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Introduction: Intradialytic hypertension (IDH) is a poorly understood phenomenon with no consensus on its definition, etiology, or related factors, and there is limited evidence on its consequences. Objective: To determine the prevalence of IDH according to different definitions in hemodialysis (HD) units, with different clinical practices and assessment of possible events after 18 months have passed. Materials and methods: A cross-sectional observational study was conducted in 2 HD units, including all prevalent patients from March 2021 to September 2022. We established 3 definitions of IDH: • Def 1: Mean arterial pressure (MAP) difference pre- and pos-HD >15 mmHg • Def 2: Systolic blood pressure (SBP) difference pre- and pos-HD >10 mmHg • Def 3: SBP difference >0 and ultrafiltration rate (UFR) >5 ml/kg/hIDH was considered present if the criterion was met in more than 50% of the 6 consecutive sessions (2 weeks) of follow-up. Personal history, medications, dialysis characteristics, and pre- and post-HD biochemical data were collected. Residual renal function (RRF) was considered as urine output >250 ml/24 h. At 18 months, the possible events of the group were analyzed. Results: We included 169 patients (68% men) with a mean age of 67.9 (14.2) years and a median HD duration of 34.5 (IQR 17.5–67.5) months. Of these, 94 come from one unit and 75 from the other. The prevalence of IDH was 8.3% according to Def 1, 27.2% according to Def 2, and 29.6% according to Def 3. Def 2 showed an association with a history of previous hypertension, use of renin-angiotensin system inhibitors (RASIs), and furosemide, as well as with patients with RRF. Def 3 showed an association only with coronary artery disease. There was an association with different prescriptions of dialysis fluids. Catecholaminergic hormones and aldosterone did not increase in patients with hypertension during the HD session. They did not present a higher incidence of cardiovascular events or mortality at 18 months. Conclusions: IDH has different prevalence rates depending on the definition used and the studied center. The future poses an important challenge: to determine which definition correlates with higher morbidity and mortality and the role of differences found in different HD units. Resumen: Introducción: La hipertensión arterial intradiálisis (HTAID) es un fenómeno poco conocido del que no existe consenso en su definición, ni datos sobre su etiología o factores relacionados, y hay poca evidencia sobre sus repercusiones. Objetivo: Definir la prevalencia según diferentes definiciones en dos unidades de hemodiálisis (HD), de dos hospitales diferentes, con distinta práctica clínica y valoración de posibles eventos después de haber pasado 18 meses. Material y métodos: Estudio observacional transversal realizado en 2 unidades de HD donde se incluyeron todos los pacientes prevalentes desde marzo 2021 hasta septiembre 2022. Establecimos 3 definiciones de HTAID: • Def 1: Diferencia de presión arterial media (PAM) pre- y pos-HD > 15 mmHg • Def 2: Diferencia de presión arterial sistólica (PAS) pre- y pos-HD > 10 mmHg • Def 3: Diferencia de PAS > 0 y UFR > 5 ml/kg/hConsideramos había HTAID si se cumplía el criterio en más del 50% de las 6 sesiones consecutivas (2 semanas) de seguimiento. Se recogieron antecedentes personales, medicamentos, características de diálisis y datos bioquímicos pre y post HD. Se consideró función renal residual (FRR) una diuresis >250 ml/24 h. Se analizó a los 18 meses los posibles eventos del grupo. Resultados: Incluimos 169 pacientes (68% hombres), con una edad media de 67,9 (14,2) años y una mediana de tiempo en HD de 34,5 (AIC 17,5–67,5) meses. De ellos 94 provienen de una unidad y 75 de la otra. La prevalencia de HTAID fue según Def1 (8,3%), Def 2 (27,2%) y Def3 (29,6%). Se evidencia una asociación en la Def2 con antecedente de HTA previa, uso de inhibidores del sistema renina angiotensina (ISRA) y furosemida y en los pacientes con FRR, en la Def3 solo asociación a coronariopatía. Existe asociación con las diferentes prescripciones de los líquidos de diálisis. No aumentaron las hormonas catecolaminérgicas y aldosterona en los pacientes con HTAID durante la sesión de HD. No presentaron mayor incidencia de eventos cardiovasculares o mortalidad a los 18 meses. Conclusiones: La HTAID tiene una prevalencia distinta tanto según la definición utilizada como la unidad estudiada. El futuro plantea un importante reto: conocer cuál de las definiciones determina una mayor implicación clínica y el papel que tienen las diferencias encontradas en las distintas unidades de HD.

Resumen: Introducción: La hipertensión arterial intradiálisis (HTAID) es un fenómeno poco conocido del que no existe consenso en su definición, ni datos sobre su etiología o factores relacionados, y hay poca evidencia sobre sus repercusiones. Objetivo: Definir la prevalencia según diferentes definiciones en 2 unidades de hemodiálisis (HD), de 2 hospitales diferentes, con distinta práctica clínica y valoración de posibles eventos después de haber pasado 18 meses. Material y métodos: Estudio observacional transversal realizado en 2 unidades de HD donde se incluyeron todos los pacientes prevalentes desde marzo de 2021 hasta septiembre de 2022. Establecimos 3 definiciones de HTAID: - Def 1: Diferencia de presión arterial media (PAM) pre- y pos-HD > 15 mmHg. - Def 2: Diferencia de presión arterial sistólica (PAS) pre- y pos-HD > 10 mmHg. - Def 3: Diferencia de PAS > 0 y UFR > 5 ml/kg/h.Consideramos que había HTAID si se cumplía el criterio en más del 50% de las 6 sesiones consecutivas (2 semanas) de seguimiento. Se recogieron antecedentes personales, medicamentos, características de diálisis y datos bioquímicos pre- y pos-HD. Se consideró función renal residual (FRR) una diuresis > 250 ml/24 h. Se analizó a los 18 meses los posibles eventos del grupo. Resultados: Incluimos 169 pacientes (68% varones), con una edad media de 67,9 (14,2) años y una mediana de tiempo en HD de 34,5 (AIC 17,5-67,5) meses. De ellos, 94 provienen de una unidad y 75 de la otra. La prevalencia de HTAID fue según Def 1 (8,3%), Def 2 (27,2%) y Def 3 (29,6%). Se evidencia una asociación en la Def 2 con antecedente de HTA previa, uso de inhibidores del sistema renina angiotensina (ISRA) y furosemida y en los pacientes con FRR, en la Def 3 solo asociación a coronariopatía. Existe asociación con las diferentes prescripciones de los líquidos de diálisis. No aumentaron las hormonas catecolaminérgicas y aldosterona en los pacientes con HTAID durante la sesión de HD. No presentaron mayor incidencia de eventos cardiovasculares o mortalidad a los 18 meses. Conclusiones: La HTAID tiene una prevalencia distinta tanto según la definición utilizada como la unidad estudiada. El futuro plantea un importante reto: conocer cuál de las definiciones determina una mayor implicación clínica y el papel que tienen las diferencias encontradas en las distintas unidades de HD. Abstract: Introduction: Intradialytic hypertension (IDH) is a poorly understood phenomenon with no consensus on its definition, etiology, or related factors, and there is limited evidence on its consequences. Objective: To determine the prevalence of IDH according to different definitions in hemodialysis (HD) units, with different clinical practices and assessment of possible events after 18 months have passed. Materials and methods: A cross-sectional observational study was conducted in two HD units, including all prevalent patients from March 2021 to September 2022. We established three definitions of IDH: Def 1: Mean arterial pressure (MAP) difference pre- and pos-HD > 15 mmHg. Def 2: Systolic blood pressure (SBP) difference pre- and pos-HD > 10 mmHg. Def 3: SBP difference >0 and ultrafiltration rate (UFR) > 5 ml/kg/h.IDH was considered present if the criterion was met in more than 50% of the six consecutive sessions (2 weeks) of follow-up. Personal history, medications, dialysis characteristics, and pre- and post-HD biochemical data were collected. Residual renal function (RRF) was considered as urine output >250 ml/24 h. At 18 months, the possible events of the group were analyzed. Results: We included 169 patients (68% men) with a mean age of 67.9 (14.2) years and a median HD duration of 34.5 (IQR: 17.5-67.5) months. Of these, 94 come from one unit and 75 from the other. The prevalence of IDH was 8.3% according to Def 1, 27.2% according to Def 2, and 29.6% according to Def 3. Def 2 showed an association with a history of previous hypertension, use of renin-angiotensin system inhibitors (RASIs), and furosemide, as well as with patients with RRF. Def 3 showed an association only with coronary artery disease. There was an association with different prescriptions of dialysis fluids. Catecholaminergic hormones and aldosterone did not increase in patients with hypertension during the HD session. They did not present a higher incidence of cardiovascular events or mortality at 18 months. Conclusions: IDH has different prevalence rates depending on the definition used and the studied center. The future poses an important challenge: to determine which definition correlates with higher morbidity and mortality and the role of differences found in different HD units.

