Physical Activity Elements and Adverse Outcomes in Patients with Chronic Kidney Disease in Guangdong (PEAKING) project: protocol for a prospective cohort study.

INTRODUCTION: Physical inactivity is prevalent and associated with adverse outcomes among patients with chronic kidney disease (CKD). Most previous studies have relied on subjective questionnaires to assess levels of physical activity (PA) and mainly focused on patients undergoing dialysis. Therefore, the Physical Activity Elements and Adverse Outcomes in Patients with Chronic Kidney Disease in Guangdong study aims to investigate the levels and types of PA elements and their association with adverse outcomes in Chinese non-dialysis CKD (ND-CKD) patients. METHODS AND ANALYSIS: In this prospective cohort study, 374 patients with ND-CKD will be recruited from Guangdong province, South of China. The primary exposure will be levels of PA assessed by ActiGraph GT3X+ accelerometer including the intensity, duration, frequency and type of PA. The traditional Chinese exercises such as tai chi and Baduanjin will also be assessed. The primary outcomes will be all-cause mortality. Other variables including demographics, comorbidities, medication and laboratory markers will be registered. All data will be updated annually for at least 5 years, or until the occurrence of death or initiation of renal replacement therapy. The Spearman correlation coefficient will be used to investigate the correlation between questionnaire-derived and accelerometry-derived PA. The Cox proportional hazards model will be used to investigate the association between level of PA and adverse outcomes. Non-linear associations between PA levels and outcomes, as well as the minimum desirable PA level, will be evaluated using restricted cubic splines. ETHICS AND DISSEMINATION: The ethical permission for this study was obtained from the ethics committee of Guangdong Provincial Hospital of Chinese Medicine in Guangzhou, China (B2015-152-02). Written informed consent is obtained from all participants. The results will be disseminated by publication in a peer-reviewed journal and presented at relevant conferences.

Inflammation and Vitamin D Receptor Polymorphism: Impact on All-Cause and Cardiovascular Mortality in Mexican Women on Dialysis.

Mineral bone disease (MBD) is common in dialysis patients. Genetics and the hormonal environment influence the clinical picture and outcomes of women. This study aimed to determine how these factors affect mortality. In 234 female dialysis patients on Continuous Ambulatory (48%) or Automated (29%) Peritoneal Dialysis or Hemodialysis (23%), MBD biochemical variables, as well as bone density and genetic Bsm1 polymorphism of vitamin D receptor (VDR) were performed at baseline. The cohort was followed-up by 17 (IQ range 15-31) months. According to VDR polymorphism, the distribution of patients was bb: 64% and BB+Bb: 36%. Fifty-five patients died from all-cause mortality; the hs-C-reactive protein level was the most significant risk in multivariate Cox analysis. Nineteen died from cardiovascular mortality. None of the variables were significant for cardiovascular mortality. Patients with bb plus inflammation had the highest risk in the analysis; the significance persisted after adjustment for age, diabetes, and parathyroid hormone levels HR 2.33 (95% CI, 1.01-8.33) and after further adjustment for time on dialysis, albumin, and Osteoprotegerin levels HR 3.49 (95% CI, 1.20-10.9). The presence of the bb genotype from VDR and inflammation had the highest risk of death from all-cause mortality in females on CAPD, APD, and HD patient.

Dietary Needs, Barriers, and Facilitators Among Patients on Hemodialysis and Their Caregivers: The GoodRENal Project in Spain.

