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Current guidelines for dialysis specify a minimum Kt/V. For haemodialysis (HD) patients, minimum treatment time and frequency is also specified. The guidelines allow for modification to take account of renal function. The guidelines are not specifically aimed at the elderly and may not be appropriate for all patients in this group. Increasing age is accompanied by physiological and pathological changes that may modify the patient's response to uraemia and dialysis. Frailty and multi-morbidity are likely, but to a variable extent. Elderly patients could be more susceptible to the effects of uraemia and require a higher dose of dialysis. Conversely, the generation rate of uraemic toxins is lower in elderly patients, potentially reducing the need for dialysis. In the elderly, quality of life may be more adversely affected by multimorbidity than uraemic symptoms, thus the dose of dialysis may be less relevant. Higher doses of dialysis may be more difficult to achieve in the elderly and may be less well tolerated. We conclude that the prescription of dialysis in the elderly should be individualized, taking multiple factors into account. An individualized Kt/V may be useful in controlling dialysis dose and detecting problems in delivery. However, achievement of a specified Kt/V may not result in any benefit to an elderly patient and could be counterproductive. [ABSTRACT FROM AUTHOR]

Background: Polycystic kidney disease (PKD) is characterized by urinary tract infections and extrarenal abnormalities such as an increased risk of cancer. As mutations in polycystin-1 and -2 are associated with decreased proliferation of immortalized lymphoblastoid cells in PKD, we investigated whether lymphopenia could be an unrecognized trait of PKD. Methods: We studied 700 kidney transplant recipients with (n=126) or without PKD at the time of kidney transplantation between 1 January 2003 and 31 December 2014 at Ghent University Hospital. We also studied 204 patients with chronic kidney disease (CKD) with PKD and 204 matched CKD patients without PKD across comparable CKD strata with assessment between 1 January 1999 and 1 February 2016 at three renal outpatient clinics. We compared lymphocyte counts with multiple linear regression analysis to adjust for potential confounders. We analysed flow cytometric immunophenotyping data and other haematological parameters. Results: Lymphocyte counts were 264/mL [95% confidence interval (CI) 144-384] and 345/mL (95% CI 245-445) (both P<0.001) lower in the end-stage kidney disease (ESKD) and CKD cohort, respectively, after adjustment for age, sex, ln(Creactive protein) and estimated glomerular filtration rate (in the CKD cohort only). In particular, CD8þ T and B lymphocytes were significantly lower in transplant recipients with versus without PKD (P<0.001 for both). Thrombocyte and monocyte counts were lower in patients with versus without PKD in both cohorts (P<0.001 for all analyses except P=0.01 for monocytes in the ESKD cohort). Conclusion: PKD is characterized by distinct cytopenias and especially lymphopenia, independent of kidney function. This finding has the potential to alter our therapeutic approach to patients with PKD. [ABSTRACT FROM AUTHOR]

The presumed superiority of renin-angiotensin-aldosterone system (RAAS)-blocking agents over other antihypertensive agents in patients with diabetes to delay development of endstage kidney disease (ESKD) has recently been challenged. In addition, there is ongoing uncertainty whether RAAS-blocking agents reduce mortality and/or delay ESKD in patients with diabetes and chronic kidney disease (CKD) stages 3-5. In this subgroup, there might be an expedited need for renal replacement therapy (RRT) when RAAS-blocking agents are used. We conducted a meta-analysis of randomized controlled trials (RCTs) of at least 6-months duration in adult patients with diabetes who also have non-dialysis CKD stages 3-5. RCTs comparing single RAAS-blocking agents to placebo or alternative antihypertensive agents were included. Outcomes of interest were allcause mortality, cardiovascular morbidity, progression of renal function, ESKD and adverse events. A total of nine trials (n=9797 participants with CKD stages 3-5) fit our inclusion criteria. There was no difference between the RAAS group and control group regarding all-cause mortality {relative risk [RR]=0.97 [95% confidence interval (CI) 0.85-1.10]}, cardiovascular mortality [RR=1.03 (95% CI 0.75-1.41)] and adverse events [RR=1.05 (95% CI 0.89-1.25)]. There was a trend for a favourable effect for non-fatal cardiovascular events [RR=0.90 (95% CI 0.81-1.00)] and a lower risk of the composite endpoint need for RRT/doubling of serum creatinine [RR=0.81 (95% CI 0.70-0.92)] in the RAAS-blocking agents group versus the control group. We found evidence that in patients with diabetes mellitus and CKD stages 3-5, treatment with RAAS-blocking agents did not result in a clear survival advantage. The effect on renal outcomes did depend on the selected outcome measure. However, we did not find evidence that the use of RAASblocking agents expedited the need for RRT in patients with CKD stages 3-5. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) is common and is associated with increased mortality, morbidity and cost. However, insufficient high-quality trial data are available to answer many relevant clinical questions in this field. In addition, a wide range of variable outcomes are used in studies, and often they are incompletely reported. Furthermore, there is a lack of patient-relevant outcomes, such as mortality, morbidity, quality of life, pain, need for dialysis or costs. Common problems with outcome reporting are as follows: choosing the wrong domains to measure; within domains, choosing the wrong measures (invalid surrogates, composite, non-patient relevant); within measures, choosing the wrong/variablemetrics; and within metrics, choosing variable presentation methods. With this article, we aim to underline why standardized outcome reporting is key to achieving evidence-based guidance and improving clinical care for patients; highlight the frameworks available for achieving core outcome sets; and starting from these frameworks, we propose steps needed to develop a core outcome set in the field of CKD. We hope that standardized core outcome sets for nephrology will lead to the most important outcome of guideline production, improving outcomes for our patients. [ABSTRACT FROM AUTHOR]

The increasing prevalence of chronic kidney disease (CKD) and diabetes over the last decade has resulted in increasing numbers of frail older patients with a combination of these conditions. Current treatment guidelines may not necessarily be relevant for such patients, who are mostly excluded from the trials upon which these recommendations are based. There is a paucity of data upon which to base the management of older patients with CKD. Nearly all current guidelines recommend less-tight glycaemic control for the older population, citing the lack of proven medium-term benefits and concerns about the high shortterm risk of hypoglycaemia. However, reports from large landmark trials have shown potential benefits for both microvascular and macrovascular complications, though the relevance of these findings to this specific population is uncertain. The trials have also highlighted potential alternative explanations for the hazards of intensive glycaemic control. These include depression, low endogenous insulin reserve, low body mass index and side effects of the medication. Over the last few years, newer classes of hypoglycaemic drugs with a lower risk of hypoglycaemia have emerged. This article aims to present a balanced view of advantages and disadvantages of intense glycaemic control in this group of patients, which we hope will help the clinician and patient to come to an individualized management approach. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) is an important health-care problem. Over the last decades, many innovative therapies and diagnostic approaches have been tried; however, none of these has been able to confirm consistently that they lead to improved outcomes. Much focus has been placed on intensive care unit (ICU)-associated AKI, whereas the bulk of AKI still concerns patients not in the ICU. Involvement of nephrologists in the care of AKI patients is necessary to further improve outcomes. It is unclear whether new technologies, such as biomarkers, are helpful and could replace nephrology consultation. [ABSTRACT FROM AUTHOR]

