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Background Kt/V-urea is the most used marker to estimate dialysis adequacy; however, it does not reflect the removal of many other uraemic toxins, and a new approach is needed. We have assessed the feasibility of estimating intradialytic serum time-averaged concentration (TAC) of various uraemic toxins from their spent dialysate concentrations that can be estimated non-invasively online with optical methods. Methods Serum and spent dialysate levels and total removed solute (TRS) of urea, uric acid (UA), indoxyl sulphate (IS) and beta 2-microglobulin (beta 2M) were evaluated with laboratory methods during 312 haemodialysis sessions in 78 patients with four different dialysis treatment settings. TAC was calculated from serum concentrations and evaluated from TRS and logarithmic mean concentrations of spent dialysate (MlnD). Results Mean (+/- standard deviation) intradialytic serum TAC values of urea, UA, beta 2M and IS were 10.4 +/- 3.8 mmol/L, 191.6 +/- 48.1 mu mol/L, 13.3 +/- 4.3 mg/L and 82.9 +/- 43.3 mu mol/L, respectively. These serum TAC values were similar and highly correlated with those estimated from TRS [10.5 +/- 3.6 mmol/L (R-2 = 0.92), 191.5 +/- 42.8 mu mol/L (R-2 = 0.79), 13.0 +/- 3.2 mg/L (R-2 = 0.59) and 82.7 +/- 40.0 mu mol/L (R-2 = 0.85)] and from MlnD [10.7 +/- 3.7 mmol/L (R-2 = 0.92), 191.6 +/- 43.8 mu mol/L (R-2 = 0.80), 12.9 +/- 3.2 mg/L (R-2 = 0.63) and 82.2 +/- 38.6 mu mol/L (R-2 = 0.84)], respectively. Conclusions Intradialytic serum TAC of different uraemic toxins can be estimated non-invasively from their concentration in spent dialysate. This sets the stage for TAC estimation from online optical monitoring of spent dialysate concentrations of diverse solutes and for further optimization of estimation models for each uraemic toxin. Funding Agencies|European Union through the European Regional Development Fund [H2020-SMEINST-2-2017]; OLDIAS2-Online Dialysis Sensor Phase2 project [767572]; Estonian Ministry of Education and Research [IUT 19-2]; Estonian Centre of Excellence in IT (EXCITE) - European Regional Development Fund; Njurfonden, Sweden; Programa Rio Hortega ISCIII FEDER funds; ERA-PerMed-JTC2018 [AC18/00064, AC18/00071]; ISCIII-RETIC REDinREN FEDER funds [RD016/0009]; Sociedad Espanola de Nefrologia; Fundacion Renal Inigo Alvarez de Toledo (FRIAT); Comunidad de Madrid [CIFRA2 B2017/BMD-3686]; [PI19/00588]; [PI19/00815]; [DTS18/00032]

Background and objectives For older patients with kidney failure, lowering symptom burden may be more important than prolonging life. Dialysis initiation may affect individual kidney failure-related symptoms differently, but the change in symptoms before and after start of dialysis has not been studied. Therefore, we investigated the course of total and individual symptom number and burden before and after starting dialysis in older patients.Design, setting, participants, & measurements The European Quality (EQUAL) study is an ongoing, prospective, multicenter study in patients >= 65 years with an incident eGFR

Optimal fluid status is an important issue in hemodialysis. Clinical evaluation of volume status and different diagnostic tools are used to determine hydration status in these patients. However, there is still no accurate method for this assessment.To propose and evaluate relative lean water signal (LWSProspective.A total of 16 healthy subjects (56 ± 6 years, 0 male) and 11 dialysis patients (60.3 ± 12.3 years, 9 male; dialysis time per week 15 ± 3.5 hours, dialysis duration 31.4 ± 27.9 months).A 3 T; 3D spoiled gradient echo.LWST-tests were used to compare differences between the healthy subjects and dialysis patients, as well as changes between before and after dialysis. Pearson correlation was calculated between MRI and non-MRI biomarkers. A P value0.05 was considered statistically significant.The LWSMRI-based LWS2.Stage 3.

Background: Nurses have a great responsibility in the daily care of arteriovenous fistulae, which entails the potential to affect patency. However, good cannulation technique involves more than placing a needle in the vessel and relies on different skills to facilitate needling. Objectives: To describe the preconditions for cannulation in arteriovenous fistulas. Design: Descriptive statistics and qualitative content analysis were used in a mixed-methods design. Participants: Haemodialysis units in Sweden. Measurements: Local guidelines regarding arteriovenous fistula cannulation were analysed in parallel with responses to a questionnaire that contained open-ended and closed-ended questions on cannulation technique. Results: Preconditions that facilitate cannulation fall into five stages, each with relevant factors in relation to the cannulation, as follows: planning cannulation-maturation and planning the cannulation, patient record, education and experience, and patient information; precannulation-physical examination, hygiene routines, arm position, tourniquet, choosing the cannulation site, and preventing pain; during cannulation-how to needle, type of needle, angle during cannulation, fixation, and adjusting; evaluating cannulation-blood flow rate and arterial and venous pressure; and postcannulation-needle withdrawal and haemostasis. The majority of dialysis units identified implementation of most of these preconditions, but the units handle several practical aspects differently. Conclusions: Tracing the chain of cannulation led to identification of necessary preconditions for facilitating good cannulation technique. The findings also show the need for a better understanding of how different preconditions affect arteriovenous fistula and patency. Funding Agencies|Region Ostergotland, Sweden; Swedish Research Council

