Effect of intradialytic aerobic exercise intervention on dialysis adequacy and quality of life in patients with end-stage kidney disease undergoing hemodialysis at Dr. Sardjito General Hospital, Indonesia.

BACKGROUND: End-stage kidney disease (ESKD) carries a significant financial burden due to the need for hemodialysis (HD). Many HD patients do not achieve optimal dialysis, particularly in developing countries like Indonesia where HD is performed twice a week. To answer this issue, a study was conducted at Dr. Sardjito hospital, Indonesia to investigate the effectiveness of intradialysis aerobic exercise in improving dialysis adequacy and quality of life in conventional HD patients. METHODS: This study is an experimental design with a pre-test-post-test control group. ESKD with HD patient was divided into treatment and control groups. The intervention group was subjected to 30 min of intradialysis aerobic exercise using an ergocycle within the first 2 h of the HD sessions, while the control group received regular care. Both groups were followed for 12 weeks. Dialysis adequacy is measured using Kt/V and Urea Reduction Ratio (URR). Quality of life is assessed using KDQOL-36 questionnaire. RESULTS: There was a significant increase in Kt/V and URR (%) in the intervention group compared to the control group, (0.122 ± 0.151 vs - 0.135 ± 0.176, p < 0.001) and (2.627 ± 4.634 vs - 2.620 ± 3.949, p < 0.001), respectively. In addition, quality of life also improved significantly with KDQOL-36 summary score was significantly higher 73.47 (39.44-89.31) to 80.97 (43.06-92.36); p = 0.007) in the intervention group. Multivariate analysis showed that intradialysis exercise (p = 0.001), female gender (p = 0.044), and intradialysis diastolic pressure (p = 0.018) can significantly affect Kt/V changes. CONCLUSION: Intradialytic aerobic exercise for 12 weeks effectively improves dialysis adequacy and quality of life in routine HD patients. This suggests an opportunity for routine deployment, especially when HD resources are limited. However, further studies are needed to investigate additional efficacy aspects and improve exercise protocols for specific ESKD patients. TRIAL REGISTRATION: TCTR202403270002 (retrospectively registered on March 27, 2024).

Five-year survival analysis and predictors of mortality of adult hemodialysis patients in Indonesia: a nationwide database analysis.

BACKGROUND: Hemodialysis (HD) is the modality of renal replacement therapy (RRT) with the highest mortality rate. The identification of prognostic factors will help achieve better outcomes among HD patients. In this study, we sought to conduct a survival analysis and determine the predictors of mortality among adult Indonesian HD patients using data obtained from Indonesian Renal Registry (IRR). METHODS: This is a retrospective cohort study which reviewed all adult hemodialysis patients in Indonesia based on the records of IRR during 2007-2022. Variables analyzed in this study include age, sex, etiology of CKD, cause of death, HD frequency, and initial vascular access. A 5-year follow-up was performed until the outcome of death or drop out was found. RESULTS: Among 99,552 eligible patients, the mean survival length was 1536.21 ± 2.50 days. The 5-year survival rate was 77%. Cox proportional hazard regression model revealed demographic and clinical characteristics that are significantly associated with mortality: male sex (HR: 1.038, 95% CI 1.002-1.075), age of 60 years or older (HR: 1.329, 95% CI 1.281-1.379), diabetic nephropathy (HR: 1.347, 95% CI 1.249-1.452), twice-weekly hemodialysis frequency (HR: 1.080, 95% CI 1.011-1.155), initial vascular accesses with femoral vein puncture (HR: 2.710, 95% CI 2.568-2.860), and CVC (HR: 2.992, 95% CI 2.848-3.144). CONCLUSIONS: The 5-year survival rate of Indonesian HD patients is 77. Male sex, age of HD onset at 60 years or older, diabetic nephropathy, twice-weekly HD frequency, and the initial vascular accesses with femoral vein puncture and CVC are associated with increased risk of mortality.

Effectiveness of Combined Hemodialysis-Hemadsorption Therapy in Improving Uremic Toxin Clearance, Inflammatory Markers, and Symptoms in Maintenance Hemodialysis Patients.