Background. The utility of renal biopsy in patients with diabetes is highly debated. Diabetics with rapidly worsening renal disease are often 'clinically' labelled as having diabetic nephropathy (DN), whereas, inmany cases, they are rather developing a nondiabetic renal disease (NDRD) or mixed forms (DN+ NDRD). Methods. We performed a systematic search for studies on patients with diabetes with data on the frequency of DN, NDRD and mixed forms, and assessed the positive predictive values (PPVs) and odds ratios (ORs) for such diagnoses by metaanalysing single-study prevalence. Possible factors explaining heterogeneity among the different diagnoses were explored by meta-regression. Results. In the 48 included studies (n = 4876), the prevalence of DN, NDRD and mixed forms ranged from 6.5 to 94%, 3 to 82.9% and 4 to 45.5% of the overall diagnoses, respectively. IgA nephropathy was the most common NDRD (3-59%). PPVs for DN, NDRD and mixed forms were 50.1% [95% confidence interval (CI): 44.7-55.2], 36.9% (95% CI: 32.3-41.8) and 19.7% (95% CI: 16.3-23.6), respectively. The PPV when combining NDRD and mixed forms was 49.2% (95% CI: 43.8-54.5). Metaregression identified systolic pressure, HbA1c, diabetes duration and retinopathy as factors explaining heterogeneity for NDRD, creatinine and glomerular filtration rate for mixed forms and only serum creatinine for DN. ORs of DN versus NDRD and mixed forms were 1.71 (95% CI: 1.54-1.91) and 4.1 (95% CI: 3.43-4.80), respectively. Conclusions. NDRD are highly prevalent in patients with diabetes. Clinical judgment alone can lead to wrong diagnoses and delay the establishment of adequate therapies. Risk stratification according to individual factors is needed for selecting patients whomight benefit from biopsy. [ABSTRACT FROM AUTHOR]

The number of elderly patients on maintenance dialysis has rapidly increased in the past few decades, particularly in developed countries, imposing a growing burden on dialysis centres. Hence, many nephrologists and healthcare authorities feel that greater emphasis should be placed on the promotion of home dialysis therapies such as peritoneal dialysis (PD) and home haemodialysis (HD). There is currently no general consensus as to the best dialysis modality for elderly patients with end-stage renal disease. In-centre HD is predominant in most countries, although it is widely recognized that PD has several advantages over HD, including the lack of need for vascular access, continuous slow ultrafiltration, less interference with patients' lifestyle and lower costs. Comparisons of outcomes between elderly patients on PD and HD rely on observational studies, as randomized controlled trials are lacking. The results of these studies are variable. However, most of them suggest that survival rates are largely similar between the two modalities, except for elderly patients with diabetes and/or beyond 1-3 years from dialysis initiation, in which cases HD appears to be superior. An equally important aspect to consider when choosing dialysis modality, particularly in this age group, is the quality of life, and in this regard most studies found no significant differences between PD and HD. In these circumstances, we believe that dialysis modality selection should be guided by patient's preference, based on comprehensive and unbiased information. A multidisciplinary team should review elderly patients starting on dialysis, aiming to identify possible barriers to PD and home HD, including physical, visual, cognitive, psychological and social problems, and to overcome such barriers by adequate care, education, psychological counselling and dialysis assistance. [ABSTRACT FROM AUTHOR]

The treatment of kidney diseases consumes a substantial amount of the health budget for a relatively small fraction of the overall population. If the nephrological community and society do not develop mechanisms to contain those costs, it will become impossible to continue assuring optimal outcomes and quality of life while treating all patients who need it. In this article, we describe several mechanisms to maintain sustainability of renal replacement therapy. These include (i) encouragement of transplantation after both living and deceased donation; (ii) stimulation of alternative dialysis strategies besides classical hospital haemodialysis, such as home haemodialysis, peritoneal dialysis or self-care and necessitating less reimbursement; (iii) promotion of educational activities guiding the patients towards therapies that are most suited for them; (iv) consideration of one or more of cost containment incentives such as bundling of reimbursement (if not affecting quality of the treatment), timely patient referral, green dialysis, start of dialysis based on clinical necessity rather than renal function parameters and/or prevention of CKD or its progression; (v) strategically planned adaptations to the expected growth of the ageing population in need of renal replacement; (vi) the necessity for support of research in the direction of helping as large as possible patient populations for acceptable costs; and (vii) the need for more patient-centred approaches. We also extend the discussion to the specific situation of kidney diseases in low- and middle-income countries. Finally, we point to the dramatic differences in accessibility and reimbursement of different modalities throughout Europe. We hope that this text will offer a framework for the nephrological community, including patients and nurses, and the concerned policy makers and caregivers on how to continue reaching all patients in need of renal replacement for affordable expenses. [ABSTRACT FROM AUTHOR]

This review focuses on the most recent scientific and clinical information on the development and clinical applicability of the cell cycle biomarkers TIMP-2 and IGFBP-7 in the diagnosis and prognosis of patients at risk for and suffering from acute kidney injury (AKI). A number of evaluation studies have demonstrated that compared with existing biomarkers, urinary excretion of the product of both biomarkers, [TIMP-2]•[IGFBP-7], improved diagnostic performance in assessing the risk for AKI, predicting the need for renal replacement therapy, AKI-related complications and short- and long-term prognoses. The reference intervals for these biomarkers, measured by the recently approved NephroCheck test, have been determined in apparently healthy adults and those with stable chronic morbid conditions without AKI. This review recognizes that the combination of these two cell cycle arrest markers for the early detection of AKI is promising but concludes that its clinical impact is still unproved. Clinicians should understand the utility and limitations of this test before deciding whether to make it available at their institution. [ABSTRACT FROM AUTHOR]

