184 patients observed, total number of 121 adverse events (AEs) were identified in 49 of the patients. The most of the AEs were of mild or moderate severity. A few serious AEs were assessed and reported as not related to the drug administration. Mean Hb levels during the study varied but were maintained stable in the range of 100-120 g/l. Conclusion Safety and tolerability of C.E.R.A. was as expected as the frequency and type of AEs was similar to the known pattern from the studies done in other countries and relevant literature. Hb levels as the primary efficacy parameter of C.E.R.A. treatment were maintained stable within the target range during the study.

Introduction Treatment of chronic total occlusions (CTO) despite improvement in techniques and results over the last years still seems to be limited to a small number of centres and operators. Application of the hybrid strategy may support further spread of CTO percutaneous coronary intervention (PCI) and increase procedural success rates. Aim Our single-centre prospective ongoing registry aims to provide details and results of recanalizations of coronary CTO performed according to the hybrid algorithm in a series of consecutive patients. Material and methods Between January 2015 and September 2019 the clinical and procedural data of CTO PCI procedures on consecutive patients were collected. Lesion complexity was assessed according to the Multicenter CTO Registry of Japan (J-CTO) score: 0 – easy, 1 – intermediate, 2 – difficult, ≥ 3 – very difficult and PROGRESS score. Strategies applied were classified as: antegrade wire escalation (AWE), antegrade dissection and re-entry (ADR), retrograde wire escalation (RWE) and retrograde dissection and re-entry (RDR). Angiographic success was defined as < 30% residual stenosis with TIMI 3 flow. Angiographic and clinical complications were reported. Results Two hundred sixty-six patients were included and 285 procedures were performed in total. Success rate was 87.7% (calculated per procedure) and 92.5% (calculated per patient). Four patients underwent successful staged double CTO recanalization. Fifteen patients out of 31 primary failures underwent a second attempt with a 73% success rate (11/15). Fifty-two patients (18.2%) were referred for a second attempt from other institutions. Mean J-CTO score was 2.6 (13 cases with J-CTO of 0, 41 cases with J-CTO of 1, 80 cases with J-CTO of 2, and 151 cases with J-CTO ≥ 3) and the success rate was respectively 92.3%, 95.1%, 91.3% and 83.4%. Higher complexity of occlusion required a higher number of applied strategies including retrograde access in over a quarter of cases. Complete revascularization was achieved in 215 (75.4%) cases. In-hospital MACCE rate was 3.5% – 1 patient died due to acute kidney injury complications, 9 (3.2%) patients sustained myocardial infarction (1 STEMI due to side branch occlusion). All 7 (2.5%) coronary perforations (Ellis 1 and Ellis 2) were treated conservatively and we recognised 10 (3.5%) cases of acute kidney injury (one dialysis). Conclusions The hybrid algorithm in CTO PCI can be successfully applied with good early results and low complication rates. Higher complexity CTOs require more procedural strategies with a significantly lower success rate in very difficult cases.

The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) CKD-MBD working group, in collaboration with the Committee of Scientific Advisors of the International Osteoporosis Foundation, published a position paper for the diagnosis and management of osteoporosis in patients with CKD stages 4-5D (eGFR < 30 ml/min 1.73 m2). The present article reports and summarizes the main recommendations included in this 2021 document. The following areas are reviewed: diagnosis of osteoporosis; risk factors for fragility fractures; fracture risk assessment; intervention thresholds for pharmacological intervention; general and pharmacological management of osteoporosis; monitoring of treatment, and systems of care, all in patients with CKD stages 4-5D. Guidance is provided for clinicians caring for CKD stages 4-5D patients with osteoporosis, allowing for a pragmatic individualized diagnostic and therapeutic approach as an alternative to current variations in care and treatment nihilism.

Increasing insight into the impact of the gut microbiota on human health has sustained the development of novel prebiotic ingredients. This exploratory study evaluated the prebiotic potential of baobab fruit pulp powder, which consists of pectic polysaccharides with unique composition as compared to other dietary sources, given that it is rich in low methoxylated homogalacturonan (HG). After applying dialysis procedures to remove simple sugars from the product (simulating their absorption along the upper gastrointestinal tract), 48 h fecal batch incubations were performed. Baobab fruit pulp powder boosted colonic acidification across three simulated human adult donors due to the significant stimulation of health-related metabolites acetate (+18.4 mM at 48 h), propionate (+5.5 mM at 48 h), and to a lesser extent butyrate (0.9 mM at 48 h). Further, there was a trend of increased lactate levels (+2.7 mM at 6h) and reduced branched chain fatty acid (bCFA) levels (−0.4 mM at 48 h). While Bacteroidetes levels increased for all donors, donor-dependent increases in Bifidobacteria, Lactobacilli, and Firmicutes were observed, stressing the potential interindividual differences in microbial composition modulation upon Baobab fruit pulp powder treatment. Overall, Baobab fruit pulp powder fermentation displayed features of selective utilization by host microorganisms and, thus, has promising prebiotic potential (also in comparison with the ‘gold standard’ prebiotic inulin). Further research will be required to better characterize this prebiotic potential, accounting for the interindividual differences, while aiming to unravel the potential resulting health benefits.

