Humoral immunity trends in a hemodialysis cohort following SARS-CoV-2 mRNA booster: A cohort study.

Background and Aims: Patients with end stage kidney disease on hemodialysis are vulnerable to SARS-CoV-2 infection. Current guidelines recommend boosters of SARS-CoV-2 mRNA-based vaccines. The long-term humoral response of hemodialysis patients infected with SARS-CoV-2 after receiving a booster of SARS-CoV-2 mRNA-based vaccines has been incompletely characterized. Here, we determined the long-term humoral response of hemodialysis patients to two and three doses of the Pfizer BioNTech (BNT162b2) mRNA SARS-CoV-2 vaccine and investigated the effect of postbooster SARS-CoV-2 infection on antibody levels over time. Methods: Samples were collected on a monthly basis and tested for anti-SARS-CoV-2 antibodies against anti-spike S1 domain. Thirty-five hemodialysis patients were enrolled in the original study and 27 of these received a booster. Patients were followed up to 6 months after the first two doses and an additional 7 months after the third BNT162b2 dose. Results are presented as the internationally harmonized binding antibody units (BAU/mL). Results: Antibody level significantly increased from prebooster to 2 weeks postbooster, with a median [25th, 75th percentile] rise from 52.72 [28.55, 184.7] to 6216 [3806, 11,730] BAU/mL in the total population. Of patients with a negative or borderline detectable antibody level 6 months after vaccination who received a third dose, 89% developed positive antibody levels 2 weeks postbooster. Postbooster antibody levels declined an average rate of 29% per month in infection-naïve patients. Antibody levels spiked in patients infected with SARS-CoV-2 after receiving a booster but declined rapidly. No patients infected postbooster required hospitalization. Conclusions: A third dose of BNT162b2 restores antibody levels to high levels in dialysis patients but levels decline over time. A third dose did not necessarily prevent infection, but no patients suffered severe infection or required hospitalization. SARS-CoV-2 recovered patients appear to have a blunted rise in antibody levels after a third dose. Although patients infected with SARS-CoV-2 postbooster had an immediate spike in antibody levels, these declined over time.

SRDA: Mobile Sensing based Fluid Overload Detection for End Stage Kidney Disease Patients using Sensor Relation Dual Autoencoder.

Chronic kidney disease (CKD) is a life-threatening and prevalent disease. CKD patients, especially endstage kidney disease (ESKD) patients on hemodialysis, suffer from kidney failures and are unable to remove excessive fluid, causing fluid overload and multiple morbidities including death. Current solutions for fluid overtake monitoring such as ultrasonography and biomarkers assessment are cumbersome, discontinuous, and can only be performed in the clinic. In this paper, we propose SRDA, a latent graph learning powered fluid overload detection system based on Sensor Relation Dual Autoencoder to detect excessive fluid consumption of EKSD patients based on passively collected bio-behavioral data from smartwatch sensors. Experiments using real-world mobile sensing data indicate that SRDA outperforms the state-of-the-art baselines in both F1 score and recall, and demonstrate the potential of ubiquitous sensing for ESKD fluid intake management.

Long-term humoral immunity decline in hemodialysis patients following severe acute respiratory syndrome coronavirus 2 vaccination: A cohort study.

Background and Aims: Dialysis patients are extremely vulnerable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with high rates of hospitalization and mortality rates. In January 2021, the University of Virginia Dialysis Program initiated a program-wide vaccination campaign to administer the Pfizer BioNTech messenger RNA SARS-CoV-2 (BNT162b2) vaccine. The aim of this study was to characterize the long-term time-dependent decline in humoral immunity in hemodialysis patients. Methods: A prospective cohort study measuring serial monthly semiquantitative IgG antibody levels to the SARS-CoV-2 spike protein receptor binding domain in fully vaccinated in-center hemodialysis patients. Samples were collected monthly and tested for anti-SARS-CoV-2 antibodies against the anti-spike S1 domain for 2-6 months post full vaccination. Results were presented as internationally harmonized binding antibody units (BAU/ml). To analyze the change in antibody levels over time, a linear mixed model with random intercept and random slope was used for longitudinal antibody levels. A multivariable model was used to estimate the slope of antibody levels by adjusting for selected patient characteristics. Based on the estimated intercepts and slopes for each subject from the unadjusted model, 10-month antibody levels were projected. Results: The mean baseline antibody level was 647.59 BAU/ml and 87.88% (29/33) of patients were considered qualitatively positive. Two patients were negative at baseline and an additional two had borderline results. Patient antibody levels declined at an adjusted average rate of 31% per month. At 6 months postvaccination, 40% of patients remaining in the cohort possessed either negative or borderline IgG antibody levels. Projecting future antibody levels suggests that 65% of the cohort will progress to borderline or negative antibody levels at 10 months post full vaccination. Conclusion: The long-term vaccine response following vaccination with the BNT162b2 in hemodialysis patients was characterized. Our data add to the limited pool of data in this patient population and emphasize the critical need for vaccine boosters.

Anti-Neurofascin-Associated Nephrotic-Range Proteinuria in Chronic Inflammatory Demyelinating Polyneuropathy.