Background. Diabetes mellitus is a frequent cause of the need for renal replacement therapy (RRT). Historically, RRT was started earlier in patients with diabetes, in an attempt to prevent complications of uraemia and diabetes. We did a systematic review to find support for this earlier start of dialysis in patients with versus without diabetes. Methods. The MEDLINE, EMBASE and CENTRAL databases were searched for articles about the timing of dialysis initiation in (subgroups of ) patients with diabetes and CKD Stage 5. Results. A total of 340 papers were screened and 11 papers were selected to be reviewed. Only three studies showed data of at least one subgroup of patients with diabetes. Two observational studies concluded that start of dialysis with a higher estimated glomerular filtration rate (eGFR) is beneficial with regard to survival, one did not find a difference and six observational studies concluded that start of dialysis with a lower eGFR is associated with better survival in patients with diabetes. The effect of timing of initiation of dialysis did not differ between patients with versus without diabetes. Lastly, one randomized controlled trial (two papers) reported that there was no difference in survival between start at higher versus lower eGFR overall and a P-value for the interaction with diabetes of P = 0.63, indicating no difference between patients with versus without diabetes with regard to the timing of start of dialysis and subsequent mortality on dialysis. Conclusions. There is no difference between early (eGFR) and late (lower eGFR) start of RRT with regard to mortality in patients with versus without diabetes. RRT should thus be initiated based on the same criteria in all patients, irrespective of the presence or absence of diabetes. [ABSTRACT FROM AUTHOR]

Background. There is a variation in dialysis withdrawal rates, but reasons for this variation across European countries are largely unknown. We therefore surveyed nephrologists' perceptions of factors concerning dialysis withdrawal and palliative care and explored relationships between these perceptions and reports of whether withdrawal actually occurred in practice. Methods. We developed a 33-item electronic survey, disseminated via an email blast to all European Renal Association- European Dialysis and Transplant Association (ERA-EDTA) members. In our data analyses, we distinguished those respondents who reported occurrence from those reporting no dialysis withdrawal in their unit. With multilevel logistic regression, we investigated the association between respondents' characteristics and perceptions and whether they reported occurrence of dialysis withdrawal or not. Results. Five hundred and twenty-eight nephrologists from 45 countries completed the questionnaire; 42% reported occurrence of withdrawal in their unit in the past year, and 56% perceived that stopping life-prolonging treatment in terminally ill patients was allowed. Few respondents reported presence in their unit of protocols on withdrawal decision making (7%) or palliative care (10%) or the common involvement of a geriatrician in withdrawal decisions (10%). The majority stated that palliative care had not been part of their core curriculum (74%) and that they had not recently attended continuous medical education sessions on this topic (73%). Respondents from Eastern and Southern Europe had a 42 and 40% lower probability, respectively, of reporting withdrawal compared with those from North European countries. Working in a public centre [odds ratio (OR), 2.41; 95% confidence interval (CI), 1.36-4.25] and respondents' perception that stopping life-prolonging treatment in terminally ill patients was allowed (OR, 1.96; 95% CI, 1.23-3.12), that withdrawal decisions were commonly shared between doctor and patient (OR, 1.97; 95% CI, 1.26-3.08) and that palliative care was reimbursed (OR, 1.81; 95% CI, 1.16- 2.83) increased the odds of reporting occurrence of withdrawal. Conclusion. Reports of dialysis withdrawal occurrence varied between European countries. Occurrence reports were more likely if respondents worked in a public centre, if stopping lifeprolonging treatments was perceived as allowed, if withdrawal decisions were considered shared between doctors and patients and if reimbursement of palliative care was believed to be in place. There is room for improvement regarding protocols on withdrawal and palliative care processes and regarding nephrologists' training and education on end-of-life care. [ABSTRACT FROM AUTHOR]

The European Best Practice Guideline group (EBPG) issued guidelines on the evaluation and selection of kidney donor and kidney transplant candidates, as well as post-transplant recipient care, in the year 2000 and 2002. The new European Renal Best Practice board decided in 2009 that these guidelines needed updating. In order to avoid duplication of efforts with kidney disease improving global outcomes, which published in 2009 clinical practice guidelines on the post-transplant care of kidney transplant recipients, we did not address these issues in the present guidelines. The guideline was developed following a rigorous methodological approach: (i) identification of clinical questions, (ii) 0 (0%) recommendations graded '1A', 15 (13%) were '1B', 19 (17%) '1C' and 17 (15%) '1D'. None (0%) were graded '2A', 1 (0.9%) was '2B', 8 (7%) were '2C' and 9 (8%) '2D'. Limitations of the evidence, especially the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research. We present here the complete recommendations about the evaluation of the kidney transplant candidate as well as the potential deceased and living donor, the immunological work-up of kidney donors and recipients and the perioperative recipient care. We hope that this document will help caregivers to improve the quality of care they deliver to patients. The full version with methods, rationale and references is published in Nephrol Dial Transplant (2013) 28: i1-i71; doi: 10.1093/ndt/ gft218 and can be downloaded freely from http://www. oxfordjournals.org/our_journals/ndt/era_edta.html. [ABSTRACT FROM AUTHOR]

Background. Contrast-induced acute kidney injury (CI-AKI) is a potential complication of radio-contrast investigations. Many organisations have published guidance documents on the prevention of CI-AKI. Our aim is to explore the scope, content, consistency, practicality in clinical practice and reasons for eventual underlying discrepancies of these documents. Methods. We searched the literature for guidance documents developed to guide prevention of CI-AKI up to 09/2014. Four reviewers appraised guideline quality using the 23-item AGREE-II instrument, which rates reporting of the guidance development process across six domains: scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence. Total scores were calculated as standardised averages by domain. Results. Twenty-four guidance documents were evaluated. The guidance documents were produced by radiologists (N = 7), intensivists (N = 2), nephrologists (N = 6) or multidisciplinary teams (N = 9). One document did not mention the background of the authors. Only guidance documents (N = 15) that were not mere adaptations of existing guidelines were evaluated more in depth, using the AGREE tool. Overall, quality was mixed: only one clinical practice guidance document obtained an average score of >50% for all domains. The evidence was rated in a systematic way in only 11, and only 7 graded the strength of the recommendations. The Kidney Diseases Improving Global Outcomes guideline was the only one recommended without adaptions by all assessors. The guidance documents agreed in recommending pre-hydration as the main preventive measure, but there was difference in recommended total volumes, composition, rate and duration of the infused solutions. There was no consensus on the use of NaHCO3, with eight recommending it, six considering it and one not. Five guidance documents mentioned oral pre-hydration as a possibility, and none recommended N-acetylcysteine as solitary preventivemeasure. More recent guidance documents recommend avoiding hypertonic contrast media, but did not recommend preference of iso-osmolar over low-osmolar contrast media. Most guidance documents recognised pre-existing chronic kidney disease, diabetes, age and cardiovascular comorbidity as risk factors. Conclusions. There seems to be a relative consensus on the need for adequate pre-hydration to avoid CI-AKI, but recommendations to define at-risk populations for whom these measures should be applied and how they should be implemented differ substantially. Based on accumulating evidence, more recent guidelines do not recommend iso-osmolar over lowosmolar contrast media, whereas all recommend avoiding hypertonic agents. [ABSTRACT FROM AUTHOR]