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Background: Encapsulating peritoneal sclerosis is a rare manifestation nowadays. Case Report: This was a case report of a young female with ESKD on hemodialysis for more than 6 months with a previous history of continuous ambulatory peritoneal dialysis (CAPD) and recurrent peritonitis which currently presented with painful abdominal distension. The CT scan of the abdomen showed a clumping of small bowel loops at the left side encased into a thin fibrocartilaginous membrane. Initially, she was treated for intrabdominal sepsis; however, after recurrent admission, intravenous Methylprednisolone was started, followed by high-dose steroids and tamoxifen as a treatment for encapsulating peritoneal sclerosis (EPS). Surprisingly, she improved and had a good clinical response. She was readmitted again after a few months with abdominal pain due to an abrupt stop in steroid but improved again after the steroid was started. Conclusion: Abdominal pain in a patient with a history of CAPD peritonitis needs to raise suspicion of EPS even though is rare. Radiological Imaging is helpful in making early diagnosis. The most important thing is steroids as a mainstay of the treatment of EPS besides tamoxifen with a minimal 1-year duration or lifelong as surgical intervention is very risky. [ABSTRACT FROM AUTHOR]

Abstract Background and objectives Hemodialysis complications remain a critical threat among dialysis patients. They result in sudden termination of the session which impacts the efficiency of dialysis. As intra-dialytic complications are the result of the interplay of multiple factors, artificial intelligence can aid in their early prediction. This research aims to compare different machine learning tools for the early prediction of the most frequent hemodialysis complications with high performance, using the fewest predictors for easier practical implementation. Methods Fifty different variables were recorded during 6000 hemodialysis sessions performed in a regional dialysis unit in Egypt. The filter technique was used to extract the most relevant features. Then, five individual classifiers and three ensemble approaches were implemented to predict the occurrence of intra-dialytic complications. Different subsets of 25, 12 and 6 from the 50 collected features were tested. Results Random forest yielded the highest accuracy of 98% with the least training time using 12 features in a balanced dataset, while the gradient boosting allowed obtaining the highest F1-score of 94%, 92%, and 78% in the prediction of hypotension, hypertension, and dyspnea, respectively, in imbalanced datasets. Conclusion Applying different machine learning algorithms to big datasets can improve accuracy, reduce training time and model complexity allowing simple implementation in clinical practice. Our models can help nephrologists predict and possibly prevent dialysis complications.

Background Despite Hemodialysis (HD) is a relatively safe procedure for End Stage Kidney Disease (ESKD) patients, Intradialytic (ID) hypotension and hypertension are frequently reported complications in many adults' studies. However, little is known about acute intradialytic complications in children. Objective This study aimed to assess the incidence of acute ID blood pressure (BP) changes among children attending the HD unit at our institute. Furthermore, it assessed the possible risk factors and the management options. Patients and methods All children with ESKD on chronic HD were enrolled. A checklist was fulfilled every dialysis session over a six-month period, including patient's demographic data, dialysis session details: frequency/week, duration of session, ultrafiltration volume, BP, vital signs, IVC diameter, dry weight and predialysis weight. All cases were subjected to echocardiography for estimation of cardiac function. Results Thirty-two patients with mean age of 9.16±2.48 years, and who dialyzed a total of 2678 sessions, were included in the current study. ID hypotension was the top (71.8%) of all complications with an incidence rate of 12.6% in all sessions, followed by ID hypertension (25.7%) with an incidence rate of 4.5% in all sessions. ID hypotension was significantly associated with males, with predialytic hypertension (P<0.001), high ultrafiltration rate (P0.033), and longer durations of sessions (mean >3.56 h±0.56 h) (P<0.001). However, less duration (mean < 3.33 h±0.55) and a lower percentage of ID weight loss were independent risk factors for the development of ID hypertension. Conclusion ID blood pressure changes are the most frequent complications in our study; hypotension is on the top of list (12.6% per sessions) followed by hypertension (4.5% per sessions). ID blood pressure is influenced by multiple risk factors; mainly by predialytic hypertension, duration of session and ID weight loss. [ABSTRACT FROM AUTHOR]

Objective: Lung ultrasonography (LUS) has recently been used to evaluate extravascular lung water, and shown to be able to predict all-cause mortality in hemodialysis (HD) patients. This study aim to compare LUS with other volume assessment methods, and to verify the prognostic value of LUS in Thai chronic HD patients. Materials and Methods: We conducted a prospective cohort study in 36 chronic HD patients. Volume status before the HD session was evaluated by physical examinations, bioimpedance analysis (BIA), and ultrasound lung comets (ULCs). Mortality and morbidities were recorded during a 1-year follow-up period. Results: The degree of lung fluid accumulation was assessed by summation of the number of ULCs, and was classified into 3 groups: mild-to-moderate (ULC<15-29), severe (ULC=30-59), and very severe (ULC=60) in 11.1%, 77.8%, and 11.1% of the patients, respectively. Either clinical edema or lung crackle had low sensitivity (20-32%) to detect extravascular lung water excess in patient with mild-to-moderate ULC and severe ULC. Overhydration assessed by BIA was found in 75% and 64.3% of patients with mild-to-moderate and severe ULC, respecively. In patients with very severe ULC, the admission rate due to volume overload was significantly higher, there was also a trend of increased mortality, as well as intradialytic complications. Conclusion: Clinical assessment and BIA have limited value in determining extravascular fluid excess in the lung. Lung ultrasound is a useful tool to detect subclinical pulmonary congestion. The long-term outcome by using LUSguided fluid management needs larger population studies. [ABSTRACT FROM AUTHOR]

Background and Objectives: Hemodialysis complications remain a critical threat among dialysis patients. They result in sudden termination of the session which impacts the efficiency of dialysis. As intra-dialytic complications are the result of the interplay of multiple factors, artificial intelligence can aid in their early prediction. This research aims to compare different machine learning tools for the early prediction of the most frequent hemodialysis complications with high performance, using the fewest predictors for easier practical implementation.Methods: Fifty different variables were recorded during 6000 hemodialysis sessions performed in a regional dialysis unit in Egypt. The filter technique was used to extract the most relevant features. Then, five individual classifiers and three ensemble approaches were implemented to predict the occurrence of intra-dialytic complications. Different subsets of 25, 12 and 6 from the 50 collected features were tested.Results: Random forest yielded the highest accuracy of 98% with the least training time using 12 features in a balanced dataset, while the gradient boosting allowed obtaining the highest F1-score of 94%, 92%, and 78% in the prediction of hypotension, hypertension, and dyspnea, respectively, in imbalanced datasets.Conclusion: Applying different machine learning algorithms to big datasets can improve accuracy, reduce training time and model complexity allowing simple implementation in clinical practice. Our models can help nephrologists predict and possibly prevent dialysis complications. [ABSTRACT FROM AUTHOR]

Introduction: Intradialytic hypertension (IDH) is a poorly understood phenomenon with no consensus on its definition, etiology, or related factors, and there is limited evidence on its consequences., Objective: To determine the prevalence of IDH according to different definitions in hemodialysis (HD) units, with different clinical practices and assessment of possible events after 18 months have passed., Materials and Methods: A cross-sectional observational study was conducted in 2 HD units, including all prevalent patients from March 2021 to September 2022. We established 3 definitions of IDH: IDH was considered present if the criterion was met in more than 50% of the 6 consecutive sessions (2 weeks) of follow-up. Personal history, medications, dialysis characteristics, and pre- and post-HD biochemical data were collected. Residual renal function (RRF) was considered as urine output >250 ml/24 h. At 18 months, the possible events of the group were analyzed., Results: We included 169 patients (68% men) with a mean age of 67.9 (14.2) years and a median HD duration of 34.5 (IQR 17.5-67.5) months. Of these, 94 come from one unit and 75 from the other. The prevalence of IDH was 8.3% according to Def 1, 27.2% according to Def 2, and 29.6% according to Def 3. Def 2 showed an association with a history of previous hypertension, use of renin-angiotensin system inhibitors (RASIs), and furosemide, as well as with patients with RRF. Def 3 showed an association only with coronary artery disease. There was an association with different prescriptions of dialysis fluids. Catecholaminergic hormones and aldosterone did not increase in patients with hypertension during the HD session. They did not present a higher incidence of cardiovascular events or mortality at 18 months., Conclusions: IDH has different prevalence rates depending on the definition used and the studied center. The future poses an important challenge: to determine which definition correlates with higher morbidity and mortality and the role of differences found in different HD units., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2024. Published by Elsevier España, S.L.U.)

