Seminars in Dialysis最新文献

Introduction: Pulmonary hypertension (PH) is highly prevalent in patients receiving dialysis. The precise mechanisms underlying PH in hemodialysis (HD) patients have not been adequately addressed. Emerging experimental evidence indicates that circulating fibrocytes may contribute significantly to this process.

Methods: We measured the proportion of circulating fibrocytes using flow cytometry analysis and prospectively analyzed patients during HD from February 1, 2017, to February 1, 2022. Then we investigated correlations between circulating fibrocytes, inflammation cytokines, PH, and their affective factors that predict the prognosis of HD patients.

Results: The cohort included 192 patients. During a follow-up of 5 years, we registered 66 all-cause deaths, and 11 patients received kidney transplantation. The incidence of PH among HD patients was 30.9%. We found that the circulating fibrocyte level significantly correlated with pulmonary arterial systolic pressure (r = 0.412, p < 0.05). In the multiple logistic regression analysis, the percentage of circulating fibrocytes was an independent predictor of PH (odds ratio [OR]: 2.080, 95% confidence interval [CI]: 1.539-2.812, p < 0.001). Controlling for confounding covariates in the multivariate Cox regression models, the presence of PH conferred an increased risk of all-cause mortality in HD patients [hazard ratio (HR): 2.183, 95% CI:1.257-3.788, p = 0.006].

Conclusion: The prevalence of PH was high in HD patients and was associated with higher all-cause mortality. Higher circulating fibrocyte level was an independent predictor of the presence of PH; these fibrocytes may serve as early detection markers and novel therapeutic targets.

Background and aim: It is feared that among chronic kidney disease patients undergoing hemodialysis, arteriovenous fistula (AVF) itself could contribute to pulmonary hypertension (PH). The impact of AVF location on PH is yet to be assessed. We hypothesize that patients with proximal AVF have higher access blood flow and hence higher pulmonary arterial systolic pressure (PASP) than those with distal AVF. We aimed to compare the PASP between patients with proximal and distal AVF.

Methods: In this cross-sectional study, PASP was estimated using Doppler echocardiography and blood flow in the AVF was assessed by Doppler ultrasound. PASP was modeled by multivariate linear regression. AVF location was the primary exposure of interest.

Results: Out of 89 patients undergoing hemodialysis, 72 (81%) had PH defined as PASP >35 mmHg. The mean blood flow in proximal and distal AVF was, respectively, 1240 and 783 mL/min (mean difference 457 mL/min, p < 0.001). Mean PASP in patients with proximal AVF was 16.6 mmHg higher than those with distal AVF (p < 0.001, 95% CI 8.3-24.9). There was a positive correlation between access blood flow and PASP (r = 0.28, p = 0.007). If access blood flow was included as a covariate in the multivariate model, the association between AVF location and PASP ceased to exist.

Conclusion: Patients with proximal AVF have a significantly higher PASP than those with distal AVF, and this could be attributed to the higher blood flow in proximal AVF compared to distal AVF.

Background: Fibrinogen to pre-albumin ratio (FPR) is a promising predictor of mortality in various cancers. The aim of this study was to explore the prognostic value of FPR to predict mortality in peritoneal dialysis (PD) patients.

Methods: We retrospectively analyzed 324 incident PD patients form January 2011 to December 2020. Patients were stratified based on the optimal thresholds for FPR at baseline to predict overall and cardiovascular mortality during follow-up. The association of FPR and all-cause and cardiovascular mortality was evaluated by Kaplan-Meier curve and Cox regression analysis.

Results: All patients were divided into three groups based on the optimal cutoff value of FPR. Higher FPR levels were strongly correlated with worse overall and cardiovascular mortality in PD patients. Compared with patients in the lowest FPR tertile (<14.3), those in the highest terile (≥18.8) had multivariable-adjusted hazard ratios (95% CI confidence interval) of 3.37 (1.76-6.49) and 2.86 (1.31-6.23) for all-cause and cardiovascular mortality, respectively. Significant differences in overall survival were observed across nearly all subgroups after stratification.

Conclusions: Patients with a high FPR had increased all-cause and cardiovascular mortality. FPR is a potential prognostic indicator in PD patients.

Background: Circuit clotting remains a major problem during continuous kidney replacement therapy (CKRT), particularly in patients with contraindications to anticoagulant use. We hypothesized that the different options of alternative replacement fluid infusion sites might affect circuit lifespan. However, research-based evidence supporting an optimal replacement fluid infusion strategy is limited. Therefore, we aimed to evaluate the effect of three dilution modes (pre-dilution, post-dilution, and pre- to post-dilution) on circuit lifespan during continuous veno-venous hemodiafiltration (CVVHDF).

Methods: This prospective cohort study was conducted between December 2019 and December 2020. Patients requiring CKRT were enrolled to receive pre-dilution, post-dilution, or pre- to post-dilution fluid infusion with CVVHDF. The primary endpoint was circuit lifespan, and the secondary outcomes included the clinical parameters of patients, such as changes in serum creatinine (Scr) and blood urea nitrogen (BUN) levels, 28-day all-cause mortality, and length of stay. For all patients included in this study, only the first circuit used was recorded.

