Vascular access for hemodialysis in Italy: What a national survey reveals.

BACKGROUND: Since in Italy there are no official data on vascular access (VA) for hemodialysis the Vascular Access Project Group (VAPG) of the Italian Society of Nephrology (SIN) designed a national survey. METHODS: A 35-question survey was designed and sent it to the Italian facilities through the SIN website. The basic questions were the prevalence, the location, and the surveillance of VA, the bedside use of ultrasound, the use of fluoroscopy for central venous catheter (CVC) placement, and of buttonhole technique, the role of nephrologist in the access creation. RESULT: The questionnaire was completed in June 2022 by 161 facilities. The survey registered 15,499 patients, approximately one-third of the Italian dialysis population. The prevalence of arteriovenous fistula (AVF), arteriovenous Graft (AVG), and CVC were 61.8%, 3.7%, and 34.5% respectively. The AVF location was 50% in distal forearm, 20% in meanproximal forearm, 30% in upper arm. For AVF creation, nephrologists were involved in 72% of facilities while for CVC placement in 62%. As regards VA monitoring, 21% of the facilities did not have a surveillance protocol; 60% did not register AVF thrombosis and 53% did not register CVC infections. Most of facilities use the fluoroscope during CVC placement, 37% when needed, and 22% never. Ultrasound-guided puncture of complex AVFs was used by 80% of facilities. Buttonhole puncture was used in 5% of patients. CONCLUSIONS: Some considerations emerge from the survey data: (1) The increasing CVC prevalence compared to DOPPS 5 study. (2) The low rate of AVG prevalence. (3) The nephrologist is the operator in many VA procedures. (4) The fluoroscopy for CVC placement and the US-guide puncture of the complex AVF are widely used in most facilities. (5) The practice of the buttonhole is not widespread. (6) When the operator is the nephrologist more distal fistulas are performed.

Gender Disparities in Vascular Access and One-Year Mortality among Incident Hemodialysis Patients: An Epidemiological Study in Lazio Region, Italy.

(1) Background: Interest in gender disparities in epidemiology, clinical features, prognosis and health care in chronic kidney disease patients is increasing. Aims of the study were to evaluate the association between gender and vascular access (arteriovenous fistula (AVF) or central venous catheter (CVC)) used at the start of hemodialysis (HD) and to investigate the association between gender and 1-year mortality. (2) Methods: The study includes 9068 adult chronic HD patients (64.7% males) registered in the Lazio Regional Dialysis Register (January 2008-December 2018). Multivariable logistic regression models were used to investigate the associations between gender and type of vascular access (AVF vs. CVC) and between gender and 1-year mortality. Interactions between gender and socio-demographic and clinical variables were tested adding the interaction terms in the final model. (3) Results: Females were older, had lower educational level and lower rate of self-sufficiency compared to males. Overall, CVC was used in 51.2% of patients. Females were less likely to use AVF for HD initiation than males. 1354 out of 8215 (16.5%) individuals died at the end of the follow-up period. Interaction term between gender and vascular access was significant in the adjusted model. From stratified analyses by vascular access, OR female vs. male (AVF) = 0.65; 95% CI 0.48-0.87 and OR female vs. male (CVC) = 0.88; 95% CI 0.75-1.04 were found. (4) Conclusions: This prospective population-based cohort study in a large Italian Region showed that in females starting chronic HD AVF was less common respect to men. The better 1-year survival of females is more evident among those women with AVF. Reducing gender disparity in access to AVF represents a key point in the management of HD patients.

Determinants of venous catheter hemodialysis onset and subsequent switch to arteriovenous fistula: An epidemiological study in Lazio region.

