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A predictive histologic classification recently was proposed to determine the prognostic value of kidney biopsy in patients with antineutrophil cytoplasmic antibody-associated renal vasculitis (AAV).A dual-purpose retrospective observational cohort study to assess the reproducibility of the new classification and clinical variables that predict outcomes.169 consecutive patients with AAV were identified; 145 were included in the reproducibility study, and 120, in the outcomes study.Kidney biopsy specimens were classified according to the predominant glomerular lesion: focal, mixed, crescentic, and sclerotic. An assessment of tubular atrophy also was performed.The primary outcome was time to end-stage kidney disease or all-cause mortality, modeled using Cox regression analysis.Estimated glomerular filtration rate, requirement for renal replacement therapy.For the reproducibility study, the overall inter-rater reliability of the classification demonstrated variability among 3 histopathologists (intraclass correlation coefficient, 0.48; 95% CI, 0.38-0.57; κ statistic=0.46). Although agreement was high in the sclerotic group (κ=0.70), it was less consistent in other groups (κ=0.51, κ=0.47, and κ=0.23 for crescentic, focal, and mixed, respectively). For the clinical outcomes study, patients with sclerotic patterns of glomerular injury displayed the worst outcomes. Patients with focal (HR, 0.26; 95% CI, 0.12-0.58; P=0.001), crescentic (HR, 0.33; 95% CI, 0.16-0.69; P=0.003), and mixed (HR, 0.39; 95% CI, 0.18-0.81; P=0.01) patterns of injury had lower risk of the primary outcome. Tubular atrophy correlated with outcome, and advanced injury was associated with worse outcomes (HR, 5.9; 95% CI, 2.25-15.47; P0.001). Level of kidney function at presentation strongly predicted outcome (HR per 10-mL/min/1.73m(2) increase in estimated glomerular filtration rate, 0.63; 95% CI, 0.46-0.81; P0.001).Data availability, given the retrospective nature of the study.Reproducibility of the classification was seen only in patients with sclerotic patterns of glomerular injury. Sclerotic pattern of glomerular injury, advanced chronic interstitial injury, and decreased kidney function all predicted poor outcomes.

Vancomycin-resistant enterococci (VRE) colonization is a frequent occurrence in patients with renal failure. Understanding the impact of VRE colonization on this group of patients has considerable clinical applicability.To understand whether VRE colonization in renal patients has an impact on number of admissions to hospital, length of stay, and mortality.A retrospective case-control study of renal dialysis patients was performed between 2000 and 2010. Cases were 134 VRE-colonized patients requiring renal replacement therapy and matched controls were 137 non-colonized patients with the same baseline characteristics. Matched cases and controls were analysed for differences in number of admissions, length of stay, and mortality.There was no difference in mortality between colonized and non-colonized patients (hazard ratio: 1.14; 95% confidence interval: 0.78-1.69; P = 0.49). Length of stay for colonized patients was 7.29 days compared with 4.14 days (P 0.001). The number of admissions for VRE-colonized patients was not significantly different compared with controls (9.34 vs 8.33, P = 0.78).VRE colonization did not increase mortality in renal patients but did contribute to increased length of stay.

Background Low serum 25-hydroxyvitamin D (25[OH]D) levels have been associated with chronic kidney disease in cross-sectional studies. However, this association has not been studied prospectively in a large general population–based cohort. Study Design Prospective cohort study. Setting & Participants 6,180 adults 25 years or older participating in the baseline and 5-year follow-up phases of the Australian Diabetes, Obesity and Lifestyle (AusDiab) Study. Predictor Serum 25(OH)D levels Outcomes & Measurements Incident chronic kidney disease was defined as being negative at baseline but positive after 5 years for (1) reduced estimated glomerular filtration rate (eGFR; 2 ) or (2) albuminuria (spot urine albumin-creatinine ratio ≥2.5 mg/mmol [≥22.1 mg/g] for men and ≥3.5 mg/mmol [≥30.9 mg/g] for women). Results 623 (10.9%) participants were vitamin D deficient, 161 developed incident reduced eGFR, and 222 developed incident albuminuria. In participants with and without vitamin D deficiency, annual age-standardized incidences were 0.92% (95% CI, 0.56%-1.30%) and 0.59% (95% CI, 0.51%-0.68%), respectively, for eGFR 2 and 1.50% (95% CI, 1.06%-1.95%) and 0.66% (95% CI, 0.56%-0.76%), respectively, for albuminuria. In multivariate regression models, vitamin D deficiency was associated significantly with the 5-year incidence of albuminuria (OR, 1.71; 95% CI, 1.12-2.61; P = 0.01), but not reduced eGFR (OR, 0.93; 95% CI, 0.53-1.66; P = 0.8). Limitations The observational nature of the study does not account for unmeasured confounders. Only baseline 25(OH)D level was measured and therefore may not accurately reflect lifetime levels. Differences in baseline characteristics of participants who were included compared with those excluded due to missing data or follow-up may limit the applicability of results to the original AusDiab cohort. Conclusions Our prospective cohort study shows that vitamin D deficiency is associated with a higher annual incidence of albuminuria and reduced eGFR and independently predicts the 5-year incidence of albuminuria. These associations warrant further exploration in long-term prospective clinical trials.