Background: Worldwide, several bodies produce renal guidelines, potentially leading to duplication of effort while other topics may remain uncovered. A collaborative work plan could improve efficiency and impact, but requires a common approved methodology. The aim of this study was to identify organizational and methodological similarities and differences among seven major renal guideline bodies to identify methodological barriers to a collaborative effort. Methods: An electronic 62-item survey with questions based on the Institute of Medicine standards for guidelines was completed by representatives of seven major organizations producing renal guidelines: the Canadian Society of Nephrology (CSN), European Renal Best Practice (ERBP), Kidney Disease Improving Global Outcome (KDIGO), Kidney Health Australia-Caring for Australians with Renal Insufficiency (KHA-CARI), Kidney Disease Outcome Quality Initiative (KDOQI), Sociedad Latino-Americano de Nefrologia eHipertension (SLANH) and United Kingdom Renal Association (UKRA). Results: Five of the seven groups conduct systematic searches for evidence, two include detailed critical appraisal and all use the GRADE framework. Five have public review of the guideline draft. Guidelines are updated as new evidence comes up in all, and/or after a specified time frame has passed (N = 3). Commentaries or position statements on guidelines published by other groups are produced by five, with the ADAPTE framework (N = 1) and the AGREEII (N = 2) used by some. Funding is from their parent organizations (N = 5) or directly from industry (N = 2). None allow funders to influence topic selection or guideline content. The budgets to develop a full guideline vary from $2000 to $500 000. Guideline development groups vary in size from <5 (N = 1) to 13-20 persons (N = 3). Three explicitly seek patient perspectives, for example, by involving patients in the scoping process, and four incorporate health economic considerations. All provide training in methodology for guideline development groups and six make their methods public. All try to avoid overlapping topics already planned or published by others. There is no common conflict of interest policy. Conclusions: Overall, there is considerable commonality in methods and approaches in renal guideline development by the different organizations, although some procedural differences remain. As the financial and human resource costs of guideline production are high, a collaborative approach is required to maximize impact and develop a sustainable work plan. Coming to consensus on methods and procedures is the first step and appears feasible. [ABSTRACT FROM AUTHOR]

Natural and man-made mass disasters directly or indirectly affect huge populations, who need basic infrastructural help and support to survive. However, despite the potentially negative impact on survival chances, these health care issues are often neglected by the authorities. Treatment of both acute and chronic kidney diseases (CKDs) is especially problematic after disasters, because they almost always require complex technology and equipment, whereas specific drugs may be difficult to acquire for the treatment of the chronic kidney patients. Since many crush victims in spite of being rescued alive from under the rubble die afterward due to lack of dialysis possibilities, the terminology of 'renal disaster' was introduced after the Armenian earthquake. It should be remembered that apart from crush syndrome, multiple aetiologies of acute kidney injury (AKI) may be at play in disaster circumstances. The term 'seismonephrology' (or earthquake nephrology) was introduced to describe the need to treat not only a large number of AKI cases, but the management of patients with CKD not yet on renal replacement, as well as of patients on haemodialysis or peritoneal dialysis and transplanted patients. This wording was later replaced by 'disaster nephrology', because besides earthquakes, many other disasters such as hurricanes, tsunamis or wars may have a negative impact on the ultimate outcome of kidney patients. Disaster nephrology describes the handling of the many medical and logistic problems in treating kidney patients in difficult circumstances and also to avoid post-disaster chaos, which can be made possible by preparing medical and logistic scenarios. Learning and applying the basic principles of disaster nephrology is vital to minimize the risk of death both in AKI and CKD patients. [ABSTRACT FROM AUTHOR]

Background. Non-euvolaemia in peritoneal dialysis (PD) patients is associated with elevated mortality risk. There is an urgent need to collect data to help us understand the association between clinical practices and hydration and nutritional status, and their effects on patient outcome. Methods. The aim of this prospective international, longitudinal observational cohort study is to follow up the hydration and nutritional status, as measured by bioimpedance spectroscopy using the body composition monitor (BCM) of incident PD patients for up to 5 years. Measures of hydration and nutritional status and of clinical, biochemical and therapy-related data are collected directly before start of PD treatment, at 1 and 3 months, and then every 3 months. This paper presents the protocol and a prespecified analysis of baseline data of the cohort. Results. A total of 1092 patients (58.1% male, 58.0 ± 15.3 years) from 135 centres in 32 countries were included. Median fluid overload (FO) was 2.0 L (males) and 0.9 L (females). Less than half of the patients were normohydrated (38.7%), whereas FO > 1.1 L was seen in 56.5%. Systolic and diastolic blood pressure were 139.5 ± 21.8 and 80.0 ± 12.8 mmHg, respectively, and 25.1% of patients had congestive heart failure [New York Heart Association (NYHA) 1 or higher]. A substantial number of patients judged to be not overhydrated on clinical judgement appeared to be overhydrated by BCM measurement. Overhydration at baseline was independently associated with male gender and diabetic status. Conclusions. The majority of patients starting on PD are overhydrated already at start of PD. This may have important consequences on clinical outcomes and preservation of residual renal function. Substantial reclassification of hydration status by BCM versus on a clinical basis was necessary, especially in patients who were not overtly overhydrated. Both clinical appreciation and bioimpedance should be combined in clinical decision-making on hydration status. [ABSTRACT FROM AUTHOR]