BACKGROUND: The factors associated with the inability to start hemodialysis with an arteriovenous fistula (AVF) in chronic kidney disease patients are not fully understood. AIM: Evaluating factors associated with type of vascular access at the first chronic hemodialysis and at 1 year after it. METHODS: The study cohort includes patients registered in the Regional Dialysis and Transplant Registry of Lazio undergoing first hemodialysis between 2008 and 2015. Logistic regression models were used to evaluate the association between socio-demographic, clinical and care/organizational factors, and vascular access at first hemodialysis. Cox regression models were used to assess the odds of switching to AVF during the first year of hemodialysis among patients starting dialysis with central venous catheter (CVC). RESULTS: In the cohort of 6208 incident hemodialysis patients, 52.7% had an AVF and 47.3% had a CVC. Among the 2939 incident patients with CVC, 27.4% switched to FAV after 1 year. A higher probability of starting dialysis with AVF was observed among males (OR = 1.83; 95% CI 1.63-2.06), while a lower probability was observed among patients aged >85 years (OR 0.64; IC 95% 0.51-0.80). Patients with early referral to a nephrologist had a triple probability of start dialysis with AVF. We observed a higher odds of switch to AVF among males (HR = 1.62; 95% CI 1.40-1.89) and a lower odds among patients over 65 years. CONCLUSION: The observed high rate of AVF at the start of hemodialysis and of the switch from CVC to AVF in the first year, although declining since 2008, is a positive outcome. However, over one-third of patients maintain the CVC as vascular access for the first year because of unmodifiable factors, such as gender, age, comorbidity. The present study suggests that logistics/management and assistance/welfare problems may contribute to the delay or lack of AVF placement in incident hemodialysis patients or within the first year of dialysis.

Functional impairment and risk of mortality in patients on chronic hemodialysis: results of the Lazio Dialysis Registry.

BACKGROUND: Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of this study was to evaluate if functional impairment represents a risk factor for reduced survival in patients on chronic hemodialysis. METHODS: All incident chronic hemodialysis patients of Lazio, a large region of central Italy, registered in the Dialysis and Transplant Lazio Region Registry (DTLRR) in the period 2008-2013 were considered eligible. Inclusion criteria were: age > 18 years, resident in Lazio, still doing dialysis after 90 days from incidence date, doing hemodialysis or hemodiafiltration treatment for > 9 h/week. Patients were stratified into three classes of functional activity: total autonomy, autonomy in some activities, and not self-sufficient. Functional activity was assessed for each patient by the referring physician for the DTLRR from the ~ 90 hemodialysis units of the Lazio region. Each patient was followed from date of first dialysis treatment to the end of the study (31/12/2015) or death or renal transplant, whichever occurred first. Cox proportional hazard models were performed to obtain mortality hazard ratios (HR), 95% confidence intervals (CI), for each class of functional activity adjusting for sex, age, country of birth, city of residence, body mass index (BMI), type of nephropathy, vascular access, previous nephrology counselling, weekly hours of hemodialysis, serum albumin, hemoglobin, and presence of comorbidities (e.g. vascular diseases, coronary disease, and diabetes). RESULTS: A total of 3356 patients were studied. In the whole follow-up period, 1622 deaths occurred (48%). Functional impairment was associated with the risk of mortality: compared to 'total autonomy', the HR for 'autonomy in some activities' was 1.30 [95% CI: 1.14-1.49] and for 'not self-sufficient' 1.71 [1.47-1.99] (p for trend < 0.05). The number of evitable deaths attributable to reduced functional activity was 237. CONCLUSION: Functional impairment represents a risk factor for reduced survival in chronic hemodialysis patients. There is a need for early identification of patients who might benefit from interventions aimed at preventing, reversing or delaying the functional impairment.

Survey on advance care planning of Italian outpatients on chronic haemodialysis.

OBJECTIVES: The clinical practice guidelines published by the Renal Physicians Association (USA) recommend instituting advance care planning (ACP) for patients with end-stage renal disease. Studies on this issue are lacking in Italy. Our aim was to determine the attitudes of patients on ACP in our dialysis centre. METHODS: We performed a cross-sectional survey. We recruited patients on maintenance haemodialysis (HD) at Hemodialysis Center of Università Cattolica del Sacro Cuore, from 1 March 2014 to 31 March 2015. The only exclusion criterion was inability to give an informed consent. Patients completed a questionnaire concerning their treatment preferences in three hypothetical disease scenarios: persistent vegetative state, advanced dementia, severe terminal illness; for each patients, we also collected clinical, functional and socioeconomic data. RESULTS: Thirty-four HD outpatients completed the study questionnaire. The majority of respondents (85%) considered information about prognosis, health conditions and treatment options, including withdrawing dialysis, as very important and 94% of respondents considered treatment of uraemic/dialytic symptoms the most important issue. In the health scenarios provided, dialysis was the treatment least withheld. Dependence on instrumental activities of daily living (0.048) and higher Charlson Comorbidity Index scores (p=0.035) were associated with continuing dialysis in at least one scenario. CONCLUSIONS: ACP should be tailored to patients' value, culture and preferences. A significant proportion of patients, however, do not want to be involved in end of life decisions. Frail elderly patients, in particular, are not inclined to interrupt dialysis, despite poor quality of life or a poor prognosis.