GUIDELINE RECOMMENDATIONS • We recommend that either synthetic or cellulosic membranes be used for symptomatic intra-dialytic hypotension as synthetic membranes offer no benefit over cellulosic membranes (1C). • We recommend that high-flux membranes be used to remove molecules such as beta-2 microglobulin because they have been shown to achieve lower serum levels (1A). • We suggest there are possible survival benefits from high-flux membranes for some groups such as those on dialysis for more than 3.7 years, those with a serum albumin below 40 g/L and diabetics (1A).

Background Patients with diabetes and chronic kidney disease (CKD) are a complex subset of the growing number of patients with diabetes, due to multi-morbidity. Gaps between recommended and received care for diabetes and chronic kidney disease (CKD) are evident despite promulgation of guidelines. Here, we document gaps in tertiary health-care, and the commonest patient-reported barriers to health-care, before exploring the association between these gaps and barriers. Methods This cross-sectional study recruited patients with diabetes and CKD (eGFR

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 (75M, 71F) 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. 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 FN T-score and were associated with fractures in both univariable and multivariable regression analyses after adjusting for age, gender, weight, eGFR and pre-transplant history of fracture (p=0.011 and p=0.042 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. This article is protected by copyright. All rights reserved.

Importance Vascular access dysfunction is a leading cause of morbidity and mortality in patients requiring hemodialysis. Arteriovenous fistulae are preferred over synthetic grafts and central venous catheters due to superior long-term outcomes and lower health care costs, but increasing their use is limited by early thrombosis and maturation failure. ω-3 Polyunsaturated fatty acids (fish oils) have pleiotropic effects on vascular biology and inflammation and aspirin impairs platelet aggregation, which may reduce access failure. Objective To determine whether fish oil supplementation (primary objective) or aspirin use (secondary objective) is effective in reducing arteriovenous fistula failure. Design, Setting, and Participants The Omega-3 Fatty Acids (Fish Oils) and Aspirin in Vascular Access Outcomes in Renal Disease (FAVOURED) study was a randomized, double-blind, controlled clinical trial that recruited participants with stage 4 or 5 chronic kidney disease from 2008 to 2014 at 35 dialysis centers in Australia, Malaysia, New Zealand, and the United Kingdom. Participants were observed for 12 months after arteriovenous fistula creation. Interventions Participants were randomly allocated to receive fish oil (4 g/d) or matching placebo. A subset (n = 406) was also randomized to receive aspirin (100 mg/d) or matching placebo. Treatment started 1 day prior to surgery and continued for 12 weeks. Main Outcomes and Measures The primary outcome was fistula failure, a composite of fistula thrombosis and/or abandonment and/or cannulation failure, at 12 months. Secondary outcomes included the individual components of the primary outcome. Results Of 1415 eligible participants, 567 were randomized (359 [63%] male, 298 [53%] white, 264 [47%] with diabetes; mean [SD] age, 54.8 [14.3] y). The same proportion of fistula failures occurred in the fish oil and placebo arms (128 of 270 [47%] vs 125 of 266 [47%]; relative risk [RR] adjusted for aspirin use, 1.03; 95% CI, 0.86-1.23; P = .78). Fish oil did not reduce fistula thrombosis (60 [22%] vs 61 [23%]; RR, 0.98; 95% CI, 0.72-1.34; P = .90), abandonment (51 [19%] vs 58 [22%]; RR, 0.87; 95% CI, 0.62-1.22; P = .43), or cannulation failure (108 [40%] vs 104 [39%]; RR, 1.03; 95% CI, 0.83-1.26; P = .81). The risk of fistula failure was similar between the aspirin and placebo arms (87 of 194 [45%] vs 83 of 194 [43%]; RR, 1.05; 95% CI, 0.84-1.31; P = .68). Conclusions and Relevance Neither fish oil supplementation nor aspirin use reduced failure of new arteriovenous fistulae within 12 months of surgery. Trial Registration anzctr.org.au Identifier:CTRN12607000569404

Home hemodialysis (HD) is undergoing a resurgence. A major driver of this is economics, however, providers are also encouraged by a combination of excellent patient outcomes and patient experiences as well as the development of newer technologies that offer ease of use. Home HD offers significant advantages in flexible scheduling and the practical implementation of extended hours dialysis. This paper explores the reasons why home HD is making a comeback and strives to offer approaches to improve the uptake of this dialysis modality.

