Hemodialysis Procedures for Stable Incident and Prevalent Patients Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance.

The demographic profile of patients transitioning from chronic kidney disease to kidney replacement therapy is changing, with a higher prevalence of aging patients with multiple comorbidities such as diabetes mellitus and heart failure. Cardiovascular disease remains the leading cause of mortality in this population, exacerbated by the cardiovascular stress imposed by the HD procedure. The first year after transitioning to hemodialysis is associated with increased risks of hospitalization and mortality, particularly within the first 90-120 days, with greater vulnerability observed among the elderly. Based on data from clinics in Fresenius Medical Care Europe, Middle East, and Africa NephroCare, this review aims to optimize hemodialysis procedures to reduce mortality risk in stable incident and prevalent patients. It addresses critical aspects such as treatment duration, frequency, choice of dialysis membrane, dialysate composition, blood and dialysate flow rates, electrolyte composition, temperature control, target weight management, dialysis adequacy, and additional protocols, with a focus on mitigating prevalent intradialytic complications, particularly intradialytic hypotension prevention.

Rheopheresis for severe peripheral arterial disease in hemodialysis patients: A clinical series.

BACKGROUND: Rheopheresis is a double-filtration plasmapheresis that removes high-molecular-weight molecules from the plasma and thereby lowers blood viscosity. This treatment has been proposed in hemodialysis (HD) patients for chronic limb-threatening ischemia (CLTI), but very few studies have evaluated the usefulness of this technique. PRINCIPAL OBJECTIVE: To assess 1-year amputation-free survival (AFS) of HD patients suffering from CLTI treated by rheopheresis. MATERIAL AND METHOD: We conducted a retrospective study of 28 consecutive HD patients treated by rheopheresis in three French dialysis centers between 1 February 2017 and 30 April 2019 in two indications resulting from CLTI, namely chronic ulceration or recent minor amputation with delayed healing. RESULTS: One-year AFS rate reached 53.6 (-19.8; +16.3)%. One-year overall survival rate reached 67.9 (-20.5; +13.1)%. Main causes of death were infections and related to palliative care implying reduction or withdrawal of regular dialysis treatment. Hypotension episodes were the main rheopheresis adverse events with a prevalence rate of 13.5%. Rheopheresis sessions significantly reduced fibrinogen, C-reactive protein, α2-macroglobulin, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, IgM, and estimated plasma viscosity (P < .0001). CONCLUSION: Rheopheresis may improve clinical outcomes of CLTI in HD patients. The assessment of rheopheresis effectiveness needs to be confirmed by a multicenter randomized controlled trial, such as the ongoing project in France (RHEO-PAD, NCT: 03975946).

From combined heart-kidney to kidney transplantation program: what nephrologists should know about dilated cardiomyopathy.

A 42-year-old hemodialysis (HD) patient was investigated in our department for symptomatic heart failure (HF) despite daily home dialysis. He had a history of living donor kidney transplantation at the age of 18 that lasted 7 years. Home dialysis was then started. At the age of 40, he developed acute heart failure symptoms. Echocardiography revealed severe dilated cardiomyopathy (DCM). Coronarography and myocardial perfusion scintigraphy showed no abnormal findings. Betablockers were administrated, and RAAS inhibitor dosing was optimized. Dyspnea persisted, and patient was referred to our department. At admission, blood pressure was 116/82 mmHg, and pulse 68 beats/min. No peripheral edema was observed. Dry weight was 62.5 kg. Patient was anuric. Hemoglobin level was 9.8 g/dl, highly sensitive troponin level was 62 ng/ml, and BNP level was 1527 ng/ml. The liver enzyme levels were normal. C-reactive protein was 4.2 mg/ml. Vitamin level, zinc levels, and thyroid function were normal.

Electrochemical skin conductance by Sudoscan®: a new tool to predict intradialytic hypotension.