Introduction: Predicting the timing and occurrence of kidney replacement therapy (KRT), cardiovascular events, and death among patients with advanced chronic kidney disease (CKD) is clinically useful and relevant. We aimed to externally validate a recently developed CKD G4+ risk calculator for these outcomes and to assess its potential clinical impact in guiding vascular access placement. Methods: We included 1517 patients from the European Quality (EQUAL) study, a European multicentre prospective cohort study of nephrology-referred advanced CKD patients aged ≥65 years. Model performance was assessed based on discrimination and calibration. Potential clinical utility for timing of referral for vascular access placement was studied with diagnostic measures and decision curve analysis (DCA). Results: The model showed a good discrimination for KRT and “death after KRT,” with 2-year concordance (C) statistics of 0.74 and 0.76, respectively. Discrimination for cardiovascular events (2-year C-statistic: 0.70) and overall death (2-year C-statistic: 0.61) was poorer. Calibration was fairly accurate. Decision curves illustrated that using the model to guide vascular access referral would generally lead to less unused arteriovenous fistulas (AVFs) than following estimated glomerular filtration rate (eGFR) thresholds. Conclusion: This study shows moderate to good predictive performance of the model in an older cohort of nephrology-referred patients with advanced CKD. Using the model to guide referral for vascular access placement has potential in combating unnecessary vascular surgeries.

Background Various prediction models have been developed to predict the risk of kidney failure in patients with CKD. However, guideline-recommended models have yet to be compared head to head, their validation in patients with advanced CKD is lacking, and most do not account for competing risks. Methods To externally validate 11 existing models of kidney failure, taking the competing risk of death into account, we included patients with advanced CKD from two large cohorts: the European Quality Study (EQUAL), an ongoing European prospective, multicenter cohort study of older patients with advanced CKD, and the Swedish Renal Registry (SRR), an ongoing registry of nephrology-referred patients with CKD in Sweden. The outcome of the models was kidney failure (defined as RRT-treated ESKD). We assessed model performance with discrimination and calibration. Results The study included 1580 patients from EQUAL and 13,489 patients from SRR. The average c statistic over the 11 validated models was 0.74 in EQUAL and 0.80 in SRR, compared with 0.89 in previous validations. Most models with longer prediction horizons overestimated the risk of kidney failure considerably. The 5-year Kidney Failure Risk Equation (KFRE) overpredicted risk by 10%-\18%. The four- and eight-variable 2-year KFRE and the 4-year Grams model showed excellent calibration and good discrimination in both cohorts. Conclusions Some existing models can accurately predict kidney failure in patients with advanced CKD. KFRE performed well for a shorter time frame (2 years), despite not accounting for competing events. Models predicting over a longer time frame (5 years) overestimated risk because of the competing risk of death. The Grams model, which accounts for the latter, is suitable for longer-term predictions (4 years).

BACKGROUND: The prognosis for kidney survival is poor in patients presenting with circulating anti–glomerular basement membrane (GBM) antibodies and severe kidney injury. It is unknown if treatment with an endopeptidase that cleaves circulating and kidney bound IgG can alter the prognosis. METHODS: An investigator-driven phase 2a one-arm study (EudraCT 2016–004082–39) was performed in 17 hospitals in five European countries. A single dose of 0.25 mg/kg of imlifidase was given to 15 adults with circulating anti-GBM antibodies and an eGFR

Background Depressive symptoms are associated with adverse clinical outcomes in patients with end-stage kidney disease; however, few small studies have examined this association in patients with earlier phases of chronic kidney disease (CKD). We studied associations between baseline depressive symptoms and clinical outcomes in older patients with advanced CKD and examined whether these associations differed depending on sex. Methods CKD patients (≥65 years; estimated glomerular filtration rate ≤20 mL/min/1.73 m2) were included from a European multicentre prospective cohort between 2012 and 2019. Depressive symptoms were measured by the five-item Mental Health Inventory (cut-off ≤70; 0–100 scale). Cox proportional hazard analysis was used to study associations between depressive symptoms and time to dialysis initiation, all-cause mortality and these outcomes combined. A joint model was used to study the association between depressive symptoms and kidney function over time. Analyses were adjusted for potential baseline confounders. Results Overall kidney function decline in 1326 patients was –0.12 mL/min/1.73 m2/month. A total of 515 patients showed depressive symptoms. No significant association was found between depressive symptoms and kidney function over time (P = 0.08). Unlike women, men with depressive symptoms had an increased mortality rate compared with those without symptoms [adjusted hazard ratio 1.41 (95% confidence interval 1.03–1.93)]. Depressive symptoms were not significantly associated with a higher hazard of dialysis initiation, or with the combined outcome (i.e. dialysis initiation and all-cause mortality). Conclusions There was no significant association between depressive symptoms at baseline and decline in kidney function over time in older patients with advanced CKD. Depressive symptoms at baseline were associated with a higher mortality rate in men.