The study objective is to evaluate the effectiveness of different approaches to correction and prevention of arterial hypotension episodes in patients undergoing long-term hemodialysis (HD).Materials and methods. The study included 35patients undergoing long-term hemodialysis in the dialysis center. In all patients, automatic non-invasive measurement of arterial pressure (AP) was performed using a built-in option of the “artificial kidney” device. Prior to the study, all patients underwent clinical test with evaluation of “dry weight” and bioelectrical impedance analysis. Crossover design was used in the study: at the beginning, hypotensive episodes were corrected in all patients using the standard method (the first 4 hemodialysis procedures); then during the following 4 procedures in addition to standard methods a computer algorithm automatically controlling ultrafiltration rate using an automatic system of pressure control (ASPC) with constant AP monitoring (AP was measured prior to hemodialysis and after it and at least 1 time in the first 5 min of the procedure; from the 4h procedure onwards, intervals were determined by the algorithm automatically) was used. Values of mean AP during hemodialysis procedures for the whole monitoring period were analyzed. The duration of the study was 3 weeks for all patients.Results. Mean pre-dialysis systolic and diastolic AP in the patients for the standard approach was 124.6 ± 27.7 and 74.5 ± 21.1 mm Hg, post-dialysis AP was 114.4 ± 24.4 and 71.3 ± 16.3 mm Hg, respectively. For ASPC, pre-dialysis and post-dialysis AP was statistically significantly higher than for the standard approach: 133.2 ± 21.3 and 79.3 ± 15.8 mm Hg (p

For peritonitis, a serious complication of peritoneal dialysis (PD), we investigated the relation between duration from the sign (PD effluent abnormalities) to treatment with appropriate antibiotics (ST time) and catheter removal. For 62 PD hospital patients, data of PD-related peritonitis (n = 109) were collected retrospectively. We examined ST time and PD catheter removal times using univariate and multivariate analyses. The catheter removal rate in the delayed ST time group (≥ 24 h) was higher than that in early ST time group (< 24 h) (38 vs. 16%, p = 0.02). Concomitant tunnel infection and delayed ST time were associated with catheter removal (OR [95% CI] 32.3 [3.15–329] and 3.52 [1.11–11.1]). Rates of catheter removal and re-development of peritonitis within 1 month after starting treatment were higher in the delayed ST time group (p = 0.02). PD duration at peritonitis and the first peritonitis episode were associated with delayed ST time (1.02 [1.00–1.04] and 3.42 [1.09–10.7]). Significant association was found between PD catheter removal and the start of treatment more than 24 h after appearance of abnormal effluent. Education for patients about prompt visitation at the onset of peritonitis with long PD duration might improve outcomes. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the impact of oral hygiene, periodontal diseases, and dental caries on all-cause mortality in hemodialysis. This prospective cohort study included 266 patients with end-stage renal disease who were undergoing hemodialysis. Medical interviews, blood biochemical tests, and comprehensive dental examinations including periodontal pocket examination on all teeth and dental plaque accumulation by debris index-simplified (DI-S), were performed. Survival rates were assessed at a 3-year follow-up. Overall, 207 patients were included in the longitudinal analysis, and 38 subjects died during the follow-up period. Cox proportional hazards analysis of the multivariate model demonstrated that the highest tertile of DI-S had a significantly higher risk of all-cause mortality than the lowest two tertiles after adjustment for age, sex, smoking habit, body mass index, diabetes, prior cardiovascular disease, hemodialysis vintage, high sensitivity C-reactive protein, albumin, and number of remaining teeth (hazard ratio, 3.04; 95% confidence interval, 1.50–6.17; p = 0.002). Moreover, the number of decayed teeth significantly increased the hazard ratio to 1.21 (95% confidence interval, 1.06.1.37; p = 0.003). This study suggests that accumulated dental plaque and untreated decay, but not periodontal disease, may be independently associated with all-cause mortality in patients undergoing hemodialysis. [ABSTRACT FROM AUTHOR]

Introduction: Staphylococcus aureus bacteremia (SAB) is a high‐risk infection and feared complication related to hemodialysis. This study aimed to investigate incidence and risk factors for SAB depending on hemodialysis access type. Methods: The Danish National Registry on Regular Dialysis and Transplantation was used to identify patients from January 1, 1996 to December 31, 2011 with end‐stage kidney disease. Patients were followed until death, the first episode of SAB, or end of study (December 31, 2011). Independent risk factors were assessed by multivariable Poisson regression with time‐updated exposure variables. Findings: Total of 9997 patients were included. The initial modality of renal replacement therapy was hemodialysis in 6826 patients and peritoneal dialysis in 2882 patients; 289 patients had preemptive kidney transplantation. SAB occurred in 1278 patients (12.8%). The incidence rate of SAB declined after 90 days and leveled off after 270 days in hemodialysis, peritoneal dialysis, and kidney transplanted. As compared to peritoneal dialysis, the adjusted rate ratio (RR) for SAB was 7.42 (95% CI 5.63–9.79) in uncuffed central venous catheter (CVC), 5.68 (95% CI 4.39–7.36) in cuffed CVC, 4.43 (95% CI 2.10–9.53) in arteriovenous graft, and 3.40 (95% CI 2.79–4.15) in arteriovenous fistula. SAB risk did not differ between uncuffed and cuffed CVC. The risk of SAB was increased during the first three months of renal replacement therapy especially for CVC (RR 11.37 [95% CI7.09–18.22]) compared with peritoneal dialysis. Diabetes mellitus (RR 1.35 [95% CI 1.20–1.51]) and male sex (RR 1.15 [95% CI 1.03–1.29]) were also associated with SAB. Discussion: Patients on hemodialysis had a high incidence rate of SAB, particularly those undergoing hemodialysis via CVC. SAB risk was comparable for cuffed and uncuffed CVC. Diabetes mellitus, male sex, and the first three months in renal replacement therapy were independently associated with SAB. [ABSTRACT FROM AUTHOR]

BACKGROUND: Guidelines recommend avoidance of several psychoactive medications such as hypnotics in older adults due to their adverse effects. Older patients on hemodialysis may be particularly vulnerable to complications related to use of these agents, but only limited data are available about the risks in this population. OBJECTIVES: To evaluate the association between the use of psychoactive medications and time to first emergency department visit or hospitalization for altered mental status, fall, and fracture among older patients receiving hemodialysis. DESIGN: Observational cohort study. SETTING: National registry of patients receiving hemodialysis (US Renal Data System). PARTICIPANTS: A total of 60 007 adults 65 years or older receiving hemodialysis with Medicare Part D coverage in 2011. MEASUREMENTS: The predictors were use of sedative‐hypnotics and anticholinergic antidepressants (modeled as separate time‐varying exposures). The outcomes were time to first emergency department visit or hospitalization for altered mental status, fall, and fracture (modeled separately). RESULTS: Overall, 17% and 6% used sedative‐hypnotics and anticholinergic antidepressants, respectively, in 2011. In multivariable‐adjusted Cox regression, anticholinergic antidepressant use was associated with a 25%, 27%, and 39% higher hazard of altered mental status, fall, and fracture, respectively, compared with no use. Use of sedative‐hypnotics was not associated with adverse outcomes. CONCLUSION: Anticholinergic antidepressants were associated with adverse outcomes in older hemodialysis patients, and alternative treatments should be considered. Sedative‐hypnotics were not associated with the risks evaluated in this study, but further investigation of the harms of this class of agents is warranted before their recommendation as a treatment option for insomnia in this population. J Am Geriatr Soc 67:449–454, 2019. See related Editorial by Rasheeda Hall in this issue. [ABSTRACT FROM AUTHOR]

A hemodialysis patient with higher-risk myelodysplastic syndrome treated with standard-dose azacitidine. Azacitidine for injection (AZA) (Vidaza, Celgene Corp., Summit, NJ), represents a well-established and registered agent in Myelodysplastic Syndromes (MDS) and in acute myeloid leukemia (AML) [[1]]. In hemodialysis patients there are only a few case reports of administration of AZA and to our knowledge it has never been investigated to which extent AZA is removed by hemodialysis [[14]]. [Extracted from the article]

Background and Objectives: Hemodialysis is the most common method of treatment for end stage renal disease .The hemodialysis dialyzers are divided into low-flux and high-flux. This study aimed to compare the effects of these two dialyzers on patient’s comfort and hemodialysis complications in end-stage renal dialysis patients. Methods: In a clinical trial, convenience and complications (variations of blood pressure, nausea, vomiting, itching, headache, and fever and chills) of 30 eligible patients were assessed during hemodialysis in two groups with low- and high-flux dialyzers. Data were analyzed using ANOVA, paired t-test, and Chi-square were analyzed. The significance level was considered to be p0.05). The incidence and severity of hemodialysis complications did not show any statistically significant changes between the two dialyzers, (p>0.05). The patient’s comfort was higher with high-flux dialyzer, but it was not significant (p>0.05). Conclusion: According to the results of this study, in the case of no statistically significant differences in the incidence and severity of complications and also the importance of dialyzers in hemodialysis patients, it is recommended that high-flux filter be used in dialysis wards.