BACKGROUND: Intradialytic hypotension (IDH), a common complication in haemodialysis (HD) patients, is associated with multiple risk factors including cardiac dysfunction and alterations of the peripheral autonomic nervous system. To what extent dysautonomia may contribute to the occurrence of IDH remains elusive. We sought to investigate the clinical utility of Sudocan®, a device that quantifies dysautonomia, in the prediction of IDH. METHODS: We conducted a prospective monocentric study in adult HD patients from July 2019 to February 2020. Dysautonomia was assessed by the measurements of hand and foot electrochemical skin conductance (ESC) using Sudocan®, before HD. The primary endpoint was the incidence of IDH (The National Kidney Foundation/Kidney-Dialysis Outcome Quality Initiative definition), according to the presence of a pathological hand and/or foot ESC value, during the 3-month study period. RESULTS: A total of 176 HD patients (64 ± 14 years old) were enrolled. Mean pre-dialysis HD hand and foot ESC was 45 ± 20 and 54 ± 22 µS, respectively. About 35% and 40% of patients had a pathological ESC at the hand and foot, respectively. IDH occurred in 46 patients. Logistic regression showed that pathologic pre-dialysis HD hand ESC was associated with an increased risk of IDH [odds ratio = 2.56, 95% CI (1.04-6.67), P = 0.04]. The cumulative risk incidence of IHD during the study was 5.65 [95% CI (2.04-15.71), P = 0.001] and 3.71 [95% CI (1.41-9.76), P = 0.008], with a pathological hand and foot ESC, respectively. CONCLUSIONS: A pathological hand ESC, as assessed by a non-invasive Sudoscan® test, is associated with an increased risk of IDH.

From combined heart-kidney to kidney transplantation program: What nephrologists should know about dilated cardiomyopathy.

A 42-year-old hemodialysis (HD) patient was investigated in our department for symptomatic heart failure (HF) despite daily home dialysis. He had a history of living donor kidney transplantation at the age of 18 that lasted 7 years. Home dialysis was then started. At the age of 40, he developed acute heart failure symptoms. Echocardiography revealed severe dilated cardiomyopathy (DCM). Coronarography and myocardial perfusion scintigraphy showed no abnormal findings. Betablockers were administrated and RAAS inhibitor dosing was optimized. Dyspnea persisted and patient was referred to our department. At admission, blood pressure was 116/82 mmHg, and pulse 68 beats/min. No peripheral edema was observed. Dry weight was 62.5 kg. Patient was anuric. Hemoglobin level was 9.8 g/dl, highly sensitive troponin level was 62 ng/ml and BNP level 1527 ng/ml. The liver enzymes levels as were normal. C-reactive protein was 4.2 mg/ml. Vitamin level, zinc levels and thyroid function were normal.

Routine online assessment of dialysis dose: Ionic dialysance or UV-absorbance monitoring?

For three-weekly hemodialysis, a single-pool Kt/V target of at least 1.4 together with a minimal dialysis dose Kt at 45 L for men and 40 L for women per each session is currently recommended. Fully automatic online calculation of Kt and Kt/V from conductivity or UV-absorbance measurements in the dialysate is standardly implemented on some hemodialysis monitors and makes it possible to estimate the dialysis dose without the need for blood or dialysate samples. Monitoring the UV-absorbance of the spent dialysate is the most direct method for estimating Kt/V as it does not require an estimate of V. Calculation of ionic dialysance from conductivity measurements is the most direct method for estimating Kt and BSA-scaled dialysis dose. Both ionic dialysance monitoring and UV-absorbance monitoring may help detect a change in urea clearance occurring during the session, but this change must be interpreted differently depending on the monitoring being considered. An abrupt decrease in urea clearance results in a decrease in ionic dialysance but, paradoxically, a sudden increase in estimated urea clearance provided by dialysate UV-absorbance monitoring. Healthcare teams who monitor both ionic dialysance and UV-absorbance in their hemodialysis units must be clearly informed of this difficulty.

Neutrophil:lymphocyte ratio predicts short-term outcome of COVID-19 in haemodialysis patients.

