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England's 10 national parks are renowned for their landscapes, wildlife, and recreational value. However, surface waters in the national parks may be vulnerable to pollution from human‐use chemicals, such as active pharmaceutical ingredients (APIs), because of factors like ineffective wastewater treatment, seasonal tourism, a high proportion of elderly residents, and the presence of low‐flow water bodies that limit dilution. The present study determined the extent of API contamination in the English national parks by monitoring 54 APIs in 37 rivers across all national parks over two seasons. Results were compared to existing data sets for UK cities and to concentration thresholds for ecological impacts and antimicrobial resistance selection. Results revealed widespread contamination of the national parks, with APIs detected at 52 out of 54 sites and in both seasons. Thirty‐one APIs were detected, with metformin, caffeine, and paracetamol showing the highest mean concentrations and cetirizine, metformin, and fexofenadine being the most frequently detected. While total API concentrations were generally lower than seen previously in UK cities, locations in the Peak District and Exmoor had higher concentrations than most city rivers. Fourteen locations had concentrations of either amitriptyline, carbamazepine, clarithromycin, diltiazem, metformin, paracetamol, or propranolol above levels of concern for fish, invertebrates, and algae or for selection for antimicrobial resistance. Therefore, API pollution of the English national parks appears to pose risks to ecological health and potentially human health through recreational water use. Given that these parks are biodiversity hotspots with protected ecosystems, there is an urgent need for improved monitoring and management of pharmaceutical pollution and pollution more generally not only in national parks in England but also in similar environments across the world. Environ Toxicol Chem 2024;43:2422–2435. © 2024 The Author(s). Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC. [ABSTRACT FROM AUTHOR]

Background: Assessment of kidney function is necessary for prescribing renally excreted drugs. The estimated glomerular filtration rate (eGFR) routinely reported by laboratories is indexed to a body surface area (BSA) of 1.73 m2. In obese patients, the indexed eGFR may underestimate directly measured GFR. Aims: To determine the prevalence of obesity in patients with chronic kidney disease (CKD) and examine the effect of adjusting the indexed eGFR for patient BSA (deindexing) across CKD Stages 2–5. Methods: We conducted a cross‐sectional study of 575 adults with stable CKD from two general nephrology clinics over 6 months. Dialysis and kidney transplant patients were excluded. We used four equations (Mosteller, Dubois, Haycock and Schlich) to determine BSA based on actual body weight and applied Bland–Altman plots and piecewise linear regression to examine the relationship between deindexed and indexed eGFR. Results: The median age was 68 years (58% male). The prevalence of overweight and obesity was 31% and 47% respectively. Mean body mass index was 29.7 kg/m2. The Schlich equation for BSA produced the smallest adjustment in eGFR, while the Haycock equation produced the largest adjustment. Males experienced the largest change in eGFR from deindexing because of larger BSAs. Although bias became increasingly positive with higher eGFR, the linear regression stratified by CKD stage indicated that deindexing had little impact with eGFR <45 mL/min/1.73 m2. Conclusions: In CKD, deindexing the Chronic Kidney Disease Epidemiology Collaboration eGFR may not be necessary when the eGFR is <45 mL/min/1.73 m2, particularly if the patient is female. [ABSTRACT FROM AUTHOR]

Background: Little is known about the relationship between patients' cultural and linguistic backgrounds and patient activation, especially in people with diabetes and chronic kidney disease (CKD). We examined the association between culturally and linguistically diverse (CALD) background and patient activation and evaluated the impact of a codesigned integrated kidney and diabetes model of care on patient activation by CALD status in people with diabetes and CKD. Methods: This longitudinal study recruited adults with diabetes and CKD (Stage 3a or worse) who attended a new diabetes and kidney disease service at a tertiary hospital. All completed the patient activation measure at baseline and after 12 months and had demographic and clinical data collected. Patients from CALD backgrounds included individuals who spoke a language other than English at home, while those from non‐CALD backgrounds spoke English only as their primary language. Paired t‐tests compared baseline and 12‐month patient activation scores by CALD status. Results: Patients from CALD backgrounds had lower activation scores (52.1 ± 17.6) compared to those from non‐CALD backgrounds (58.5 ± 14.6) at baseline. Within‐group comparisons showed that patient activation scores for patients from CALD backgrounds significantly improved by 7 points from baseline to 12 months follow‐up (52.1 ± 17.6–59.4 ± 14.7), and no significant change was observed for those from non‐CALD backgrounds (58.5 ± 14.6–58.8 ± 13.6). Conclusions: Among patients with diabetes and CKD, those from CALD backgrounds report worse activation scores. Interventions that support people from CALD backgrounds with comorbid diabetes and CKD, such as the integrated kidney and diabetes model of care, may address racial and ethnic disparities that exist in patient activation and thus improve clinical outcomes. Patient or Public Contribution: Patients, caregivers and national consumer advocacy organisations (Diabetes Australia and Kidney Health Australia) codesigned a new model of care in partnership with healthcare professionals and researchers. The development of the model of care was informed by focus groups of patients and healthcare professionals and semi‐structured interviews of caregivers and healthcare professionals. Patients and caregivers also provided a rigorous evaluation of the new model of care, highlighting its strengths and weaknesses. [ABSTRACT FROM AUTHOR]

Background: Dietary management plays an important role in patients with kidney failure. Current dietary habits of Australians and New Zealanders (ANZ) and Malaysians with chronic kidney disease (CKD Stage 4–5) have not been adequately investigated. We report the dietary habits of people with advanced CKD and their adherence to country‐specific dietary guidelines. Methods: Participants with CKD Stage 4–5, enrolled in the Omega‐3 Fatty Acids (Fish oils) and Aspirin in Vascular access Outcomes in Renal Disease (FAVOURED) trial, completed a lifestyle questionnaire at baseline on their dietary intake. Results: Of 567 participants, 538 (ANZ, n = 386; Malaysian, n = 152; mean ± SD age 54.8 ± 14.3 years, 64% male) completed the questionnaire. Dietary fruit and vegetable intakes were higher in ANZ participants; 49% (n = 189) consumed ≥2 serves day–1 of fruit and 61% (n = 235) ate ≥2 serves day–1 of vegetables compared to 24% (n = 36) and 34% (n = 52) of Malaysians, respectively (p < 0.0001). Only 4% (n = 15) of ANZ participants met Australian Dietary recommendations of two fruit and five vegetable serves day–1. Fish consumption was higher in Malaysians with 83% (n = 126) consuming ≥2 serves week–1 compared to 21% (n = 81) of ANZ participants (p < 0.001). Red meat intake was higher in ANZ participants; however, chicken consumption was similar; 48% (n = 185) consumed >2 chicken serves week–1 and 65% (n = 251) ate >2 serves week–1 of red meat compared to 43% (n = 65) and 15% (n = 23) of Malaysians, respectively. Conclusions: Significant regional variation in dietary intake for fruit, vegetables and animal protein is described that likely reflects cultural and economic differences. Barriers to meeting recommended dietary intakes require further investigation. Key Points: Dietary management plays an important role in the management of patients with kidney failure.Current dietary habits of Australians, New Zealanders and Malaysians with advanced chronic kidney disease have not been adequately investigated.Dietary fruit and vegetable intakes were significantly higher in Australia and New Zealand (ANZ) participants then Malaysian participants.Fish consumption was higher in Malaysians compared to ANZ participants.The significant regional variation in dietary intake for fruit, vegetables and animal protein likely reflects cultural and economic differences.Dietary intakes of both fruit and vegetables were inadequate by national recommendations but similar to the general population in both the ANZ and Malaysia cohorts.Barriers to meeting recommended dietary intakes require further investigation. [ABSTRACT FROM AUTHOR]