…Couchoud et al. have been able to analyse data from more than one million patients with diabetes and ESKD, gathered from 25 studies selected from several hundred references…Background Diabetes is the leading cause of end-stage kidney disease (ESKD). Because of conflicting results in observational studies, it is still subject to debate whether in diabetic patients the dialysis modality selected as first treatment (haemodialysis or peritoneal dialysis) may have a major impact on outcomes. We therefore aimed at performing a systematic review of the available evidence. Methods MEDLINE, EMBASE and CENTRAL databases were searched until February 2014 for English-language articles without time or methodology restrictions by highly sensitive search strategies focused on diabetes, end-stage kidney disease and dialysis modality. Selection of relevant studies, data extraction and analysis were performed by two independent reviewers. Results Twenty-five observational studies (23 on incident and 2 on prevalent cohorts) were included in this review. Mortality was the only main outcome addressed in large cohorts. When considering patient survival, results were inconsistent and varied across study designs, follow-up period and subgroups. We therefore found no evidence-based arguments in favour or against a particular dialysis modality as first choice treatment in patients with diabetes and ESKD. However, peritoneal dialysis (PD) as first choice seems to convey a higher risk of death in elderly and frail patients. Conclusions The available evidence derived from observational studies is inconsistent. Therefore evidence-based arguments indicating that HD or PD as first treatment may improve patient-centred outcomes in diabetics with ESKD are lacking. In the absence of such evidence, modality selection should be governed by patient preference, after unbiased patient information. [ABSTRACT FROM AUTHOR]

Background Although measurement of haemoglobin A1c has become the cornerstone for diagnosing diabetes mellitus in routine clinical practice, the role of this biomarker in reflecting long-term glycaemic control in patients with chronic kidney disease has been questioned. Methods Consensus review paper based on narrative literature review. Results As a different association between glycaemic control and morbidity/mortality might be observed in patients with and without renal insufficiency, the European Renal Best Practice, the official guideline body of the European Renal Association-European Dialysis and Transplant Association, presents the current knowledge and evidence of the use of alternative glycaemic markers (glycated albumin, fructosamine, 1,5-anhydroglucitol and continuous glucose monitoring). Conclusion Although reference values of HbA1C might be different in patients with chronic kidney disease, it still remains the cornerstone as follow-up of longer term glycaemic control, as most clinical trials have used it as reference. [ABSTRACT FROM AUTHOR]

Medical management of patients with kidney disease is complex and resource intensive. In times of limited health care budgets, economic evaluations have become more important over the past few years in identifying interventions with a beneficial cost-effectiveness to maximize the benefits served from the available resources. However, integrating evidence from health-economic evaluations into clinical practice guidelines remains a challenge. European Renal Best Practice (ERBP), the official guideline body of the European Renal Association–European Dialysis and Transplant Association (ERA–EDTA) herewith presents some lines of thought that need consideration in the discussion on incorporating health-economic considerations into clinical guideline development. [ABSTRACT FROM PUBLISHER]

Among renal diseases, over 100 conditions meet the epidemiological criteria to be defined as rare, including disorders in development, transport and metabolism. Clinical management of rare diseases is likely to be less investigated than that of common disorders and for this reason the scientific evidence to support clinical practice is limited. Furthermore, no specific and validated methods for designing, carrying out or analyzing clinical trials in small populations exist with important consequences for evidence-based medicine. In this paper we aim at discussing the inherent difficulty in finding evidence in rare renal diseases, providing some suggestions on how the quality of evidence and the guidance in these diseases can be improved. [ABSTRACT FROM AUTHOR]

This educational paper discusses a variety of indicators that can be used to measure the quality of care in renal medicine. Based on what aspect of care they reflect, indicators can be grouped into four main categories: structure, process, surrogate outcome and outcome indicators. Each category has its own advantages and disadvantages, and we give some pointers on how to balance these pros and cons while taking into account the aim of the measurement initiative. Especially within initiatives that link payment or reputation to indicator measurement, this balancing should be done with utmost care to avoid potential, unintended consequences. Furthermore, we suggest consideration of (i) a causal chain—i.e. subsequent aspects of care connected by evidence-based links—as a starting point for composing a performance indicator set and (ii) adequate case-mix adjustment, not only of (surrogate) outcomes, but also of process indicators in order to obtain fair comparisons between facilities and within facilities over time. [ABSTRACT FROM PUBLISHER]

The increasing volume of evidence on how to treat kidney patients makes it difficult for nephrologists and renal nurses to keep up-to-date. This potentially widens the gap between what is known about best practice and how daily renal care is provided. Rigorously developed clinical practice guidelines can be important tools to bridge this gap. However, just developing and publishing guidelines does not ensure their use in actual practice. In this paper, we distinguish and illustrate three types of modifiable factors (i.e. barriers) that potentially impede renal healthcare professionals to provide care according to the guidelines: barriers related to knowledge, to attitudes and to behaviour. European Renal Best Practice (ERBP) produces guidelines for care of kidney patients in Europe and neighbouring regions. To facilitate implementation of its guidelines, ERBP aims to optimize ‘guideline implementability’, which regards the intrinsic characteristics of guidelines (i.e. format and content). The last section of this paper describes some of the associated ERBP activities, which are planned or pending. [ABSTRACT FROM AUTHOR]

Background During haemodialysis, anticoagulants are required to prevent clotting in the extracorporeal circuit. Low-molecular weight heparins (LMWH) are frequently used because of the ease of a single injection at the start of dialysis. Disadvantages of LMWH include the lack of a reliable bedside assay for measuring their anticoagulant effect. Methods We investigated a bedside test for LMWH activity. The relationship between anti-Xa (chromogenic assay) and Hemonox point-of-care assay was evaluated in 21 dialysis patients (12 men and 9 women) with a median age of 71 years, receiving tinzaparin at the start of a haemodiafiltration session. Results At the start, before tinzaparin administration, median (interquartile ranges) of Hemonox values were 74 (67–82) s. Thirty minutes after tinzaparin administration, Hemonox values were increased to 496 (360–736) s, followed by a decrease to 149 (135–301) s after 120 min, 102 (97–144) s after 180 min and 92 (83–100) s after 240 min. Corresponding anti-Xa activities were 0 (0–0), 1.12 (0.9–1.29), 0.74 (0.57–0.96), 0.47 (0.31–0.7) and 0.31(0.16–0.49) IU/mL. Hemonox values showed an exponential relation to anti-Xa levels. Interchangeability of tests was shown by Bland–Altman plot. Conclusion Point-of-care Hemonox test is a valuable bedside method for monitoring anti-Xa activity in dialysis patients anticoagulated with tinzaparin. [ABSTRACT FROM AUTHOR]