BACKGROUND: Information regarding coronavirus disease 2019 (COVID-19) in haemodialysis (HD) patients is limited and early studies suggest a poor outcome. We aimed to identify clinical and biological markers associated with severe forms of COVID-19 in HD patients. METHODS: We conducted a prospective, observational and multicentric study. Sixty-two consecutive adult HD patients with confirmed COVID-19 from four dialysis facilities in Paris, France, from 19 March to 19 May 2020 were included.Blood tests were performed before diagnosis and at Days 7 and 14 after diagnosis. Severe forms of COVID-19 were defined as requiring oxygen therapy, admission in an intensive care unit or death. Cox regression models were used to compute adjusted hazard ratios (aHRs). Kaplan-Meier curves and log-rank tests were used for survival analysis. RESULTS: Twenty-eight patients (45%) displayed severe forms of COVID-19. Compared with non-severe forms, these patients had more fever (93% versus 56%, P < 0.01), cough (71% versus 38%, P = 0.02) and dyspnoea (43% versus 6%, P < 0.01) at diagnosis. At Day 7 post-diagnosis, neutrophil counts, neutrophil:lymphocyte (N:L) ratio, C-reactive protein, ferritin, fibrinogen and lactate dehydrogenase levels were significantly higher in severe COVID-19 patients. Multivariate analysis revealed an N:L ratio >3.7 was the major marker associated with severe forms, with an aHR of 4.28 (95% confidence interval 1.52-12.0; P = 0.006). After a median follow-up time of 48 days (range 27-61), six patients with severe forms died (10%). CONCLUSIONS: HD patients are at increased risk of severe forms of COVID-19. An elevated N:L ratio at Day 7 was highly associated with the severe forms. Assessing the N:L ratio could inform clinicians for early treatment decisions.

Anaemia and acute kidney injury: the tip of the iceberg?

Acute kidney injury (AKI) is a common disorder that complicates the hospital course of many patients. AKI is linked with an independent risk of death, hospital length of stay and chronic kidney disease (CKD). Several preoperative predictors are found to be associated with AKI after surgery independent of its origin (cardiac versus non-cardiac). Among these, anaemia has been widely recognized and studied. Anaemia is more common within the surgical population for various reasons (iron deficiency, blood loss, anaemia of chronic disease such as inflammatory state, malignancy or CKD). Both pre- and postoperative anaemia have a deleterious impact on different clinical outcomes including AKI. In this issue, Nishimoto et al. investigated whether AKI could be a risk factor for anaemia (and not the opposite) and whether anaemia could be an independent mediator of mortality after AKI.

Feasibility and outcomes of native arteriovenous fistula in octogenarians.

INTRODUCTION: While the native arteriovenous fistula (AVF) is the preferred dialysis access, it is a matter of debate for individuals older than 80 years due to reduced primary patency rates. MATERIALS AND METHODS: We initiated a single-center, observational retrospective analysis of adult dialysis patients from January 2015 to December 2018. We included all patients older than 70 years with a minimum of 12 months of follow-up, beginning from the AVF creation. Patients were separated into two groups, octogenarians (> 80 years old) and controls (70 - 79 years old). The primary end point was the primary patency (the interval from arteriovenous access creation to the first intervention). The secondary end point were the complications at 3 months (failures of puncture, canceled dialysis sessions, local hematoma, AVF bleeding). RESULTS: 29 patients (octogenarian = 17, control = 12) were included in the analysis. The AVF radio-cephalic was the most common vascular access in each group. Primary patency was comparable between groups, but octogenarians required 40% more procedures to obtain or maintain patency. Overall, a functional AVF was obtained for all patients except in cases of complications such as hematomas, which were more frequent in octogenarians compared to controls (25 vs. 82%, p < 0.01). All catheters were removed at 6 months follow-up, with a median time to removal of 27 days (range 5 - 157 days). DISCUSSION: Despite a higher rate of interventions and local complications during the first 3 months, AVF and particularly radio-cephalic AVF, is a valid procedure for octogenarians, without lengthening the exposure time to the catheter.

A hepcidin-based approach for iron therapy in hemodialysis patients: A pilot study.