Aim: To compare small, middle and large‐middle molecule clearance; and expression of markers of inflammation, between Solacea‐190H (asymmetric cellulose triacetate [ATA]) and FX‐80 dialysers in long‐hour haemodialysis patients. Methods: This pilot, randomized cross‐over trial recruited 10 home haemodialysis patients. The total study duration was 8 weeks, using each dialyser for 4 weeks. Removal of small (urea, phosphate, creatinine and indoxyl sulfate [IS]), middle and large‐middle molecules (beta‐2 microglobulin [β2M], albumin), markers of inflammation (interleukin‐6 [IL‐6], malondialdehyde‐modified low density lipoprotein [MDA‐LDL] and alpha‐1 microglobulin [α1M]), was evaluated in serum and dialysate samples. Results: Reduction ratios [RR] were calculated for variables at the fourth week of each dialyzer sequence and results expressed as difference in mean RR between dialyzers. There was no difference in clearance of small molecules, with difference in mean RR for urea −2.43 (95% CI ‐6.44, 1.57; p =.19), creatinine −1.82 (95% CI ‐5.50, 1.85; p =.28) and phosphate −2.61 (95% CI −12.45, 7.23; p =.55); clearance of middle and large‐middle molecules with difference in mean RR (range) for β2M 2.2 (95% CI −3.2, 7.7; p =.35), IS 1.8 (95% CI −9.5, 13; p =.72) and albumin −0.6 (95% CI −5.5, 4.2; p =.77). There was lack of induction of markers of inflammation, including IL‐6 15.2 (95% CI −31.9, 62.2; p =.47), MDA‐LDL −8.1 (95% CI ‐22.1, 5.8; p =.21) and α1M −3.50 (95% CI −29.2, 22.2; p =.76). Dialysate removal results were concurrent. Conclusion: This study showed no difference in clearance of small, middle and large‐middle molecules, nor expression of markers of inflammation between dialysers. SUMMARY AT A GLANCE: This pilot cross‐over randomized controlled trial compares small, middle and large‐middle molecule clearance between Solacea‐190H (asymmetric cellulose triacetate [ATA]) and FX‐80 dialysers in 10 patients using long‐hour haemodialysis over an 8‐week period, and showed no difference in clearance between the two dialysers. [ABSTRACT FROM AUTHOR]

The size of single crystals of the metal‐organic framework CPO‐27‐Ni was incrementally increased through a series of modulated syntheses. A novel linker modulated synthesis using 2,5‐dihydroxyterephthalic acid and the isomeric ligand 4,6‐dihydroxyisophthalic acid yielded large single crystals of CPO‐27‐Ni (∼70 μm). All materials were shown to have high crystallinity and phase purity through powder X‐ray diffraction, electron microscopy methods, thermogravimetry, and compositional analysis. For the first time single‐crystal structure analyses were carried out on CPO‐27‐Ni. High BET surface areas and nitric oxide (NO) release efficiencies were recorded for all materials. Large single crystals of CPO‐27‐Ni showed a prolonged NO release and proved suitable for in situ single‐crystal diffraction experiments to follow the NO adsorption. An efficient activation protocol was developed, leading to a dehydrated structure after just 4 h, which subsequently was NO‐loaded, leading to a first NO loaded single‐crystal structural model of CPO‐27‐Ni. [ABSTRACT FROM AUTHOR]

Introduction: The 3‐day interdialytic interval (IDI) is associated with high interdialytic weight gain (IDWG), but little is known about the effect of public or religious holidays on IDWG. Consequently, we evaluated the impact of the "Christmas holiday effect" on IDWG of hemodialysis patients. Methods: A retrospective cohort study of adult hemodialysis patients (over 18 years) was conducted across five dialysis units in Australia. Demographic and clinical data were collected from electronic medical records. IDWG was established for three time points; regular 3‐day IDI, 2‐day IDI preceding the Christmas holiday and a 3‐day IDI that included the Christmas holiday. Paired t‐tests and logistic regression were used to compare differences in mean IDWG before and after the Christmas holiday and to examine factors associated with high IDWG, respectively. Findings: Two hundred and fifty‐two patients, 69% of whom were male, with mean (SD) age of 65.4 ± 15.3 years, were studied. Most had end‐stage kidney disease due to diabetes (44%), and they had been on hemodialysis for a median of 25.5 (IQR, 60–10) months. There was a significant increase in absolute IDWG (MD 0.21 kg, 95% CI −0.07 to 0.36; P = 0.004) and relative IDWG (MD 0.3%, 95% CI 0.10‐0.40; P = 0.01) after the holiday 3‐day IDI compared with the regular 3‐day IDI. Older age (OR 0.12; 95% CI 0.02‐0.55) and a unit increase in hemoglobin (OR 0.94; 95% CI 0.89‐0.99) were associated with lower odds of high relative IDWG while speaking a language other than English increased the odds for high relative IDWG (OR 5.03; 95% CI 1.12‐22.65). Conclusion: Absolute and relative IDWG increased significantly after the Christmas holiday. Individualizing dialysis needs may improve outcomes for these patients. [ABSTRACT FROM AUTHOR]

Diabetic nephropathy (DN) is the leading cause of end‐stage kidney disease. TGF‐β1/Smad3 signalling plays a major pathological role in DN; however, the contribution of Smad4 has not been examined. Smad4 depletion in the kidney using anti‐Smad4 locked nucleic acid halted progressive podocyte damage and glomerulosclerosis in mouse type 2 DN, suggesting a pathogenic role of Smad4 in podocytes. Smad4 is upregulated in human and mouse podocytes during DN. Conditional Smad4 deletion in podocytes protects mice from type 2 DN, independent of obesity. Mechanistically, hyperglycaemia induces Smad4 localization to mitochondria in podocytes, resulting in reduced glycolysis and oxidative phosphorylation and increased production of reactive oxygen species. This operates, in part, via direct binding of Smad4 to the glycolytic enzyme PKM2 and reducing the active tetrameric form of PKM2. In addition, Smad4 interacts with ATPIF1, causing a reduction in ATPIF1 degradation. In conclusion, we have discovered a mitochondrial mechanism by which Smad4 causes diabetic podocyte injury. Synopsis: This study reveals a mitochondrial role of Smad4 in the pathogenesis of diabetic nephropathy. Hyperglycemia induces Smad4 localization to mitochondria of podocytes.Smad4 depletion in podocytes protects mice from glomerulosclerosis in type 2 diabetes models.Smad4 depletion promotes glycolysis and OXPHOS activity under high glucose conditions.Hyperglycemia promotes the interaction between Smad4 and PKM2, thereby increasing PKM2 tetramerization and activity.Smad4 directly interacts with ATP synthase inhibitor ATPIF1 and inhibits it degradation. [ABSTRACT FROM AUTHOR]

Aim: Patients with autosomal dominant polycystic kidney disease (ADPKD) are at increased risk of premature mortality, morbidities and complications, which severely impair quality of life. However, patient‐centered outcomes are not consistently reported in trials in ADPKD, which can limit shared decision‐making. We aimed to identify outcomes important to patients and caregivers and the reasons for their priorities. Methods: Nominal group technique was adopted involving patients with ADPKD and caregivers who were purposively selected from eight centres across Australia, France and the Republic of Korea. Participants identified, ranked and discussed outcomes for trials in ADPKD. We calculated an importance score (0–1) for each outcome and conducted thematic analyses. Results: Across 17 groups, 154 participants (121 patients, 33 caregivers) aged 19 to 78 (mean 54.5 years) identified 55 outcomes. The 10 highest ranked outcomes were: kidney function (importance score 0.36), end‐stage kidney disease (0.32), survival (0.21), cyst size/growth (0.20), cyst pain/bleeding (0.18), blood pressure (0.17), ability to work (0.16), cerebral aneurysm/stroke (0.14), mobility/physical function (0.12), and fatigue (0.12). Three themes were identified: threatening semblance of normality, inability to control and making sense of diverse risks. Conclusion: For patients with ADPKD and their caregivers, kidney function, delayed progression to end‐stage kidney disease and survival were the highest priorities, and were focused on achieving normality, and maintaining control over health and lifestyle. Implementing these patient‐important outcomes may improve the meaning and relevance of trials to inform clinical care in ADPKD. SUMMARY AT A GLANCE: The authors identified and ranked 55 patient‐centered outcomes in 121 autosomal dominant polycystic kidney disease patients and 33 of their caregivers from 17 groups from Australia, France and Korea. They found kidney function, delayed progression to end‐stage kidney disease and survival to be of the highest priorities. These data could help to design clinical trials in autosomal dominant polycystic kidney disease and health education. [ABSTRACT FROM AUTHOR]