Aims and objectives The aim of this study was to describe the basis for choosing a cannulation technique for arteriovenous fistula. Background Four cannulation techniques are relevant to cannulating an arteriovenous fistula: rope ladder, area puncture and buttonhole using blunt or sharp needles. The chosen technique may affect both the patency and number of complications. Design The study used a convergent mixed methods design and inductive approach. Methods A questionnaire and an inquiry of local guidelines were sent to nurses in all dialysis units in Sweden. Questionnaires were answered by nurses from 37 units, and 29 units included their local guidelines. The questionnaires were analysed using descriptive statistics and qualitative content analysis, and the guidelines were analysed using qualitative content analysis. The different analyses were combined in a final result. The study is based on GRAMMS guidelines. Results Local guidelines, patients and nurses own judgement, and consultation with colleagues were found to greatly influence the choice of cannulation technique. Buttonhole was the most preferred cannulation technique in the participating units and was favoured by nurses when choosing a cannulation technique. The process of choosing a cannulation technique was found to be influenced by the dedication to good cannulation technique and healthy arteriovenous fistulas, whether the technique is perceived as being easy to use and is expected to prevent complications and based on the experienced-based knowledge of each dialysis unit. Conclusions Choosing a cannulation technique is a process based on the nurse, local guidelines and the patient. Most dialysis nurses and units in Sweden consider buttonhole to be a good cannulation technique and use it as their standard technique. Relevance to clinical practice The results provide insight into why cannulation techniques are chosen differently in different units. The results also show the importance of evidence in making decisions on cannulation technique. Funding Agencies|Region Ostergotland; Swedish Research Council

BackgroundSarcopenia is a prevalent condition in patients on maintenance hemodialysis and associates with mortality. Research using magnetic resonance imaging (MRI) has demonstrated the importance of a proper body size-adjustment in the assessment of muscle mass, and that a muscle composition assessment including measurements of both muscle volume and fat infiltration improves the prediction of comorbidity and survival related to sarcopenia. Such combined muscle composition assessment has not previously been performed in hemodialysis patients.MethodsEleven hemodialysis patients were scanned using whole-body fat and water separated MRI and followed regarding survival and comorbidity for five years. Muscle composition was assessed using AMRA® Researcher. Using data from 9615 UK Biobank participants, sex and BMI-matched muscle volume z-scores and sex-adjusted muscle fat infiltration values were calculated for each patient. These measurements were then used for the calculation of a combined muscle score. Resulting three muscle measurements were associated with survival and comorbidity index.ResultsSix patients exhibited low muscle volume (muscle volume z-score th percentile (population wide)), and six patients presented with high muscle fat infiltration (>75th percentile (population wide)). During a 68-months follow-up, five patients died, four were transplanted and two remained on hemodialysis treatment. The combined muscle score was significantly associated with comorbidity index (pConclusionsThe combined assessment including both body size-adjusted muscle volume and muscle fat infiltration can be used to analyze muscle composition in hemodialysis patients. MRI based muscle composition assessment reflected comorbidity and predicted survival in hemodialysis patients.

In anti-glomerular basement membrane (anti-GBM) disease, IgG class autoantibodies induce rapidly progressive glomerulonephritis. Regrettably, many patients are diagnosed at a late stage when even intensive conventional treatment fails to restore renal function The endopeptidase IdeS (Immunoglobulin G degrading enzyme of Streptococcus pyogenes) (imliflidase) rapidly cleaves all human IgG subclasses into F(ab′)2 and Fc fragments. We received permission to treat three patients with refractory anti-GBM nephritis without pulmonary involvement on a compassionate basis. All patients were dialysis-dependent for days or weeks when treated, and all had high levels of circulating anti-GBM despite plasma exchange. A single dose of IdeS led to complete clearance of circulating anti-GBM antibodies in all three patients. After about a week, all rebounded but the rebounds were easily managed by plasma exchange in two of three cases. Renal histology demonstrated severe crescentic glomerulonephritis with acute but mainly chronic changes. Staining for the Fc fragment was negative in all while Fab was positive in two patients. Unfortunately, none of the patients regained independent renal function. Thus, treatment with IdeS led to rapid clearance of circulating and kidney bound anti-GBM antibodies. The clinical utility, dosing and usage to preserve renal function remain to be determined.

Rapid progression of vascular calcification (VC) in hemodialysis (HD) patients is caused by several factors including inflammation and an imbalance between active inducers and inhibitors of VC. Growing evidence shows that online hemodiafiltration (ol-HDF), a combination of diffusive and convective solute transport, has positive effects on the uremic environment that affects patients on dialysis. However, we recently reported that serum 25-hydroxyvitamin D (25(OH)D) decreased after a switch from HD to ol-HDF. As a consequence of this finding, the present study was undertaken to investigate if inducers and inhibitors of VC (i.e. the inactive matrix Gla protein fractions dp-ucMGP and t-ucMGP, fetuin-A, Gla-rich protein (GRP), osteopontin (OPN), bone-specific alkaline phosphatase (BALP), and osteoprotegerin (OPG)) also are affected by ol-HDF. This non-comparative prospective study comprised 35 prevalent patients who were investigated 6, 12, and 24 months after their switch from HD to ol-HDF. Most patients had increased levels of the calcification inhibitors OPN and OPG; and of the inactive calcification inhibitor dp-ucMGP during the study period irrespective of the dialysis modality. BALP and t-ucMGP were mostly within the reference interval, but fetuin-A was mostly below the reference interval during the study period. OPN was significantly associated with BALP and parathyroid hormone, r = 0.62 and r = 0.65 (p

