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Resumen: Introducción: La hemodiálisis domiciliaria (HDD) está especialmente implementada en la Comunidad Valenciana en comparación con el resto del territorio nacional, con una prevalencia de 13,4 pacientes pmp a diciembre de 2018. Realizamos una valoración de las características de los pacientes y de la supervivencia global y técnica del paciente en HDD en función del momento histórico de inicio y de su procedencia. Material y métodos: Pacientes incluidos en el Registro de Enfermos Renales de la Comunidad Valenciana desde que se reportan datos al mismo hasta diciembre de 2020. Estudio descriptivo y retrospectivo, calculando supervivencia global (evento combinado muerte-fallo técnico, censurando trasplante) y supervivencia técnica (evento fallo técnico, censurando muerte y trasplante). Comparamos la supervivencia de la técnica en función de era de inicio: antigua (1976-2000) vs. moderna (2001-2020), y en función de la modalidad de procedencia. Realizamos regresión de Cox uni- y multivariante en el total de la serie tanto para supervivencia global como técnica. Resultados: Doscientos treinta y seis pacientes en HDD (611,4 pacientes-año de seguimiento), edad media 49,7 ±16,3 años; tiempo terapia renal sustitutiva previa 0,2 años de mediana. Los ratios de trasplante, muerte y fallo técnico fueron 13,2; 4,4 y 7 eventos por 100 pacientes-año respectivamente. En la comparación por eras según inicio en HDD, antigua (n = 57) vs. moderna (n = 179) fue estadísticamente significativa la edad (37,5 vs. 53,5 años), la DM (3,5 vs. 13,4%) y la nefropatía tubulointersiticial crónica (24,6 vs. 8,9%) como causa de enfermedad renal crónica. Hubo en la era moderna mayor probabilidad de provenir de consulta externa (33,3 vs. 48,6%) y de diálisis peritoneal (1,8 vs. 12,8%) con significación estadística. En era antigua un único hospital centralizaba el 57,9% de los pacientes, y en era moderna entre 2 hospitales centralizaban el 55,8% de los pacientes. La supervivencia global en era antigua fue del 83,7% al año, del 77,4% a 2 años y del 61% a 5 años; y en era moderna del 87,3% al año, del 83% a 2 años y del 47,8% a 5 años (Log Rank: 0,521). La supervivencia técnica en era antigua fue 85,4% al año, 79% a 2 años y 64,1% a 5 años; y en era moderna 91,4% al año, 88,5% a 2 años y 74,5% a 5 años (Log Rank: 0,195). No hubo diferencias estadísticas en la comparación en función de la procedencia. En la regresión de Cox fueron estadísticamente significativos para supervivencia global la edad y estar diagnosticado de cardiopatía, enfermedad vascular o neoplasia activa, y para la supervivencia técnica hepatopatía o problema social, tanto en análisis univariante como en multivariante. Conclusión: En la era moderna existe un incremento considerable de pacientes en HDD en la Comunidad Valenciana. Hubo un efecto centro en el desarrollo de los programas de HDD, la mayoría de los pacientes dependían de pocos centros asistenciales. Los pacientes fueron de mayor edad y mayor comorbilidad en la era moderna, pese a ello sin afectar ni la supervivencia técnica y ni global de la HDD. Abstract: Introduction: Home hemodialysis (HDD) is implemented in the Valencian Community with a higher prevalence than to the rest of the national territory, with a prevalence of 13.4 patients’ pmp in December 2018. We carried out an assessment of the patients’ characteristics and the overall and technical survival in HDD depending on the historical moment of onset and its origin. Material and methods: We conducted a retrospective and descriptive study including patients of the Valencian Registry of Renal Patients from the beginning of data reported until December 2020. We calculated overall survival (combined event death-technical failure, censoring transplantation) and technical survival (event technical failure, censoring exitus and transplantation). Comparing technical survival according to the starting era: ancient (1976–2000) vs modern (2001–2020) and according to the modality of origin. We performed univariate and multivariate Cox regression in the total series for both overall and technical survivals. Results: 236 patients on HDD (611.4 patient-years of follow-up), mean age 49.7 ± 16.3 years; median time of prior renal replacement therapy 0.2 years. The ratio of transplantation, death, and technical failure were 13.2, 4.4, and 7 events per 100 patient-years, respectively. In the comparison by ancient (n = 57) vs modern (n = 179) eras, age (37.5 vs 53.5 years), DM (3.5 vs 13.4%) and chronic tubuleinterstitial nephropathy (24.6 vs 8.9%) as a cause of chronic kidney disease were statistically significant. The probability of coming from outpatient consultation (33.3 vs 48.6%) and peritoneal dialysis (1.8 vs 12.8%) were higher in modern era with statistical significance. In the ancient era a single hospital centralized 57.9% of the patients, and in the modern era between two hospitals centralized 55.8% of the patients. Overall survival in the ancient era was 83.7% at 1 year, 77.4% at 2 years, and 61% at 5 years; and in the modern era 87.3% per year, 83% 2 years and 47.8% 5 years (Log Rank 0.521). Technical survival in the ancient era was 85.4% at 1 year, 79% 2 years, and 64.1% 5 years; and in the modern era 91.4% per year, 88.5% 2 years and 74.5% 5 years (Log Rank 0.195). There were no statistical differences in the comparison based on technical of provenance. In the Cox regression it was statistically significant for overall survival: the age and being diagnosed with heart disease, vascular disease or active neoplasia and for technical survival liver disease or social problem, both in univariate and multivariate. Conclusion: In the modern era there is a considerable increase in HDD patients in the Valencian Community. There was a center effect in the development of HDD programs, most of the patients depended on few healthcare centers. The patients were older and had greater comorbidity in the modern era, despite this without affecting the technical and overall survival of the HDD.