INTRODUCTION: Hepcidin is a key factor that regulates iron homeostasis. In hemodialysis patients (HD), a high hepcidin level may decrease intestinal iron absorption and reduce the efficacy of Oral iron vs Intravenous iron therapy. Whether the hepcidin level in HD could guide oral iron therapy is unclear. METHODS: We report a monocentric study on nine "erythropoietin (EPO)-free" patients (without recombinant human EPO [rHU-EPO] for at least 6 months) and normal hepcidin level (<20 ng mL) during the study. After 15 days of washout, oral iron (ferrous sulfate 80 mg/day) was introduced. The primary end point was the hemoglobin response and iron store at 3 months. FINDINGS: Nine patients (8 men, 1 woman) with a median age of 62 years (range 42-79) were included. After 1 week of treatment, the median transferrin saturation index increased from 15% (range 6-61) to 34% (range 13-42), P = 0.62, reflecting intestinal absorption. The median ferritin level remained stable 80 µg/L (35-293) vs 82 µg/L (range 37-496) between M0 and M3, P = 0.43. During the 3-month study, median hemoglobin level increased from 11.5 d/dL (range10.4-13.7) to 12.8 g/dL (range 11.1-15.2), P = 0.01. No major side effects were observed. Quality of life assessed by the SF-36 criteria was similar during the 3-month study. DISCUSSION: Oral iron therapy is effective and safe in EPO-free patients with normal hepcidin levels. These findings suggest that serum hepcidin may be a marker for defining iron therapy strategies in HD patients. HD patients treated with rHU-EPO and with normal hepcidin levels could benefit from oral iron treatment.

Relative Change of Protidemia Level Predicts Intradialytic Hypotension.

Background Hemodialysis patients are at risk of intradialytic hypotension (IDH), which is associated with mortality and cardiovascular and neurological events. The use of biomarkers of volemia such as relative change in protidemia and BNP (B-natriuretic peptide) levels to predict IDH remains unknown. Methods and Results We conducted a prospective observational study, which enrolled 170 chronic hemodialysis patients in a single center from September 2015 to March 2016. BNP and the relative change of protidemia level (Δprotidemia=postdialysis protidemia-predialysis protidemia) were measured monthly over 6 months. A logistic mixed regression model was used to define the best biomarkers that predict the 30-day risk of IDH. Receiver operating characteristic analysis area under the curve was used to define the cutoff values of Δprotidemia that predict IDH A logistic mixed model reveals that Δprotidemia predicts the 30-day risk of IDH but not BNP or age; odds ratio=1.12, 95% CI 1.08-1.17), odds ratio=0.81, 95% CI (0.64; 1.07) and odds ratio =0.015 95% CI (0.99; 1.03), respectively. Adding the ultrafiltration rate did not improve the model. A receiver operating characteristic curve analysis showed that Δprotidemia of 10 g/L allowed for discrimination of the patients with IDH (area under the curve= 0.67; 95% CI 0.62-0.72, P<0.05). There was an increase in area under the curve to 0.71 (95% CI 0.63-0.76) in a subgroup of hemodialysis with BNP <300 ng/L, for a cutoff value of 11 g/L, especially for the nondiabetic patients. Conclusions Relative change in protidemia level (Δprotidemia) outperforms BNP and ultrafiltration rate as a predictor for 30-day risk of IDH. These results should be confirmed by a prospective study.

Mathematical model to predict B-type natriuretic peptide levels in haemodialysis patients.