Background Patient participation is considered central for good healthcare. Yet, the concept is not fully understood when it comes to patients experiences of participation in conjunction with their preferences, particularly in long-term healthcare. The aim of this study was to investigate the extent and variation of preference-based patient participation in patients with end-stage kidney disease (ESKD). Methods A cross-sectional study was conducted with 346 patients in renal care. The main variables were patients preferences for and experiences of patient participation, determined using the Patient Preferences for Patient Participation tool, the 4Ps. Analyses identified the degree of match between preferences and experiences, that is, the preference-based patient participation measure. Results Overall, 57%-84% of the patients reached a sufficient level of preference-based patient participation on the items, while 2%-12% reached an insufficient level. A mismatch indicated either less or more participation than preferred; for example, 40% had less experience than preferred for taking part in planning, and 40% had more than preferred for managing treatment. Conclusion This study shows that, although many patients reach a sufficient level of preference-based patient participation, this is not the case for all patients and/or attributes. Further opportunities for a mutual understanding of patients preferences are needed for healthcare professionals to support person-centred patient participation. Patient or Public Contribution The 4Ps is manufactured in collaboration with people with experience of the patient role, and persons living with ESKD were engaged in identifying their preferences and experiences of participation in renal care. Funding Agencies|Forskningsradet i Sydostra Sverige [930678]; Njurfonden [F2018-0036]

Tryptophan is an essential dietary amino acid that originates uremic toxins that contribute to end-stage kidney disease (ESKD) patient outcomes. We evaluated serum levels and removal during haemodialysis and haemodiafiltration of tryptophan and tryptophan-derived uremic toxins, indoxyl sulfate (IS) and indole acetic acid (IAA), in ESKD patients in different dialysis treatment settings. This prospective multicentre study in four European dialysis centres enrolled 78 patients with ESKD. Blood and spent dialysate samples obtained during dialysis were analysed with high-performance liquid chromatography to assess uremic solutes, their reduction ratio (RR) and total removed solute (TRS). Mean free serum tryptophan and IS concentrations increased, and concentration of IAA decreased over pre-dialysis levels (67%, 49%, -0.8%, respectively) during the first hour of dialysis. While mean serum total urea, IS and IAA concentrations decreased during dialysis (-72%, -39%, -43%, respectively), serum tryptophan levels increased, resulting in negative RR (-8%) towards the end of the dialysis session (p < 0.001), despite remarkable Trp losses in dialysate. RR and TRS values based on serum (total, free) and dialysate solute concentrations were lower for conventional low-flux dialysis (p < 0.001). High-efficiency haemodiafiltration resulted in 80% higher Trp losses than conventional low-flux dialysis, despite similar neutral Trp RR values. In conclusion, serum Trp concentrations and RR behave differently from uremic solutes IS, IAA and urea and Trp RR did not reflect dialysis Trp losses. Conventional low-flux dialysis may not adequately clear Trp-related uremic toxins while high efficiency haemodiafiltration increased Trp losses. Funding Agencies|European Union through the European Regional Development FundEuropean Union (EU) [H2020-SMEINST-2-2017]; Estonian Ministry of Education and ResearchMinistry of Education and Research, Estonia [IUT 19-2]; Estonian Centre of Excellence in IT (EXCITE) - European Regional Development Fund; Njurfonden (2017), Sweden; Njurfonden (2018), Sweden; Programa Rio Hortega ISCIII FEDER funds; ISCIII-RETIC REDinREN [RD016/0009]; Sociedad Espanola de Nefrologia; Fundacion Renal Inigo Alvarez de Toledo (FRIAT)Fonds de la Recherche Scientifique - FNRS; Comunidad de MadridComunidad de MadridInstituto de Salud Carlos III [CIFRA2 B2017/BMD-3686]; OLDIAS2-Online Dialysis Sensor Phase2 project [767572]; ERA-PerMed-JTC2018 [KIDNEY ATTACK AC18/00064, PERSTIGAN AC18/00071]; FEDER fundsEuropean Union (EU); [PI19/00588]; [PI19/00815]; [DTS18/00032]

Background Safe health care of good quality depends on structured and unceasing efforts to progress, promoting strategies tailored to the context, including elements such as patients preferences. Although patient participation is a common concept in health care, there is yet limited understanding of the factors that facilitate and hinder it in a healthcare context. Aims This paper identifies what patients and health professionals depict in terms of enablers and barriers for patient participation in dialysis care. Methods An explorative qualitative design was applied with seven focus group discussions with patients, staff, and managers across different types of hospitals, with the texts analyzed with content analysis. Results The dialysis context represents three key elements-people, resources, and interactions-that can both enable and hinder patient participation. Both barriers and facilitators for patient participation were found to reside at individual, team, and organizational levels, with a greater number of enabling factors implied by both patients and staff. Linking Evidence to Action While the dialysis context comprises opportunities for progress in favor of patient participation, a shared understanding of the concept is needed, along with how contextual factors can facilitate conditions for participation by patient preferences. In addition, the most favorable strategy for implementing person-centered care is not yet known, but to facilitate patient participation from a patient perspective, creating opportunities to enable staff and patients to share a common understanding is needed, along with tools to facilitate a dialogue on patient participation. Funding Agencies|Forskningsradet i Sydostra Sverige [FORSS-751311]