Background: Intradialytic hypotension (IDH) is a frequent complication of hemodialysis, and is associated with significant morbidity and mortality. Off-label use of the alpha-1 andrenergic receptor agonist midodrine to reduce the frequency and severity of IDH is common. However, limited data exist to support this practice. This study sought to examine real-world efficacy of midodrine with respect to relevant clinical and hemodynamic outcomes.Methods: Here, we compared a variety of clinical and hemodynamic outcomes among adult patients who were prescribed midodrine (n = 1,046) and matched controls (n = 2,037), all of whom were receiving in-center hemodialysis treatment at dialysis facilities in the United States (July 2015 - September 2016). Mortality, all-cause hospitalization, cardiovascular hospitalization, and hemodynamic outcomes were considered from the month following the initiation of midodrine (or corresponding month for controls) until censoring for discontinuation of dialysis, transplant, loss to follow-up, or study end (September 30, 2016). Rate outcomes were compared using Poisson models and quantitative outcomes using linear mixed models; all models were adjusted for imbalanced patient characteristics.Results: Compared to non-use, midodrine use was associated with higher rates of death (adjusted incidence rate ratio 1.37, 95% CI 1.15-1.62), all-cause hospitalization (1.31, 1.19-1.43) and cardiovascular hospitalization (1.41, 1.17-1.71). During follow-up, midodrine use tended to be associated with lower pre-dialysis systolic blood pressure (SBP), lower nadir SBP, greater fall in SBP during dialysis, and a greater proportion of treatments affected by IDH.Conclusion: Although residual confounding may have influenced the results, the associations observed here are not consistent with a potent beneficial effect of midodrine with respect to either clinical or hemodynamic outcomes. [ABSTRACT FROM AUTHOR]

Background: Arteriovenous (AV) access dysfunction is a common complication in hemodialysis patients. Markers of vascular calcification are associated with cardiovascular outcomes and mortality in this population, but their association with vascular access outcomes is unknown. In this study, we aimed to evaluate the association between selected vascular calcification makers and vascular access complications in a cohort of hemodialysis patients.Method: Fetuin-A, osteopontin (OPN), osteoprotegerin (OPG), and bone morphogenetic protein-7 (BMP-7) were measured in blood samples from 219 dialysis patients in the Choice for Healthy Outcomes in Caring for end-stage renal disease study; these patients were using a permanent vascular access. Participants were followed for up to 1 year or until the occurrence of a vascular access intervention or replacement. Associations with AV fistula (AVF) and AV graft (AVG) intervention-free survival were assessed in models adjusted for demographic characteristics, comorbidities, and inflammation.Results: A total of 24 out 103 participants with an AVF and 43 out of 116 participants with an AVG had an intervention during follow-up. Lower fetuin-A, higher OPN, and higher BMP-7 were associated with a higher risk of AVF intervention (adjusted hazard ratios [aHR] for highest versus lowest tertile = 0.30 [95% CI 0.10-0.94]) for fetuin-A, 3.84 (95% CI 1.16-12.74) for OPN, and 3.49 (95% CI 1.16-10.52) for BMP-7. OPG was not significantly associated with the risk of AVF intervention. The associations of OPN and BMP-7 with AVF intervention appeared stronger among participants without diabetes (aHR 8.06; 95% CI 1.11-58.57 for OPN and aHR 2.55; 95% CI 1.08-6.08 for BMP-7, respectively) than among their counterparts with diabetes (p interaction = 0.06). None of the markers studied were significantly associated with AVG interventions.Conclusion: Lower fetuin-A and higher OPN and BMP-7 are associated with complications in AVF but not in AVG, suggesting a role for calcification in the pathogenesis AVF failure. [ABSTRACT FROM AUTHOR]

Fluid volume overload is common and is associated with adverse outcomes in hemodialysis patients. Practicing physicians individually manage fluid volume balance in their dialysis patients according to blood pressure, interdialytic weight gain, cardiac function, nutritional status, and other comorbidities. However, accurate assessment of fluid volume status remains a concern. Indicators of dry weight target have been explored further with newer concepts and technologies. In general, total body water comprises approximately 50%-60% of adult body weight (range, 45%-75%), and water comprises 73.3% of lean body mass. The standard hydration status between intracellular water and extracellular water is maintained at a ratio of 62:38 in healthy adults, which, however, is influenced universally by body cell volume driven by age and muscle mass. Fluid volume imbalance in dialysis patients also is characterized primarily by decreased body cell mass associated with aging and muscle attenuation, as well as excess extracellular water content associated with sodium retention, which may be associated with the reserve capacity for volume overload. Indeed, dialysis patients with a leaner body mass have a higher prevalence of hypertension, poorer hypertension control, and greater left ventricular hypertrophy. Understanding of these body composition changes by aging and sarcopenia can aid clinical decision making in the dry weight assessments in dialysis patients. Advising patients with consistently high interdialytic weight gain to practice salt restriction and providing appropriate nutritional support for malnourished patients with downward trajectory in their dry weight would be of great help to achieve optimal fluid volume status. [ABSTRACT FROM AUTHOR]

Protein energy wasting (PEW) is a condition commonly occurring among patients with ESRD on hemodialysis. PEW is characterized by depletion of protein and energy stores and is caused by multiple factors related to chronic kidney disease, acute and chronic comorbidities and by renal replacement therapy itself. Anorexia is central in the pathogenesis of PEW; it is frequently observed in these patients whose protein and energy intakes are typically lower than guidelines recommendations. If untreated, PEW invariably leads to major complications, and may activate a vicious circle with further worsening of nutritional status. Dietary counseling and nutritional status monitoring play a key role in the prevention and treatment of PEW, since they allow an early identification of high risk patients, as well as the assessment of the response to nutritional intervention. Different nutritional approaches can be implemented following thorough nutritional counseling. These are chosen on the basis of patients' spontaneous dietary intake, severity of PEW and acute comorbidities. Initially, regular encounters with the dietitian allow patients to clarify doubts and strengthen basic concepts on nutrition to improve dietary intake and prevent PEW. When PEW is present or the patient is at high risk, the clinician may opt for the administration of oral intradialytic or daily supplements, aiming at increasing energy and protein intake, while in selected cases intradialytic parenteral nutrition may be used. This review addresses the main issues of nutritional status in ESRD patients on hemodialysis-its evaluation and monitoring, as well as at describing the available nutritional interventions. [ABSTRACT FROM AUTHOR]

Despite the advent of cinacalcet and noncalcium-containing phosphate binders, controlling the progression of vascular calcification (VC) is still challenging. Recent reports demonstrate that carbamylation driven by high urea concentration aggravates VC, suggesting the importance of adequate dialysis in retarding its progression. Theoretically, other promising measures include the use of iron-based phosphate binders, vitamin K, and magnesium supplements, which should be investigated in future randomized controlled trials (RCTs), ideally with hard outcomes. While incidence of hip fracture in patients on dialysis is decreasing in the United States and Japan (possibly owing to better control of PTH levels by cinacalcet) it remains much higher than that in the general population. Many drugs used in the treatment of osteoporosis, including bisphosphonate, raloxifene, denosumab, and teriparatide can, under specific conditions, increase bone mineral density (BMD), which is associated with a lower fracture rate. However, the efficacy of these drugs in reducing the fracture rate remains to be proven in hemodialysis (HD) patients, given their adverse effects such as severe hypocalcemia and resultant worsening of secondary hyperparathyroidism. Some clinical studies have shown that cinacalcet, lanthanum carbonate, and sevelamer reduce mortality in elderly patients on HD, suggesting the benefits of reducing PTH and serum phosphate levels. However, the target ranges of PTH and phosphate levels are based solely on observational studies. This is also the case when treating low PTH levels by decreasing vitamin D or calcium load. RCTs with hard clinical endpoints comparing different targets are necessary in the future. [ABSTRACT FROM AUTHOR]

Renal anemia is a serious and common complication in hemodialysis (HD) patients. The introduction of erythropoiesis-stimulating agents (ESAs) has dramatically improved hemoglobin levels and outcomes. Several interventional studies reported that excessive correction of anemia and the massive use of ESA can trigger cardiovascular disease (CVD), and consequently may worsen the prognosis of patients undergoing HD. Therefore, it has been widely recognized that large doses of ESA should be used with caution. An effective use of iron preparations is required to yield the optimal effect of ESA. It is well-known that iron utilization is inhibited under pathological conditions, such as chronic inflammation, resulting in ESA resistance. It is postulated that a new class of therapeutic agents for renal anemia, hypoxia inducible factor prolyl hydroxylase (HIF-PH) inhibitors, will have beneficial treatment effects in patients on HD. HIF is induced by hypoxia and promotes erythropoietin production. In the absence of a hypoxic state, HIF is decomposed by the HIF catabolic enzyme. HIF-PH inhibitors inhibit this degrading enzyme and stimulate endogenous erythropoietin production via HIF induction. Additionally, HIF-PH inhibitors promote effective utilization of iron and raise erythropoietin to physiological concentrations. Accordingly, HIF-PH inhibitors improve anemia and iron metabolism. It appears that this effect persists irrespective of chronic inflammatory conditions. HIF-PH inhibitors do not overshoot erythropoietin above physiological concentrations like ESAs. Therefore, it is hypothesized that HIF-PH inhibitors would not increase the risk of CVD in patients undergoing HD. [ABSTRACT FROM AUTHOR]