KDIGO is a good example of a global guidelines body derived from a country initiative (KDOQI) which could give local standards of care. This body should then also spend efforts in the integration and harmonization of guidelines for related or common co-existing diseases in such a way that practice recommendations in different guidelines are complementary rather than contradictory. This approach would most likely: efficient use of expertise, time, and money; one standardized methodology; no duplication; better discussion on the common themes and on the exceptions; learning from each other; central repository for skills, training, techniques and data as well as the issued guidelines…The prime mission of European Renal Best Practice (ERBP) is to improve the outcome of patients with kidney disease in a sustainable way through enhancing the availability of the knowledge on the management of these patients in a format that stimulates its use in clinical practice in Europe. A key activity is to produce clinical practice guidelines to help clinicians make the healthcare decisions they face. To further improve the quality and validity of its clinical practice guidelines, ERBP has revised its guideline development process. The present document outlines the principles of ERBP's 10-step approach. Important features include standard procedures for selecting topics, for assembling the guideline development group, for choosing and formulating questions, for finding, appraising and summarizing the evidence, for generating recommendations, for preparing reports and organizing peer review. ERBP has adopted the Grading of Recommendations Assessment, Development and Evaluation system for rating the quality of the evidence and strength of recommendations and has addressed implementation in the development process by integrating the GuideLine Implementability Appraisal tool. Ultimately, it is anticipated that these changes will not only further improve the quality of the guideline development process, but also enhance the quality of care and improve outcomes of patients with kidney disease across Europe. [ABSTRACT FROM AUTHOR]

Developing guidelines on a subject as broad as hypertension is difficult, especially when the guidance relates to hypertension in the chronic kidney disease (CKD) population. The Kidney Disease: Improving Global Outcomes Guideline Development Group has applied a rigorous methodology in reviewing all available evidence, and their recommendations are consistent with the evidence-based approach. As a result, the European Renal Best Practice endorses most of its recommendations. However, the Work Group feels that some additional advice could help clinicians in daily practice: (i) individualization of treatment should be taken into account, especially (cardiovascular) co-morbidities, age, gender and race; (ii) side-effects, such as postural dizziness should be monitored closely, particularly in elderly, diabetics and patients with arterial stiffness; (iii) the importance of salt restriction should not be neglected; (iv) although angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blocker (ARBs) remain a cornerstone in the management of hypertension, and especially cardiovascular protection, in some particular situations such as in advanced CKD and in patients without proteinuria, their role is less well defined; (v) as most CKD patients need more than one antihypertensive drug to achieve blood pressure control, the specific (renal) (dis)advantages of other classes than ACE-I or ARB should be taken into account. [ABSTRACT FROM PUBLISHER]

Hyponatraemia, defined as a serum sodium concentration !135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice. [ABSTRACT FROM AUTHOR]

This paper provides an endorsement of the KDIGO guideline on acute kidney injury; more specifically, on the part that concerns renal replacement therapy. New evidence that has emerged since the publication of the KDIGO guideline was taken into account, and the guideline is commented on from a European perspective. Advice is given on when to start and stop renal replacement therapy in acute kidney injury; which modalities should be preferentially be applied, and in which conditions; how to gain access to circulation; how to measure adequacy; and which dose can be recommended. [ABSTRACT FROM AUTHOR]

Background Volume status, lean and fat tissue are gaining interest as prognostic predictors in patients on dialysis. Comparative data in peritoneal dialysis (PD) versus haemodialysis (HD) patients are lacking. Methods In a cohort of PD (EuroBCM) and HD (Euclid database) patients, matched for country, gender, age and dialysis vintage, body composition was assessed by bioimpedance spectroscopy (BCM, Fresenius Medical Care). Time-averaged volume overload (TAVO) was defined as the mean of pre- and post-dialysis volume overload (VO), and relative (%) (TA)VO as (TA)VO/ECV. Results Four hundred and ninety-one matched pairs (55.2% males, median age 60.0 years) were included. The body mass index (BMI, PD = 26.5 ± 4.7 versus HD = 25.9 ± 4.6 kg/m², P = 0.18 in males and 27.4 ± 5.8 versus 27.5 ± 6.6 kg/m², P = 0.75 in females) and fat tissue index (males: 11.5 ± 5.3 versus 11.4 ± 5.4 kg/m², P = 0.90, females: 14.8 ± 6.7 versus 15.4 ± 7.2 kg/m², P = 0.30) were not different in PD versus HD patients, whereas the lean tissue index (LTI) was higher in PD versus HD patients (males: 14.5 ± 3.4 versus 13.7 ± 3.1 kg/m², P = 0.001, females: 12.6 ± 3.3 versus 11.5 ± 2.6 kg/m², P < 0.0001). VO/extracellular water (ECW) was not different between PD versus just before the HD treatment (males: 10.8 ± 12.1 versus 9.2 ± 10.2%, P = 0.09; females: 6.5 ± 10.8 versus 7.7 ± 9.4%, P = 0.19). The relative TAVO was higher in PD versus HD (10.8 ± 12.1% versus 3.2 ± 11.2%, and 6.5 ± 10.8% versus 1.2 ± 10.9%, both P < 0.0001). Conclusions The LTI was impaired, and this was more in males versus females, but was better preserved on PD versus HD, whereas fat tissue index (FTI) was increased, but not different between PD and HD. Volume overload was more present in PD versus HD when TAVO, but not when predialysis volume status, was used as a reference. [ABSTRACT FROM PUBLISHER]

Background For some patients with end-stage renal disease (ESRD), providing conservative care until death may be an acceptable alternative for renal replacement therapy (RRT). We aimed to estimate the occurrence of conservative care in Europe and evaluated opinions about which factors nephrologists consider important in their decision not to offer RRT. Methods With a web-based survey sent to nephrologists in 11 European countries, we inquired how often RRT was not started in 2009 and how specific factors would influence the nephrologists’ decision to provide conservative care. We compared subgroups by nephrologist and facility characteristics using chi-square tests and Mann–Whitney U tests. Results We received 433 responses. Nephrologists decided to offer conservative care in 10% of their patients [interquartile range (IQR) 5–20%]. An additional 5% (IQR 2–10%) of the patients chose conservative care as they refused when nephrologists intended to start RRT. Patient preference (93%), severe clinical conditions (93%), vascular dementia (84%) and low physical functional status (75%) were considered extremely or quite important in the nephrologists’ decision to provide conservative care. Nephrologists from countries with a low incidence of RRT, not-for-profit centres and public centres more often scored these factors as extremely or quite important than their counterparts from high-incidence countries, for-profit centres and private centres. Conclusions Nephrologists estimated conservative care was provided to up to 15% of their patients in 2009. The presence of severe clinical conditions, vascular dementia and a low physical functional status are important factors in the decision-making not to start RRT. Patient preference was considered as a very important factor, confirming the importance of extensive patient education and shared decision-making. [ABSTRACT FROM PUBLISHER]