Background Recent evidence suggests that increased frequency and/or duration of dialysis are associated with improved outcomes. We aimed to describe the outcomes associated with patients starting extended-hours hemodialysis and assess for risk factors for these outcomes. Study Design Case series. Setting & Participants Patients were from 6 Australian centers offering extended-hours hemodialysis. Cases were patients who started treatment for 24 hours per week or longer at any time. Outcomes All-cause mortality, technique failure (withdrawal from extended-hours hemodialysis therapy), and access-related events. Measurements Baseline patient characteristics (sex, primary cause of end-stage kidney disease, age, ethnicity, diabetes, and cannulation technique), presence of a vascular access–related event, and dialysis frequency. Results 286 patients receiving extended-hours hemodialysis were identified, most of whom performed home (96%) or nocturnal (77%) hemodialysis. Most patients performed alternate-daily dialysis (52%). Patient survival rates using an intention-to-treat approach at 1, 3, and 5 years were 98%, 92%, and 83%, respectively. Of 24 deaths overall, cardiac death (n = 7) and sepsis (n = 5) were the leading causes. Technique survival rates at 1, 3, and 5 years were 90%, 77%, and 68%, respectively. Access event–free rates at the same times were 80%, 68%, and 61%, respectively. Access events significantly predicted death (HR, 2.85; 95% CI, 1.14-7.15) and technique failure (HR, 3.76; 95% CI, 1.93-7.35). Patients with glomerulonephritis had a reduced risk of technique failure (HR, 0.31; 95% CI, 0.14-0.69). Higher dialysis frequency was associated with elevated risk of developing an access event (HR per dialysis session, 1.56; 95% CI, 1.03-2.36). Limitations Selection bias, lack of a comparator group. Conclusions Extended-hours hemodialysis is associated with excellent survival rates and is an effective treatment option for a select group of patients. The major treatment-associated adverse events were related to complications of vascular access, particularly infection. The risk of developing vascular access complications may be increased in extended-hours hemodialysis, which may negatively affect long-term outcomes.

Background Adults on dialysis are at increased risk of foot ulceration, which commonly precedes more serious lower limb complications, including amputation. Limited data exist regarding the prevalence and factors associated with foot disease in this population. Hence, this study set out to investigate factors associated with foot ulceration and amputation in a dialysis cohort. Methods This study presents a cross-sectional analysis of baseline data from a multi-center prospective cohort study. We recruited 450 adults with end-stage renal disease on dialysis from multiple satellite and home-therapy dialysis units in Melbourne, Australia from January to December 2014. Data collection consisted of a participant interview, medical record review, health-status questionnaire and non-invasive foot examination. Logistic regression analyses were conducted to evaluate associations between screened variables and study outcomes. Results Mean age was 67.5 (SD, 13.2) years, 64.7% were male, 94% were on hemodialysis, median dialysis duration was 36.9 (IQR, 16.6 to 70.1) months, and 50.2% had diabetes. There was a high prevalence of previous ulceration (21.6%) and amputation (10.2%), 10% had current foot ulceration, and 50% had neuropathy and/or peripheral arterial disease. Factors associated with foot ulceration were previous amputation (OR, 10.19), peripheral arterial disease (OR, 6.16) and serum albumin (OR, 0.87); whereas previous and/or current ulceration (OR, 167.24 and 7.49, respectively) and foot deformity (OR, 15.28) were associated with amputation. Conclusions Dialysis patients have a high burden of lower limb complications. There are markedly higher risks of foot ulceration and/or amputation in those with previous and/or current ulceration, previous amputation, peripheral arterial disease, lower serum albumin, and foot deformity. Although not a major risk factor, diabetes in men was an important effect modifier for risk of ulceration. Electronic supplementary material The online version of this article (10.1186/s12882-017-0711-6) contains supplementary material, which is available to authorized users.

BACKGROUND AND OBJECTIVES: We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end of life care among patients choosing conservative care with those initiating RRT.DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two-sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival.RESULTS: In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18% were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55; 95% confidence interval, 1.36 to 1.77), baseline serum albumin CONCLUSIONS: Survival after 3 years of conservative management is common, with relatively few patients switching to dialysis. Specialist palliative care services are used more frequently and at an earlier time point for conservatively managed patients, a practice associated with better symptom management and quality of life.

The Fragility Index is a tool for testing robustness of randomized controlled trial results for dichotomous outcomes. It describes the minimum number of individuals in whom changing an event status would render a statistically significant result nonsignificant. Here we identified all randomized controlled trials in five nephrology and five general journals from 2005-2014. A total of 127 randomized controlled trials reporting at least one dichotomous statistically significant outcome (p less than 0.05) were included and the Fragility Index was calculated. Twenty randomized controlled trials had a Fragility Index of zero and were excluded from further analysis. Linear regression was performed to assess factors associated with Fragility Indexes stratified by primary or secondary outcomes. The median sample size was 134 (range 2211506) with 36 (range 5–2743) total number of events. The median Fragility Index was three (range 1–166), indicating that in half the trials the addition of three events to the treatment with the lowest number of events rendered the result nonsignificant. For primary outcome studies a doubling in total event number and sample size significantly increased the geometric mean Fragility Index by 52% and 42%, respectively. Compared to a reported p value of 0.05 to 0.01, those reporting 0.01 to 0.001 or less than 0.001 had a significant 57% and 472% increase in the median Fragility Index, respectively. Forty-one percent had a Fragility Index less than the total loss to follow-up, indicating a potential to change a trial result had all individuals been accounted for. Thus, our study highlights the need for larger randomized controlled trials with accurate accounting for loss to follow-up to adequately guide evidence-based practice.