OBJECTIVE: Dietary restrictions are common in patients undergoing hemodialysis (HD). These restrictions result in a complex diet that becomes difficult for patients to understand and to follow. Therefore, we aimed to identify dietary needs, barriers, and facilitators that influence the adherence to dietary recommendations as perceived by patients on HD and their caregivers. METHODS: Seventy-two Spanish patients on HD and 57 caregivers participated in this explorative study by replying a questionnaire consisting of 20 and 10 questions respectively. The responses were assessed using a Likert scale varying from 1 to 5 (strongly agree, agree, neither disagree or disagree, disagree, strongly disagree, respectively) to evaluate the perception of patients and caregivers regarding dietary needs, barriers, and facilitators to adhere to the recommended diet. For analysis purposes, the responses were grouped in 3 categories (agree, neither agree or disagree, disagree). RESULTS: Seventy percent of the patients agreed that knowing the food sources of potassium, protein and phosphate was a need for them to know to be able to adhere to the dietary recommendations. Moreover, patients stated that not being able to eat what they liked, and feeling thirsty, were important barriers. For caregivers, the support of a renal dietitian was mentioned as an important facilitator to assist those they cared for to adhere to the diet. CONCLUSIONS: Knowing food sources of potassium, phosphate, and protein, exploring foods patients like to eat and adjusting fluid intake to avoid feeling thirsty were identified as important by the patients. These findings can be used to develop strategies and educational material to improve the dietary adherence in patients undergoing HD. Moreover, the presence of a renal dietitian was identified as an important resource by the caregivers.

Peripheral Blood Lymphocyte Subgroups in Patients Undergoing Hemodialysis with Medium Cutoff Membranes and High-Flux Membranes: THE SHE Continuation Study.

INTRODUCTION: Chronic kidney disease (CKD) poses a significant global health burden, with increasing prevalence and high morbidity and mortality rates, particularly in end-stage kidney disease (ESKD). While traditional risk factors contribute, the exact mechanisms remain elusive, with inflammation playing a pivotal role. Medium cutoff (MCO) membranes offer promise in improving dialysis outcomes by efficiently clearing uremic toxins without substantial albumin loss. We aimed to elucidate the impact of MCO and high-flux (HF) membranes on peripheral blood lymphocyte subpopulations in hemodialysis patients. METHODS: Twenty-four ESKD patients underwent 36 sessions each with MCO and HF membranes. Immunophenotyping by flow cytometry was performed to analyze lymphocyte subsets. RESULTS: NK cell percentages significantly increased with MCO, returning to baseline with HF. Th1 cells decreased post-HF, while Th2 and Tfh cells increased with MCO and persisted. Treg cells remained stable with MCO but decreased with HF. CONCLUSION: MCO dialysis induced an anti-inflammatory shift, evidenced by increased Th2 and Tfh cells and stable Treg cells. NK cells also responded favorably to MCO. These findings underscore MCO membranes' potential to modulate immune responses and improve patient outcomes in ESKD.

Protein Intake and Mortality in Older Adults With Chronic Kidney Disease.

Importance: Avoiding high protein intake in older adults with chronic kidney disease (CKD) may reduce the risk of kidney function decline, but whether it can be suboptimal for survival is not well known. Objective: To estimate the associations of total, animal, and plant protein intake with all-cause mortality in older adults with mild or moderate CKD and compare the results to those of older persons without CKD. Design, Setting, and Participants: Data from 3 cohorts (Study on Cardiovascular Health, Nutrition and Frailty in Older Adults in Spain 1 and 2 and the Swedish National Study on Aging and Care in Kungsholmen [in Sweden]) composed of community-dwelling adults 60 years or older were used. Participants were recruited between March 2001 and June 2017 and followed up for mortality from December 2021 to January 2024. Those with no information on diet or mortality, with CKD stages 4 or 5, or undergoing kidney replacement therapy and kidney transplant recipients were excluded. Data were originally analyzed from June 2023 to February 2024 and reanalyzed in May 2024. Exposures: Cumulative protein intake, estimated via validated dietary histories and food frequency questionnaires. Main Outcomes and Measures: The study outcome was 10-year all-cause mortality, ascertained with national death registers. Chronic kidney disease was ascertained according to estimated glomerular filtration rates, urine albumin excretion, and diagnoses from medical records. Results: The study sample consisted of 8543 participants and 14 399 observations. Of the 4789 observations with CKD stages 1 to 3, 2726 (56.9%) corresponded to female sex, and mean (SD) age was 78.0 (7.2) years. During the follow-up period, 1468 deaths were recorded. Higher total protein intake was associated with lower mortality among participants with CKD; adjusted hazard ratio (HR) for 1.00 vs 0.80 g/kg/d was 0.88 (95% CI, 0.79-0.98); for 1.20 vs 0.80 g/kg/d, 0.79 (95% CI, 0.66-0.95); and for 1.40 vs 0.80 g/kg/d, 0.73 (95% CI, 0.57-0.92). Associations with mortality were comparable for plant and animal protein (HRs, 0.80 [95% CI, 0.65-0.98] and 0.88 [95% CI, 0.81-0.95] per 0.20-g/kg/d increment, respectively) and for total protein intake in participants younger than 75 years vs 75 years or older (HRs, 0.94 [95% CI, 0.85-1.04] and 0.91 [95% CI, 0.85-0.98] per 0.20-g/kg/d increment in total protein intake, respectively). However, the hazards were lower among participants without CKD than in those with CKD (HRs, 0.85 [95% CI, 0.79-0.92] and 0.92 [95% CI, 0.86-0.98] per 0.20-g/kg/d increment, respectively; P = .02 for interaction). Conclusions and Relevance: In this multicohort study of older adults, higher intake of total, animal, and plant protein was associated with lower mortality in participants with CKD. Associations were stronger in those without CKD, suggesting that the benefits of proteins may outweigh the downsides in older adults with mild or moderate CKD.