European Renal Best Practice (ERBP) is the official guidance-providing body of the European Renal Association—European Dialysis and Transplant Association. This paper introduces the mission statement of ERBP, and provides insight on what this implies for guideline production. We will discuss that improving patient outcome does not only require attention to high-quality evidence, but also understanding of the processes of medical decision making. We will advocate that rigorous methodology is the cornerstone of guideline production, but in those cases where this does not retrieve quality evidence, consensus-based guidance might be suitable. Based on its mission statement, ERBP advocates that guidelines should encourage shared decision making. [ABSTRACT FROM AUTHOR]

Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anaemia in CKD patients. These guidelines addressed all of the important points related to anaemia management in CKD patients, including therapy with erythropoieis stimulating agents (ESA), iron therapy, ESA resistance and blood transfusion use. Because most guidelines were ‘soft’ rather than ‘strong’, and because global guidelines need to be adapted and implemented into the regional context where they are used, on behalf of the European Renal Best Practice Advisory Board some of its members, and other external experts in this field, who were not participants in the KDIGO guidelines group, were invited to participate in this anaemia working group to examine and comment on the KDIGO documents in this position paper. In this article, the group concentrated only on those guidelines which we considered worth amending or adapting. All guidelines not specifically mentioned are fully endorsed. [ABSTRACT FROM AUTHOR]

Fabry disease (FD) is an X-linked disorder of glycosphingolipid catabolism resulting in the accumulation of glycolipids including globotriaosylceramide in cells of various tissues resulting in end-organ manifestations. Initially, FD is typically characterized by angiokeratoma and recurrent episodes of neuropathic pain in the extremities occurring during childhood or adolescence. Most affected patients also exhibit a decreased ability to sweat. Later in life, FD results in left ventricular hypertrophy, proteinuria, renal failure and stroke. These later disease manifestations are non-specific and also common in diabetes, hypertension and atheromatosis and thus for most practitioners do not point into the direction of FD. As a consequence, FD is under-diagnosed and screening of high-risk groups is important for case finding, as is a thorough pedigree analysis of affected patients. In the nephrology clinic, we suggest to screen patients for FD when there is unexplained chronic kidney disease in males younger than 50 years and females of any age. In men, this can be performed by measuring α-galactosidase A activity in plasma, white blood cells or dried blood spots. In women, mutation analysis is necessary, as enzyme measurement alone could miss over one-third of female Fabry patients. A multidisciplinary team should closely monitor all known Fabry patients, with the nephrologist screening kidney impairment (glomerular filtration rate and proteinuria) on a regular basis. Transplanted Fabry patients have a higher mortality than the regular transplant population, but have acceptable outcomes, compared with Fabry patients remaining on dialysis. It is unclear whether enzyme replacement therapy (ERT) prevents deterioration of kidney function. In view of the lack of compelling evidence for ERT, and the low likelihood that a sufficiently powered randomized controlled trial on this topic will be performed, data of all patients with FD should be collected in a central registry. [ABSTRACT FROM PUBLISHER]

AKI biomarkers (…) appear to have value, (…) informing on the pathobiology of AKI. However, their performance is influenced by patient characteristics, co-morbid illness, inciting kidney injury event, timing of measurement and selected thresholds for diagnosis.Background Acute kidney injury (AKI) remains associated with high morbidity and mortality, despite progress in medical care. Although the RIFLE (Risk, Injury, Failure, Loss, End-Stage Kidney Disease) and AKIN (Acute Kidney Injury Network) criteria, based on serum creatinine and urine output, were a step forward in diagnosing AKI, a reliable tool to differentiate between true parenchymal and pre-renal azotaemia in clinical practice is still lacking. In the last decade, many papers on the use of new urinary and serum biomarkers for the diagnosis and prognostication of AKI have been published. Thus, the question arises which biomarker is a reliable differential diagnostic tool under which circumstances. Methods We searched Medline from inception to April 2012 using medical subject heading and text words for AKI and biomarkers [neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), Cystatin C, interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-18 (IL-18), N-acetyl-glucosaminidase (NAG), glutathione transferases (GST) and liver fatty acid binding protein (LFABP)] to identify relevant papers in five different settings (paediatrics, cardiac surgery, emergency department, critically ill and contrast-induced nephropathy). Results We included 87 relevant papers, reporting on 74 studies. Depending upon the setting, 7–27 different definitions of AKI were used. Reported diagnostic performance of the different biomarkers was variable from poor to excellent, and no consistent generalizable conclusions can be drawn on their diagnostic value. Conclusions Early diagnosing of AKI in clinical conditions by using new serum and urinary biomarkers remains cumbersome, especially in those settings where timing and aetiology of AKI are not well defined. Putting too much emphasis on markers that have not convincingly proven reliability might lead to incorrect interpretation of clinical trials. Further research in this field is warranted before biomarkers can be introduced in clinical practice. [ABSTRACT FROM AUTHOR]

Background. Peritoneal dialysis (PD) is associated with functional and morphological alterations of the peritoneal membrane (PM). It is hypothesized that vascular endothelial growth factor (VEGF) plays a role in this process. Sulodexide is a glycosaminoglycan with effects on vascular biology. Therefore, the impact of oral sulodexide on PM function and morphology in a rat model of peritoneal perfusion was evaluated. Methods. Rats received 10 mL peritoneal dialysate fluid (PDF) twice daily via a tunnelled PD catheter. The test-PD group (Sul) received 15 mg/kg/day oral sulodexide versus none in the control–PD group (Con). A third group received no PDF (Sham). After 12 weeks, a peritoneal equilibration test was performed and the PM was sampled. Neo-angiogenesis was evaluated using immunostaining with von Willebrand, and epithelial-to-mesenchymal transition (EMT) using co-localization of cytokeratin and α-smooth muscle actin. VEGF was determined in the dialysate by enzyme-linked immunosorbent assay. Results. PD induced loss of ultrafiltration, also in the sulodexide group. Creatinine and glucose transport were better preserved, and sodium dip was more pronounced in the sulodexide group versus control. Submesothelial thickness, neo-angiogenesis and EMT were more pronounced in the Con versus Sul versus Sham group. VEGF in the dialysate, corrected for diffusion was higher in Con and Sul versus Sham. Conclusion. Oral sulodexide administration diminishes neo-vascularization, submesothelial thickening and EMT induced by exposure to PDF in a rat model. As there was no difference in VEGF at the protein level in the dialysate, we hypothesize that oral sulodexide inhibits VEGF locally by binding. [ABSTRACT FROM AUTHOR]