The purpose of this study was to investigate changes in sleep quality, fatigue, mental health, and health-related quality of life (HRQoL) over a two-year period among patients undergoing peritoneal dialysis treatment at home. We further explored the extent to which sleep quality, fatigue, and mental health predicted health-related quality of life outcomes. This prospective study included 55 patients. Sleep parameters changed over two years, independently of treatment. Sleep variables at baseline, to some extent, predicted sleep quality after two years. Daytime sleepiness can be a long-term problem. Findings indicate improvements in nocturnal sleep over a two-year time period, independently of dialysis treatment. In contrast, fatigue remained unchanged over the same time period. Transplantation seems to generally benefit the outcome of HRQoL. Strategies to improve sleep and HRQoL may include systematic risk factor modification and efforts to optimise symptomatic treatment.

A method for computer-aided assessment of blood vessel geometries based on shape-fitting algorithms from metric vision was evaluated. Acoustic images of cross sections of the radial artery and cephalic vein were acquired, and medical practitioners used a computer application to measure the wall thickness and nominal diameter of these blood vessels with a caliper method and the shape-fitting method. The methods performed equally well for wall thickness measurements. The shape-fitting method was preferable for measuring the diameter, since it reduced systematic errors by up to 63% in the case of the cephalic vein because of its eccentricity.

Background and objective End‐stage renal disease (ESRD) affects a multitude of aspects in the patient's daily life, often entailing their own involvement in various aspects of the treatment. Although patient participation is a core health‐care value, what the concept signifies is not yet fully known. The purpose of this paper is to conceptualize patient participation in dialysis care, depicting patients’ and health‐care professionals’ perspectives. Design This explorative study employed qualitative interviews and content analysis. Setting and participants Seven focus group discussions engaging 42 key informants were performed, including patients, staff and managers with experience of dialysis care. Results In dialysis care, patient participation connotes a sharing of information and knowledge, the learning of and planning of care, including partaking in shared decisions with regards to treatment and management, and being involved in the management of one's own health‐care treatment and/or self‐care activities. Although these attributes were illustrated by all stakeholders, their significance varied: patients suggested that their preferences regarding primary aspects of participation vary, while staff considered patients’ performance of dialysis to be the ultimate form of participation. Further, while patients considered multiple ways to execute participation, staff suggested that aspects such as sharing information were a route to, rather than actual, involvement. Conclusions Without a common understanding to denote the idea of patient participation, staff and patients are exposed to a potential deficit in terms of facilitating patient participation in everyday encounters of dialysis treatment. Further studies and means to serve a mutual understanding are needed.

Background: Haemodialysis requires a vascular access, most commonly an arteriovenous fistula, which many patients consider a lifeline. It is important to select a cannulation technique assuring a low number of complications. Buttonhole cannulation using sharp needles is a common technique, but information is scarce regarding its long-term consequences. In this study, we aimed to investigate whether the choice of cannulation technique – buttonhole with sharp or blunt needles – affected the development of arteriovenous fistula complications. Methods: We retrospectively reviewed medical records from 2008 to 2015, including 49 patients and 52 AVFs. We compared the complications in patients cannulated with the buttonhole technique using sharp needles versus blunt needles. Results: The recorded complications were grouped into major and everyday complications. Although major complications were not significantly more frequent with sharp needles than with blunt needles, there were higher numbers of bleedings between dialyses with sharp needles. In addition, everyday complications (e.g. infiltration, oozing and large scabs) were significantly more frequent with sharp needles than blunt needles. Moreover, patients with multiple everyday complications had a higher probability of experiencing a major complication with sharp needles. Conclusion: More frequent cannulation with blunt needles can reduce the rate of everyday complications. This practice may additionally reduce patient suffering and the incidence of major complications.

Aim and objectives Our aim was to explore the experiences of hemodialysis patients who are waiting for a kidney transplant. Background Currently, more than 100,000 persons are waiting for kidney transplantation in the United States. In Sweden, the number is exceeding 600. The waiting period for a deceased donor can be one to three years or even longer in Sweden. This can be challenging, since the patients' situation, with chronic treatment and illness, is burdensome and requires advanced self-care. Design This study included a purposeful sample of eight patients (33–53 years old) who had been undergoing hemodialysis treatment for at least six months and were waiting for kidney transplantation. Methods The patients were interviewed, and descriptive content analysis was performed. Results Four categories emerged: (1) ‘The waiting process,’ what thoughts and expectations occur and what to do and how to be prepared for the transplant. (2) ‘Awareness that time is running out,’ patients felt tied up by treatment and by needing to be available for transplantation, and they had concerns about health. (3) ‘Need for communication,’ patients described needing support from others and continuous information from the staff. (4) ‘Having relief and hope for the future,’ patients described how to preserve the hope of being able to participate fully in life once again. Conclusions This study reveals the need for extra attention paid to patients waiting for kidney transplantation. Patients' experiences during the waiting period indicate that pretransplant patients have an increased need to be prepared for the transition and for life post-transplantation. Relevance to clinical practice Dialysis patients on waiting lists must be prepared for the upcoming life change. This includes preserving hope during the waiting period and being mentally prepared for transplantation and a dialysis-free life. A pretransplant education program to prevent medical and psychosocial issues is highly recommended.