Remote monitoring of automated peritoneal dialysis reduces mortality, adverse events, and hospitalizations: a cluster randomized controlled trial.

BACKGROUND AND HYPOTHESIS: Remote monitoring (RM) of patients on automated peritoneal dialysis (APD) prevent complications and improve treatment quality. We analyzed the effect of RM-APD on mortality and complications related to cardiovascular disease (VD), fluid overload and insufficient dialysis efficiency. METHODS: In a cluster-randomized, open-label, controlled trial, 21 hospitals with APD programs were assigned to use either RM-APD (10 hospitals; 403 patients) or conventional APD (11 hospitals; 398 patients) for the treatment of adult patients starting PD. Primary outcomes were time to first event of: 1) Composite Index-1 comprising all-cause mortality, first adverse events and hospitalizations of any cause, and 2) Composite Index-2 comprising cardiovascular mortality, first adverse event and hospitalizations related to CVD, fluid overload and insufficient dialysis efficiency. Secondary outcomes were time to first event of individual components of the two composite indices, and rates of adverse events, hospitalizations, unplanned visits, and transfer to hemodialysis. Patients were followed for a median of 9.5 months. Primary outcomes were evaluated by competing-risk analysis and restricted mean survival time (RMST) analysis. RESULTS: While time to reach Composite Index-1 did not differ between the groups, Composite Index-2 was reached earlier (ΔRMST: -0.85 months; p=0.02), and all-cause mortality (55 vs. 33 deaths, p=0.01; sHR 1.69 (95%CI 1.39-2.05), p<0.001) and hospitalizations of any cause were higher in APD group than in RM-APD as were cardiovascular deaths (24 vs. 13 deaths, p=0.05; sHR 2.44 (95%CI 1.72 - 3.45), p<0.001) and rates of adverse events and hospitalizations related to CVD, fluid overload or insufficient dialysis efficiency. Dropouts were more common in the APD group (131 vs. 110, p=0.048). CONCLUSIONS: This randomized controlled trial shows that remote monitoring may add significant advantages to APD, including improved survival and reduced rate of adverse events and hospitalizations, which can favorably impact the acceptance and adoption of the therapy.

Plant-based diet in hyperkalemic chronic kidney disease patients receiving sodium zirconium cyclosilicate: a feasibility clinical trial.