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.

Background Health-care for co-morbid diabetes and chronic kidney disease (CKD) is often sub-optimal. To improve health-care, we explored the perspectives of general practitioners (GPs) and tertiary health-care professionals concerning key factors influencing health-care of diabetes and CKD. Methods A total of 65 health professionals were purposively sampled from Australia’s 2 largest cities to participate in focus groups and semi-structured interviews. Four focus groups were conducted with GPs who referred to 4 tertiary health services in Australia’s 2 largest cities, with 6 focus groups conducted with tertiary health-care professionals from the 4 tertiary health services. An additional 8 semi-structured interviews were performed with specialist physicians who were heads of diabetes and renal units. All discussions were facilitated by the same researcher, with discussions digitally recorded and transcribed verbatim. All qualitative data was thematically analysed independently by 2 researchers. Results Both GPs and tertiary health-care professionals emphasised the importance of primary care and that optimal health-care was an inter-play between patient self-management and primary health-care, with specialist tertiary health-care support. Patient self-management, access to specialty care, coordination of care and a preventive approach were identified as key factors that influence healthcare and require improvement. Both groups suggested that an integrated specialist diabetes-kidney service could improve care. Unit heads emphasised the importance of quality improvement activities. Conclusions GPs and tertiary health-care professionals emphasised the importance of patient self-management and primary care involvement in the health-care of diabetes and CKD. Supporting GPs with an accessible, multidisciplinary diabetes-renal health service underpinned by strong communication pathways, a preventive approach and quality improvement activities, may improve health-care and patient outcomes in co-morbid diabetes and CKD. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0262-2) contains supplementary material, which is available to authorized users.

OBJECTIVES The Coping Strategies Inventory-Short Form (CSI-SF) measures four coping strategies based on 16 items: 4 items each indicating problem- vs. emotion-focused engagement or disengagement. Here we provide the first assessment of reliability and construct validity of the CSI-SF among hemodialysis patients across 13 countries. METHODS The CSI-SF was completed by patients in 9 languages in phase 4 of the Dialysis Outcomes and Practice Patterns Study (2009-11). Cronbach's alpha was used to assess internal consistency. Exploratory and confirmatory factor analyses were applied to assess the factor structure of the CSI-SF by country and language. CSI-SF data were analyzed from 7201 patients (60% male; median age 62.5 [range 18-96] years). RESULTS Good internal consistency (α=0.56-0.80) was seen for three scales in English (US, UK, Canada, Australia, New Zealand), German, and Swedish versions. The fourth scale was internally consistent if two items were dropped. In these countries, both exploratory and confirmatory factor analyses indicated a factor structure consistent with the four CSI-SF scales. Other language versions showed a factor structure inconsistent with these four scales. CONCLUSION The slightly modified English, German, and Swedish versions of the CSI-SF are reliable and valid instruments for measuring coping strategies in hemodialysis patients.

Hypertension is highly prevalent yet poorly controlled in the majority of dialysis patients and represents a significant burden of disease, with rates of morbidity and mortality greater than those in the general population. In dialysis, blood volume plays a critical role in the pathogenesis of hypertension, with expansion of extracellular volume increasingly recognized as an independent risk factor for morbidity and mortality. Within the current paradigm of dialysis prescription the majority of patients remain chronically volume expanded. However, management of blood pressure and volume state is difficult for clinicians with a paucity of randomized evidence adding to the complexity of nonlinear morbidity and mortality associations. With dialysis itself as a significant cardiac stressor, control of volume state is critical to minimize intradialytic hemodynamic instability, aid in preservation of cardiac anatomy and prevent progression to cardiovascular morbidity and mortality. This review explores the relationship of blood volume to blood pressure and potential targets for management in this at risk population.

KDOQI practice guidelines recommend pre-dialysis blood pressure (BP)

In late 2009 transplant organizations recommended that kidney recipients be vaccinated for pandemic H1N1 influenza (pH1N1); however, the vaccine efficacy was unknown. We had offered a monovalent non-adjuvanted pH1N1 vaccine to transplant recipients. Here we compared the pre- and post-vaccination seroresponses of 151 transplant recipients to that of 71 hemodialysis patients and 30 healthy controls. Baseline seroprotection was similar between groups but was significantly different at 1 month (44, 56, and 87%, respectively). Seroconversion was significantly less common for transplant recipients (32%) than dialysis patients (45%) and healthy controls (77%). After adjusting for age and gender, dialysis patients were significantly more likely (2.7-fold) to achieve new seroprotection than transplant recipients. The likelihood of seroprotection in transplant recipients was significantly reduced by mycophenolate use (adjusted odds ratio 0.24), in a dose-dependent manner, and by reduced eGFR (adjusted odds ratio 0.16 for worst to best). Seroprotection and geometric mean antibody titers increased substantially in 49 transplant recipients who subsequently received the 2010 seasonal influenza vaccine. Thus, patients requiring renal replacement therapy had reduced seroresponses to vaccination with the monovalent vaccine compared with healthy controls. Transplant recipient responses were further reduced if they were receiving mycophenolate or had significantly lower graft function.