Background: Ultrafiltration rate (UFR) has attracted attention as a modifiable aspect of volume management.Objective: The objective of this review is to summarize the evidence that links UFR to patient outcomes and discuss UFR cut-offs proposed, and discuss possible consequences of adapting UFR as a quality metric.Results: Higher UFRs has been associated with younger age, longer dialysis vintage, greater prevalence of comorbidities, higher Kt/V, lower weight, greater interdialytic weight gain, lower residual renal function, and shorter treatment times. Many of the characteristics associated with high UFRs have also been independently associated with poor patient outcomes. Four observational studies have assessed the association between UFR and patient mortality. All of them reported an association between higher UFR and greater patient mortality, though the studies differed in their definition of UFR, follow-up, and adjustment for confounding. Evidence for the association between higher UFR and potential mediations of the mortality association, such as interdialytic hypotension, cardiac remodeling, and cardiovascular events was less consistent. There was a graded association between higher UFRs and all-cause mortality; no definitive cut-off for acceptable UFR can be established based on the current evidence. Targeting UFR in isolation might result in volume expansion and worsening patient outcomes. Residual confounding likely contributed to the findings of the observational studies. No randomized controlled trials addressed the questions.Conclusion: Evidence supporting UFR limits is weak and confounded. Randomized controlled trials are needed before UFR can be used as a quality of care indicator. [ABSTRACT FROM AUTHOR]

Accumulation of amyloid fibrils from β2-microglobulin (β2M) was first recognized as a characteristic osteoarticular complication in long-term hemodialysis (HD) patients and called "HD-related amyloidosis" (HRA). However, this syndrome can also be observed in end-stage renal diseases (ESRD) patients undergoing peritoneal dialysis, and even in patients with chronic renal failure before the initiation of dialytic therapy, suggesting that HD is not a direct cause but that accumulation of β2M or some β2M-associated molecules in the body is a common pathogenesis. Currently the term "dialysis-related amyloidosis" (DRA) is widely used for β2M-amyloid (Aβ2M) amyloidosis associated with ESRD, although DRA patients consist mostly of those undergoing long-term HD. Factors other than β2M accumulation also play a role in the formation/local deposition of Aβ2M and disruption of tissue architecture. Conformational changes of β2M by misfolding/unfolding, and promoting/inhibitory effects induced by other coexisting molecules, advanced glycation and oxidation, and direct cell toxicity have also been documented. Two technological improvements of HD have been the keys to prevent the development and progression of DRA: the efficient removal of β2M by using high-flux membranes, high-volume convection and adsorptive column/membrane, as well as the use of biocompatible membranes and dialysates (eg, ultrapure and acetate-free dialysates) have minimized both inflammation and β2M production. Epidemiologically, a decrease in the incidence of DRA has recently been reported; however, longer survival of HD patients may contribute to the development of more DRA, though with a delayed onset. In this article, we describe the pathogenesis of DRA, the strategies developed for its prevention and minimization, and the favorable epidemiological data achieved by these efforts. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Hemolysis is one of the rare and occasionally fatal complications of hemodialysis. The cause of hemolysis should be found for the prevention of further hemolysis and deaths. The checklist for the cause of hemolysis requires every detail of dialysis process to be reviewed, though clinical experience and the literature are still insufficient to guide medical professionals in solving the problem. The aim of this article was to increase awareness regarding the failure of the current evidence to solve the problem of hemolysis in hemodialysis. MATERIAL and METHODS: Clinical, procedural and technical data regarding 11 episodes of hemolysis in 9 patients on 5 machines from two hemodialysis centers were investigated. The cause for hemolysis was investigated step by step based on the available evidence and instructions of the respective hemodialysis machines. RESULTS: Both the frequent and rare causes of hemolysis in hemodialysis such as blood tubing sets, dialysis membranes, needles, water system and machine contamination, chloramines, high temperature dialysis, and hypo-osmolar dialysis were excluded. Technical investigations of the hemodialysis machines by the authorized services were also of no help. Lastly, replacement of the 5 suspected hemodialysis machines resulted in permanent cessation of the hemolysis episodes. CONCLUSION: The current evidence for the causes of hemolysis in hemodialysis may be insufficient, and replacement of the suspected hemodialysis machines may be the last resort. [ABSTRACT FROM AUTHOR]

Case series Patient: Male, 24 ; Female, 55 ; Female, 56 ; Male, 72 Final Diagnosis: Hypertension Symptoms: Dyspnea Medication: -- Clinical Procedure: Intravascular renal denervation Specialty: Cardiology Objective: Unusual setting of medical care Background: Hypertension is a common complication of renal dialysis and is inadequately controlled in approximately one-third of patients. Intravascular renal denervation is an option to control sympathetic overdrive and decrease blood pressure. Four renal dialysis patients are presented with uncontrolled hypertension who were treated with intravascular renal denervation. Case Reports: In a renal dialysis unit, patients were screened for therapy-resistant hypertension, which was defined as an out-patient blood pressure >160/100 mmHg and a blood pressure by interdialytic ambulatory blood pressure monitoring (ABPM) >130/80 mmHg. Four patients were identified with a mean ABPM of 175/95 mmHg. The four patients included a 24-year-old man with neurogenic bladder undergoing hemodialysis; a 55-year-old woman with a history of type 1 diabetes mellitus undergoing peritoneal dialysis; a 56-year-old woman with a history of autosomal dominant polycystic kidney disease (ADPKD) undergoing peritoneal dialysis; and a 72-year-old man with a history of ADPKD undergoing hemodialysis Following intravascular renal denervation, one patient had antihypertensive medicines withdrawn at 12 months, and he remained normotensive up to renal transplantation at 24 months. In two patients, ABPM did not decrease until renal transplantation was performed. The fourth patient was not a candidate for renal transplantation, and he was also a non-responder for intravascular renal denervation. None of the patients experienced hypotension or other adverse events following intravascular renal denervation. Conclusions: A case series of four patients showed that, for some patients who have unresponsive hypertension while on renal dialysis, intravascular renal denervation is a safe procedure. [ABSTRACT FROM AUTHOR]

Background Among aging hemodialysis patients, loss of physical function has become a major issue. We developed and validated a model of predicting loss of physical function among elderly hemodialysis patients. Methods We conducted a cohort study involving maintenance hemodialysis patients  ≥65 years of age from the Dialysis Outcomes and Practice Pattern Study in Japan. The derivation cohort included 593 early phase (1996–2004) patients and the temporal validation cohort included 447 late-phase (2005–12) patients. The main outcome was the incidence of loss of physical function, defined as the 12-item Short Form Health Survey physical function score decreasing to 0 within a year. Using backward stepwise logistic regression by Akaike’s Information Criteria, six predictors (age, gender, dementia, mental health, moderate activity and ascending stairs) were selected for the final model. Points were assigned based on the regression coefficients and the total score was calculated by summing the points for each predictor. Results In total, 65 (11.0%) and 53 (11.9%) hemodialysis patients lost their physical function within 1 year in the derivation and validation cohorts, respectively. This model has good predictive performance quantified by both discrimination and calibration. The proportion of the loss of physical function increased sequentially through low-, middle-, and high-score categories based on the model (2.5%, 11.7% and 22.3% in the validation cohort, respectively). The loss of physical function was strongly associated with 1-year mortality [adjusted odds ratio 2.48 (95% confidence interval 1.26–4.91)]. Conclusions We developed and validated a risk prediction model with good predictive performance for loss of physical function in elderly hemodialysis patients. Our simple prediction model may help physicians and patients make more informed decisions for healthy longevity. [ABSTRACT FROM AUTHOR]