Aim. This study investigates the difference in the incidence of renal replacement therapy (RRT) between Flanders and the Netherlands and possible explanations for this difference. Methods. End-stage renal disease incidence data were obtained from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA). Additional sources were the National Institute of Statistics (NIS), the Central Bureau of Statistics (CBS), the Organisation for Economic Cooperation and Development (OECD) health data and the WHO Health For All database (WHO-HFA). Results. There is remarkable difference in incidence rate of RRT between Flanders and the Netherlands, with a higher rate in Flanders. This difference is already present in patients aged 45–64 years and increases with age, being >2-fold higher in subjects of ≥75 years. With respect to the renal diagnoses leading to need for RRT, a higher share of especially diabetes mellitus type 2 and renovascular disease was observed in Flanders. Remarkably, the difference in incidence rate of RRT is not associated with a difference in survival on RRT, not even in the elderly, arguing against a restricted access to RRT in the Netherlands. In the general population, the expected number of healthy life years at birth is lower in Belgium than in the Netherlands, and in Belgium, the hospital discharge rates for diabetes, acute myocardial infarction and cerebrovascular accident and the number of coronary bypass procedures and percutaneous coronary interventions per capitum is higher, as is the prevalence of obesity. Conclusion. Our data do not support the assumption that the differences in RRT incidence in the elderly between Flanders and the Netherlands are due to a more restricted access to RRT in the Netherlands but may be due to differences in underlying comorbidity and life style between the two populations. [ABSTRACT FROM AUTHOR]

Background. The incidence of renal replacement therapy (RRT) among patients aged ≥65 years is much higher in Flanders, the Dutch speaking region of Belgium, than in the Netherlands. We studied whether differences in referral policy to nephrologists by primary care physicians (PCPs) and specialists between Flanders and the Netherlands may play a role. Methods. A vignette study was performed among 329 PCPs and 96 specialists in Flanders and compared to the vignette study that was conducted among 209 PCPs and 162 specialists in the Netherlands. Physicians were offered six vignettes concerning case reports of patients with chronic kidney disease and varying co-morbidities or social circumstances. Each vignette was presented for a 65- and an 80-year-old patient. Physicians were asked about the likelihood of referral of the patients in the given circumstances. Univariate and logistic regression analyses were performed to identify whether country affected the likelihood of referral. Results. Univariate analyses showed that the percentage of PCPs who would probably or definitely refer a 65- or an 80-year-old patient with less severe co-morbidity was significantly (P ≤ 0.001) higher in the Netherlands than in Flanders. However, the likelihood of referral of PCPs-concerning patients with more severe co-morbidity did not differ significantly. Specialists in Flanders did not differ in the likelihood to refer patients from that of specialists in the Netherlands. Logistic regression analysis showed that country (higher referral in the Netherlands) was an important predictor for the referral of PCPs, and this was especially the case for patients with less severe co-morbidity. These patterns persisted, even after controlling for other possible predictors as physicians’ age, gender, religion and years in practice. Conclusions. This study suggests that the lower RRT incidence in the Netherlands cannot be explained by a more restrictive referral policy among physicians in the Netherlands. The data suggested that the latter group had a similar or even more liberal attitude to the referral of older patients than physicians in Flanders. [ABSTRACT FROM PUBLISHER]

Background. Arterial stiffness is a strong predictor of outcome. Hypomagnesaemia, by its association with arterial hypertension, endothelial dysfunction, dyslipidaemia and inflammation, might affect vascular stiffness. As hypomagnesaemia is common in renal transplant recipients (RTR), we examined its potential association with arterial stiffness.Methods. Cross-sectional analysis. Evaluation of vascular stiffness in 512 RTR from two university centres at a median of 72 months post-transplantation. Determination of carotid–femoral pulse wave velocity (PWV) (SphygmoCor). A multiple linear regression analysis was used to investigate the independent relationship between magnesium serum level and PWV with the following covariates: age, diabetes, smoking status, body mass index, blood pressure, heart rate (HR), C-reactive protein (CRP), high-density lipoprotein cholesterol, parathyroid hormone and use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, diuretics, calcium channel blockers, statins and calcineurin inhibitors next to their drug levels.Results. Lower serum magnesium was independently associated with PWV (P = 0.018) in addition to age, CRP, HR, diabetes and mean arterial pressure (model R2 = 0.45; P < 0.001). The relationship between magnesium and PWV was attenuated (P = 0.054) after adjustment for the use of sirolimus, which was associated with higher magnesium levels (P<0.001) and lower PWV (P = 0.013). In patients >55 years (median age), however (low), magnesium remained an independent predictor of PWV (P = 0.024) after accounting for the same covariates.Conclusions. Serum magnesium is an independent predictor of arterial stiffness in RTR, especially in patients >55 years. [ABSTRACT FROM AUTHOR]

The article presents several clinical advices on how to evaluate the characteristics of peritoneal membrane in order to guide peritoneal dialysis (PD) prescription. It states that the evaluation of peritoneal membrane characteristics such as solute transport rate and ultrafiltration capacity is needed in PD prescription. It also suggests epidemiological follow-up of the relation among membrane characteristics, patient characteristics, treatment parameters and outcome.

The author reflects on the diagnosis and treatment of catheter-related blood stream infections (CRBSI). He cites the order of preference of using tunnelled catheters compared to the non-tunnelled ones. The author discusses several ways to prevent catheter-related infections which include the insertion of catheters based on the conditions formulated by the European Best Practice Guidelines (EBPG), the use of antimicrobial locks in the catheter, and the use of antibiotic ointment.

The article presents clinical advice on renal replacement therapy (RRT) modality selection for end-stage renal disease (ESRD) patients issued by the European Renal Best Practice (ERBP) Expert Group. The initial modality choice is to be made by the patient, after being informed and based on what is suitable for them. The dwell time of the patient is to be matched with their peritoneal transport type, in choosing between continuous ambulatory peritoneal dialysis (CAPD) or automated PD (APD).