Aim: Extended‐hours haemodialysis has long been regarded as the optimal form of dialysis for solute clearance. With emerging benefits of haemodiafiltration, we wanted to compare these two head‐to‐head. Methods: In this randomized cross‐over trial, we recruited existing nocturnal haemodialysis patients, who had not been hospitalized in the prior 3 months. After a baseline 8 h haemodialysis session, subjects were randomized to either 2 weeks of 8 h haemodialysis or 4 h haemodiafiltration with cross‐over to the alternative treatment after a 2‐week washout period. Subjects were additionally randomized to the Fresenius FX80 or Nipro Elisio in a parallel design. Blood and dialysate samples were collected at baseline and at the end of both study periods. Results: Twelve patients completed the study. Mean (SD) age and body mass index were 55.1 ± 11.5 years and 36.4 ± 10.8, respectively. Urea and creatinine reduction ratios were higher with extended‐hours haemodialysis compared to haemodiafiltration (difference 14.0%, 95% CI = 10.6, 17.3; P < 0.001 and 9.1%, 95% CI = 11.0, 7.2; P < 0.001). Fibroblast growth factor 23 (FGF23) clearance was superior with haemodiafiltration (difference 20.1%, 95% CI = 8.7, 31.6; P = 0.001). No difference was seen in reduction ratios for phosphate, retinol binding protein, alpha‐1‐microglobulin, beta‐2‐microglobulin and fetuin with both modalities. Compared to Nipro Elisio, Fresenius FX80 dialyser achieved higher beta‐2‐microglobulin clearance (Period 1: difference 7.8%, 95% CI = 1.3, 14.4; P = 0.02, Period 2:7.5%, 95% CI = 1.0, 14.1; P = 0.02). Conclusions: Small solute clearance was superior with extended‐hours haemodialysis while haemodiafiltration enhanced FGF23 clearance. Beta‐2‐microglobulin clearance was improved with Fresenius FX80 dialyser, but this difference is unlikely to be clinically significant. Summary at a Glance: This small randomized cross‐over trial compared solute clearance between patients on 8 h extended haemodialysis and 4 h haemodiafiltration over a period of 2 weeks, and found that the former was associated with superior urea and creatinine clearance while the latter enhanced FGF23 clearance. [ABSTRACT FROM AUTHOR]

There have been few new therapies for patients with chronic kidney disease in the last decade. However, the management of patients affected by genetic kidney disease is rapidly evolving. Inherited or genetic kidney disease affects around 10% of adults with end‐stage kidney disease and up to 70% of children with early onset kidney disease. Advances in next‐generation sequencing have enabled rapid and cost‐effective sequencing of large amounts of DNA. Next‐generation sequencing‐based diagnostic tests now enable identification of a monogenic cause in around 20% of patients with early‐onset chronic kidney disease. A definitive diagnosis through genomic testing may negate the need for prolonged diagnostic investigations and surveillance, facilitate reproductive planning and provide accurate counselling for at‐risk relatives. Genomics has allowed the better understanding of disease pathogenesis, providing prognostic information and facilitating development of targeted treatments for patients with inherited or genetic kidney disease. Although genomic testing is becoming more readily available, there are many challenges to implementation in clinical practice. Multidisciplinary renal genetics clinics serve as a model of how some of these challenges may be overcome. Such clinics are already well established in most parts of Australia, with more to follow in future. With the rapid pace of new technology and gene discovery, collaboration between expert clinicians, laboratory and research scientists is of increasing importance to maximize benefits to patients and health‐care systems. Summary at a Glance: The authors reckoned the importance of genomic testing as it allows better understanding of disease pathogenesis, provides prognostic information and facilitates development of targeted treatment, particularly for patients with inherited or genetic kidney disease. [ABSTRACT FROM AUTHOR]

The phylogeny of the fungus gnat family Mycetophilidae (Diptera) is reconstructed with a focus on the species‐rich and taxonomically difficult subfamilies Gnoristinae and Mycomyinae. The multigene phylogenetic analyses are based on five nuclear (18S, 28S, CAD, MCS, ITS2) and four mitochondrial (12S, 16S, COI, CytB) gene markers. The analyses strongly support the monophyly of Mycetophilidae and the subfamilies Manotinae, Sciophilinae, Leiinae, and Mycomyinae, although Gnoristinae is paraphyletic with respect to Mycetophilinae. All the genera and groups of genera included are supported as monophyletic, except for Acomoptera Vockeroth, Boletina Staeger, Dziedzickia Johannsen, Ectrepesthoneura Enderlein, and Neoempheria Osten Sacken. Ancestral character state reconstructions were applied to two morphological features present in Gnoristinae and Mycomyinae (i.e. presence of setae on wing membrane and wing vein R4) in order to assess their evolution. The wing vein R4 appears as an unstable character, spread throughout different clades. A dated phylogeny of the family Mycetophilidae showed that most of the subfamilies of Mycetophilidae originated and diversified during the Cretaceous. The youngest subfamilies, originated in the Paleogene, appear to be Mycomyinae and Mycetophilinae. A new multigene phylogeny of fungus gnats is presented based on a comprehensive taxon sampling, with a focus on the species‐rich and taxonomically difficult subfamilies Gnoristinae and Mycomyinae.The subfamily Gnoristinae is found to be paraphyletic with respect to Mycetophilinae. All the genera included are supported as monophyletic, except for Acomoptera, Boletina, Dziedzickia, Ectrepesthoneura, and Neoempheria.A dated phylogeny of the family is presented for the first time. Most of the subfamilies originated and diversified in the Cretaceous, except for Mycomyinae and Mycetophilinae, with Paleogene origin. [ABSTRACT FROM AUTHOR]

An otherwise well 42-year-old male presented to the emergency department by ambulance with an impalement injury to the right side of the neck by a 5-cm diameter and 27-cm length tree branch following a motor bike accident. A subsequent computed tomography scan of the head, neck and chest with contrast demonstrated that the foreign body was directly threatening the aortic arch, right and left common carotid arteries and right internal jugular vein. [Extracted from the article]

Abstract: Diabetes and chronic kidney disease (CKD) are two of the most prevalent co‐morbid chronic diseases in Australia. The increasing complexity of multi‐morbidity, and current gaps in health‐care delivery for people with co‐morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co‐morbid diabetes and CKD have not been co‐designed with stake‐holders or formally evaluated. Particular components of health‐care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self‐management by the patient; and upskill primary health‐care. Here we present an integrated patient‐centred model of health‐care delivery incorporating these components and co‐designed with key stake‐holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health‐professionals; and semi‐structured interviews of care‐givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient‐support through a phone advice line; and focused primary health‐care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient‐centred health‐care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas. [ABSTRACT FROM AUTHOR]

Objective This study aimed to examine the association between performance of self-care activities and patient or disease factors as well as patient activation levels in patients with diabetes and chronic kidney disease ( CKD) in Australia. Methods A cross-sectional study was conducted among adults with diabetes and CKD ( eGFR <60 mL/min/1.73m2) who were recruited from renal and diabetes clinics of four tertiary hospitals in Australia. Demographic and clinical data were collected, as well as responses to the Patient Activation Measure ( PAM) and the Summary of Diabetes Self-Care Activities ( SDSCA) scale. Regression analyses were performed to determine the relationship between activation and performance of self-care activities. Results A total of 317 patients (70% men) with a mean age of 66.9 ( SD=11.0) years participated. The mean ( SD) PAM and composite SDSCA scores were 57.6 (15.5) % (range 0-100) and 37.3 (11.2) (range 0-70), respectively. Younger age, being male, advanced stages of CKD and shorter duration of diabetes were associated with lower scores in one or more self-care components. Patient activation was positively associated with the composite SDSCA score, and in particular the domains of general diet and blood sugar checking ( P<.05), but not specific diet, exercising and foot checking. Conclusion In people with diabetes and CKD, a high level of patient activation was positively associated with a higher overall level of self-care. Our results identify subgroups of people who may benefit from tailored interventions to further improve their health outcomes. Further prospective studies are warranted to confirm present findings. [ABSTRACT FROM AUTHOR]

ABSTRACT Haemolysis in haemodialysis, although rare in current times, is associated with significant mortality and morbidity. As such prompt recognition, treatment, analysis of root cause and correction of underlying causative factors is crucial. Dialysate, extracorporeal circuit and patient related factors all contribute to haemolysis risk. Haemolysis can manifest with non-specific signs and symptoms including but not restricted to hypertension, nausea, pain (abdominal, chest, back) and dyspnoea. It may present acutely during the dialysis session or may take a protracted course. Potential life threating consequences include; hyperkalaemia induced cardiac arrhythmias, profound anaemia and associated acute coronary events and respiratory distress, and severe necrotizing pancreatitis. Chronic haemolysis results in impaired endothelial function thus contributing to the long-term cardiovascular risk profile in haemodialysis patients. Stringent national and international standards, technological advancements in membrane and dialysis equipment design, dialyser purification methods and water treatment systems have greatly reduced the incidence of haemolysis. Despite these improvements recognition of haemolysis risk and ongoing clinical vigilance is important. [ABSTRACT FROM AUTHOR]