Background and purpose Aromatherapy, a CAM therapy, is a natural way of treating the mind, body and soul of individuals. The purpose of this study was to systematically review the literature to determine the effect of aromatherapy on hemodialysis complications. Methods In this systematic review, international (PubMed, Google Scholar, Web of Science, CINHAL, EMBASE and Scopus) and national databases (SID and Magiran) were searched from inception of the databases to 30 December 2017. Results The results showed that aromatherapy reduced some of the complications of hemodialysis, including anxiety, fatigue, pruritus, pain of arteriovenous fistula puncture, sleep quality, depression, stress and headache. In one case, it improved the quality of life of hemodialysis patients. Conclusion Considering the complications and heavy costs of managing complications in patients undergoing hemodialysis, it appears that aromatherapy can be used as an inexpensive, fast-acting and effective treatment to reduce complications in hemodialysis patients. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: The safe delivery of hemodialysis (HD) faces dual challenges; the accurate detection of systemic circulatory stress producing cardiovascular (CV) injury, and the ability to enable effective preemptive intervention for such injury. We performed a pilot study to examine the capability of a new noninvasive, real‐time monitoring system to detect the deleterious effects of HD on CV stability. Methods: Eight patients were evaluated with echocardiography prior to the initiation of HD and again at peak HD stress. Continuous CV physiologic monitoring was performed throughout using oximeter‐based pulse waveform analysis (CVInsight® Monitoring System, Intelomed, Inc., Warrendale, PA, USA). Longitudinal strain (LS) values for 12 left ventricular segments were generated using speckle‐tracking software (EchoPac, GE), to assess the presence of HD‐induced regional wall motion abnormalities (RWMA), indicative of myocardial stunning. Findings: A reduction in pulse strength (PS) of ≥40% detected by CVI was associated with the development of RWMA (P = 0.005). This reduction occurred in 6/8 patients, all of whom exhibited myocardial stunning. Two patients had no significant reduction in PS nor evidence of myocardial stunning. In subjects with cardiac stunning, the decrease in PS was evident early during HD, 11.49 ± 10 minutes into HD treatment, prior to the detection of RWMA, which were assessed at peak HD stress, mean 210 ± 16.43 minutes into HD treatment. Discussion: Percutaneous perfusion monitoring, using pulse wave analysis, appears to be useful in identifying circulatory stress during HD and predicting the development of HD‐induced myocardial stunning with a lead time long enough to consider timely intervention. [ABSTRACT FROM AUTHOR]

Background. The contribution of the hemoglobin concentration to the incidence of hemorrhagic or ischemic stroke in patients undergoing hemodialysis is unclear. Methods. In total, 3436 patients undergoing prevalent hemodialysis were followed up for 4 years. The primary outcome was the first development of hemorrhagic or ischemic stroke. The baseline hemoglobin concentration was divided into quartiles [hemoglobin (g/dL): Q1, ≤9.7; Q2, 9.8-10.5; Q3, 10.6-11.1; Q4, ≥11.2]. The association between the hemoglobin concentration and each type of stroke was examined using the Kaplan-Meier method and a Cox proportional hazards model. Results. During the follow-up period, 76 (2.2%) patients developed hemorrhagic stroke and 139 (4.0%) developed ischemic stroke. The 4-year incidence rate of hemorrhagic stroke was significantly higher in patients with lower hemoglobin concentrations. Compared with the quartile of patients with the highest hemoglobin concentrations (Q4), the multivariable-adjusted hazard ratios for hemorrhagic stroke were 1.18 (95% confidence interval, 0.56-2.51), 1.59 (0.82-3.21) and 2.31 (1.16-4.73) in patients in Q3, Q2 and Q1, respectively. No association was identified between the 4-year incidence rate of ischemic stroke and the hemoglobin concentration. Compared with the quartile of patients with the lowest hemoglobin concentrations (Q1), the multivariable-adjusted hazard ratios for ischemic stroke were 1.17 (95% confidence interval, 0.73-1.89), 0.88 (0.51-1.51) and 1.10 (0.66-1.83) in patients in Q2, Q3 and Q4, respectively. Conclusions. Our results suggest that low hemoglobin concentrations are associated with a high risk of hemorrhagic stroke, but not of ischemic stroke, in patients undergoing hemodialysis. [ABSTRACT FROM AUTHOR]

Background. Contemporary data on venous thromboembolism (VTE) risk in dialysis patients are limited. Our objective was to determine the risk and complications of VTE among incident maintenance dialysis patients. Methods. We performed a retrospective cohort study using administrative databases. We included adult incident dialysis patients from 2004 to 2010 (n = 13315). Dialysis patients were age- and sex-matched to individuals of the general population using a 1:4 ratio (n = 53 260). We determined the 3-year cumulative incidence and incidence rate (IR) of VTE, pulmonary embolism (PE) and deep venous thrombosis (DVT). We examined outcomes of bleeding and all-cause mortality following a VTE event among matched dialysis patients who did and did not experience a VTE. We used Cox proportional hazards regression models, stratified on matched sets, to calculate the hazard ratios (HRs) for all outcomes of interest. Results. VTE occurred in 1114 (8.4%) dialysis patients compared with 1233 (2.3%) individuals in the general population {IR 37.1 versus 8.1 per 1000 person-years; HR 4.5 [95% confidence interval (CI) 4.1-4.9]; adjusted HR 2.9 (95% CI 2.6-3.4)}. Both components of VTE [PE and DVT; adjusted HR 4.0 (95% CI 2.9-5.6) and HR 2.8 (95% CI 2.4-3.2), respectively] occurred more frequently in dialysis patients. Compared with dialysis patients without a VTE, those with a VTE had a higher risk of bleeding [adjusted HR 2.0 (95% CI 1.3-2.9)] and all-cause mortality [adjusted HR 2.4 (95% CI 2.0-2.8)]. Conclusions. VTE is common in dialysis patients and confers a high risk of major bleeding and all-cause mortality. Thromboprophylaxis and VTE treatment studies in dialysis patients are needed. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) is associated with an imbalanced human microbiome due not only to CKD-associated factors such as uremia, increased inflammation and immunosuppression, but also to pharmacological therapies and dietary restrictions. End-stage renal disease patients require renal replacement therapies commonly in the form of hemodialysis (HD) or peritoneal dialysis (PD). HD implies the existence of a vascular access, such as an arteriovenous fistula/graft or a venous catheter, whereas PD implies a long-term peritoneal catheter and the constant inflow of peritoneal dialysate. Also, dietary adaptations are mandatory in both therapies. This revision explores the impact of HD or PD therapies on human microbiome. HD and PD appear to be associated with different changes in the gut microbiome, for example a decrease in Proteobacteria relative abundance in HD patients and increase in PD patients. Both therapies may also have an impact on the human microbiome beyond the gut, leading to increased relative abundance of specific bacteria in the blood microbiome of HD patients and increased relative abundance of other bacteria in the peritoneal microbiome of PD patients. HD and PD catheter biofilms may also play an important role in the changes observed in these microbiomes. A more interdisciplinary approach is needed to further clarify the role of microbial groups other than bacteria in all body habitats to allow the complete understanding of the impact of HD or PD on the microbiome of CKD patients. Moreover, strategies that promote a healthy balance of the human microbiome on these patients should be explored. [ABSTRACT FROM AUTHOR]

Background: Intradialytic hypotension (IDH) remains the most common complication of hemodialysis (HD) with potentially devastating consequences despite the technological advances regarding the hemodialysis techniques of the last decades. The increasing number of advanced-age patients, diabetics and patients with cardiovascular comorbidities undergoing hemodialysis emphasizes the need on implementation of new IDH avoidance tactics. Aim of the Work: Our work aimed to evaluate serum albumin (Alb) level and C-reactive protein level in hemodialysis patients and their correlation with dialysis-induced hypotension (DIH). Patients and Methods: This prospective study was conducted based on data collected from HD patients treated at Aswan University Hospital, dialysis unit, in a period from 1/1/2017 to 30/5/2017. It included 40 chronic HD patients with no history of endocrine tumors, diabetes mellitus, liver failure, heart failure, or unstable coronary artery disease. Patients with hemoglobin less than 9 mg/dL, feverish patients, and patients with any source of apparent infection were excluded. The age of the patients ranged from over 18 to less than 75 years. Results: : the mean value of serum albumin level in group (A) was (2.97 ± 0.71) with the highest serum albumin was 4.4 and the lowest serum albumin was 2.1, while in Group (B) the mean value of serum albumin level was (4.53 ± 0.74) with the highest serum albumin was 5.5 and the lowest serum albumin was 2.8. There was a significant decrease in serum albumin level in patients in group (A) who had developed hypotensive episodes during hemodialysis (P value < 0.001), in group (A) also there were 18 patients had positive C-reactive protein (90 %) and 2 patients had negative C-reactive protein (10 %) with a mean value (15.67 ± 13.27), while in group B : there were 2 patients had positive C-reactive protein level (10 %) and 18 patients had negative C-reactive protein level (90 %) with a mean value (2.07 ± 1.48), So, there was a significant increase in C-reactive protein level in patients in group (A) who had developed hypotensive episodes during dialysis (P value < 0.001). Conclusion: Serum Alb. levels and high levels of CRP may predict an increased risk of DIH in regular HD patients and this was the main issue for our study, however we also found that there were some other biochemical markers, which can come inbetween with our two main markers, which confirm our results. Recommendations: Further studies on a larger scale of patients are needed to confirm these results. [ABSTRACT FROM AUTHOR]