AIM: Clinical interpretation of B-type natriuretic peptide (BNP) levels in haemodialysis (HD) patients for fluid management remains elusive. METHODS: We conducted a retrospective observational monocentric study. We built a mathematical model to predict BNP levels, using multiple linear regressions. Fifteen clinical/biological characteristics associated with BNP variation were selected. A first cohort of 150 prevalent HD (from September 2015 to March 2016) was used to build several models. The best model proposed was internally validated in an independent cohort of 75 incidents HD (from March 2016 to December 2017). RESULTS: In cohort 1, mean BNP level was 630 ± 717 ng/mL. Cardiac disease (CD - stable coronary artery disease and/or atrial fibrillation) was present in 45% of patients. The final model includes age, systolic blood pressure, albumin, CD, normo-hydrated weight (NHW) and the fluid overload (FO) assessed by bio-impedancemetry. The correlation between the measured and the predicted log-BNP was 0.567 and 0.543 in cohorts 1 and 2, respectively. Age (ß = 3.175e-2 , P < 0.001), CD (ß = 5.243e-1 , P < 0.001) and FO (ß = 1.227e-1 , P < 0.001) contribute most significantly to the BNP level, respectively, but within a certain range. We observed a logistic relationship between BNP and age between 30 and 60 years, after which this relationship was lost. BNP level was inversely correlated with NHW independently of CD. Finally, our model allows us to predict the BNP level according to the FO. CONCLUSION: We developed a mathematical model capable of predicting the BNP level in HD. Our results show the complex contribution of age, CD and FO on BNP level.

Skin lesions and vancomycin use in a hemodialysis patient.

Vancomycin is a widely used antibiotic in hemodialysis patients. The main complications include renal toxicity and skin lesions. Herein, we report the case of a 29-year-old hemodialysis patient who presented a bullous pruriginous dermatosis after vancomycin treatment. A skin biopsy revealed a linear IgA bullous dermatosis (LABD). This is a rare form of dermatosis and is either idiopathic or more likely vancomycin-induced. Similarities in the molecular structure of vancomycin and epidermal basement membrane glycoproteins could explain the auto-immune response. The overall prognosis after drug discontinuation and dermocorticoid treatment was good.

Functional erythropoietin-hepcidin axis in recombinant human erythropoietin independent haemodialysis patients.

AIM: Relatively few haemodialysis (HD) patients remain independent of recombinant human erythropoietin ('rHU-EPO free patients'). We investigated the role of EPO and hepcidin, two key hormones involved in anaemia. METHODS: We report a monocentric case-control series. Iron status, EPO and hepcidin levels were analysed in 15 Adult HD (Age > 18 years) with a stable haemoglobin (Hb) level that have not received rHU-EPO for at least 6 months (=rHU-EPO free patients); and in 60 controls with a stable rHU-EPO dose and Hb level. RESULTS: The rHU-EPO free patients had a higher Hb level compared to controls (12.1 ± 0.99 g/dL vs 11.1 ± 0.73, P = 0.0014), and a lower ferritin level (183 ± 102 vs 312 ± 166 ng/mL, P = 0.001). Hepcidin levels were lower in the rHU-EPO free patients (12.53 ± 10.46 ng/mL) compared to the controls (37.95 ± 34.33 ng/mL), P = 0.0033. Hepcidin levels correlated significantly with ferritin levels; but neither with transferrin saturation, C-reactive protein nor EPO levels. Unsupervised analysis revealed that rHU-EPO free patients had a specific clinical/biological profile (presence of renal cyst, longer dialysis vintage, lower ferritin, and EPO and hepcidin levels compared to the control group). Finally, we showed that a lower ferritin level might be a surrogate marker of a lower hepcidin status in this population. CONCLUSION: Recombinant human erythropoietin free patients seem to restore the EPO-hepcidin axis that is critical for erythropoiesis. A specific combination of clinical and biological parameters may help to detect future rHU-EPO free patients.

An unusual cause of gastrointestinal bleeding in a hemodialysis patient.

Iron deficiency caused by gastrointestinal (GI) bleeding is a common cause of anemia in hemodialysis patient. Herein, we report the case of an 89-year-old hemodialysis patient who presented with acute anemia and melena. Endoscopy found gastritis and diverticulosis without active bleeding. A capsule endoscopy (CE) was then performed and revealed multiple vascular lesions that lead to the diagnosis of Blue Rubber Bleb Nevus syndrome (BRBNS). This rare disease is associated with multiple venous malformations in the skin and the GI tract, usually observed in children. The patient developed 4 months latter 2 skin lesions compatible with BRBNS. Treatment included blood transfusion and intravenous iron supplementation. We reported an unusual presentation of venous malformation BRBS which differs from angioectasia, in an adult hemodialysis patient. Overall prognosis is good.