BACKGROUND: Plant-based diets (PBD) may induce hyperkalemia in chronic kidney disease (CKD) patients. OBJECTIVES: We explored the safety and feasibility of PBD in hyperkalemic CKD patients receiving the potassium binder sodium zirconium cyclosilicate (SZC). METHODS: In the current 6-wk trial, 26 hyperkalemic patients with CKD stage 4-5 not on dialysis received a low-protein low-potassium diet plus SZC for 3 wk and then a PBD with high potassium content delivered as a weekly food basket while continuing SZC for subsequent 3 wk. Plasma potassium was monitored weekly and SZC was titrated to achieve normokalemia. The 24-h urine excretion of potassium and sodium, 24-h food records, dietary quality, nutritional status, Bristol stool scale, Quality of life (QoL), and renal treatment satisfaction were assessed at baseline (week 0), week 3, and week 6. RESULTS: Mean plasma potassium decreased from 5.5 to 4.4 mEq/L within 48-72 h after baseline, then rose to 4.7-5.0 mEq/L throughout the remaining study period following dose adjustments of SZC that matched the increased potassium intake of PBD from week 3 to week 6. Over the study period, 24-h urinary potassium excretion decreased from week 0 to week 3 and increased from week 3 to week 6. During the study, 58% of patients had fasting plasma potassium between 3.5 and 5.0 mEq/L and there was no episode of plasma potassium >6.5 mEq/L or <3.0 mEq/L during the study. P-carbon dioxide increased from baseline until week 6 (21 ± 2 to 23 ± 2 mEq/L; P = 0.002; mean ± SD), whereas remaining laboratory values remained unchanged. Fiber intake, dietary quality, the domain physical functioning from QoL, and 1 question of renal treatment satisfaction improved, whereas stool type and frequency did not change after starting PBD. CONCLUSIONS: PBD in hyperkalemia-prone CKD patients receiving SZC improved dietary quality and increased the intake of healthy foods, whereas plasma potassium concentration remained stable within normal values for most patients. TRIAL REGISTRATION NUMBER: This trial was registered at the https://clinicaltrials.gov/study/NCT04207203 as NCT04207203.

Interaction of general obesity and abdominal obesity with frailty in patients with chronic kidney disease: a nationally representative analysis.

Background: General and abdominal obesity are prevalent, with established associations to frailty in the elderly. However, few studies have investigated these associations in patients with chronic kidney disease (CKD), yielding inconsistent results. Methods: This cross-sectional study analysed data from the National Health and Nutrition Examination Survey (NHANES 2003-2018). Frailty was evaluated by the 36-item frailty index. General obesity was defined as a body mass index (BMI) >30 kg/m2; abdominal obesity was identified if waist circumference (WC) reached 102 cm in men and 88 cm in women. The associations of general and abdominal obesity with frailty were analysed using weighted multivariate logistic regression and restricted cubic splines. The interaction of general and abdominal obesity with frailty was examined. Results: A total of 5604 adult patients (median age 71 years, 42% men) with CKD were included in this analysis, with a median estimated glomerular filtration rate of 57.3 ml/min/1.73 m2. A total of 21% were frail with general obesity and 32% were frail with abdominal obesity. Neither general nor abdominal obesity alone was associated with frailty. There was an interaction between general and abdominal obesity with frailty. Compared with individuals with normal BMI and WC, those with both general and abdominal obesity, rather than either alone, exhibited significantly increased odds of frailty {odds ratio [OR] 1.53 [95% confidence interval (CI) 1.20-1.95]}. General obesity was associated with being frail only when CKD patients had abdominal obesity [OR 1.59 (95% CI 1.08-2.36)]. Conclusions: There may be an interaction between general and abdominal obesity with frailty in patients with CKD. Interventions aimed at preventing frailty should consider both aspects.

Can one long peritoneal dwell with icodextrin replace two short dwells with glucose?