There are few case reports of concomitant chronic inflammatory demyelinating polyneuropathy (CIDP) and focal segmental glomerulosclerosis. A rare autoantibody to a neuronal and podocyte structural component, neurofascin, may be contributory. A Black man in his 40s presented with worsening polyneuropathy requiring mechanical ventilation and initially acute inflammatory demyelinating polyneuropathy was diagnosed. After a poor response to intravenous immunoglobulin, plasmapheresis was initiated. The patient also had concomitant new-onset nephrotic-range proteinuria. A limited kidney biopsy was interpreted as minimal change disease and was treated with prednisone. After some improvement, the patient was extubated; however, he later re-presented with worsening symptoms requiring mechanical ventilation and was re-treated with plasmapheresis. Due to the protracted course and poor response to intravenous immunoglobulin, acute-onset CIDP was diagnosed and a neuromuscular antibody workup returned positive for neurofascin, supporting the diagnosis of seropositive acute-onset CIDP. A repeat kidney biopsy demonstrated focal segmental glomerulosclerosis and acute tubular damage. The patient was treated with steroids and tacrolimus and later transitioned to rituximab. Neurofascin enzyme-linked immunosorbent assay then tested negative with concomitant resolution of both neuropathy and proteinuria. Further studies will help validate these findings and the treatment strategy.

Approach to Electrolyte Abnormalities, Prerenal Azotemia, and Fluid Balance.

Volume and electrolyte evaluation and management is seen frequently in primary care practices. Some of the most common abnormalities encountered in outpatient practices are prerenal azotemia, dysnatremias, and altered potassium levels. Perturbations in volume or electrolyte concentrations can lead to serious organ dysfunction as well as hemodynamic collapse. This review focuses on the maintenance and regulation of intravascular volume and electrolytes, specifically sodium and potassium.

A recurrent neural network approach to predicting hemoglobin trajectories in patients with End-Stage Renal Disease.

The most severe form of kidney disease, End-Stage Renal Disease (ESRD) is treated with various forms of dialysis - artificial blood cleansing. Dialysis patients suffer many health burdens including high mortality and hospitalization rates, and symptomatic anemia: a low red blood cell count as indicated by a low hemoglobin (Hgb) level. ESRD-induced anemia is treated, with variable patient response, by erythropoiesis stimulating agents (ESAs): expensive injectable medications typically administered during dialysis sessions. The dosing protocol is typically a population level protocol based on original clinical trials, the use of which often results in Hgb cycling. This cycling phenomenon occurs primarily due to the mismatch in the time between dosing decisions and the time it takes for the effects of a dosing change to be fully realized. In this paper we develop a recurrent neural network approach that uses historic data together with future ESA and iron dosing data to predict the 1, 2, and 3 month Hgb levels of patients with ESRD-induced anemia. The results of extensive experimentation indicate that this approach generates predictions that are clinically relevant: the mean absolute error of the predictions is comparable to estimates of the intra-individual variability of the laboratory test for Hgb.

Improving Incident ESRD Care Via a Transitional Care Unit.

Dialysis care in the United States continues to move toward an emphasis on continuous quality improvement and performance benchmarking. Government- and industry-sponsored programs have evolved to assess and incentivize outcomes for many components of end-stage renal disease care. One aspect that remains largely unaddressed at a systemic level is the high-risk transition period from chronic kidney disease and acute kidney injury to permanent dialysis dependence. Incident dialysis patients experience disproportionately high mortality and hospitalization rates coupled with high costs. This article reviews the clinical case for a special emphasis on this transition period, reviews published literature regarding prior transitional care programs, and proposes a novel iteration of the first 30 days of dialysis care: the transitional care unit (TCU). The goal of a TCU is to improve awareness of all aspects of renal replacement therapy, including modalities, access, transplantation options, and nutritional and psychosocial aspects of the disease. This enables patients to make truly informed decisions regarding their care. The TCU model is open to all patients, including incident patients with end-stage renal disease, those for whom peritoneal dialysis is failing, or those with failing transplants. This model may be especially beneficial to those who are deemed inadequately prepared or "crash start" patients.

Influenza and the patient with end-stage renal disease.

Influenza is a commonly encountered and serious pathogen. Patients with end-stage renal disease are more susceptible to serious morbidity and mortality associated with influenza infection. Proper management of patients includes: vaccination, monitoring for symptoms and isolation of potentially infected patients as well as appropriate antiviral therapies. In some cases of exposure, chemoprophylaxis is warranted. Vaccination and appropriate therapies are associated with improved outcomes.

Lixivaptan - an evidence-based review of its clinical potential in the treatment of hyponatremia.

Hyponatremia is the most common electrolyte abnormality seen in clinical practice. Most cases of euvolemic or hypervolemic hyponatremia involve arginine vasopressin (AVP). AVP leads to a concentrated urine and negative free water clearance. Given this primary role of AVP, antagonizing its effect through blockade of its receptor in the distal tubule is an attractive therapeutic target. Lixivaptan is a newer, non-peptide, vasopressin type 2 receptor antagonist. Recent studies have demonstrated efficacy. This review summarizes the clinical pharmacology and data for this new agent.

Comanagement of diabetic kidney disease by the primary care provider and nephrologist.

DKD is a complex and multifaceted disease. A substantial portion of patients remain unable to attain clinical targets for glycosylated hemoglobin, lipids, and blood pressure. Improving outcomes requires multifactorial interventions that are best delivered through collaborative care. Targets for improvement should include screening, diagnosis, and early referral. Following referral, the patient should be cared for in an integrated framework using the 4 elements of an effective DKD care delivery model: clear roles and responsibilities, integrated QI programs, MDT approach, and effective communication facilitated through access to a shared EMR. Given the differences in the pathophysiology of DM in the renal population, a nephrologist and endocrinologist can be invaluable in improving care for this population. Large-scale trials are needed to validate the cost and usefulness of collaborative care as current data are insufficient. Based on available data, models such as the one proposed here should serve to maximize the strengths of individual providers and provide improved quality of care to patients.