INTRODUCTION: Combined hemodialysis (HD) and hemadsorption (HA) therapy has shown the highest clearance rates for middle and large-sized uremic toxin molecules and reduced mortality rates among maintenance HD (MHD) patients. This study aims to investigate the effectiveness of combined HD and HA therapy in patients undergoing MHD. METHODS: Forty patients with end-stage renal disease (ESRD) were divided into three groups: HD only (14), HD+biweekly HA (14), and HD+weekly HA (12). The duration of the study was 8 weeks. Uremic toxins (ß2-microglobulin, leptin, parathyroid hormone), inflammatory markers (interleukin-6, C-reactive protein), and symptoms (appetite, pruritus, sleep quality) were assessed before the start and at the completion of therapy. Changes in the parameters were compared between the three groups. Mean differences of parameters in each group were also compared between before and after therapy. RESULTS: Decrease in BUN level (-61.34 mg/dL [95% CI:-71.33 to -51.34], p <0.0001) and pruritus score (-3.93 [95% CI:-6.89 to -0.97], p=0.013) was significantly larger in HD+biweekly HA group compared to the others. Only HD + biweekly HA group showed significant reductions in CRP level (-0.10 mg/L [95%: -0.18 to -0.01], p=0.034), VAS appetite score (10.43 [95% CI: 4.99 to 15.87], p = 0.001), and pruritus score (-3.93 [95% CI: -6.89 to -0.97], p =0.013) after therapy. Both HD+biweekly HA (-2.79 [95% CI: -4.97 to -0.60], p=0.016) and HD+weekly HA group (-2.33 [95% CI: -4.59 to -0.08], p=0.044) exhibited a significant improvement in sleep quality score after therapy. CONCLUSIONS: HD combined with a biweekly HA is associated with a greater reduction in BUN level and better improvement of pruritus in ESRD patients compared to HD alone. HD+biweekly HA can significantly reduce CRP levels, alleviate pruritus, improve appetite, and enhance sleep quality.

Immunogenicity and safety of inactivated SARS-CoV-2 vaccine in haemodialysis patients: a prospective cohort study.

End-stage renal disease patients on haemodialysis (HD) have been largely excluded from SARS-CoV-2 vaccine trials due to safety reasons and shown to mount lower responses to vaccination. This study aims to evaluate the immunogenicity and safety of inactivated COVID-19 vaccine among HD patients compared to healthy controls. All subjects who received the primary inactivated COVID-19 vaccination had their blood samples tested 21 days after the second dose. We report the immunogenicity based on anti-RBD IgG titre (IU/mL), the inhibition rate of neutralizing antibodies (NAbs) (%) to RBD, and seroconversion rates. Adverse events were assessed within 30 min and on the 7th day after each dose. Among 75 HD patients and 71 healthy controls, we observed no significant difference in all immunogenicity measures: anti-RBD IgG GMT (277.91 ± 7.13 IU/mL vs. 315.50 ± 3.50 IU/mL, p = 0.645), NAbs inhibition rate (82% [53-96] vs. 84% [39-98], p = 0.654), and seroconversion rates (anti-RBD IgG: 86.7% vs. 85.9%, p = 0.895; NAbs: 45.3% vs. 60.6%, p = 0.065). The number of adverse events is not significantly different between the two groups. The primary inactivated SARS-CoV-2 vaccination elicits an adequate antibody response and can be safely administered in haemodialysis patients.

Immunogenicity and safety of COVID-19 BNT162b2 booster vaccine in end-stage kidney disease patients receiving haemodialysis in Yogyakarta, Indonesia: a cohort prospective study.

BACKGROUND: A significant decrease in antibody titres several months after COVID-19 primary vaccination in end-stage kidney disease (ESKD) patients receiving maintenance haemodialysis has recently been reported. The waning in antibody titres has led to the recommendations for a booster dose to increase the antibody titres after vaccination. Consequently, it is crucial to analyse the long-term humoral immune responses after COVID-19 primary vaccination and assess the immunogenicity and safety of booster doses in haemodialysis (HD) patients. METHODS: Patients on maintenance haemodialysis who received the primary vaccine of CoronaVac (Sinovac) vaccine were administered with BNT162b2 (Pfizer-BioNTech) as the booster dose. The immunogenicity was assessed before (V1), one month (V2) and eight months (V3) after the primary vaccination, as well as one month after the booster dose (V4). Patients were followed up one month after the booster dose to assess the adverse events (AEs). RESULTS: The geometric mean titre (GMT) of anti-SARS-CoV-2 S-RBD IgG antibody at 8 months after the primary vaccination increased significantly to 5,296.63 (95%CI: 2,930.89-9,571.94) U/mL (p = < 0.0001) compared to before the primary vaccination. The GMT also increased significantly to 19,142.56 (95% CI: 13,489.63-27,227.01) U/mL (p < 0.0001) 1 month after the booster vaccine. Meanwhile, the median inhibition rate of neutralizing antibodies (NAbs) at 8 months after the primary vaccine and 1 month after the booster dose were not significantly different (p > 0.9999). The most common AEs after the booster dose included mild pain at the injection site (55.26%), mild fatigue (10.53%), and swelling at the injection site (10.53%). No serious AEs were reported. CONCLUSIONS: The majority of ESKD patients on haemodialysis mounted a good antibody response to the BNT162b2 booster vaccination with tolerable adverse events.