Background: Due to the slower dissipation of the osmotic gradient, icodextrin-based solutions, compared to glucose-based solutions, can improve water removal. We investigated scenarios where one icodextrin-based long dwell (Extraneal) replaced two glucose-based exchanges. Methods: The three-pore model with icodextrin hydrolysis was used for numerical simulations of a single exchange to investigate the impact of different peritoneal dialysis schedules on fluid and solute removal in patients with different peritoneal solute transfer rates (PSTRs). We evaluated water removal (ultrafiltration, UF), absorbed mass of glucose (AbsGluc) and carbohydrates (AbsCHO, for glucose and glucose polymers), ultrafiltration efficiency (UFE = UF/AbsCHO) per exchange, and specified dwell time, and removed solute mass for sodium (ReNa), urea (ReU), and creatinine (ReCr) for a single peritoneal exchange with 7.5% icodextrin (Extraneal®) and glucose-based solutions (1.36% and 2.27%) and various dwell durations in patients with fast and average PSTRs. Results: Introducing 7.5% icodextrin for the long dwell to replace one of three or four glucose-based exchanges per day leads to increased fluid and solute removal and higher UF efficiency for studied transport groups. Replacing two glucose-based exchanges with one icodextrin exchange provides higher or similar water removal and higher daily sodium removal but slightly lower daily removal of urea and creatinine, irrespective of the transport type present in the case of reference prescription with three and four daily exchanges. Conclusion: One 7.5% icodextrin can replace two glucose solutions. Unlike glucose-based solutions, it resulted only in minor differences between PSTR groups in terms of water and solute removal with UFE remaining stable up to 16 h.

Nutritional Status of Patients Starting on Peritoneal Dialysis: A Comparison Between Planned and Unplanned Dialysis Initiation.

OBJECTIVE: A suboptimal dialysis initiation with insufficient or no planning before urgent start of dialysis remains a common problem associated with increased morbimortality. Whether nutritional markers differ between patients starting peritoneal dialysis (PD) in unplanned and planned modes has not yet been explored. Therefore, we aimed to evaluate whether the nutritional status at the start of dialysis differed between patients with unplanned and planned PD initiation. METHODS: In this observational study comprising 47 adult patients starting PD (age 58 ± 15 years, 51% female), 29 patients had unplanned (starting dialysis up to 72 hours after peritoneal catheter implantation) and 18 planned (follow-up predialysis >90 days) dialysis initiation. Within 30 days of PD initiation, nutritional status was evaluated using anthropometric measurements, multifrequency bioelectrical impedance analysis, appetite assessment, handgrip strength, laboratory markers, and the malnutrition-inflammation score. Physical activity and performance were also evaluated. RESULTS: Patients with an unplanned PD initiation had a higher frequency of diabetes, higher blood glucose, urea, and glycated hemoglobin levels, and lower hemoglobin and albumin levels. Furthermore, they had a lower calf circumference, slower gait speed, higher protein intake, and greater malnutrition-inflammation score, while their physical activity level and appetite did not differ. CONCLUSION: Patients with an unplanned PD had unfavorable clinical and nutritional markers compared with those with planned PD. These findings indicate that a lack of follow-up prior to dialysis initiation can influence the clinical and nutritional statuses of patients, reinforcing the importance of conservative treatment prior to dialysis initiation.

Hypoxic Inducible Factor Stabilization in Pericytes beyond Erythropoietin Production: The Good and the Bad.

The paracrine signaling pathways for the crosstalk between pericytes and endothelial cells are essential for the coordination of cell responses to challenges such as hypoxia in both healthy individuals and pathological conditions. Ischemia-reperfusion injury (IRI), one of the causes of cellular dysfunction and death, is associated with increased expression of genes involved in cellular adaptation to a hypoxic environment. Hypoxic inducible factors (HIFs) have a central role in the response to processes initiated by IRI not only linked to erythropoietin production but also because of their participation in inflammation, angiogenesis, metabolic adaptation, and fibrosis. While pericytes have an essential physiological function in erythropoietin production, a lesser-known role of HIF stabilization during IRI is that pericytes' HIF expression could influence vascular remodeling, cell loss and organ fibrosis. Better knowledge of mechanisms that control functions and consequences of HIF stabilization in pericytes beyond erythropoietin production is advisable for the development of therapeutic strategies to influence disease progression and improve treatments. Thus, in this review, we discuss the dual roles-for good or bad-of HIF stabilization during IRI, focusing on pericytes, and consequences in particular for the kidneys.

Handgrip strength and mortality in a cohort of kidney failure patients: Comparative analysis of different normalization methods.