Background Poor nutritional status and both hyper- and hypophosphatemia are associated with increased mortality in maintenance hemodialysis (HD) patients. We assessed associations of phosphate binder prescription with survival and indicators of nutritional status in maintenance HD patients. Study Design Prospective cohort study (DOPPS [Dialysis Outcomes and Practice Patterns Study]), 1996-2008. Setting & Participants 23,898 maintenance HD patients at 923 facilities in 12 countries. Predictors Patient-level phosphate binder prescription and case-mix–adjusted facility percentage of phosphate binder prescription using an instrumental-variable analysis. Outcome All-cause mortality. Results Overall, 88% of patients were prescribed phosphate binders. Distributions of age, comorbid conditions, and other characteristics showed small differences between facilities with higher and lower percentages of phosphate binder prescription. Patient-level phosphate binder prescription was associated strongly at baseline with indicators of better nutrition, ie, higher values for serum creatinine, albumin, normalized protein catabolic rate, and body mass index and absence of cachectic appearance. Overall, patients prescribed phosphate binders had 25% lower mortality (HR, 0.75; 95% CI, 0.68-0.83) when adjusted for serum phosphorus level and other covariates; further adjustment for nutritional indicators attenuated this association (HR, 0.88; 95% CI, 0.80-0.97). However, this inverse association was observed for only patients with serum phosphorus levels ≥3.5 mg/dL. In the instrumental-variable analysis, case-mix–adjusted facility percentage of phosphate binder prescription (range, 23%-100%) was associated positively with better nutritional status and inversely with mortality (HR for 10% more phosphate binders, 0.93; 95% CI, 0.89-0.96). Further adjustment for nutritional indicators reduced this association to an HR of 0.95 (95% CI, 0.92-0.99). Limitations Results were based on phosphate binder prescription; phosphate binder and nutritional data were cross-sectional; dietary restriction was not assessed; observational design limits causal inference due to possible residual confounding. Conclusions Longer survival and better nutritional status were observed for maintenance HD patients prescribed phosphate binders and in facilities with a greater percentage of phosphate binder prescription. Understanding the mechanisms for explaining this effect and ruling out possible residual confounding require additional research.

Introduction On sait peu de choses sur les differentes strategies d’adaptation utilisees par les patients hemodialyses (HD) pour faire face a leur maladie (concept de coping) et comment cela pourrait affecter leur etat de sante. Notre objectif etait d’estimer les effets de 4 strategies d’adaptation sur la qualite de vie (QV), la depression et la mortalite. L’hypothese etait qu’une adaptation active entrainerait de meilleurs resultats de sante pour les patients plutot que l’evitement ou le desengagement. Patients et methodes Dans DOPPS 4 (2009–11), les strategies d’adaptation ont ete rapportees par 2339 patients HD (62 ± 15 ans, H/F = 1,44) residant aux Etats-Unis, Royaume-Uni, Australie, Nouvelle-Zelande, Canada, Allemagne et Suede, via le questionnaire Coping Strategies Inventory-Short Form (CSI-SF) : 14 questions reparties en 4 strategies (un score par strategie variant de 1 a 5) : engagement et desengagement axes sur les problemes (PFE et PFD) ou sur l’emotion (EFE et EFD). Des analyses multivariees (Cox ou regressions lineaires) ont ete realisees pour estimer les associations de chaque strategie (par quartile) avec la mortalite toutes causes, la QV (KDQoL) et la depression (CES-D). Resultats Plus les patients utilisaient la strategie PFE, plus leur QV etait bonne (Δ = 3 a 18 points entre 1er et 4e quartile selon la dimension) et moins ils rapportaient de symptomes depressifs (Δ = 5). L’inverse etait observe avec les strategies de desengagement (PFD et EFD). Par rapport aux patients du 1er quartile PFE, le risque de mortalite (IC95 %) etait de 0,73 (0,55–0,98) pour ceux du 2e quartile, 0,67 (0,49–0,93) pour ceux du 3e quartile et 0,74 (0,53–1,03) pour ceux du 4e quartile. De faibles associations etaient observees entre EFE, PFD ou EFD et la mortalite. Discussion Premiere utilisation du CSI-SF chez des patients HD, traduit et valide dans ces 7 pays DOPPS. Nous ne pouvons pas exclure la confusion residuelle et, dans ces analyses transversales, la causalite inverse. Conclusion Les patients HD presentaient de meilleurs resultats de sante lorsqu’ils utilisaient des strategies d’engagement, et le contraire pour les strategies de desengagement. Identifier les strategies efficaces, puis permettre aux patients de les developper lors d’interventions specifiques, pourrait ameliorer la gestion de leur maladie.

