Seminars in Dialysis最新文献

Peritoneal dialysis (PD) outcomes analysis presents challenges due to heterogeneous outcomes. Our study aims to evaluate mortality, transition to hemodialysis (HD), and kidney transplant (KT) rates and investigate potential baseline patient characteristics influencing these outcomes. We conducted an observational retrospective registry-based single-center cohort study involving 722 incident adult PD patients admitted between 1985 and 2022. Follow-up duration extended from PD initiation to the first occurrence of death (n = 143), transfer to HD (n = 313), or KT (n = 202). Utilizing competitive risks analysis, we calculated cumulative incidence (CI) functions and applied a Fine and Gray model to baseline variables to understand their impact. The majority of patients were female (n = 401; 55.54%), with an average age of 49.64 ± 15.80 years. Transfer to HD had the highest probability (CI of 0.38 at 60 months), followed by KT (CI of 0.27 at 60 months) and death (CI of 0.19 at 60 months). Diabetes correlated solely with death (HR 1.71 (0.18); p = 0.004). PD-first was associated with a lower risk of HD transfer (HR 0.76 (0.13); p = 0.036) and positively influenced KT (HR 1.73 (0.16); p < 0.01). Vascular access as the reason for PD selection was associated with death (HR 2.16 (0.19); p < 0.001). The main risk for PD patients is transitioning to HD, unaffected by baseline patient characteristics. PD-first option positively influences KT access, and mortality rates remain low and unaffected by this option, ensuring the safety of the technique. Vascular access-related PD initiations correlate with increased mortality, potentially due to comorbidities.

Objective: The aim of this study is to investigate the impact of the causes of arteriovenous fistula (AVF) stenosis on the 1-year primary patency rate of AVF following percutaneous transluminal angioplasty (PTA) and to identify the independent risk factors that affect vascular access patency post-PTA.

Methods: In this investigation, we analyzed the clinical data of 78 patients who underwent successful PTA for dysfunctional autologous AVF in the Nephrology Department of our hospital between January 2020 and September 2022. The primary focus of this study was to observe the postoperative patency rate of AVF in these patients. Subsequently, the patients were categorized based on primary diseases, Charlson comorbidity index (CCI), AVF typing, and causes of AVF stenosis. The postoperative patency rates of AVF were then compared among the respective groups. To further analyze the relevant risk factors influencing vascular access patency following PTA, the Cox proportional hazard model was employed.

Results: A total of 78 eligible patients who underwent PTA were included in this study revealing patency rates of 93%, 85%, 80%, and 72% at 3, 6, 9, and 12 months postoperatively, respectively. Analysis using the Kaplan-Meier curve indicated no significant association between the presence of diabetic nephropathy (p = 0.313) and AVF stenosis typing (p = 0.195) with post-PTA patency of AVF. However, the 1-year patency rate demonstrated notable differences, with higher rates observed in the CCI < 7 group compared with the CCI ≥ 7 group and similarly in the simple AVF stenosis group compared with the intimal hyperplasia group (p < 0.001). Furthermore, based on multivariate survival analysis (Cox regression model), the causes of AVF stenosis and CCI index were identified as independent risk factors influencing AVF patency following PTA (p < 0.05).

Conclusion: Patients with intimal hyperplasia were found to have a higher likelihood of AVF restenosis compared with those with simple stenosis. Similarly, individuals with a high CCI were more prone to AVF restenosis than those with low CCI. The causes of AVF stenosis and CCI were identified as independent risk factors influencing vascular access patency following PTA.

Acquired reactive proliferating collagen (ARPC), usually associated with systemic diseases, is a rare skin disease characterized by the elimination of altered dermal collagen through the epidermis. Here, we report two cases of ARPC in maintenance hemodialysis patients, one of which is combined with type 2 diabetes, chronic renal failure, and hypertension and the other is combined with chronic renal failure and hypothyroidism. Two patients were treated with oral thalidomide and ebastine, local application of fluticasone propionate cream, and enhanced dialysis. After treatment, the itching and the rash significantly improved. We report for the first time that ARPC in patients with hemodialysis could be improved by oral thalidomide and antihistamines and local application of steroid. This report provides reference for guiding the understanding of ARPC and the new treatment of ARPC in hemodialysis patients.