Asymptomatic urolithiasis is common and of mixed composition in patients with β-thalassaemia major. Twenty-seven subjects were imaged using dual-energy computer tomography to determine the presence and composition of urolithiasis. The prevalence of urolithiasis was 59% and affected patients generally had multiple stones, often with more than one component: struvite (33%), calcium oxalate (31%) and cystine (22%). Hypercalciuria was present in 78% of subjects and calcium-containing urolithiasis was associated with reduced femoral neck Z scores. [ABSTRACT FROM AUTHOR]

Purpose Increased fracture rates are observed in renal transplant recipients (RTRs) compared with the general population. Risk factors include age, diabetes, dialysis vintage, immunosuppression and mineral and bone disorders.1 Low serum phosphorus levels occur post-transplantation; however, its relationship with fracture risk has not been evaluated. The purpose of this study was to evaluate risk factors for fracture in RTRs at a single tertiary referral centre. Methods A retrospective cross-sectional analysis of 146 patients (75 M, 71 F) who had been referred for dual energy X-ray densitometry ( DXA) post-renal transplantation was performed. Aetiology of end stage kidney disease ( ESKD), duration of dialysis, parathyroidectomy history, immunosuppression regimen, bone mineral density ( BMD), biochemistry and fractures were documented. Statistical analyses included univariable and multivariable regression. Results The mean age of patients was 54 years and mean time post-transplantation 6.7 years. A total of 79 fractures occurred in 52 patients (35%), with 40 fractures occurring post-transplantation. Ankle/foot fractures were most common (48%). Lower serum phosphorus levels and declining femoral neck ( FN) T-score and were associated with fractures in both univariable and multivariable regression analyses after adjusting for age, gender, weight, estimated glomerular filtration rate and pre-transplant history of fracture ( P=.011 and P=.042 respectively). The relationship between serum phosphorus and fracture remained significant independent of FN T-score, parathyroid hormone levels, parathyroidectomy status and prednisolone use. Conclusion Fracture was common post-renal transplantation. Lower serum phosphorus levels and declining FN T-scores were associated with fractures. The mechanism of this previously unreported observation requires further evaluation in prospective studies. [ABSTRACT FROM AUTHOR]

Background and Aims People with end-stage kidney disease receiving haemodialysis are restricted to holidays where dialysis services are readily available. Holiday dialysis in regional, rural and remote areas is particularly challenging. The aims of this study were to evaluate the wellbeing of those who received dialysis in a holiday haemodialysis bus and to measure patient well-being with that of a comparable cohort of haemodialysis patients. Methods A three machine haemodialysis bus, the Big Red Kidney Bus, was built to enable people, their families and carers to take holidays across a range of tourist destinations in Victoria, Australia. Measures included pre-post subjective well-being, dialysis symptoms and mood questionnaires complemented by post semi-structured telephone interviews. Results Participating holidaymakers were positive about the haemodialysis bus service and the standard of care experienced. They reported decreased dialysis side effects of fatigue, muscle cramp and dry skin. The overall number of reported symptoms decreased, and the perceived level of bother associated with symptoms also decreased. No changes in subjective well-being and mood were detected. Mean Personal Wellbeing Index scores were significantly higher than in a comparative haemodialysis sample. Conclusion The Big Red Kidney Bus provided a safe and feasible holiday dialysis service. Holidaymakers' well-being was reflected by the decreased dialysis patient side effects. [ABSTRACT FROM AUTHOR]

Introduction: Higher calcium dialysate is recommended for quotidian nocturnal hemodialysis (NHD) (≥6 nights/week) to maintain bone health. It is unclear what the optimal calcium dialysate concentration should be for alternate night NHD. We aimed to determine the effect of low calcium (LC) versus high calcium (HC) dialysate on cardiovascular and bone parameters in this population. Methods: A randomized controlled trial where participants were randomized to LC (1.3 mmol/L, n = 24) or HC dialysate (1.6 or 1.75 mmol/L, n = 26). Primary outcome was change in mineral metabolism markers. Secondary outcomes included change in vascular calcification (VC) scores [CT abdominal aorta (AA) and superficial femoral arteries (SFA)), pulse wave velocity (PWV), bone mineral density (BMD) and left ventricular mass index (LVMI) over 12 months. Findings: In the LC group, pre-dialysis ionised calcium decreased −0.12 mmol/L (−0.18-0.06, P = 0.0001) and PTH increased 16 pmol/L (3.5-28.5, p = 0.01) from baseline to 12 months with no significant change in the HC group. In both groups, there was no progression of VC in AA or SFA and no change in PWV, LVMI or BMD. At 12 months, calcimimetics were prescribed in a higher percentage in the LC vs. HC groups (45.5% vs. 10.5%) with a lower proportion of the HC group being prescribed calcitriol (31.5% vs. 72%). Discussion: Although dialysate calcium prescription influenced biochemical parameters it was not associated with difference in progression of VC between HC and LC groups. An important finding was the potential impact of alternate night NHD in attenuating progression of VC and inducing stabilisation of LVMI and PWV. [ABSTRACT FROM AUTHOR]

Aim The average age of patients requiring haemodialysis is on the rise and has resulted in an increase in the number of elderly people receiving dialysis. While haemodialysis is one of the treatment options for this patient group, questions about its effectiveness have been raised. A second question centres on how much haemodialysis is actually needed to maintain quality of life (QoL). This study examined the relationship between dialysis adequacy and the QoL of elderly patients on haemodialysis. Method A prospective cohort of 40 haemodialysis patients aged 75 years and above was recruited and studied over 3 months. Quality of life was assessed with the European Quality of Life-5 Dimensions questionnaire and dialysis adequacy with the urea reduction ratio (URR), and the relationship between the two examined using a simple linear regression model. Results The average age of the participants was 79.8 ± (3.9 years; 45% were women, and diabetes was the main cause of kidney disease (42.5%). The mean URR, visual analogue scale, European Quality of Life-5 Dimensions indices score and Charlson comorbidity index scores were 78.1 ± (5.5)%, 65.4 ± (13.7)%, 0.7 ± (0.27) and 6.3 ± (2.15), respectively. There was no clear relationship between dialysis adequacy and QoL, r = 0.093. Dialysis adequacy did not significantly predict QoL ( P = 0.09). Conclusion There was no evidence for an association between haemodialysis adequacy and QoL in elderly patients receiving haemodialysis across a URR range of 64.0% to 88.9%. Attempts to improve dialysis adequacy beyond these levels may not be necessary for maintaining the QoL of elderly patients on dialysis. Key message Modern therapy should embrace the concept of quality of life and focus more on symptom relief and optimization of self-management skills to improve the well-being of the elderly patients with ESKD. [ABSTRACT FROM AUTHOR]

Aim Nocardia infections are an uncommon but important cause of morbidity and mortality in renal transplant recipients. The present study was carried out to determine the spectrum of Nocardia infections in a renal transplant centre in Australia. Methods A retrospective chart analysis of all renal transplants performed from 2008 to 2014 was conducted to identify cases of culture proven Nocardia infection. The clinical course for each patient with nocardiosis was examined. Results Four of the 543 renal transplants patients developed Nocardia infection within 2 to 13 months post-transplant. All patients were judged at high immunological risk of rejection pre-transplant and had received multiple sessions of plasmaphoeresis and intravenous immunoglobulin before the onset of the infection. Two patients presented with pulmonary nocardiosis and two with cerebral abscesses. One case of pulmonary nocardiosis was complicated by pulmonary aspergillosis and the other by cytomegalovirus pneumonia. All four patients improved with combination antibiotic therapy guided by drug susceptibility testing. At the time of Nocardia infection all four patients were receiving primary prophylaxis with trimethoprim/sulphamethoxazole ( TMP/ SMX) 160/800 mg, twice weekly. Conclusion Plasmaphoeresis may be risk factor for Nocardia infection and need further study. Nocardia infection may coexist with other opportunistic infections. Identification of the Nocardia species and drug susceptibility testing is essential in guiding the effective management of patients with Nocardia. Intermittent TMP-SMX (one double strength tablet, twice a week) appears insufficient to prevent Nocardia infection in renal transplant recipients. [ABSTRACT FROM AUTHOR]