OBJECTIVES: Reduced handgrip strength (HGS) is associated with adverse clinical outcomes. We analyzed and compared associations of HGS with mortality risk in dialysis patients, using different normalization methods of HGS. METHODS: HGS and clinical and laboratory parameters were measured in a cohort of 446 incident dialysis patients (median age 56 y, 62% men). The area under the receiver operating characteristic curve (AUROC) was used to compare different normalization methods of HGS as predictors of mortality: absolute HGS in kilograms; HGS normalized to height, weight, or body mass index; and HGS of a reference population of sex-matched controls (percentage of the mean HGS value [HGS%]). Multivariate linear regression analysis was used to assess HGS predictors. Competing risk regression analysis was used to evaluate 5-year all-cause mortality risk. Differences in survival time between HGS% tertiles were quantitated by analyzing the restricted mean survival time. RESULTS: The AUROC for HGS% was higher than the AUROCs for absolute or normalized HGS values. Compared with the high HGS% tertile, low HGS% (subdistribution hazard ratio [sHR] = 2.36; 95% CI, 1.19-3.70) and middle HGS% (sHR = 1.79; 95% CI, 1.12-2.74) tertiles were independently associated with higher all-cause mortality and those with high HGS% tertile survived on average 7.95 mo (95% CI, 3.61-12.28) and 18.99 mo (95% CI, 14.42-23.57) longer compared with middle and low HGS% tertile, respectively. CONCLUSIONS: HGS% was a strong predictor of all-cause mortality risk in incident dialysis patients and a better discriminator of survival than absolute HGS or HGS normalized to body size dimensions.

Making the invisible visible: imaging techniques for assessing muscle mass and muscle quality in chronic kidney disease.

Muscle wasting and low muscle mass are prominent features of protein energy wasting (PEW), sarcopenia and sarcopenic obesity in patients with chronic kidney disease (CKD). In addition, muscle wasting is associated with low muscle strength, impaired muscle function and adverse clinical outcomes such as low quality of life, hospitalizations and increased mortality. While assessment of muscle mass is well justified, the assessment of skeletal muscle should go beyond quantity. Imaging techniques provide the means for non-invasive, comprehensive, in-depth assessment of the quality of the muscle such as the infiltration of ectopic fat. These techniques include computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. Dual energy X-ray absorptiometry is also an imaging technique, but one that only provides quantitative and not qualitative data on muscle. The main advantage of imaging techniques compared with other methods such as bioelectrical impedance analysis and anthropometry is that they offer higher precision and accuracy. On the other hand, the higher cost for acquiring and maintaining the imaging equipment, especially CT and MRI, makes these less-used options and available mostly for research purposes. In the field of CKD and end-stage kidney disease (ESKD), imaging techniques are gaining attention for evaluating muscle quantity and more recently muscle fat infiltration. This review describes the potential of these techniques in CKD and ESKD settings for muscle assessment beyond that of muscle quantity.

A tool to predict the risk of lower extremity amputation in patients starting dialysis.

BACKGROUND: Non-traumatic lower extremity amputation (LEA) is a severe complication during dialysis. To inform decision-making for physicians, we developed a multivariable prediction model for LEA after starting dialysis. METHODS: Data from the Swedish Renal Registry (SNR) between 2010 and 2020 were geographically split into a development and validation cohort. Data from Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) between 1997 and 2009 were used for validation targeted at Dutch patients. Inclusion criteria were no previous LEA and kidney transplant and age ≥40 years at baseline. A Fine-Gray model was developed with LEA within 3 years after starting dialysis as the outcome of interest. Death and kidney transplant were treated as competing events. One coefficient, ordered by expected relevance, per 20 events was estimated. Performance was assessed with calibration and discrimination. RESULTS: SNR was split into an urban development cohort with 4771 individuals experiencing 201 (4.8%) events and a rural validation cohort with 4.876 individuals experiencing 155 (3.2%) events. NECOSAD contained 1658 individuals experiencing 61 (3.7%) events. Ten predictors were included: female sex, age, diabetes mellitus, peripheral artery disease, cardiovascular disease, congestive heart failure, obesity, albumin, haemoglobin and diabetic retinopathy. In SNR, calibration intercept and slope were -0.003 and 0.912, respectively. The C-index was estimated as 0.813 (0.783-0.843). In NECOSAD, calibration intercept and slope were 0.001 and 1.142 respectively. The C-index was estimated as 0.760 (0.697-0.824). Calibration plots showed good calibration. CONCLUSION: A newly developed model to predict LEA after starting dialysis showed good discriminatory performance and calibration. By identifying high-risk individuals this model could help select patients for preventive measures.