The objective of India's One Nation One Dialysis (ONOD) program is to remove the barriers that end-stage kidney disease patients face in accessing consistent, quality dialysis services across the nation. A unified and standardized dialysis care approach is what ONOD aims to achieve at a national level. The objective of ONOD is to improve access to, affordability of, and quality in dialysis services for economically weaker segments of society and those living in remote areas of the country by providing dialysis services through public-private partnerships. The ONOD program places a lot of emphasis on the infrastructure development, funding support, skill development, regulatory reforms, and technological integration of dialysis services. By implementing ONOD, India can improve patient outcomes, close the supply-demand gaps for end-stage kidney disease kidney replacement therapy, and create a more balanced and sustainable kidney healthcare ecosystem.

Expanded hemodialysis (HDx) represents a transformative innovation in renal replacement therapy, addressing the limitations of conventional hemodialysis and high-flux modalities. By employing medium cut-off (MCO) membranes, HDx ensures efficient clearance of middle- and large-molecular-weight uremic toxins, such as β₂-microglobulin and cytokines, while selectively retaining vital proteins like albumin. This comprehensive review examines the clinical efficacy, safety, and broader implications of HDx, highlighting its potential to improve outcomes for patients with chronic kidney disease (CKD). The review synthesizes findings from comparative studies, emphasizing HDx's superior toxin removal capabilities, particularly for solutes implicated in systemic inflammation and cardiovascular complications. Key mechanisms, including the internal filtration-backfiltration process, contribute to hemodynamic stability and enhanced toxin clearance. HDx demonstrates significant reductions in inflammatory biomarkers, improved arterial compliance, and better cardiovascular outcomes compared with traditional methods. Patient-reported outcomes further underscore HDx's benefits, with shorter recovery times, enhanced quality of life, and reduced intradialytic complications. While albumin loss remains a consideration, studies confirm its clinical acceptability and minimal impact on nutritional status. HDx's economic viability, reduced infrastructure requirements, and compatibility with existing systems position it as a cost-effective alternative, especially in resource-limited settings. Despite promising evidence, the review identifies gaps in long-term data, particularly regarding mortality and sustained quality-of-life improvements. Future directions include refining membrane technologies and incorporating personalized medicine approaches to optimize HDx protocols. By bridging these gaps, HDx has the potential to redefine renal replacement therapy, offering a safer, more effective, and scalable solution for CKD management.

Background: This study compares the outcomes of tunneled catheters (TCs) and non-tunneled catheters (NTCs) in incident hemodialysis patients undergoing early arteriovenous fistula (AVF) creation.

Methods: Adult incident ESKD patients were randomized in two catheter groups (TC and NTC) for hemodialysis initiation and were followed for 12 weeks from March 2021 in a 3-year study period. Catheter salvage was attempted in both the groups until AVF maturation in cases of catheter-related bloodstream infection (CRBSI) or mechanical dysfunction. Catheter insertion and removal dates, infection episodes, and mechanical dysfunction events were recorded. CRBSI rates, dysfunction rates, and catheter survival were compared.

Results: A total of 133 patients were randomized into TC (65) and NTC (68) groups. Seventy-six patients developed symptoms of CRBSI, of whom eight patients required catheter removal (TC: 2, NTC: 6). CRBSI episodes per 1000 catheter days were 15.14 for TCs and 16.85 for NTCs, but mechanical dysfunction rates were 0.96 and 1.68, respectively. By 6 weeks, one catheter was removed in the TC group (AVF maturation), and eight in the NTC group were removed (four due to AVF maturation, three due to CRBSI, and one due to mechanical dysfunction). Kaplan-Meier analysis showed significantly longer catheter survival for TCs compared to NTCs (66.9 vs. 57.9 days, p = 0.001).

Conclusion: CRBSI rates and catheter patency were comparable between TCs and NTCs at 6 weeks, but TCs demonstrated better survival beyond this period. When early AVF creation is ensured, NTCs may serve as a viable short-term vascular access option, particularly in resource-limited settings.

Tunneled dialysis catheter is the alternative for dialysis patients who cannot benefit from an arteriovenous fistula. The insertion of such catheters is usually ultrasound-guided to prevent complications. A 36-year old patient had an unexpected complication following the insertion of a right femoral tunneled dialysis catheter: Although the blood collected from the catheter was venous after insertion, the blood turned arterial few minutes after initiating a continuous renal replacement therapy (CRRT). It became venous again after stopping the therapy. The first, yet unlikely hypothesis, was an arterial location of the catheter. In fact, it turned out not to be. We describe the management of such a case.