Renal transplantation is the best management for patients suffering from end-stage renal disease (ESRD). It has many benefits which overcome the complications of dialysis, it has some acute and long term complications that could result in failure. Failure of transplant is the fourth cause of death among patients with end stage kidney disease. The causes of failure is still a debate but rejection, drug toxicity and fibrosis as well as chronic allograft nephropathy and patient's immunity related factors. This review will provide important information regarding the causes associated with post-renal transplant failure. [ABSTRACT FROM AUTHOR]

Background: The traditional systemic heparinization used for anticoagulation in extracorporeal therapies may cause fatal complications in animals at risk of bleeding. Hypothesis/Objectives: To develop and validate a protocol of regional citrate anticoagulation (RCA) for intermittent hemodialysis in dogs. Animals: A total of 172 dogs treated with hemodialysis for acute kidney injury. Methods: In vitro titration was performed, adding trisodium citrate and calcium chloride to heparinized canine blood. A tentative protocol was used first in 66 treatments with additional heparinization and subsequently in 518 heparin‐free treatments. Safety and adequacy of RCA were assessed based on clinical and laboratory monitoring, dialyzer pressure gradient, treatment completion, and visual scoring of the extracorporeal circuit. Results: Addition of 1 mmol/L citrate to heparinized blood decreased the ionized calcium concentration by 0.23 mmol/L (95% confidence interval [CI], 0.16–0.30) and 1 mmol/L calcium increased it by 0.62 mmol/L (95% CI, 0.45–0.79). Heparin‐free treatments were initiated with infusion of trisodium citrate (102 mmol/L) at 2.55 mmol/L blood and calcium chloride (340 mmol/L) at 0.85 mmol/L. Citrate and calcium administrations were adjusted in 27 and 34% of the treatments, respectively. Overall, anticoagulation was satisfactory in 92% of the treatments, with expected azotemia reduction in 95% (urea) and 86% (creatinine), stable dialyzer pressure gradient in 82%, and clean extracorporeal circuits in 92% of the treatments. Eighteen treatments (3.5%) were discontinued prematurely, 9 because of clotting and 9 for reasons unrelated to the RCA procedure. Conclusions and Clinical Importance: Regional citrate anticoagulation allows safe and efficient heparin‐free hemodialysis in dogs at risk of bleeding. [ABSTRACT FROM AUTHOR]

Vascular access stenosis and venous needle dislodgement (VND) are frequent and serious life-threatening complications during hemodialysis (HD). According to dialysis survey reports, these complications are key issues for nephrology nurses, medical staff, and patients. Existing detection techniques and early warning tools provide promising solutions in these issues. However, these methods cannot screen for stenosis and VND complications during HD. Clinical examinations show that increases in transverse vibration pressure (TVP) are highly correlated with stenosis screening in arterial anastomosis sites (inflow needle); conversely, TVP drops in the event of a blood leak or VND in venous anastomosis sites (outflow needle). As an early-warning implementation, this study proposes a combination of fractional order integrator (FOI) and info-gap (IG) decision-making to detect these complications. FOI is used to calculate the TVPs' area under curve (AUC), while AUC ratio (AUCR) quantifies the differences in TVPs between the normal condition and pressure sensor reading. An estimated function of the two-point form shows that AUCRs have a high correlation with TVP variations. Therefore, AUCR is employed to identify changes in TVPs and arrange specific allocations. The IG decision-making scheme produces inference profiles with specific allocations to separate the normal cases from vascular access stenosis or VND/blood leakage. The test results obtained from practical experiments were validated and compared with the results obtained using existing methods such as acoustic techniques, warning products, and homodynamic analysis. The findings also show that the proposed framework employing pressure sensors can be implemented in an early warning monitor for clinical and telemedicine applications. [ABSTRACT FROM AUTHOR]

Intradialytic hypotension (IDH) is a common complication in hemodialysis, particularly with the time and frequency constraints of standard session delivery in contemporary practice. High intradialytic weight gain (IDWG), high ultrafiltration rates (UFR), and frequent IDH are highly interlinked, and separately or together contribute to the high cardiovascular morbidity and mortality observed in the hemodialysis population. Using a lower concentration of sodium in the dialysate (D-Na) reduces sodium delivery to the patient during dialysis, and several studies reported the beneficial effect in controlling IDWG, UFR, and hypertension. On the other hand, high dialysate sodium is associated with more hemodynamic benefits in an unstable patient. The resulting sodium loading may, however, induce a vicious cycle of higher IDWG, requiring more rapid ultrafiltration, eventually contributing to intradialytic symptoms and hypotension. In this article, we review the available literature on fixed and profiled dialysate sodium prescriptions, and we recommend a tailored approach that considers the patient's status to optimize dialysis delivery. [ABSTRACT FROM AUTHOR]

Intradialytic hypotension (IDH) is a common and often distressful complication of hemodialysis. However, despite its clinical significance, there is no consensus, evidence-based medical definition for the condition. Over the years, numerous definitions have been implemented in both the clinical and research settings. Definition inconsistencies have hindered data synthesis and the development of evidence-based guidelines for the prevention and treatment of IDH, as well as prevented accurate estimation of the population burden of IDH and patient risk assessment. Most existing IDH definitions are comprised of one or more of the following components: (1) intradialytic BP criteria (requisite BP declines or minimum BP thresholds), (2) the provision of interventions aimed at restoring effective arterial volume, and/or (3) patient-reported symptoms. Remarkably, there are insufficient data to inform IDH definition construction, and it remains unknown if a single, universal definition can adequately capture the condition across patient subgroups, and in clinical and research settings. [ABSTRACT FROM AUTHOR]

The risk of intradialytic hypotension (IDH) is determined by various factors, among them dialysis modality and dialyzer membrane. We conducted a literature search in PubMed on November 1, 2016 and selected relevant randomized controlled and cross-over trials, and prospective and retrospective cohort studies published in English that investigated the association between IDH and dialysis modality and membrane, respectively. This literature search revealed 669 publications on dialysis modality, 64 on dialysis membrane, and 24 on acetate/bicarbonate dialysate. After omission of duplicate papers and publications outside the scope of this review, we selected 34 papers for inclusion, 19 on dialysis modality, 8 on dialyzer membrane, and 7 on acetate/bicarbonate dialysate. Several strands of evidence indicate that hemodiafiltration (HDF) is associated with lower IDH rates compared to hemodialysis (HD). Data do not show an unequivocal benefit of synthetic vs nonsynthetic dialyzer membranes with respect to IDH occurrence. Acetate-based vs bicarbonate-based dialysate appears to be associated with an increased IDH rate. [ABSTRACT FROM AUTHOR]

Background: Vascular calcification is associated with structural and functional abnormality of the heart and blood vessels. We investigated the relationship between intradialytic hypotension (IDH) and vascular calcification in hemodialysis (HD) patients, and their impacts on cardiovascular events (CVEs). Method: We enrolled 191 maintenance HD patients who underwent plain abdomen radiography for abdominal aortic calcification score (AACS). A nadir systolic blood pressure (BP) < 90 mm Hg or the requirement of bolus fluid administration was required to quantify the hypotension diagnosis. IDH was defined as > 2 hypotension episodes during 10 HD treatments. Results: Among the 191 patients, IDH occurred in 32. AACS was higher in the IDH group compared with the no-IDH group (8.4 ± 6.0 vs. 4.9 ± 5.2, respectively; P = 0.001). High AACS was an independent risk factor after adjustment for age, diabetes mellitus, ultrafiltration, diastolic BP, and calcium level (odds ratio (OR) = 1.09, 95% CI = 1.01–1.18; P = 0.03). Patients with both IDH and AACS ≧ 4 had the highest cumulative CVE rate (27.9%, P = 0.008) compared with 11.2%, 12.5%, and 6% for those with AACS ≧ 4 only, with IDH only, and neither, respectively. In multivariate analysis, the presence of both IDH and AACS ≧ 4 was a significant predictor of CVE (hazard ratio (HR) = 2.84, 95% CI = 1.04–7.74, P = 0.04). Conclusion: IDH is associated with abdominal aortic calcification and is an independent risk factor for IDH. Both IDH and high AACS were significant predictors of CVE. [ABSTRACT FROM AUTHOR]