A method for computer-aided assessment of blood vessel geometries based on shape-fitting algorithms from metric vision was evaluated. Acoustic images of cross sections of the radial artery and cephalic vein were acquired, and medical practitioners used a computer application to measure the wall thickness and nominal diameter of these blood vessels with a caliper method and the shape-fitting method. The methods performed equally well for wall thickness measurements. The shape-fitting method was preferable for measuring the diameter, since it reduced systematic errors by up to 63% in the case of the cephalic vein because of its eccentricity.

The aim of the study was to examine the possibility of postdialysis urea rebound assessment using UV-absorbance measurements in spent dialysate. Twenty-six patients on chronic three-times-a-week hemodialysis (HD) were studied in two separate studies. Double-beam spectrophotometer was used for the determination of UV absorbance in the collected spent dialysate samples. Also, on-line UV absorbance was monitored. The equilibrium concentration (C(eq)) of urea at the end of the rebound phase was calculated based on urea concentration in blood and dialysate and UV absorbance in spent dialysate. Based on C(eq), urea rebound was expressed relative to urea concentration at the end of HD (R1) and relative to the decrease in urea concentration during HD (R2). Estimates based on UV-absorbance values in spent dialysate (R(1_a), R(2_a)) slightly over assess postdialysis rebound compared with results based on the blood sample drawn 30 min after HD (R(1_30post), R(2_30post)), but R(1_a) and R(2_a) presented greater consistency and accuracy compared with the estimates based on the intradialytic blood sample (R(1_b), R(2_b)). In summary, the results show that it is possible to assess postdialysis urea rebound in blood based on UV-absorbance measurements in spent dialysate.

Sera from 84 haemodialysis (HD) patients and 68 healthy blood donors were analysed with commercially available ELISA techniques for fibroblast growth factor 23 (FGF-23), hepatocyte growth factor (HGF), interleukin-6 (Il-6), high-sensitivity C-reactive protein (hs-CRP) and soluble urokinase plasminogen activator receptor (suPAR), to find a possible correlation of FGF-23 and HGF with the earlier recognized inflammatory markers Il-6 and hs-CRP or suPAR. All patients studied had significantly elevated levels of FGF-23, HGF, hs-CRP and suPAR as compared to the controls. Il-6 and hs-CRP correlated for patients (R = 0.6) as well as for patients and controls altogether. Ln (natural logarithm) of HGF correlated weakly with Ln Il-6 and Ln CRP (R 0.28-0.37). Ln FGF-23 correlated only with Ln HGF (r = -0.25) in controls. Ln HGF correlated with ln suPAR (r = 0.6) in both patients and controls. Although elevated as compared to controls, we found no correlation of FGF-23 with the recognized inflammatory markers Il-6, hs-CRP, nor HGF or the new marker suPAR in HD patients. Ln HGF correlated with Ln Il-6, Ln CRP and Ln suPAR. Although probably involved in vessel disease, FGF-23 and HGF may play other roles than acting in inflammatory vessel disease in HD patients. Further studies are necessary to evaluate the role of these immunological markers in chronic haemodialysis patients with atherosclerosis.

Aim: The aim of the study was to develop an optical method for the estimation of creatinine (Cr) removal during dialysis using UV-absorbance. Material and methods: 29 hemodialysis patients on chronic 3-times-a-week hemodialysis were studied in 6 separate studies. Double-beam pectrophotometer was used for the determination of UV-absorbance in the collected spent dialysate samples. A single wavelength (SW) and a multi-wavelength (MW) model were developed using stepwise regression utilizing Cr values from the laboratory as the dependent parameter. The reduction ratio (RR) and total removed Cr (TRCr) were estimated. Results: For blood-Cr RRb (mean ± SD) was 60.9 ± 5.0% (calibration set) and 58.1 ± 6.0% (validation set), for SW UVabsorbance RR_SW was 61.5 ± 5.9% and 57.3 ± 6.0%, and for MW UV-absorbance RR_MW was 65.8 ± 5.8% and 61.7 ± 6.4% respectively. RR_SW and RRb were not statistically different. RR_MW was higher compared to RRb (p < 0.05). TRCr_lab was 13.8 ± 3.8 mmol, TRCr_SW 14.5 ± 2.5 mmol and TRCr_MW 13.8 ± 2.6 mmol, being not statistically different. Conclusion: In summary, creatinine removal during dialysis can be estimated as reduction ratio and total removed creatinine with the UV-absorbance technique.