Outcomes of vaccinations against respiratory diseases in patients with end-stage renal disease undergoing hemodialysis: A systematic review and meta-analysis.

Due to the nature of the disease, end-stage renal disease (ESRD) patients suffer from dysfunction of the adaptive immune system, which leads to a poorer response to vaccination. Accordingly, it is crucial to evaluate the efficacy and safety of management strategies, including vaccinations, which could potentially reduce the risk of respiratory diseases, such as pneumonia, influenza, or COVID-19, and its associated outcomes. We searched PubMed, CENTRAL, ScienceDirect, Scopus, ProQuest, and Google Scholar databases using designated MeSH keywords. The risk of bias was assessed using ROBINS-I. The quality of evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Relative risk (RR) and 95% confidence interval (CI) were calculated. Heterogeneity was investigated using forest plots and I2 statistics. This systematic review included a total of 48 studies, with 13 studies of influenza (H1N1 and H3N2) vaccination and 35 studies of COVID-19 vaccination. H1N1 vaccination in ESRD patients undergoing hemodialysis induced lower seroconversion rates (RR 0.62, 95% CI: 0.56-0.68, p <0.00001) and lower seroprotection rates (RR 0.76, 95% CI: 0.70-0.83, p <0.00001) compared to controls. H3N2 vaccination in ESRD patients undergoing hemodialysis yielded lower seroconversion rates (RR 0.76, 95% CI: 0.68-0.85, p <0.00001) and lower seroprotection rates (RR 0.84, 95% CI: 0.77-0.90, p <0.00001) compared to controls. Twenty-nine studies demonstrate significantly lower antibody levels in ESRD patients undergoing hemodialysis compared to the controls following COVID-19 vaccination. This review presents evidence of lower seroconversion and seroprotection rates after vaccination against viral respiratory diseases in patients with ESRD undergoing hemodialysis. Since hemodialysis patients are more susceptible to infection and severe disease progression, a weakened yet substantial serological response can be considered adequate to recommend vaccination against respiratory diseases in this population. Vaccination dose, schedule, or strategy adjustments should be considered in stable ESRD patients on maintenance hemodialysis. Trial registration: Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255983, identifier: CRD42021255983.

Persistent Left Superior Vena Cava Identified After Hemodialysis Catheter Insertion: A Case Report.

INTRODUCTION: Central venous catheter (CVC) insertion is the most commonly performed clinical procedure when a patient initiates hemodialysis. Despite its clinical benefits, CVC insertion has several risks of complications. Thrombosis, venous stenosis, infection, arrhythmia, pneumothorax, and bleeding are among these complications. Malposition of the tip of the CVC can also occur with an incidence of up to 7%. One of several factors that could contribute to malposition is venous anatomy variation. Persistent left superior vena cava (PLSVC) is an extremely rare venous anatomical disorder but might have a significant clinical impact. CASE PRESENTATION: Here we report a PLSVC case that was identified in chest radiography after the insertion of a CVC catheter in a patient with end-stage renal disease (ESRD). A 40-year-old woman with a history of type 2 diabetes mellitus, hypertension, dyslipidemia, and obesity was presented in the emergency room with dyspnea for 1 week. Acute hemodialysis was required because of the ESRD and pulmonary edema. The PLSVC condition accompanied by various complications that occurred in this patient became a dilemma for the nephrologist in determining the diagnosis and proper CVC management. DISCUSSION: PLSVC is the most common congenital abnormality of the vena cava, even though it has a very small incidence. PLSVC occurs in about 0.1-0.5% of the total population and reaches 10% in individuals with congenital heart abnormalities. Most PLSVC presents along with normal superior vena cava and drains into the right atrium, which makes it very difficult to see the clinical signs and symptoms. Almost all PLSVC conditions are found incidentally during or after invasive procedures such as CVC insertion. CVC insertion in the PLSVC condition needs proper management to minimize the risk of complications. CONCLUSION: This case shows the importance of understanding the PLSVC condition, which, although very rare, is expected to increase the awareness of the nephrologist in making the diagnosis, determining appropriate management, and preventing complications, thereby improving patient safety.