Aim The Fish oils and Aspirin in Vascular access OUtcomes in REnal Disease ( FAVOURED) trial investigated whether 3 months of omega-3 polyunsaturated fatty acids, either alone or in combination with aspirin, will effectively reduce primary access failure of de novo arteriovenous fistulae. This report presents the baseline characteristics of all study participants, examines whether study protocol amendments successfully increased recruitment of a broader and more representative haemodialysis cohort, including patients already receiving aspirin, and contrasts Malaysian participants with those from Australia, New Zealand and the United Kingdom ( UK). Method This international, randomized, double-blind, placebo-controlled trial included patients older than 19 years with stage 4 or 5 chronic kidney disease currently receiving, or planned within 12 months to receive haemodialysis. Results Participants ( n = 568) were overweight (28.6 ± 7.3 kg/m2), relatively young (54.8 ± 14.3 years), and predominantly male (63%) with a high prevalence of diabetes mellitus (46%) but low rate of ischaemic heart disease (8%). Sixty one percent were planned for lower arm arteriovenous fistula creation. Malaysian participants ( n = 156) were younger (51.8 ± 13.6 years vs 57.1 ± 14.2 years, P < 0.001) with a higher prevalence of diabetes mellitus (65% vs 43%, P < 0.001), but less ischaemic heart disease (5% vs 14%, P < 0.01) compared with the combined Australian, New Zealand and UK cohort ( n = 228). Protocol modifications allowing for inclusion of patients receiving aspirin increased the prevalence of co-morbidities compared with the original cohort. Conclusions The FAVOURED study participants, while mostly similar to patients in contemporary national registry reports and comparable recent clinical trials, were on average younger and had less ischaemic heart disease. These differences were reduced as a consequence of including patients already receiving aspirin. [ABSTRACT FROM AUTHOR]

However, as poor kidney function and proteinuria are independent risk factors for both cardiovascular disease and all-cause mortality, more people die with CKD than experience kidney failure. The rate of disease progression and the likelihood of requiring kidney replacement therapy increase with the patient's degree of proteinuria. Keywords: Renal dialysis EN Renal dialysis 137 138 2 02/22/22 20220215 NES 220215 Older patients may never need kidney replacement therapy, but their other medical conditions require attention Chronic kidney disease (CKD) is a public health problem worldwide.1 An estimated 1.7 million Australian adults, about 10% of the population, have biomedical signs of CKD,2 but more than half are unaware of their condition. [Extracted from the article]

ABSTRACT: A 54 year old male with b‐Thalassemia major developed ESRD and was managed with continuous ambulatory peritoneal dialysis. Although not able to be transfused due to high titre red cell antibodies he did require management of iron overload. Deferasirox (Exjade) was administered orally. There was concern that excretion of iron via the peritoneal dialysate may raise the risk of iron‐dependent infections (Yersinia and Rhizopus).Whilst receiving Exjade 1000mg /day, a total collection of 12.7L of peritoneal dialysate was collected over a 24 hour period by the patient. The dialysate total iron levels were measured by ICP‐MS at 0.46mmol/L which equates to 0.33mg of Fe in total. Over a 6 month period his serum ferritin fell from 3869μg/l to 1545μg/l. There were no episodes of peritonitis. Since only 7‐8% of the deferasirox and iron complex is excreted through the urine, the amount of Fe seen in the patient's dialysate might be expected to be up to 1.5‐1.6mg. Yet, the results of the Fe levels in the patient’s PD fluid was a meagre 0.33mg, about five times lower than expected.Whilst only moderately effective at a dosage of 1000mg/day, deferasirox may be a safe agent for iron removal in iron overloaded peritoneal dialysis patients, as relatively low dialysate iron levels reduces the risk of Yersinia and Rhizopus infection. [ABSTRACT FROM AUTHOR]

A middle-aged man received a kidney transplant from a deceased multi-organ donor. The recipient suffered cardiac arrest several days post-operatively and sustained hypoxic brain injury and was declared brain dead. Following the family's consent, the allograft kidney was retrieved and re-transplanted into a man with end-stage renal failure secondary to reflux nephropathy. The liver was not transplanted due to suspicion of fatty changes based on macroscopic appearance. After transplantation of other organs, liver histology revealed coagulative parenchymal necrosis with nuclear inclusions and moderate parenchymal cholestasis, suggestive of herpes viral hepatitis. Renal implantation biopsy showed histiocytes with enlarged nuclei containing viral inclusions in the capsular fibrous tissue, with positive immunostaining for herpes simplex virus ( HSV). Anti-viral therapy was commenced immediately after obtaining histological evidence of donor HSV infection. Our recipient had pre-formed immunoglobulin G antibodies to HSV-1 and HSV-2, and was immunoglobulin M negative pre-transplant. HSV viraemia was detected day 5 post-transplant with a viral load of 7688 copies/mL by polymerase chain reaction assay. The recipient completed a 30 day course of intravenous ganciclovir before switching to oral valganciclovir as standard cytomegalovirus prophylaxis. The HSV polymerase chain reaction became undetectable on day 7 of intravenous ganciclovir and has remained undetectable. The patient remains well 9 months post-transplant with an estimated glomerular filtration rate of 61 mL/min per 1.73 m2. Although renal allograft re-use has been shown to be technically possible with a good outcome in this recipient, this does raise issues including assessment of allografts that have undergone repeated severe ischaemic insults and the potential of transmission of infections. [ABSTRACT FROM AUTHOR]

Since their inception in the 1960s, home-based dialysis therapies have been viable alternatives to conventional thrice weekly in center hemodialysis. In spite of this, uptake of these therapies has been steadily declining over past decades with utilization varying globally; dependent on training support, funding models, and prevailing Nephrologist beliefs. In the Australian context, home dialysis (predominantly peritoneal dialysis and extended hours nocturnal hemodialysis) is now again increasing in popularity-with enthusiasm driven not only by evidence of an array of physiological and psychological patient benefit but also significant economic advantage: critical in the current climate where dialysis therapies in Australia take approximately $1 billion dollars per year from the healthcare budget. When assessing the significant advantages of home-based therapies, it is important to consider not only the increasing body of evidence around improved survival but also that for dramatically better health-related quality of life, decreased economic burden and the overall benefits of undertaking treatment in the home. With patient-centered care an increasingly important aspect of our decision making paradigm, home-based dialysis should be considered as the default option in all patients transitioning to renal replacement therapy. [ABSTRACT FROM AUTHOR]

Aim There has been a global decline in the uptake of home-based dialysis therapies in the past 20 years. The ability to provide appropriate information to potential patients in this area may be confounded by a lack of knowledge of home dialysis options. The aim of this study was to develop a web-based education package for health professionals to increase knowledge and positive perceptions of home-based dialysis options. Methods A three-module e-learning package concerning home dialysis was developed under the auspices of the home dialysis first project. These modules were tested on 88 undergraduate health professionals. Changes in attitudes and knowledge of home dialysis were measured using custom designed surveys administered electronically to students who completed the modules. Matched pre and post responses to the survey items were compared using Wilcoxon signed rank tests. Results The pre survey indicated clear deficits in existing knowledge of home dialysis options. In particular, when asked if haemodialysis could be performed at home, 22% of participants responded 'definitely no' and a further 24% responded 'probably no'. Upon completion of the e-learning, post survey responses indicated statistically significant improvements ( P < 0.001) in eight of the nine items. When asked if the e-learning had increased their knowledge about home dialysis, 99% of participants responded 'definitely yes'. Conclusion A suite of web-based education modules can successfully deliver significant improvements in awareness and knowledge around home dialysis therapies. [ABSTRACT FROM AUTHOR]

Summary at a glance: This is a concise and objective assessment of the potential benefits of different types of membranes: notably synthetic high flux membranes. This review represents CARI's guidelines and should be beneficial to the nephrologists. [ABSTRACT FROM AUTHOR]

Alternate night nocturnal hemodialysis (HD) is a popular modality in Australia. This modality grew out of a desire to increase the availability and accessibility of nocturnal HD without incurring excessive costs. It has proven popular with staff, patients, and administrators. There are limited data to support the benefits of this modality and undoubtedly, more data are required. As in 5-6 times per week nocturnal HD, the major benefits appear to be in phosphate control, volume control, and patient wellbeing. Economically, this approach to nocturnal HD costs much the same as conventional home HD, with only one extra dialysis session every 2 weeks. This review expands on some aspects of this dialysis modality and how it is practiced in Australia. [ABSTRACT FROM AUTHOR]