Despite medical achievements, the number of patients with end-stage kidney disease keeps steadily raising, thereby entailing a high number of surgical and interventional procedures to establish and maintain arteriovenous vascular access for hemodialysis. Due to vascular disease, aneurysms or infection, the preferred access—an autogenous arteriovenous fistula—is not always available and appropriate. Moreover, when replacing small diameter blood vessels, synthetic vascular grafts possess well-known disadvantages. A continuous multilayered gradient electrospinning was used to produce vascular grafts made of collagen type I nanofibers on luminal and adventitial graft side, and poly-ɛ-caprolactone as medial layer. Therefore, a custom-made electrospinner with robust environmental control was developed. The morphology of electrospun grafts was characterized by scanning electron microscopy and measurement of mechanical properties. Human microvascular endothelial cells were cultured in the graft under static culture conditions and compared to cultures obtained from dynamic continuous flow bioreactors. Immunofluorescent analysis showed that endothelial cells form a continuous luminal layer and functional characteristics were confirmed by uptake of acetylated low-density-lipoprotein. Incorporation of vancomycin and gentamicin to the medial graft layer allowed antimicrobial inhibition without exhibiting an adverse impact on cell viability. Most striking a physiological hemocompatibility was achieved for the multilayered grafts. [ABSTRACT FROM AUTHOR]

Graphical abstract New clues were found that the adsorbed proteins on dialysis membrane might be the reason of complications of hemodialysis according to the novel proteomic techniques, ionic liquid assisted sample preparation method (ILSP method) and pseudo-isobaric dimethyl labeling method (pIDL method). Abstract The complications of hemodialysis accompanied the hemodialysis and threaten the patients' life. Besides the loss of nutrient substance, such as amino acid and vitamin, we found new clues that the adsorbed proteins on common-used polysulfone-based dialysis membrane might be the reason according to the qualitative proteomic study by ionic liquid assisted sample preparation method. Our results indicated that the adsorbed proteins on the membrane were related with complement activation, blood coagulation, and leukocyte-related biological process. The quantitative proteome further demonstrated some significant changes of signal proteins in the post-dialysis plasma after the hemodialysis, such as beta-2-microglobulin and platelet factor-4, which would further verify these new clues. [ABSTRACT FROM AUTHOR]

Background: Several epidemiological studies have demonstrated associations between variability in a number of biological parameters and adverse outcomes. As the variability may reflect impaired homeostatic regulation, we assessed albumin variability over time in chronic hemodialysis (HD) patients. Methods: Data from 1346 subjects who received chronic HD treatment from May 2001 to February 2015 were analyzed according to three phases of HD treatment: post-HD initiation, during maintenance HD treatment, and before death. The serum albumin values were grouped according to the time interval from HD initiation or death, and the yearly trends for both the albumin levels and the intra-individual albumin variability (quantified by the residual coefficient of variation: Alb-rCV) were examined. The HD initiation and death-associated changes were also analyzed using generalized additive mixed models. Furthermore, the long-term trend throughout the maintenance treatment period was evaluated separately using linear regression models. Results: Albumin levels and variability showed distinctive changes during each of the 3 periods. After HD initiation, albumin variability decreased and reached a nadir within a year. During the subsequent maintenance treatment period (interquartile range = 5.2–11.0 years), the log Alb-rCV showed a significant upward trend (mean slope: 0.011 ± 0.035 /year), and its overall mean was -1.49 ± 0.08 (equivalent to an Alb-rCV of 3.22%). During the 1–2 years before death, this upward trend clearly accelerated, and the mean log Alb-rCV in the last year of life was -1.36 ± 0.17. The albumin levels and variability were negatively correlated with each other and exhibited exactly opposite movements throughout the course of chronic HD treatment. Different from the albumin levels, albumin variability was not dependent on chronological age but was independently associated with an individual’s aging and death process. Conclusion: The observed upward trend in albumin variability seems to be consistent with a presumed aging-related decline in homeostatic capacity. [ABSTRACT FROM AUTHOR]

Key Clinical Message An EIM (ethanol infusion into the vein of Marshall [ VOM]) provoked a fatal complication in a chronic hemodialysis patient. Autopsy revealed a lacerated VOM covered with thrombi as the only potential cause. The EIM caused vascular damage and clots resulting in myocardial necrosis and interstitial bleeding around the lacerated VOM. [ABSTRACT FROM AUTHOR]

Background: patients undergoing maintenance heamodialysis (HD) have a progressively loss of residual renal function (RRF), Short-term morbidity and mortality are significantly higher in patients lost RRF, and these patients frequently die before the development of long -term complications of dialysis. HD patients without preserved RRF have greater hospitalization rate, more significant malnutrition and health related quality of life. Aim: the aim of the present study was to assess impact of RRF on QoL in chronic HD patients and to study clinical and laboratory characteristics of these patients. Patients and Methods: this cross sectional study was carried out on 40 adult clinical stable regular HD Patients. They were divided into 2 groups according to the presence or absence of RRF.Group 1 included 20 HD patients with RRF (defined as urine volume >200 ml/24 h) and group 2 included 20 patients without RRF (defined as urine volume <200 ml/24 h). Results: patients with preserved RRF had a positive significant correlation between QoL scores, male gender, younger age, employment, higher BMI (p=0.006), higher hemoglobin (p=0.036), higher predialysis serum creatinine (p=0.033), less complication during HD sessions hypotenstion (p=0.003), hypertenstion(p=0.003), vomiting (p=0.017), cramps(p=0.010)and Less use of Phosphate binders and Erythropoietin dose (p=0.020). Conclusion: HD patients with preserved RRF had better QoL scores compared to patients without RRF.Efforts to preserve RRF in HD patients could improve outcomes and should be encouraged. [ABSTRACT FROM AUTHOR]

Background: Hepatitis B virus (HBV) occult infection (OBI) is a risk factor to be taken into account in transfusion, hemodialysis and organ transplantation. The aim of this study was to identify and characterize at the molecular level OBI cases in patients with end-stage liver disease. Methods: Sixty-six liver samples were obtained from patients with diagnosis of end-stage liver disease submitted to liver transplantation in Medellin (North West, Colombia). Samples obtained from patients who were negative for the surface antigen of HBV (n = 50) were tested for viral DNA detection by nested PCR for ORFs S, C, and X and confirmed by Southern-Blot. OBI cases were analyzed by sequencing the viral genome to determine the genotype and mutations; additionally, viral genome integration events were examined by the Alu-PCR technique. Results: In five cases out of 50 patients (10%) the criteria for OBI was confirmed. HBV genotype F (subgenotypes F1 and F3), genotype A and genotype D were characterized in liver samples. Three integration events in chromosomes 5q14.1, 16p13 and 20q12 affecting Receptor-type tyrosine-protein phosphatase T, Ras Protein Specific Guanine Nucleotide Releasing Factor 2, and the zinc finger 263 genes were identified in two OBI cases. Sequence analysis of the viral genome of the 5 OBI cases showed several punctual missense and nonsense mutations affecting ORFs S, P, Core and X. Conclusions: This is the first characterization of OBI in patients with end-stage liver disease in Colombia. The OBI cases were identified in patients with HCV infection or cryptogenic cirrhosis. The integration events (5q14.1, 16p13 and 20q12) described in this study have not been previously reported. Further studies are required to validate the role of mutations and integration events in OBI pathogenesis. [ABSTRACT FROM AUTHOR]

Background No consensus exists regarding the factors influencing mortality in patients undergoing hemodialysis (HD). This meta-analysis aimed to evaluate the impact of various patient characteristics on the risk of mortality in such patients. Methods PubMed, Embase, and Cochrane Central were searched for studies evaluating the risk factors for mortality in patients undergoing HD. The factors included age, gender, diabetes mellitus (DM), body mass index (BMI), previous cardiovascular disease (CVD), HD duration, hemoglobin, albumin, white blood cell, C-reactive protein (CRP), parathyroid hormone, total iron binding capacity (TIBC), iron, ln ferritin, adiponectin, apolipoprotein A1 (ApoA1), ApoA2, ApoA3, high-density lipoprotein (HDL), total cholesterol, hemoglobin A1c (HbA1c), serum phosphate, troponin T (TnT), and B-type natriuretic peptide (BNP). Relative risks with 95% confidence intervals were derived. Data were synthesized using the random-effects model. Results Age (per 1-year increment), DM, previous CVD, CRP (higher versus lower), ln ferritin, adiponectin (per 10.0 μg/mL increment), HbA1c (higher versus lower), TnT, and BNP were associated with an increased risk of all-cause mortality. BMI (per 1 kg/m 2 increment), hemoglobin (per 1 d/dL increment), albumin (higher versus lower), TIBC, iron, ApoA2, and ApoA3 were associated with reduced risk of all-cause mortality. Age (per 1-year increment), gender (women versus men), DM, previous CVD, HD duration, ln ferritin, HDL, and HbA1c (higher versus lower) significantly increased the risk of cardiac death. Albumin (higher versus lower), TIBC, and ApoA2 had a beneficial impact on the risk of cardiac death. Conclusions Multiple markers and factors influence the risk of mortality and cardiac death in patients undergoing HD. [ABSTRACT FROM AUTHOR]