Clinical use of computational modeling for surgical planning of arteriovenous fistula for hemodialysis.

BACKGROUND: Autogenous arteriovenous fistula (AVF) is the best vascular access (VA) for hemodialysis, but its creation is still a critical procedure. Physical examination, vascular mapping and doppler ultrasound (DUS) evaluation are recommended for AVF planning, but they can not provide direct indication on AVF outcome. We recently developed and validated in a clinical trial a patient-specific computational model to predict pre-operatively the blood flow volume (BFV) in AVF for different surgical configuration on the basis of demographic, clinical and DUS data. In the present investigation we tested power of prediction and usability of the computational model in routine clinical setting. METHODS: We developed a web-based system (AVF.SIM) that integrates the computational model in a single procedure, including data collection and transfer, simulation management and data storage. A usability test on observational data was designed to compare predicted vs. measured BFV and evaluate the acceptance of the system in the clinical setting. Six Italian nephrology units were involved in the evaluation for a 6-month period that included all incident dialysis patients with indication for AVF surgery. RESULTS: Out of the 74 patients, complete data from 60 patients were included in the final dataset. Predicted brachial BFV at 40 days after surgery showed a good correlation with measured values (in average 787 ± 306 vs. 751 ± 267 mL/min, R = 0.81, p < 0.001). For distal AVFs the mean difference (±SD) between predicted vs. measured BFV was -2.0 ± 20.9%, with 50% of predicted values in the range of 86-121% of measured BFV. Feedbacks provided by clinicians indicate that AVF.SIM is easy to use and well accepted in clinical routine, with limited additional workload. CONCLUSIONS: Clinical use of computational modeling for AVF surgical planning can help the surgeon to select the best surgical strategy, reducing AVF early failures and complications. This approach allows individualization of VA care, with the aim to reduce the costs associated with VA dysfunction, and to improve AVF clinical outcome.

Functional impairment is associated with an increased risk of mortality in patients on chronic hemodialysis.

BACKGROUND: Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of the present study was to determine the characteristics associated with functional impairment in chronic hemodialysis, and to evaluate if functional impairment represents a risk factor for reduced survival in chronic hemodialysis. METHODS: All 132 chronic hemodialysis referring to the Hemodialysis Service of the Catholic University, Rome, Italy between November 2007 and May 2015 were included. All patients underwent comprehensive geriatric assessment; functional ability was estimated using two questionnaires exploring independency in bathing, dressing, toileting, transferring, continence, feeding (ADLs), and independency in using the telephone, shopping, food preparation, housekeeping, laundering, traveling, taking medications, and handling finances (IADLs). Functional impairment was diagnosed in presence of dependence in one or more ADLs/IADLs. Mood was assessed using the 30-item Geriatric Depression Scale. Logistic regression was used to evaluate factors associated with functional impairment. The association between functional impairment and survival was assessed by Cox regression. RESULTS: ADLs impairment was present in 34 (26 %) participants, while IADLs impairment was detected in 64 (48 %) subjects. After a follow up of 90 months, 55 (42 %) patients died. In logistic regression, depressive symptoms were associated with ADLs and IADLs impairment (OR 1.12; 95 % CI = 1.02-1.23; OR 1.16; 95 % CI = 1.02-1.33; respectively). In Cox regression, ADLs impairment was associated with mortality (HR 2.47; 95 % CI-1.07-5.67) while IADLs impairment was not associated with reduced survival (HR .80; 95 % CI-.36-1.76). CONCLUSIONS: Functional impairment is associated with depressive symptoms; also, impairment in the ADLs represents a risk factor of reduced survival in chronic hemodialysis. These associations and their potential implication should be assessed in dedicated studies.

The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology.

The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.

Postdialysis Fatigue: A Frequent and Debilitating Symptom.

Postdialysis fatigue (PDF) is a frequent and debilitating symptom of patients on chronic hemodialysis that affects their daily living and quality of life. Little is known about the mechanisms underlying this symptom and its severity. Only a few studies have investigated therapeutic interventions and with conflicting results. Given the major impact of PDF on the quality of life of hemodialysis patients, a larger effort is warranted to better understand, prevent, and treat PDF.

Mortality in hospitalized chronic kidney disease patients starting unplanned urgent haemodialysis.