After early strong support, home hemodialysis (HHD) has all but disappeared as a viable modality in most western countries--except in Australia and New Zealand (ANZ), where a mean 12.9% of all HD (June 2010) is home-based. The reasons for this unique difference are neither demographic nor geographic; rather, they result from a strong belief held by ANZ nephrologists, nurses, and funding agencies in the clinical outcome and economic benefits of HHD. This 'hemodialysis is best at home' approach has permitted ANZ programs to take full advantage of a renewed interest in extended hour and higher frequency dialysis. This article explores the reasons for the success of HHD in this region. [ABSTRACT FROM AUTHOR]

ABSTRACT: Aim: Spot urine measurement of albumin is now the most commonly accepted approach to screening for proteinuria. Exertion prior to the collection may potentially influence the result of spot urine albumin estimation. We aim to evaluate the effect of exercise on albuminuria in subjects at various stages of diabetic nephropathy in comparison with healthy control volunteers. Methods: Thirty-five people with diabetes (19 with normoalbuminuria (NA), nine with microalbuminuria (MA) and seven with overt proteinuria (OP)) and nine control subjects were assessed. A 1 km treadmill walk was performed. Four spot urine specimens were collected: first morning void, immediately prior to exercise, and 1 h and 2 h after exercise. A random effects linear regression mixed model was used to assess the effect of exercise on albumin/creatinine ratio (uACR). Results are presented separately for male and female subjects with diabetes due to a significant exercise/gender interaction ( P < 0.05). Results: No significant effect of exercise on uACR was seen in control subjects. In NA males with diabetes no effect of exercise was seen, while in females uACR 1 h after exercise was significantly higher than the early morning sample (3.55 mg/mmol (96% confidence interval 0.27-6.83). Both female and male diabetes subjects with MA have increase in uACR 1 h after exercise (87.8, −24.3-199.4 and 6.7, 2.1-11.3). For both males and females with OP, uACR was significantly increased 1 h post exercise (67.5, 22-113 and 21.6, 8.4-34.8, respectively). In all groups uACR at 2 h after exercise was not significantly different to the early morning sample. Conclusions: Exercise increased uACR estimation in normoalbuminuric subjects with diabetes with a larger effect in females. Whether exercise unmasks early diabetic nephropathy in NA subjects requires further study. [ABSTRACT FROM AUTHOR]

Australia's commitment to home dialysis therapies has been significant. However, there is marked regional variation in the uptake of home haemodialysis (HD) and peritoneal dialysis (PD) suggesting further scope for the expansion of these modalities. Between 1 April and 5 August 2009, Australian nephrologists were invited to complete an online survey. Seventy-six questions were asked covering characteristics of the dialysis units, responders' experience, adequacy of facilities and support structures, attitudes to the use of home HD and PD and issues impeding the increased uptake of home dialysis. Completed surveys were received and analysed from 71 respondents; 27 from Heads of Units (35% response rate) and 44 (16%) from other nephrologists. There was strong agreement that HD with long hours was advantageous and that this was most easily accomplished in the home. PD was not considered to be an inferior therapy. A 'PD first' policy existed in 34% of Renal Units. The most commonly reported impediments to expanding home dialysis services were financial disadvantage for home HD patients, and lack of physical infrastructure for training, support and education. Areas of concern for expanding home dialysis programmes included psychiatry support, access to respite care and home visits, and lack of support from medical administration and government. The majority of nephrologists would recommend home dialysis to more patients if these impediments could be overcome. This survey identified support from nephrologists for the expansion of home dialysis in Australia and highlighted important barriers to improving access to these therapies. This study of nephrologist attitudes to home dialysis therapies provides good insights into the issues in Australia affecting uptake of these treatments. It finds differences between Australia and other jurisdictions that have published in this area. Publication of this will help provide a basis for further research and help support efforts to increase home therapy utilization. [ABSTRACT FROM AUTHOR]

Vascular calcification is prevalent in patients with chronic kidney disease. Abdominal aortic calcification (AAC) can be detected by X-ray, although AAC is less well documented in anatomical distribution and severity compared with coronary calcification. Using simple radiological imaging we aimed to assess AAC and determine associations in prevalent Australian haemodialysis (HD) patients. Lateral lumbar X-ray of the abdominal aorta was used to determine AAC, which is related to the severity of calcific deposits at lumbar vertebral segments L1 to L4. Two radiologists determined AAC scores, by semi-quantitative measurement using a validated 24-point scale, on HD patients from seven satellite dialysis centres. Regression analysis was used to determine associations between AAC and patient characteristics. Lateral lumbar X-ray was obtained in 132 patients. Median age of patients was 69 years (range 29-90), 60% were male, 36% diabetic, median duration of HD 38 months (range 6-230). Calcification (AAC score ≥ 1) was present in 94.4% with mean AAC score 11.0 ± 6.4 (median 12). Independent predictors for the presence and severity of calcification were age ( P = 0.03), duration of dialysis ( P = 0.04) and a history of cardiovascular disease ( P = 0.009). There was no significant association between AAC and the presence of diabetes or time-averaged serum markers of mineral metabolism, lipid status and C-reactive protein. AAC detected by lateral lumbar X-ray is highly prevalent in our cohort of Australian HD patients and is associated with cardiovascular disease, increasing age and duration of HD. This semi-quantitative method of determining vascular calcification is widely available and inexpensive and may assist cardiovascular risk stratification. The main finding of this study is that abdominal aortic calcification detected by lateral lumbar X-ray is highly prevalent in Australian HD patients and is associated with CV disease, increasing age and duration of HD. This semi-quantitative inexpensive method is useful in detecting vascular calcification and may assist cardiovascular risk stratification in Australian HD patients. [ABSTRACT FROM AUTHOR]

Vascular calcification (VC) contributes to cardiovascular disease in haemodialysis (HD) patients. Few controlled studies have addressed interventions to reduce VC but non-calcium-based phosphate binders may be beneficial. No published randomized study to date has assessed the effect of lanthanum carbonate (LC) on VC progression. We conducted a pilot randomized controlled trial to determine the effect of LC on VC. Forty-five HD patients were randomized to either LC or calcium carbonate (CC). Primary outcome was change in aortic VC after 18 months. Secondary outcomes included superficial femoral artery (SFA) VC, bone mineral density (BMD) of lumbar spine and serum markers of mineral metabolism. At baseline, 6 and 18 month computed tomography was performed to measure VC and BMD. A random effect linear regression model was performed to assess differences. Thirty patients completed the study (17 LC, 13 CC); baseline median age 58 years, 38% diabetic, 64% male. Ninety-three per cent had aortic VC at commencement and 87% showed progression. At 18 months, there was significantly less aortic VC progression with LC than CC (adjusted difference −98.1 (−149.4, −46.8) Hounsfield units (HU), P < 0.001). There was also a non-significant reduction with LC in left SFA VC (−25.8 (−67.7, 16.1) HU, P = 0.2) and right SFA VC (−35.9 (−77.8, 5.9) HU, P = 0.09). There was no difference in lumbar spine BMD and serum phosphate, calcium and parathyroid hormone levels between groups. Limitations to the study include small sample size and loss to follow up. Lanthanum carbonate was associated with reduced progression of aortic calcification compared with CC in HD patients over 18 months. Vascular calcification (VC) contributes to cardiovascular disease in haemodialysis patients. This is an 18 month ( n = 30) randomized, controlled study to test lanthanum carbonate (LC) on VC. Compared with CaCO, LC has significantly less VC in HD patients. [ABSTRACT FROM AUTHOR]

Patients on extended hours (>15 h/week) hemodialysis may be at a higher risk of deficiency of water-soluble vitamins than conventional (≤15 h/week) hemodialysis patients due to their increased weekly hours of dialysis. We compared serum levels of the water-soluble vitamins in a group of extended and conventional hours hemodialysis patients. Predialysis serum levels of vitamin C, vitamin B, thiamine, pyridoxine, and folate were measured in 52 patients: 26 extended group and 26 conventional group. Information on patient's intake of vitamin supplements and dialysis regimen was obtained. Data were log transformed due to the skewed distribution of the results. Median vitamin C levels were significantly lower in the extended group (0.30 vs. 1.14 mg/dL, P<0.001), with 7 patients having a level <0.18 mg/dL. Thiamine levels were also lower in the extended group (median 211 vs. 438.5 nmol/L, P=0.0005). However, extended patients had higher levels of pyridoxine (23.2 vs. 11.1 ng/mL, P=0.03). Vitamin B and folate levels were not significantly different between the groups. There was significant variability in vitamin supplement prescription in both groups, and dietary data were not obtained. This study showed a high incidence of vitamin C deficiency in extended hours hemodialysis patients, suggesting that supplementation is warranted. It also supports an ongoing role for multivitamin supplementation in conventional hemodialysis patients. [ABSTRACT FROM AUTHOR]

The article presents the views expressed by the participants of a roundtable discussion on how to deal with the rising demand for dialysis held during the Second Congress of the International Society for Hemodialysis in Hong Kong, China in August 2009. The conference was attended by academic nephrologists, health care officials, and nephrology society representatives. Focal to the roundtable discussion was dialysis economics and the ways to tackle the dialysis burden around the world.