The role of irisin in kidney diseases.

Irisin is a hormone that is produced mainly by skeletal muscles in response to exercise. It has been found to have a close correlation with obesity and diabetes mellitus for its energy expenditure and metabolic properties. Recent research has revealed that irisin also possesses anti-inflammatory, anti-oxidative and anti-apoptotic properties, which make it associated with major chronic diseases, such as chronic kidney disease (CKD), liver diseases, osteoporosis, atherosclerosis and Alzheimer s disease. The identification of irisin has not only opened up new possibilities for monitoring metabolic and non-metabolic diseases but also presents a promising therapeutic target due to its multiple biological functions. Studies have shown that circulating irisin levels are lower in CKD patients than in non-CKD patients and decrease with increasing CKD stage. Furthermore, irisin also plays a role in many CKD-related complications like protein energy wasting (PEW), cardiovascular disease (CVD) and chronic kidney disease-mineral and bone disorder (CKD-MBD). In this review, we present the current knowledge on the role of irisin in kidney diseases and their complications.

High Osmol Gap Hyponatremia Caused by Icodextrin: A Case Series Report.

Recently, hyperosmolar hyponatremia following excessive off-label use of two exchanges of 2 L icodextrin daily during peritoneal dialysis (PD) was reported. We encountered a cluster of 3 cases of PD patients who developed hyperosmolar hyponatremia during on-label use of icodextrin. This appeared to be due to absorption of icodextrin since after stopping icodextrin, the serum sodium level and osmol gap returned to normal, while a rechallenge again resulted in hyperosmolar hyponatremia. We excluded higher than usual concentrations of specific fractions of dextrins in fresh icodextrin dialysis fluid (lot numbers of used batches were checked by manufacturer). We speculate that in our patients, either an exaggerated degradation of polysaccharide chains by α-amylase activity in dialysate, lymph, and interstitium and/or rapid hydrolysis of the absorbed larger degradation products in the circulation may have contributed to the hyperosmolality observed, with the concentration of oligosaccharides exceeding the capacity of intracellular enzymes (in particular maltase) to metabolize these products to glucose. Both hyponatremia and hyperosmolality are risk factors for poor outcomes in PD patients. Less conventional PD prescriptions such as off-label use of two exchanges of 2 L icodextrin might raise the risk of this threatening side effect. This brief report is intended to create awareness of a rare complication of on-label icodextrin use in a subset of PD patients and/or PD prescriptions.

Needs, barriers and facilitators for a healthier lifestyle in haemodialysis patients: The GoodRENal project.

BACKGROUND: Malnutrition, sedentary lifestyle, cognitive dysfunction and poor psychological well-being are often reported in patients on haemodialysis (HD). AIMS: We aimed to explore needs, barriers and facilitators-as perceived by patients, their carers, and healthcare professionals (HCPs) for increasing the adherence to the diet, to physical activity and cognition and psychological well-being. METHODS: This is an observational cross-sectional study following the STROBE statement. This study is part of an ERASMUS+ project, GoodRENal-aiming to develop digital tools as an educational approach to patients on HD. For that, the GoodRENal comprises HD centers located in four Belgium, Greece, Spain and Sweden. Exploratory questionnaires were developed regarding the perceived needs, barriers and facilitators regarding the diet, physical activity, cognition and psychological well-being from the perspective of patients, their carers and HCPs. RESULTS: In total, 38 patients, 34 carers and 38 HCPs were included. Nutrition: For patients and carers, the main needs to adhere to the diet included learning more about nutrients and minerals. For patients, the main barrier was not being able to eat what they like. Physical activity: As needs it was reported information about type of appropriate physical activity, while fatigue was listed as the main barrier. For Cognitive and emotional state, it was perceived as positive for patients and carers perception but not for HCPs. The HCPs identified as needs working as a team, having access to specialised HCP and being able to talk to patients in private. CONCLUSIONS: Patients and their carers listed as needs guidance regarding nutrition and physical activity but were positive with their cognitive and emotional state. The HCPs corroborated these needs and emphasised the importance of teamwork and expert support.