AIM: Data on the outcome of chronic kidney disease (CKD) patients who are hospitalized and start unplanned urgent haemodialysis (HD) are lacking. This prospective, longitudinal, observational study aimed to define the hospital mortality rate and associated factors in CKD patients who start unplanned urgent HD. METHODS: Between January 2003 and December 2009, all patients with CKD who were hospitalized, diagnosed with ESRD and started unplanned urgent haemodialysis at Haemodialysis Service of the Catholic University of Rome, Italy were recruited. Exclusion criteria were: acute renal failure, prior history of dialysis, multiple organ failure, coma, and dementia. Hospital mortality rate was the primary outcome. RESULTS: Three and hundred sixteen patients were studied: 99 died after 19.5 ± 27.3 days and 217 survived until discharge. Of these, 154 were prescribed chronic HD and 63 restored renal function. Patients who died were significantly older and had a higher Charlson Comorbidity Index score. The mortality rates were 51.1% in patients with 81-90 years, 37.8% with 71-80 years, 34.1% with 61-70 years and 13.9% with age ≤60 years. Logistic regression analysis showed that age only was an independent risk factor for all-cause mortality. CONCLUSIONS: In CKD patients who need hospitalization and start unplanned urgent haemodialysis the mortality is very high and significantly related to age.

Fatigue Is Associated with Increased Risk of Mortality in Patients on Chronic Hemodialysis.

BACKGROUND: Little is known about the correlation between fatigue and survival in patients on chronic hemodialysis and whether fatigue is an independent predictor of outcome above and beyond the effects of depression. The aim of the present study was to determine if fatigue is a predictor of mortality in patients on chronic hemodialysis (CHP) and if this occurs independently of the symptoms of depression. METHODS: CHP referring to the Hemodialysis Service of the Università Cattolica of Rome, Italy between November 2007 and January 2015 were studied. Demographic, clinical, and laboratory data were recorded for each patient at the moment of the inclusion in the study. Fatigue levels were assessed in patients using the Vitality Scale of SF-36 (SF-36 VS), functional ability by the activities of daily living (ADL) and instrumental activities of daily living (IADL), depressive symptoms through the Geriatric Depression Scale (GDS), cognitive function using the Mini Mental State Examination (MMSE), and comorbidity through the Charlson Comorbidity Index (CCI). Patients were grouped into four groups (quartiles): Quartile 1 (Q1), >65; Q2, ≥50 to <65; Q3, ≥35 to <50; Q4, <35. RESULTS: We studied 126 patients: 11 were transplanted and 53 died. Patients who later died were older and had a worse cognitive performance, higher CCI and GDS scores, lower ADL, IADL and SF-36 VS scores, lower serum creatinine and albumin levels. Kaplan-Meier survival was significantly lower in Q4 than in Q1 (p = 0.0001). According to Cox regression analysis, higher fatigue (Q4) was associated with a higher risk of mortality (HR, 95% CI: 5.29, 2.2-12.73). CONCLUSION: Fatigue is associated with an increased risk of mortality in CHP, with the relationship independent of symptoms of depression. Fatigue should be assessed routinely and may be a potential target of interventions that aim to reduce mortality in CHP.

Wishful Thinking: The Surprisingly Sparse Evidence for a Relationship between Oxidative Stress and Cardiovascular Disease in Hemodialysis Patients.

The increased frequency of cardiovascular disease observed in hemodialysis patients is secondary to the combination of many traditional (age, male sex, hypertension, smoking, diabetes mellitus, and dyslipidemia) and novel and uremia-related (inflammation, uremic toxins, adipokine imbalance, coagulation disorders, protein-energy wasting, volume overload, endothelial dysfunction, hyperparathyroidism, and subclinical hypothyroidism) risk factors. Usually, in the latter group, oxidative stress is included. However, after decades of research, it remains essentially unknown if oxidative stress has a causative role in the development of cardiovascular disease in long-term hemodialysis patients because adequate longitudinal studies are lacking. Data deriving from cross-sectional studies suggest that biomarkers of oxidative stress are associated with cardiovascular disease prevalence. Conversely, conflicting and inconclusive results have been obtained on the association between oxidative stress and coronary artery calcification, atherosclerosis, and all-cause and cardiovascular disease-related outcome. It is desirable that further studies are conducted on this topic in the near future.

Fatigue is associated with serum interleukin-6 levels and symptoms of depression in patients on chronic hemodialysis.