Patients with β-thalassemia major require iron-chelation therapy to avoid the complication of iron overload. Until recently, deferoxamine (DFO) was the major iron chelator used in patients requiring chronic hypertransfusion therapy, but DFO required continuous subcutaneous therapy. The availability of deferasirox (Exjade®), an orally active iron chelator, over the past 4 years represented a necessary alternative for patients requiring chelation therapy. However, there have been increasing reports of proximal renal tubular dysfunction and Fanconi Syndrome associated with deferasirox in the literature. We report a case of hypophosphataemic osteomalacia secondary to deferasirox therapy. © 2012 American Society for Bone and Mineral Research

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.

Background There is a resurgence of interest in home hemodialysis (HD), especially frequent or extended forms involving unconventionally frequent (>3 times/wk) and/or long (>6 hours) treatments. This resurgence is driven by cost containment and experience suggesting lower mortality risk compared with facility HD and peritoneal dialysis (PD). Study Design We performed an observational cohort study using the Australia and New Zealand Dialysis and Transplant Registry, using marginal structural modeling to adjust for time-varying medical comorbidity as both a source of selection bias and an intermediary variable on the causal pathway to death. Setting & Participants All adult patients starting renal replacement therapy in Australia and New Zealand since March 31, 1996, followed up to December 31, 2007. Predictor The main predictor was dialysis modality (conventional facility HD, conventional home HD, frequent/extended facility HD, frequent/extended home HD, and PD). We adjusted for the confounding effects of patient demographics and comorbid conditions. Outcome Patient mortality. Results We analyzed 26,016 patients with 856,007 patient-months of follow-up. Relative to conventional facility HD, adjusted mortality HRs were 0.51 (95% CI, 0.44-0.59) for conventional home HD, 1.16 (95% CI, 0.94-1.44) for frequent/extended facility HD, 0.53 (95% CI, 0.41-0.68) for frequent/extended home HD, and 1.10 (95% CI, 1.06-1.16) for PD. The apparent benefit of home HD on mortality risk was less for patients who were nonwhite, non-Asian, and older. Limitations Potential for residual confounding from the limited collection of comorbid conditions (no collection of cognitive or motor impairment, depression, left ventricular volume or structure, or blood pressure/fluid volume status) and lack of socioeconomic, medication, and biochemical data in analyses. Conclusions Our study supports a survival advantage of home HD without a difference between conventional and frequent/extended modalities. Suitably designed clinical trials of frequent/extended HD are needed to determine the presence and extent of mortality benefit with this modality.

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.

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.

The transfer of young patients from pediatric to adult renal care takes place after a transition process which involves both sides. It is important that it is individualized for each young person, focusing on self-management skills as well as assessing support structures. The consensus statement has been developed by the panel of adult and pediatric nephrologists and endorsed by the councils of both ISN and IPNA. It is hoped that the statement will provide a basis for the development of locally appropriate recommendations for clinical practice.

AIMS To evaluate the relationship between the severity of secondary hyperparathyroidism (SHPT) - defined in terms of baseline plasma intact parathyroid hormone (iPTH) level - and the magnitude of response to cinacalcet. MATERIALS AND METHODS In this post hoc analysis, data were pooled from three randomized, placebo-controlled trials in which dialysis patients with iPTH ≥ 300 pg/ml were dose-titrated with cinacalcet or placebo in addition to conventional treatment to achieve iPTH ≤ 250 pg/ml. In 953 patients analyzed (cinacalcet, 545; placebo, 408), baseline iPTH levels were categorized in 100 pg/ml intervals (300 - ≥ 1,000 pg/ml), and the impact of baseline iPTH on changes in iPTH, phosphate (P), calcium (Ca) and calcium- phosphate product (Ca × P) was evaluated. RESULTS Cinacalcet reduced iPTH (47% reduction), P (9%), Ca (7%), and Ca × P (15%) across all subgroups. For patients receiving cinacalcet, the mean percentage reduction from baseline in iPTH varied from 35 to 55%, being consistently decreased across the severity subgroups. The mean absolute change in iPTH was more pronounced in patients with higher baseline iPTH levels, particularly in the ≥ 1,000 pg/ml subgroup vs. the other subgroups. However, as baseline iPTH levels increased, iPTH ≤ 250 pg/ml was achieved in fewer patients. A trend towards greater absolute change from baseline was observed for P in patients with more severe disease (iPTH ≥ 800 pg/ml) treated with cinacalcet compared with patients with less severe disease (iPTH 300 - < 800 pg/ml). CONCLUSIONS Cinacalcet lowers plasma iPTH and serum P, Ca and Ca × P levels in dialysis patients with SHPT, regardless of disease severity. Patients with more severe disease experienced greater reductions in PTH and P, but fewer achieved iPTH ≤ 250 pg/ml by the efficacy assessment phase. Use of cinacalcet when baseline PTH is lower may result in more stable control of SHPT and help to control bone and mineral alterations.