The authors compiled a positional statement on dialysis economics from the second congress of the international society for hemodialysis, focusing on promoting home-based dialysis therapies to tackle the dialysis burden. They have added a further statement to urge local health authorities to increase this form of therapy. [ABSTRACT FROM AUTHOR]

Background: Vascular calcification (VC) is a major contributor to increased cardiovascular (CV) disease in chronic kidney disease (CKD) and an independent predictor of mortality. VC is inversely correlated with bone mineral density (BMD). Screening for VC may be useful to determine those at greater CV risk and dual-energy X-ray absorptiometry (DXA) may have a dual role in providing VC measurement as well as BMD. Methods: We report cross-sectional data on 44 patients with CKD stages 3–4 and aim to determine and validate measurement of VC using DXA. Patients had computed tomography (CT) of abdominal aorta and DXA of lateral lumbar spine, to determine both aortic VC and BMD. Semi-quantitative measurement of VC from DXA was determined (blinded) using previously validated 8- and 24-point scales, and compared with VC from CT. BMD determination from L2 to L4 vertebrae on CT was compared with DXA-reported BMD. Results: Patients 66% male, 57% diabetic, had mean age 63.4 years and mean estimated glomerular filtration rate 31.4 ± 12 mL/min. Aortic VC was present in 95% on CT, mean 564.9 ± 304 Hounsfield units (HU). Aortic VC was seen in 68% on lateral DXA, mean scores 5.1 ± 5.9 and 1.9 ± 1.9 using 24- and 8-point scales, respectively. Strong correlation of VC measurement was present between CT and DXA ( r 0.52, P < 0.001). For DXA VC 24-point score, intraclass correlations for intra-rater and inter-rater agreement were 0.91 and 0.64, respectively (8-point scale, intraclass correlations 0.90 and 0.69). Vertebral BMD measured by CT (mean 469.3 HU L2–4) also significantly correlated with lateral DXA-reported BMD (mean spine T-score –0.67 ± 1.6) ( r 0.56, P < 0.001). Conclusion: Despite limitations in CKD, DXA may be useful as lateral DXA images provide concurrent assessment of aortic calcification as well as lumbar spine BMD, both correlating significantly with CT measurements. Lateral DXA may provide VC screening to determine patients at greater CV risk although more studies are needed to evaluate their potential role. [ABSTRACT FROM AUTHOR]

Haemodialysis, by design, uses a semipermeable membrane to separate blood from dialysate. The qualities of this membrane determine the nature of the ‘traffic’ between the blood and dialysate. In this sense, the qualities of the membrane determine what size molecules move from one compartment to the other, the amount and rate at which they might move and the amount and rate of water movement across the membrane. In addition, the nature of the membrane influences the biological response of the patient both in terms of what is or is not removed by the dialysis process and by way of the reaction to the biocompatibility of the membrane. This brief review will explore aspects of dialysis membrane characteristics. [ABSTRACT FROM AUTHOR]

The article focuses on home haemodialysis in Australia. Home haemodialysis was frequently applied to patients with chronic kidney disease (CKD) in the 1970s which later became less frequently used in later years due to the introduction of peritoneal and satellite haemodialysis. The introduction of simpler and user-friendly equipment from the year 2000 brought back and led to the increased acceptance of home haemodialysis.

Extrapolation of evidence-based management of disorders in the general population to patients with chronic kidney disease (CKD) is not always appropriate, and the prevention of bone fracture and reduction of fracture risk in CKD stages 3–5 is one example. Compared to the general population, fracture risk is greater in CKD patients, especially those on dialysis (CKD-5D). Fractures in CKD-5D are associated with a marked increase in morbidity and mortality and with an aging dialysis population the burden of disease caused by fracture is likely to increase. Patients with CKD-5D have distinct risks for fracture, as well as sharing risks identified in the general population. The development of the CKD mineral and bone disorder constitutes a significant cause for these differences. Literature addressing the determination of fracture risk and the efficacy of treatments to reduce fracture in patients on dialysis is limited. While some tools used for the diagnosis and monitoring of osteoporosis are applicable to patients on dialysis, bone mineral density measurement by dual-energy X-ray absorptiometry is generally not helpful and therapeutic interventions that reduce fracture risk in the nonuremic population cannot be generalized to patients on dialysis. This review outlines available evidence on the incidence, risk factors, and management of fractures in CKD-5D with recommendations for strategies to reduce fracture risk. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease in dialysis patients is associated with increased vascular calcification (VC) and arterial stiffness, both inversely correlated with bone mineral density (BMD). Few studies have correlated VC in the dialysis population with measurements of BMD and arterial compliance. Methods: We report cross-sectional data on 45 haemodialysis (HD) patients assessing the prevalence of VC and its associations. Patients had computed tomography scans through abdominal aorta and superficial femoral arteries (SFA) to determine VC, pulse wave velocity (PWV) using SphygmoCor device measuring arterial stiffness, and dual-energy X-ray absorptiometry (DXA) to determine BMD. Results: Patients, 64% male, 38% diabetic, had median age 58 years. Mean PWV was 8.7 ± 3.5 m/s and median aortic VC score 488.1 ± 298 Hounsfield units, with 91% having aortic VC present. In univariate linear regression analysis, aortic VC correlated positively with length of HD ( P = 0.03) and diabetes ( P = 0.06). Increasing PWV was positively associated with age ( P = 0.001), diabetes ( P = 0.05) and VC (aortic P = 0.08, SFA P = 0.01). In multivariate regression analysis, length of HD and diabetes were significantly associated with aortic VC, whereas age and diabetes were associated with SFA VC and PWV. Mean lumbar spine and femoral neck T-scores on DXA were 0.14 and −1.66 respectively. Conclusion: Increased VC and reduced arterial compliance, both closely related, are common in Australian HD patients. Both are associated with diabetes and increasing age, and greater aortic VC is seen with longer duration of dialysis. [ABSTRACT FROM AUTHOR]

Aim: Cardiovascular diseases (CVD) are the major cause of morbidity and mortality in end-stage renal failure (ESRF). Establishing whether traditional risk factors are valid predictors of CVD in ESRF is important in order to devise preventive and interventional strategies for the ESRF populations. Methods: In this retrospective cohort study, a cohort of patients on dialysis were examined between September 2000 and February 2001. Only those without previous CVD events at baseline were included. For each individual, 5 year CVD risk was calculated using the New Zealand 5 year CVD risk prediction charts based on the Framingham Heart Study prognostic algorithm. The subsequent 5 year CVD outcome for each patient was determined and the observed rate of first CVD events was compared to the predicted risk. Relation of individual risk factors with the CVD outcome was also assessed. Results: Of the patients, 274 were without previous CVD events at baseline and 27% experienced CVD events during the subsequent 5 years. Observed CVD risk was more than twofold that of predicted risk although there was a linear correlation between the two. Among individual risk factors, increasing age, diabetes and smoking were significantly related to the incidence of the CVD events but, unlike in the general population, systolic blood pressure, total cholesterol/high-density lipoprotein ratio and body mass index were not significantly related to CVD events. Conclusion: The very high incidence of CVD in ESRF patients suggest that non-traditional risk factors present in the uraemic state are independent risk factors for CVD in ESRF patients. Nevertheless, the application of traditional cardiovascular risk profiles does allow risk stratification of the ESRF population. [ABSTRACT FROM AUTHOR]