Background/Aims: Treatment strategies for abnormal mineral metabolism in chronic kidney disease are largely based on achieving target ranges of biomarkers that vary considerably over time, yet determinants of their variability are poorly defined. Methods: Observational study including 162 patients of three dialysis cohorts (peritoneal dialysis, n = 78; hemodialysis, n = 49; hemodiafiltration, n = 35). Clinical and biochemical determinants of parathyroid hormone (PTH) and fibroblast growth factor-23 (FGF23) variability were analyzed in the peritoneal dialysis cohort. All cohorts were used for comparison of PTH and FGF23 intra-subject variability (intra-class correlation), and their intra-subject variability in different modes of dialysis was explored. Results: High PTH variability was independently associated with lower 25-hydroxyvitamin D concentration and factors of lipid and glucose metabolism, whereas high FGF23 variability was mainly associated with lower baseline serum phosphorous. These results were consistent in multivariate and sensitivity analyses. The intra-subject variability of FGF23 was lower than for PTH irrespective of dialysis mode. Conclusions: Baseline vitamin D status and serum phosphorous are independent determinants of the longitudinal variation in PTH and FGF23, respectively. The clinical utility of FGF23 measurement remains unknown, yet it appears favorable based on its greater temporal stability than PTH in dialysis patients.

Patients with chronic renal failure are known to have renal osteodystrophy (bone disease) and increased calcification of vessels. A new marker of bone disease, sclerostin, the two pro-inflammatory cytokines tumour necrosis factor-alpha (TNF-alpha) and interleukin-18 (IL-18), and the fibroblast growth factor-23 (FGF-23) receptor-associated marker Klotho were tested in 84 haemodialysis (HD) patients and in healthy controls. The patients had significantly higher levels of the three former markers than of the controls while Klotho was significantly higher in the controls. Low level, but significant, correlations were observed in the patient group when the levels of these four markers were compared to each other and to those of 5 cytokines and growth factors tested earlier; high-sensitive CRP (hsCRP), interleukin-6 (IL-6), hepatocyte growth factor (HGF), fibroblast growth factor-23 (FGF-23) and soluble urokinase plasminogen activator (suPAR). Ln sclerostin correlated positively to Ln hsTNF-alpha, Ln HGF and Ln suPAR. Ln hsTNF-alpha correlated positively to Ln sclerostin, Ln hsCRP, Ln IL-6, Ln FGF-23, Ln suPAR and Ln IL-18. Ln IL-18 correlated positively to Ln suPAR and Ln TNF-alpha. Ln Klotho correlated negatively to Ln hsCRP but did not correlate to Ln FGF-23. The markers studied here may be involved in the calcification of vessels seen in HD patients due to a combination of inflammation and bone disease. The mechanisms are still not fully known but may be of importance for future therapeutic possibilities in this group of patients. Funding agencies: County Council of ostergotland; Research Council of South Eastern Sweden (FORSS)

The aim of this study was to evaluate the contribution and removal dynamics of the main fluorophores during dialysis by analyzing the spent dialysate samples to prove the hypothesis whether the fluorescence of spent dialysate can be utilized for monitoring removal of any of the protein bound uremic solute. A high performance liquid chromatography system was used to separate and quantify fluorophoric solutes in the spent dialysate sampled at the start and the end of 99 dialysis sessions, including 57 hemodialysis and 42 hemodiafiltration treatments. Fluorescence was acquired at excitation 280 nm and emission 360 nm. The main fluorophores found in samples were identified as indole derivatives: tryptophan, indoxyl glucuronide, indoxyl sulfate, 5-hydroxy-indoleacetic acid, indoleacetyl glutamine, and indoleacetic acid. The highest contribution (35 +/- 11%) was found to arise from indoxyl sulfate. Strong correlation between contribution values at the start and end of dialysis (R-2 = 0.90) indicated to the stable contribution during the course of the dialysis. The reduction ratio of indoxyl sulfate was very close to the decrease of the total fluorescence signal of the spent dialysate (49 +/- 14% vs 51 +/- 13% respectively, P = 0.30, N = 99) and there was strong correlation between these reduction ratio values (R-2 = 0.86). On-line fluorescence measurements were carried out to illustrate the technological possibility for real-time dialysis fluorescence monitoring reflecting the removal of the main fluorophores from blood into spent dialysate. In summary, since a predominant part of the fluorescence signal at excitation 280 nm and emission 360 nm in the spent dialysate originates from protein bound derivatives of indoles, metabolites of tryptophan and indole, the fluorescence signal at this wavelength region has high potential to be utilized for monitoring the removal of slowly dialyzed uremic toxin indoxyl sulfate. Funding Agencies|County Council of Ostergotland, Sweden; Estonian Science Foundation [8621]; Estonian targeted financed project [SF0140027s07]; Estonian Ministry of Education and Research [IUT 19-2]; European Union through the European Regional Development Fund

Background: Phosphate is an important factor in explaining the high progress of vascular calcification among dialysis patients. Today, phosphate concentration is measured in plasma on a regular basis. The aim of this study was to find out if it is possible to estimate total removed phosphate (TRp) in spent dialysate utilizing UV absorbance during hemodiafiltration. Methods: Eleven patients were monitored online with UV absorbance at 297 nm, three times during one week each (n = 33). Dialysate samples were taken at different times during treatment and from a collection tank to chemically determine phosphate concentrations. Two mathematical models (UVIND and UVGROUP) were tested to estimate TRp with supervision by UV absorbance and compared with TRp measured in the tank (reference). Results: High correlation between UV absorbance and phosphate concentration for each single patient and lower for the whole group together was found. TRp was (mean ± SD) 30.7 ± 7.3 mmol for the reference and 30.8 ± 8.2 and 29.1 ± 5.2 mmol for UVIND and UVGROUP, respectively (p > 0.05). Conclusion: This study demonstrates a novel possibility to estimate TRp based on linear relationship between online monitoring of UV absorbance and concentration of phosphate in spent dialysate.