There are many variations in the delivery of hemodialysis. These variations include components of conventional dialysis, such as membrane type, dialysis dose, and session duration. In addition, alternative approaches to dialysis, such as hemodiafiltration, nocturnal hemodialysis, and short daily hemodialysis, also may be considered. For some of these practice variations, data exist to support one approach over another (eg, fistulas rather than grafts and catheters), but for many, no such data exist. Very few practice variations have been examined in randomized trials, and we are reliant predominantly on observational data. This review examines some practice variations in hemodialysis delivery, attempting to highlight which of these may be appropriate to consider when optimizing dialysis delivery in the clinic.

Glomerular injury and podocyte loss leads to secondary tubulointerstitial damage and the development of fibrosis. The possibility of genetically reprogramming adult cells, termed induced pluripotent stem cells (iPS), may pave the way for patient-specific stem-cell-based therapies. Here, we reprogrammed normal human mesangial cells to pluripotency by retroviral transduction using defined factors (OCT4, SOX2, KLF4 and c-Myc). The kidney iPS (kiPS) cells resembled human embryonic stem-cell-like colonies in morphology and gene expression: They were alkaline phosphatase-positive; expressed OCT3/4, TRA-1 to 60 and TRA-1 to 81 proteins; and showed downregulation of mesangial cell markers. Quantitative (qPCR) showed that kiPS cells expressed genes analogous to embryonic stem cells and exhibited silencing of the retroviral transgenes by the fourth passage of differentiation. Furthermore, kiPS cells formed embryoid bodies and expressed markers of all three germ layers. The injection of undifferentiated kiPS colonies into immunodeficient mice formed teratomas, thereby demonstrating pluripotency. These results suggest that reprogrammed kidney induced pluripotent stem cells may aid the study of genetic kidney diseases and lead to the development of novel therapies.

Aim: 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.

Aim: 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. Methods: 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. Results: 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. Conclusions: 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.

Background: The uremic retention solutes indoxyl sulfate and p-cresyl sulfate are linked to cardiovascular disease and overall survival. Dialytic clearances are limited, which is principally attributed to tight protein binding. Extending dialysis duration would be expected to substantially increase protein-bound uremic solute removal. The aim of the current study was to study protein-bound uremic retention solute clearances and kinetics during longer-hours nocturnal hemodialysis. Methods: In a prospective cohort study of 32 maintenance alternate-night nocturnal hemodialysis patients, we followed serum concentrations, solute removals and solute clearances of p-cresyl sulfate and indoxyl sulfate. Spent dialysate sampling was fractionated to compare solute removals between the first 4 h and next 4 h of nocturnal dialysis. Single-compartment variable volume kinetics were calculated. Results: Dialytic clearances of protein-bound uremic retention solutes are maintained during nocturnal (longer-hours) dialysis. Clearances of indoxyl sulfate exceed those of p-cresyl sulfate, presumably due to less tight protein-binding. Apparent distribution volumes increase substantially during nocturnal dialysis, indicative of multi-compartmental behavior of the protein-bound uremic retention solutes indoxyl sulfate and p-cresyl sulfate. Conclusions: During nocturnal hemodialysis, serum concentrations of protein-bound solute concentrations are reduced less than predicted. Reduction ratios are not a valid tool to estimate total solute removal of protein-bound uremic retention solutes.

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 B12, 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

In the mid 1970s, home haemodialysis accounted for nearly half of all patients on dialysis, both in Australia and elsewhere. The advent of both peritoneal dialysis (itself a home therapy) and satellite haemodialysis resulted in a gradual attrition in the use of home haemodialysis. Since 2000, the introduction of nocturnal home haemodialysis has begun to change this pattern in Australia, with a sharp growth in the uptake of home haemodialysis. Home haemodialysis, which enables longer hours and more frequent treatments than facility-based (hospital or satellite centre) dialysis, appears to offer improved patient outcomes in observational studies; randomised studies are necessary to confirm these findings. Home haemodialysis is also a cheaper form of therapy than facility-based dialysis. As newer, simpler and more user-friendly equipment is emerging that will make home haemodialysis even more accessible and attractive to the consumer, we believe that this trend toward a greater uptake of home haemodialysis should and will continue.

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.

Background: End-stage kidney disease registry data have reported increased mortality in patients with diabetes as compared with those without. Here we examine whether diabetes is independently associated with an increased risk of major cardiovascular events and death in patients with advanced chronic kidney disease (CKD). Methods: Data from 315 participants with CKD in the Atherosclerosis and Folic Acid Supplementation Trial (ASFAST) were assessed. Primary end-points were fatal or non-fatal cardiovascular events, including myocardial infarction, stroke, unstable angina, coronary revascularisation and peripheral vascular events assessed both jointly and separately using Cox-proportional hazard models. Results: Twenty-three per cent reported diabetes. Median follow up was 3.6 years. In those with diabetes, an increased risk for major cardiovascular events was observed, crude hazard ratio (HR) 2.87 (95% confidence interval (CI) 2.11–3.90). After adjustment for age, gender, smoking, systolic blood pressure, body mass index, past ischaemic heart disease and use of preventive therapies, diabetes was associated with an HR of 1.83 (1.28–2.61) for major cardiovascular events. The risk for peripheral vascular events was also increased, adjusted HR 6.31 (2.61–15.25). For all-cause death, major coronary and stroke events, the risk in those with diabetes was not significantly increased (all-cause death, adjusted HR 1.31 (95% CI 0.80–2.14); major coronary events, adjusted HR 1.26 (95% CI 0.64–2.49); and major stroke events, adjusted HR 1.28 (95% CI 0.55–2.99)). Conclusions: Diabetes significantly increases the risk of major cardiovascular events, especially peripheral vascular events in patients with advanced CKD. Trials of multifactorial management of cardiovascular risk factors are required to determine if outcomes for this population may be improved.