Home hemodialysis (HD) in Australia represents 11% of the dialysis population. This percentage has declined over the last 20 years but the absolute number of home HD patients has increased since 2001. The major reason for this resurgence has been the institution of nocturnal HD at home. Predominantly, this has been as a strictly alternate day exercise, although 5–6 times per week dialysis is also practised. Short-daily HD is uncommon in Australia. Nocturnal HD now comprises 30% or more of all home HD. Most home HD in Australia is practiced without remote monitoring, using simple machines with separate reverse osmosis units. Patients tend to self-needle and not all have a “partner.” The enthusiasm for nocturnal HD in particular has been fuelled by ANZDATA Registry data demonstrating a survival advantage for patients dialyzing alternate days compared with 3 times per week; and for patients dialyzing for >18 hours per week compared with 12 or 15 hours per week. [ABSTRACT FROM AUTHOR]

Cardiovascular (CV) disease is the most common cause of mortality in end-stage kidney disease (ESKD), and arterial stiffness, measured by pulse wave velocity (PWV), is an independent predictor of all-cause and CV mortality. B-type natriuretic peptide (BNP) levels are high in patients with CV disease and ESKD, and increases in BNP may also be a marker of CV risk. Regular exercise has many benefits on quality of life and physical strength and may also improve CV risk, but few studies have addressed the impact of exercise on CV risk in ESKD. We performed a prospective cross-over trial in 19 hemodialysis (HD) patients to assess the impact of regular exercise on surrogate markers of CV risk-arterial compliance and BNP levels. Exercise involved the use of a bicycle ergometer for minimum 30 min at each HD session for 3 months, with a 1-month washout period. Group A (n=9) exercised for the first 3 months only, while group B (n=10) performed no intradialytic exercise initially and exercised for 3 months at cross-over (month 4). Pulse wave velocity was performed using a SphygmoCor device, with concurrent measurements of BNP and other serum markers, at the commencement of the study, at 3 months, and on completion. The mean PWV (A: 10.4±3.1 m/s, B: 9.8±3.8 at baseline) showed a trend toward improvement with exercise (A: 8.7±2.7, p=0.07), and no significant change without (B: 10.5±3.6, p=0.31). After cross-over, there was an increase in PWV in group A with cessation of exercise (9.75±2.4, p=0.01 vs. 3 months) and an improvement in group B with exercise (9.33±2.3, p=0.11 vs. 3 months). When comparing PWV after 3 months of exercise vs. 3 months of no exercise (paired t test), there was a significant difference in favor of exercise (9.04±0.59 vs. 10.16±0.74, p=0.008). The mean BNP levels following 3 months of exercise were also lower than those after 3 months of no exercise (504.4±101.2 vs. 809.4±196.1[N<100], p=0.047). There was an overall improvement in PWV, and to a lesser extent BNP levels, with 3 months of intradialytic exercise compared with no exercise, suggesting that regular exercise in ESKD may be associated with improvements in arterial compliance and a reduction in CV risk. [ABSTRACT FROM AUTHOR]

In Australia and New Zealand the prevalence and incidence of end-stage renal disease (ESRD) has increased. In Australia alone the financial burden is estimated to reach $500 million by 2007 (data from the National Chronic Kidney Disease Strategy Workshop Report 2005). The leading cause of ESRD in Australia and New Zealand, and throughout the developed world, is type 2 diabetes, having overtaken glomerulonephritis in 2004. 1 To date, management of patients with diabetes and ESRD has been, according to guidelines, given for patients without ESRD. This commentary raises three important emerging concerns in the clinical care of these patients: (i) the lack of reliable tools to measure glycaemic control; (ii) limitations of the current data set supporting a relationship between outcome and glycaemic control in ESRD; and (iii) lack of studies examining the effect of intensive diabetes care and glucose control in patients with ESRD. [ABSTRACT FROM AUTHOR]

Cardiovascular (CV) disease is the commonest cause of mortality in patients with chronic kidney disease (CKD). Vascular calcification (VC), induced by calcium and phosphate excess and uraemia, is a major risk factor and is independently associated with CV events and death. Local and systemic calcium-regulatory proteins as well as inhibitory extracellular factors are involved in the pathogenesis of VC. In CKD the balance becomes dysregulated leading to differentiation of vascular smooth muscle cells into phenotypically distinct osteoblast-like cells with subsequent ossification of the arterial wall. Associated with imbalances in mineral metabolism, VC has intimate interactions with bone mineralization and enhanced bone resorption. Arterial stiffness represents the functional disturbance of VC, with reduced compliance of large arteries, and predominantly results from greater medial calcification. As with VC, arterial stiffness is an independent predictor of CV mortality and patients with CKD have greater arterial stiffness than the general population resulting in the principal consequences of left ventricular hypertrophy and altered coronary perfusion. Both VC and arterial stiffness can be measured through non-invasive techniques involving computed tomography, ultrasound, echocardiography, and pulse wave velocity. Management in CKD is difficult but detection, prevention and treatment is crucial to reduce CV mortality. The optimal control of mineral metabolism, especially hyperphosphatemia with non-calcium based phosphate binders, has been shown to be effective to reduce VC, and attenuation of arterial stiffness, especially with good blood pressure control, can have a favourable effect with regression of left ventricular hypertrophy. The use of bisphosphonates, calcimimetics, vitamin D therapy and newer experimental treatments, as well as nocturnal dialysis, may have potential benefit. [ABSTRACT FROM AUTHOR]

Benefits of dialysate with greater calcium (Ca) concentration are reported in nocturnal hemodialysis (NHD) to prevent Ca depletion and subsequent hyperparathyroidism. Studies with patients dialyzing against 1.25 mmol/L Ca baths demonstrate increases in alkaline phosphatase (ALP) and parathyroid hormone (PTH) and increasing dialysate Ca subsequently corrects this problem. However, whether 1.5 or 1.75 mmol/L dialysate Ca is most appropriate for NHD is yet to be determined, and differences in the effect on mineral metabolism of daily vs. alternate daily NHD have also not been well defined. We retrospectively analyzed mineral metabolism in 48 patients, from 2 institutions (30 at Monash and 18 at Geelong), undergoing home NHD (8 hr/night, 3.5–6 nights/week) for a minimum of 6 months. Thirty-seven patients were dialyzed against 1.5 mmol/L Ca bath and 11 patients against 1.75 mmol/L. We divided patients into 4 groups, based on dialysate Ca and also on the hours per week of dialysis, <40 (1.5 mmol/L, n=29 and 1.75 mmol/L, n=8) or ≥40 (n=4 and 7). We compared predialysis and postdialysis serum markers, time-averaged over a 6-month period, and the administration of calcitriol and Ca-based phosphate binders between 1.5 and 1.75 mmol/L Ca dialysate groups. Baseline characteristics between all groups were similar, with a slightly longer, but nonsignificant, duration of NHD in both 1.75 mmol/L dialysate groups compared with 1.5 mmol/L. The mean predialysis Ca, phosphate, and Ca × P were similar between the 1.5 and 1.75 mmol/L groups, regardless of NHD hr/week. Postdialysis Ca was significantly greater, with 1.75 vs. 1.5 mmol/L in those dialyzing <40 hr/week (2.64±0.19 vs. 2.50±0.12 mmol/L, p=0.046), but postdialysis Ca × P were similar (2.25±0.44 vs. 2.16±0.29 mmol2/L2, p=0.60). Parathyroid hormone was also lower with 1.75 vs. 1.5 mmol/L baths in the <40 hr/week groups (31.99±26.99 vs. 14.47±16.36 pmol/L, p=0.03), although this difference was not seen in those undertaking NHD ≥40 hr/week. Hemoglobin, ALP, and albumin were all similar between groups. There was also no difference in vitamin D requirement when using 1.75 mmol/L compared with the 1.5 mmol/L dialysate. Multivariate analysis to determine independent predictors of postdialysis serum Ca showed a statistically significant positive association with predialysis Ca, dialysate Ca, and total NHD hr/week. An elevated dialysate Ca concentration is required in NHD to prevent osteopenia but differences in serum markers of mineral metabolism between 1.5 and 1.75 mmol/L Ca dialysate in NHD in our study were few. This was similar for patients undertaking NHD <40 or ≥40hr/week, although differences in the frequency of NHD may also be as important as dialysate Ca with regard to serum Ca levels. With concerns that prolonged higher Ca levels contribute to increased cardiovascular mortality, the optimal Ca dialysate bath is still unknown and further studies addressing bone metabolism with larger NHD numbers are required. [ABSTRACT FROM AUTHOR]