Background: Currently, bicarbonate-based dialysate needs a buffer to prevent precipitation of bicarbonate salts with the bivalent cations, and acetate at 3–4 mmol/L is the most used. However, citrate is being postulated as a preferred option because of its association with better clinical results by poorly understood mechanisms. In that sense, this hypothesis-generating study aims to identify potential metabolites that could biologically explain these improvements found in patients using citrate dialysate.Methods: A unicentric, cross-over, prospective untargeted metabolomics study was designed to analyze the differences between two dialysates only differing in their buffer, one containing 4 mmol/L of acetate (AD) and the other 1 mmol/L of citrate (CD). Blood samples were collected in four moments (i.e., pre-, mid-, post-, and 30-min-post-dialysis) and analyzed in an untargeted metabolomics approach based on UPLC-Q-ToF mass spectrometry.Results: The 31 most discriminant metabolomic variables from the plasma samples of the 21 participants screened by their potential clinical implications show that, after dialysis with CD, some uremic toxins appear to be better cleared, the lysine degradation pathway is affected, and branched-chain amino acids post-dialysis levels are 9–10 times higher than with AD; and, on its part, dialysis with AD affects acylcarnitine clearance.Conclusion: Although most metabolic changes seen in this study could be attributable to the dialysis treatment itself, this study successfully identifies some metabolic variables that differ between CD and AD, which raise new hypotheses that may unveil the mechanisms involved in the clinical improvements observed with citrate in future research.

Resumen: Se describe la experiencia de un hospital terciario y cuatro centros concertados de hemodiálisis adscritos al mismo durante la epidemia de COVID-19. Se resume la organización asistencial que se ha llevado a cabo y el curso clínico de los 16 casos de COVID-19 en pacientes en hemodiálisis. La aplicación conjunta de medidas que incluyen el cribado de pacientes, la investigación precoz de casos posibles, el aislamiento de los casos confirmados, en investigación o en contactos, así como la utilización de medidas de protección individuales, han permitido controlar la epidemia. Se compara el curso clínico de estos 16 pacientes con la serie publicada por el Hospital Universitario de Wuhan y con los datos del registro de infecciones COVID-19 de la Sociedad Española de Nefrología. En nuestra experiencia, y a diferencia de lo comunicado por el centro de Wuhan, la enfermedad COVID-19 en los pacientes en hemodiálisis es grave en un porcentaje importante de los casos y la letalidad, elevada, es mayormente causada por la propia infección. Las medidas de contención de la epidemia son eficaces. Abstract: The experience of a tertiary hospital and four hemodialysis centers attached to it during the COVID-19 epidemic is described. The organization of care that has been carried out and the clinical course of the 16 cases of COVID-19 in hemodialysis patients are summarized. The joint application of measures, including patient screening, the early investigation of possible cases, the isolation of confirmed, investigational or contact cases, as well as the use of individual protection measures, has enabled the epidemic to be controlled. The clinical course of these 16 patients is compared with the series published by the Wuhan University Hospital and with the data from the COVID-19 infection registry of the Spanish Society of Nephrology. In our experience, and unlike what was reported by the Wuhan Center, COVID-19 disease in hemodialysis patients is severe in a significant percentage of cases, and high lethality is mostly caused by the infection itself. Measures to contain the epidemic are effective.

Acetate is widely used as a dialysate buffer to avoid the precipitation of bicarbonate salts. However, even at low concentrations that wouldn’t surpass the metabolic capacity of the Krebs tricarboxylic acid (TCA) cycle, other metabolic routes are activated, leading to undesirable clinical consequences by poorly understood mechanisms. This study aims to add information that could biologically explain the clinical improvements found in patients using citrate dialysate. A unicentric, cross-over, prospective targeted metabolomics study was designed to analyze the differences between two dialysates, one containing 4 mmol/L of acetate (AD) and the other 1 mmol/L of citrate (CD). Fifteen metabolites were studied to investigate changes induced in the TCA cycle, glycolysis, anaerobic metabolism, ketone bodies, and triglyceride and aminoacidic metabolism. Twenty-one patients completed the study. Citrate increased during the dialysis sessions when CD was used, without surpassing normal values. Other differences found in the next TCA cycle steps showed an increased substrate accumulation when using AD. While lactate decreased, pyruvate remained stable, and ketogenesis was boosted during dialysis. Acetylcarnitine and myo-inositol were reduced during dialysis, while glycerol remained constant. Lastly, glutamate and glutarate decreased due to the inhibition of amino acidic degradation. This study raises new hypotheses that need further investigation to understand better the biochemical processes that dialysis and the different dialysate buffers induce in the patient’s metabolism.