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.

BACKGROUND Nutritional status predicts outcome in dialysis populations. Increased dialysis time and/or frequency reportedly improves nutritional status. We examined the impact of more intensive dialysis on body composition. METHODS A cross-sectional, matched study comparing home haemodialysis (HHD) patients (>15 h/week, n = 28) and conventional haemodialysis (CHD) patients (

SUMMARY 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.

Rituximab may improve graft survival in renal acute antibody-mediated rejection (AMR), but data confirming efficacy and optimal dosing is lacking. High-dose regimens may be associated with significant rates of infective complications. We therefore conducted a pilot study of a single low-fixed dose (500 mg) of rituximab in seven consecutive patients with AMR resistant to standard therapy. After a mean follow-up of 21 months (range, 9.5-33 months), graft and patient survival were 100% with serum creatinine levels significantly lower than peak rejection levels (171+/-73 micromol/L vs. 559+/-358 micromol/L, P=0.028). B cells were undetectable in all patients for more than or equal to 6 months and in six of seven patients for more than or equal to 12 months after rituximab. Three patients encountered a significant infective complication including cytomegalovirus reactivation, viral pneumonia, and polyoma viral nephropathy. All have since resolved. A single low-fixed dose of rituximab may help improve graft survival in AMR and offers the potential advantage of reduced infective complications.

Background and objectives: Vascular calcification (VC) contributes to increased cardiovascular (CV) disease in dialysis patients and is inversely correlated with bone mineral density (BMD). Screening for VC may determine patients at greater CV risk and bone densitometry may have dual role in assessing VC as well as BMD. The aim of this study was to determine measurement of VC using dual-energy x-ray absorptiometry (DXA) with correlation to gold standard computed tomography (CT). Design, setting, participants, & measurements: Forty hemodialysis patients had abdominal aortic CT and lateral DXA of lumbar spine to determine aortic VC and BMD. Semiquantitative measurement of aortic VC from lateral DXA was determined using previously validated 24- and 8-point scales and correlated with aortic VC with CT. Anteroposterior (AP) and lateral DXA-reported BMD was compared with BMD from L2 through L4 with CT. Results: Patients, 70% men, 38% diabetic, had median age 58.5 yr. Aortic VC was present in 94% with CT and 68% on lateral DXA. For 24- and 8-point scores, intraclass correlation coefficients for intrarater agreement were 0.93 and 0.88, respectively. DXA-measured VC correlated with CT. Sensitivity and specificity for CT aortic VC ≥ 500 HU was 50 and 86%, respectively, for DXA VC ≥ 6 on a 24-point scale. Lateral DXA-reported BMD significantly correlated with BMD from CT, but AP DXA did not. Conclusions: Lateral DXA may be useful because images may provide concurrent assessment of aortic calcification as well as more accurate lumbar spine BMD, avoiding some of the limitations of AP DXA.

Background Starting hemodialysis therapy with an arteriovenous fistula (AVF) is associated with improved patient survival. Clinical audit showed that less than 50% of our patients started hemodialysis therapy with an AVF. Study Design Quality improvement report, prospective before and after study. Setting & Participants Tertiary referral hospital with 184 patients starting hemodialysis therapy in 2005 and 2006. Quality Improvement Plan Situational analysis showed poor overall coordination of surgical waiting lists. Multifaceted intervention included vascular access nurse coordinator and an algorithm to prioritize surgery. Outcomes Vascular access used at first hemodialysis treatment in patients with pre–end-stage renal disease in the 12 months before and after the intervention. Measurements Proportions of patients starting hemodialysis therapy with an AVF. Results Overall, 65% of patients started hemodialysis therapy with an AVF; 2%, with an arteriovenous graft; and 33%, with a catheter. The proportion of patients starting hemodialysis therapy with an AVF increased from 56% preimplementation to 75% postimplementation ( P = 0.007). After adjustment for age, sex, late referral, cause of renal failure, and presentation type, patients starting dialysis therapy in the implementation phase were twice as likely to start treatment with an AVF (odds ratio, 2.85; P = 0.008). The total number of catheter-days in the implementation phase was half that of the preimplementation phase (2,833 v 4,685 days). Limitations Nonrandomized study. Conclusions Implementation of a multifaceted intervention including a vascular access nurse and an algorithm to prioritize surgery significantly increased the proportion of patients starting dialysis therapy with an AVF by improving the overall coordination of the surgical waiting list.

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.

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