Prevalence and associated factors of frailty in patients with chronic kidney disease: a cross-sectional analysis of PEAKING study.

AIM:  Frailty is common and is reported to be associated with adverse outcomes in patients with chronic diseases in Western countries. However, the prevalence of frailty remains unclear in individuals with chronic kidney disease (CKD) in China. We examined the prevalence of frailty and factors associated with frailty in patients with CKD. METHODS:  This was a cross-sectional analysis of 177 adult patients (mean age 54 ± 15 years, 52% men) with CKD from the open cohort entitled Physical Evaluation and Adverse outcomes for patients with chronic Kidney disease IN Guangdong (PEAKING). Frailty at baseline were assessed by FRAIL scale which included five items: fatigue, resistance, ambulation, illnesses, and loss of weight. Potential risk factors of frailty including age, sex, body mass index, and daily step counts recorded by ActiGraph GT3X + accelerometer were analyzed by multivariate logistic regression analysis. RESULTS: The prevalence of prefrailty and frailty was 50.0% and 11.9% in patients with stages 4-5 CKD, 29.6% and 9.3% in stage 3, and 32.1% and 0 in stages 1-2. In the multivariate logistic regression analysis, an increase of 100 steps per day (OR = 0.95, 95% CI 0.91-0.99, P = 0.01) and an increase of 5 units eGFR (OR = 0.82, 95% CI 0.68-0.99, P = 0.045) were inversely associated with being frail; higher BMI was associated with a higher likelihood of being frail (OR = 1.52, 95% CI 1.11-2.06, P = 0.008) and prefrail (OR = 1.25, 95% CI 1.10-1.42, P = 0.001). CONCLUSION:  Frailty and prefrailty were common in patients with advanced CKD. A lower number of steps per day, lower eGFR, and a higher BMI were associated with frailty in this population.

Automated Peritoneal Dialysis With Remote Patient Monitoring: Clinical Effects and Economic Consequences for Poland.

OBJECTIVES: Remote patient monitoring (RPM) of patients treated with automated peritoneal dialysis (APD) at home allows clinicians to supervise and adjust the dialysis process remotely. This study aimed to review recent scientific studies on the use of RPM in patients treated with APD and based on extracted relevant data assess possible clinical implications and potential economic value of introducing such a system into practice in Poland. METHODS: A systematic literature review was performed in the MEDLINE, EMBASE, and Cochrane databases. The model of clinical effects and costs associated with APD was built as a cost-effectiveness analysis with a 10-year time horizon from the Polish National Health Fund perspective. Cost-effectiveness analysis compared 2 strategies: APD with RPM versus APD without RPM. RESULTS: Thirteen publications assessing the clinical value of RPM among patients with APD were found. The statistical significance of APD with RPM compared with APD without RPM was identified for the main clinical outcomes: frequency and length of hospitalizations, APD technique failure, and death. An incremental cost-effectiveness ratio was equal to €27 387 per quality-adjusted life-year. The obtained incremental cost-effectiveness ratio is below the willingness-to-pay threshold for the use of medical technologies in Poland (€36 510 per quality-adjusted life-year), which means that APD with RPM was a cost-effective technology. CONCLUSIONS: RPM in patients starting APD is a clinical option that is worth considering in Polish practice because it has the potential to decrease the frequency of APD technique failure and shorten the length of hospitalization.