Results: Among the 132 patients enrolled in this study, 40 were in the pre-dilution mode, 42 were in the post-dilution mode, and 50 were in the pre- to post-dilution mode. The mean circuit lifespan was significantly longer in the pre- to post-dilution group (45.72 h, 95% CI, 39.75-51.69 h) than in the pre-dilution group (31.58 h, 95% CI, 26.33-36.82 h) and the post-dilution group (35.20 h, 95% CI, 29.62-40.78 h). There was no significant difference between the pre- and post-dilution group circuit lifespan (p > 0.05). Kaplan-Meier survival analysis revealed a significant difference between the three dilution modes (p = 0.001). No significant differences were observed in terms of changes in the Scr and BUN levels, admission day, and 28-day all-cause mortality among the three dilution groups (p > 0.05).

Conclusion: The pre- to post-dilution mode significantly prolonged circuit lifespan but did not reduce Scr and BUN levels, compared with the pre-dilution and post-dilution modes during CVVHDF when no anticoagulants were used.

Introduction: Recent studies report that latent tuberculosis infection (LTBI) may lead to an increased risk of cardiovascular disease (CVD) that led us to hypothesize that LTBI may play an important role in major adverse cardiovascular events (MACE) in dialysis patients.

Methods: A single-center retrospective cohort study was conducted. A total of 270 patients undergoing hemodialysis or peritoneal dialysis more than 3 months were included. The interferon enzyme-linked immunospot (IFN-γ ELISPOT) assay was used for the diagnosis of LTBI. Primary endpoints were MACE, including all-cause death and acute coronary syndrome (ACS). The association between LTBI and MACE was examined using multivariate Cox proportional hazards regression after adjusting for covariates and Kaplan-Meier survival analysis.

Results: In our study, the patients were classified into LTBI (n = 47) or non-LTBI (n = 223) groups. Independent risk factors for LTBI in dialysis population were prior tuberculosis (TB) history (odds ratio [OR] 4.817 [1.064-22.306]), tobacco use (OR 2.903 [1.155-7.299]), and older age (OR 1.027 [1.002-1.053]). After a median follow-up of 39 months, the incidence of active TB was 6.4% versus 0% in dialysis patients with and without LTBI, respectively (p = 0.005). Multivariate Cox analysis showed that LTBI was significantly associated with MACE (hazard ratio [HR] 2.540 [1.490-4.350]) after adjustment for potential confounders.

Conclusions: Prior TB history, tobacco use, and the elderly can be used to select cost-effective LTBI screening target groups in dialysis patients. LTBI is not only closely related to active TB but also an independent risk factor for higher incidence of MACE in dialysis population.

A number of systems of feedback control during dialysis have been developed, which have the shared characteristic of prospectively measuring physiological parameters and then automatically altering dialysis parameters in real time according to a pre-specified dialysis prescription. These include feedback systems aimed at reducing intradialytic hypotension based on relative blood volume monitoring linked to adjustments in ultrafiltration and dialysate conductivity, and blood temperature monitoring linked to alterations in dialysate temperature. Feedback systems also exist that manipulate sodium balance during dialysis by assessing and adjusting dialysate conductivity. In this review article, we discuss the rationale for automated feedback systems during dialysis, describe how the different feedback systems work, and provide a review of the current evidence on their clinical effectiveness.

Introduction: Arteriovenous fistula or arteriovenous graft is essential to long-term survival and quality of life in patients receiving hemodialysis. To date, no research has examined the clinical impacts of different puncture methods. This study compared the rope ladder and area puncture techniques in terms of vascular patency, pain, and quality of life among patients receiving hemodialysis.

Methods: A prospective longitudinal study was performed with 6-month follow-up. A total of 98 participants recruited from a hemodialysis center in Taiwan were randomly assigned to receive the rope ladder technique (experimental group) or the area puncture technique (control group). Vascular patency was assessed by examining access flow and percutaneous transluminal angioplasty rate. Pain and quality of life were measured using the Numerical Pain Rating Scale (NPRS) and Kidney Disease Quality of Life Instrument (KDQOL-36™), respectively. All outcome variables were measured repeatedly and analyzed using a generalized estimating equation.

Results: Overall, quality of life was significantly better for the experimental group than for the control group (β = 47.23, p < 0.001). The percutaneous transluminal angioplasty rate was lower for the experimental group than for the control group (12.0% vs. 18.8%). However, no significant differences were found in access flow and pain level between the two groups over time.

Conclusion: Hemodialysis patients who received the rope ladder puncture technique had a lower percutaneous angioplasty rate and better quality of life than patients who received the area puncture technique, suggesting that the rope ladder technique could be implemented as a routine cannulation method in hemodialysis clinics.

Vascular access thrombosis (VAT) is common among patients receiving hemodialysis and leads to missed dialysis treatments, hospitalizations, catheter placement, and graft/fistula abandonment. This article reviews the association between hypercoagulability and VAT and the high prevalence of hypercoagulable states in end-stage kidney disease (ESKD). This article reviews the role of antithrombotic and anticoagulant medications in preventing VAT. The article concludes by reviewing the unique challenges of using vitamin K antagonists in patients with ESKD.