The aim of this work was to evaluate the contributions of the main chromophores to the total UV absorbance of the spent dialysate and to assess removal dynamics of these solutes during optical on-line dialysis dose monitoring. High performance chromatography was used to separate and quantify UV-absorbing solutes in the spent dialysate sampled at the start and at the end of dialysis sessions. Chromatograms were monitored at 210, 254 and 280 nm routinely and full absorption spectra were registered between 200 and 400 nm. Nearly 95% of UV absorbance originates from solutes with high removal ratio, such as uric acid. The contributions of different solute groups vary at different wavelengths and there are dynamical changes in contributions during the single dialysis session. However, large standard deviation of the average contribution values within a series of sessions indicates remarkable differences between individual treatments. A noteworthy contribution of Paracetamol and its metabolites to the total UV absorbance was determined at all three wavelengths. Contribution of slowly dialyzed uremic solutes, such as indoxyl sulfate, was negligible.

Background/Aims: Plasma concentrations of the N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) are increased in end-stage renal disease. Improvement in hemodynamic stability has been reported when switching from hemodialysis (HD) to on-line hemodiafiltration (ol-HDF). The aim of this study was to investigate plasma concentrations of NT-proBNP, BNP and neuropeptide Y (NPY) during a 1-year follow-up, after a change from high-flux HD to postdilution ol-HDF. Additional variables were also studied, e.g. pulse wave velocity and ordinary clinical parameters. Method: We conducted a prospective, single-center study including 35 patients who were switched from HD to HDF. Plasma concentrations of NT-proBNP, BNP and NPY before and after dialysis were measured at baseline (i.e. HD) and at 1, 2, 4, 6 and 12 months on HDF. Results: All three peptide levels decreased significantly during HD and HDF when comparing concentrations before and after dialysis. Mean absolute value (before/after) and relative decrease (%) before versus after dialysis was 13.697/9.497 ng/l (31%) for NT-proBNP, 62/40 ng/ml (35%) for BNP and 664/364 pg/l (45%) for NPY. No significant differences were observed when comparing predialysis values over time. However, postdialysis NT-proBNP concentration showed a significant decrease of 48% over time after the switch to HDF. Conclusion: The postdialysis plasma levels of NT-proBNP, BNP and NPY decreased significantly during both dialysis modes when compared to before dialysis. The postdialysis lowering of NT-proBNP increased further over time after the switch to ol-HDF; the predialysis levels were unchanged, suggesting no effect on its production in the ventricles of the heart.

The discussion was initiated by a paper comparing the measurement of dialysis dose (Kt/V) and solute clearance using on-line ultra-violet absorbance, blood and dialysate urea and ionic dialysance by Uhlin et al (NDT 2006). Participants from 14 countries discussed the theory behind the UV absorbance technique and the potential for its use in routine practice, the correlation between Kt/V measured using different methods, the use of ionic dialysance and the optimisation of dose monitoring. The 'take-home' messages from the discussion were that UV-absorbance could help ensure the delivery of dialysis dose as it provides real time feedback on the effect interventions such as repositioning of needles. The technology is relatively inexpensive and requires no consumables but changes in the dialysis machine settings could lead to misleading measurements if not communicated to the UV monitor. Session-to-session variation in dialysis dose can be measured using on-line clearance monitoring. If it is already on the machine and costs nothing, why not use it? Alternatively, regular access recirculation checks and a record of the total blood volume processed at each session allow problems with delivered dialysis dose to be picked up between routine blood tests.

Objective. To study the patency and complications associated with the Dialock, an access device for haemodialysis. Material and methods. The records of seven Swedish patients who were treated with ...

Background/aims Vitamin D deficiency and elevated serum fibroblast growth factor-23 (FGF23) levels are hallmark features and surrogate markers of adverse clinical outcomes in patients with chronic kidney disease (CKD). Convection of molecules over the dialysis membrane during online hemodiafiltration (ol-HDF) increases the removal of larger waste molecules compared with traditional high-flux hemodialysis (HD). The primary aim of this study was to explore the long-term impact of ol-HDF on serum 25(OH)D and FGF23. Method An observational, prospective, noncomparator study including 35 patients who were switched from HD to ol-HDF. Serum 25(OH)D and FGF23 were measured at baseline (i.e., time of switch to ol-HDF) and at 6, 12, and 24 months. Results At follow-up time points, there was a significant reduction in serum 25(OH)D compared with baseline (p 0.05). The decrease in 25(OH)D was more prominent in individuals with higher baseline 25(OH)D levels. Conclusion Ol-HDF may lower systemic 25(OH)D levels by convective mechanisms although the clinical significance remains unknown. Further controlled studies are warranted to replicate these findings in larger patient cohorts.