Background: Peritoneal dialysis (PD) and hemodialysis (HD) form the basis of renal replacement therapy (RRT) in patients with end-stage renal disease. Both methods have advantages, and in our study, we aimed to examine the effect of both methods on exhaled nitric oxide (FeNO) levels.

Methods: Our study included RRT patients between 18 and 65 who our hospital's nephrology clinic followed up for at least 2 years. A total of 100 patients, 35 patients from both RRT groups and 30 healthy control groups, were included in our study. Echocardiography (ECHO) and FeNO measurements were performed.

Results: In the comparison of the groups' mean pulmonary arterial pressure (PAP) and pre-RRT FeNO levels, it was observed that both levels were higher in HD patients compared to PD patients (p = 0.04, < 0.001, respectively). The control group observed that both predialysis and postdialysis FeNO levels in HD patients showed a statistically significant difference compared to the control group (p ≤ 0.001, 0.01, respectively). It was observed that mean arterial pressure (MAP) levels were higher in HD patients compared to PD patients before RRT (p = 0.01). FeNO positively correlated with age and gamma-glutamyl transferase (GGT) level (R = 0.542, p = 0.01, R = 0.629, p = 0.01, respectively).

Conclusion: FeNO is known as an essential indicator of oxidative stress and inflammation. The higher FeNO level in HD patients compared to PD and its positive correlation with oxidative stress markers such as GGT suggest that PD may be more suitable for the physiological structure.

Background: Tunneled dialysis catheters (TDCs) are preferred over temporary noncuffed catheters for access in patients on maintenance hemodialysis. The removal of TDC after catheter-related blood stream infections (CRBSIs) is often not practiced even when indicated, and the adverse outcomes after such salvage are presently unclear.

Aims and objectives: The study aimed to evaluate adverse outcomes after the first episode of definite or probable CRBSI. The composite adverse outcome was recorded as the presence of at least one of three adverse outcomes-death in the index hospital admission, occurrence of recurrent bacteremia, and death within 3 months.

Results: During the study period, the TDC CRBSI incidence rate was 6.9/1000 catheter days. Of the 110 study participants, majority were male (63%), with a median age of 35 years, belonging to rural (56%) and agrarian (39%) communities, and 66% were getting dialyzed at stand-alone dialysis units. Gram-negative infections predominated (64%), with 37% of isolates showing resistance to carbapenems. Catheter salvage was practiced in 80%, and immediate catheter removal was done only in the sickest of patients (in seven of eight with in-hospital mortality). Predictors of composite adverse outcomes included sites other than right internal jugular vein (OR 3.6) and resistance to β lactam-β lactamase inhibitors (OR 16.2). At a median follow-up of 7 months, all survivors at 3 months were alive and 46% had recurrent TDC CRBSIs.

Conclusion: Up to one-half of patients with end-stage kidney disease experienced composite adverse outcomes after the first episode of TDC CRBSI, with infection-related 3-month mortality of 15%.

Trial registration: Clinical trial number: CTRI/2023/10/058556.

Background: Potassium imbalance, particularly hypokalemia, is a critical risk factor for adverse outcomes in patients undergoing hemodialysis (HD). However, the association between hypokalemia and mortality is unclear.

Methods: For this systematic review and meta-analysis, we assessed the association between hypokalemia and mortality in patients undergoing HD. We performed a systematic search of electronic databases (PubMed, Embase, Cochrane Library, and Scopus) to identify relevant studies published up to April 2024. Eligible studies were prospective or retrospective cohort studies reporting hazard ratios (HRs) for mortality in association with the presence of hypokalemia among patients undergoing HD. We used the assessed study Newcastle-Ottawa Scale to assess quality of the selected studies.

Results: We carried out both qualitative and quantitative assessments. For the meta-analysis, we pooled the HRs for all-cause and cardiovascular mortalities. The overall pooled HR for all-cause mortality and cardiovascular mortality were 1.34 (95% CI, 1.15, 1.55) and 1.49 (95% CI, 1.12, 1.98), respectively, indicating significant associations between hypokalemia and all-cause mortality and cardiovascular mortality in patients undergoing HD. Additionally, we conducted subgroup analyses based on study design, geographical location, type of dialysis, and serum potassium levels.

Conclusion: Our findings provide robust evidence of a significant association between hypokalemia and mortality in patients undergoing HD. Early detection and proactive management of hypokalemia are crucial for improving outcomes and reducing mortality risk in these patients.