Dialysis and nutrition are two sides of the same coin—dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.

High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions, the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting drugs and favouring “natural” medicine focussing on lifestyle and diet; (3) encouraging the reuse of “household” hospital material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and supplies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly approaches in the building of new facilities.

Background: The aim of A MAastricht Contrast-Induced Nephropathy Guideline (AMACING) trial was to evaluate non-inferiority of no prophylaxis compared to guideline-recommended prophylaxis in preventing contrast induced nephropathy (CIN), and to explore the effect on long-term post-contrast adverse outcomes. The current paper presents the long-term results. Methods: AMACING is a single-centre, randomised, parallel-group, open-label, phase 3, non-inferiority trial in patients with estimated glomerular filtration rate [eGFR] 30–59 mL/min/1.73 m2 combined with risk factors, undergoing elective procedures requiring intravenous or intra-arterial iodinated contrast material. Exclusion criteria were eGFR

Aims The impact of mechanical ventilation (MV) at the time of heart transplantation is not well understood. In addition, MV was recently removed as a criterion from the new US heart transplantation allocation system. We sought to assess for the association between MV at transplantation and 1-year mortality. Methods and results We utilized the United Network for Organ Sharing database and included all adult, single organ heart transplantations from 1990 to 2019. We utilized multivariable logistic regression adjusting for demographics, comorbidities, and markers of clinical acuity. We identified 60 980 patients who underwent heart transplantation, 2.4% (n = 1431) of which required MV at transplantation. Ventilated patients were more likely to require temporary mechanical support, previous dialysis, and had a shorter median waitlist time (21 vs. 95 days, P Conclusion We found a strong association between the presence of MV at heart transplantation and 90-day and 1-year mortality. Future studies are needed to identify which patients requiring MV have reasonable outcomes, and which are associated with substantially poorer outcomes.

BACKGROUND Patients undergoing kidney transplantation are often placed on anticoagulation or antiplatelet therapy, and their perioperative management is often challenging. This study aimed to determine the safety of continuing anticoagulation or antiplatelet therapy prior to kidney transplantation. The primary outcome was bleeding after transplantation. MATERIAL AND METHODS Patients who underwent kidney transplantation between January 2017 and July 2019 were included and divided into 3 groups: pretransplant anticoagulation with warfarin (WARF; n=23); pretransplant antiplatelet therapy with clopidogrel/aspirin (ASA/CLOP; n=32); and control (CTL; n=197). Patients received kidneys from live or deceased donors. Preoperative INRs and platelet counts were compared to ensure therapeutic anticoagulation in the warfarin group and no significant platelet count variation among groups. The primary outcome was graft exploration for bleeding at 3 and 6 months after transplantation. Secondary outcomes included perioperative transfusion requirements, prolonged length of stay (>7 days), and outcomes at 3 and 6 months after transplantation, including hemodialysis and rejection rates and creatinine levels. RESULTS Pretransplant INR was significantly greater in the warfarin group (CTL 1.1, WARF 2.2, ASA/CLOP 1.2; P

Background: Despite a significant shortage of kidneys for transplantation in the US, kidneys from older deceased donors are infrequently transplanted. This is primarily over concern of graft quality and transplant durability. Methods: The US national transplant database (2000–2018) was assessed for deceased donor kidney transplant patient and graft survival, graft durability and stratified by donor age (), Kidney Donor Profile Index (KDPI) and estimated glomerual filtration rate (GFR) one year post-transplantation (eGFR-1) were calculated. Findings: Recipients of kidneys transplanted from deceased donors >65 years had a lower eGFR-1, (median 39 ml/min) than recipients of younger donor kidneys (median 54 ml/min). However, death-censored graft survival, stratified by eGFR-1, demonstrated similar survival, irrespective of donor age or KDPI. The durability of kidney survival decreases as the achieved eGFR-1 declines. KDPI has a poor association with eGFR-1 and lesser for graft durability. While recipients of kidneys > 65 years had a higher one year mortality than younger kidney recipients, recipients of kidneys > 65 years and an eGFR-1

BACKGROUND Our kidney transplant waitlist includes 20% re-transplantations (TX2). Knowing what to expect is a clinical obligation. MATERIAL AND METHODS We compared graft and patient survival of all 162 TX2 patients, transplanted 2000 to 2009, with 162 patients after first transplantation (TX1) matched for age, sex, living/non-living donation, and transplantation date. Patient follow-up was 10 years. RESULTS TX2 graft and patient survivals were inferior to TX1 (p