CONTEXT: Little is known about activated immune-inflammatory pathways and interleukin-6 (IL-6) in the development of fatigue and/or depression in patients with end-stage renal disease on chronic hemodialysis (HD). OBJECTIVES: To evaluate the possible correlation between fatigue and serum levels of IL-6 in patients on chronic HD. METHODS: One hundred HD patients were assessed for the presence of fatigue using the SF-36 Vitality subscale and were administered the Beck Depression Inventory (BDI), the Hamilton Anxiety Rating Scale (HARS), the Mini-Mental State Examination (MMSE), the activities of daily living (ADL), and the instrumental activities of daily living (IADL). We also calculated the time of recovery after hemodialysis (TIRD) and the number/severity of comorbidities using the Charlson Comorbidity Index (CCI). Laboratory parameters were measured as well as serum IL-6. RESULTS: Forty-three patients constituted the fatigued group and 57 the nonfatigued group. Age, CCI, BDI, HARS, and TIRD were significantly higher in fatigued patients than in the nonfatigued patients. Conversely, the scores of ADL, IADL, and MMSE were significantly lower in fatigued than in nonfatigued patients. Serum IL-6 levels (pg/mL) were higher in the fatigued group (5.1 ± 3.4) than in the nonfatigued group (1.6 ± 1.5; P < 0.001); serum albumin and creatinine levels were significantly lower. Twenty-six patients (26%) had no symptoms of depression (BDI score <10), and 74 patients (74%) had symptoms of depression (BDI score >9). Patients with a BDI score >9 were older; had a higher CCI; a lower MMSE; a higher TIRD; lower serum albumin, creatinine, and urea levels; and higher serum IL-6 levels. The correlation analyses showed that the score of the SF-36 Vitality subscale was associated with age, dialytic age, TIRD, ADL, IADL, CCI, BDI, HARS, MMSE, serum urea, creatinine, albumin, and IL-6 levels. On multivariate general linear model analyses, with fatigue as the dependent variable and gender as a second factor, BDI and serum IL-6 levels were independently associated with the score of the SF-36 Vitality subscale. A canonical correlation analysis was performed including in the model fatigue, BDI, and biomarkers; the correlation was 0.679 (R(2) = 0.462). Fatigue, BDI, and IL-6 among biomarkers showed the strongest association with the underlying construct (standardized canonical coefficients = -0.989, 0.015, and 0.852, respectively), thus explaining a correlation of IL-6 with both depression and fatigue. CONCLUSION: Fatigue was significantly associated with symptoms of depression and serum IL-6 levels in patients receiving chronic HD.

Self-reported physical activity in patients on chronic hemodialysis: correlates and barriers.

BACKGROUND AND AIMS: The knowledge of the barriers that are associated with decreased physical activity (PA) in patients on chronic hemodialysis (PCH) may be of primary importance for the nephrologists. Thus, we aimed to assess the barriers associated with the absent or reduced PA in PCH of a Mediterranean country. METHODS: Patients were invited to answer the question 'How often do you exercise during your leisure time?'. Also, patients included in the study were asked to answer questions regarding barriers to physical activity lower than desired. RESULTS: We studied 105 patients. Forty (38.1%) patients reported to never exercise, 6 (5.7%) reported to exercise less than once/week, 4 (3.8%) once/week, 23 (21.9%) two to three times/week, 12 (11.4%) four to five times/week and 20 (19%) daily. Overall, 46 (43.8%) patients never exercised or exercised less than once/week ('inactive') and 59 (56.2%) did exercise more often ('active'). At the multivariate analysis, reduced walking ability, fatigue on the non-dialysis days, and shortness of breath were independently and negatively associated with PA. The same results were found when the reduced model of the multivariate logistic backward regression was built introducing in the model also clinical and laboratory variables. CONCLUSION: In PCH, fatigue on the non-dialysis days, reduced walking ability, and shortness of breath are barriers independently associated to decreased PA. Knowledge about the causes and mechanisms that generate these barriers has to be acquired.

Dietary intake of trace elements, minerals, and vitamins of patients on chronic hemodialysis.

PURPOSE: We aimed to estimate dietary intakes of trace elements, minerals, and vitamins in hemodialysis patients (HDP) of three centers in one metropolitan and two urban areas of Italy. METHODS: Daily dietary intake was assessed using a 3-day diet diary in 128 HDP. RESULTS: Mean daily intakes of trace elements were as follows: zinc, 7.6 ± 5.4 mg; copper, 14.3 ± 11.8 mg; selenium, 28.3 ± 18.1 µg; and iron, 7.2 ± 4.1 mg (7.8 ± 2.6 mg in women, 6.9 ± 2.4 mg in men). The distribution of patients by daily intakes of trace elements showed most were under the recommended values, with the exception of copper intake, which was much higher. Mean daily intakes of minerals were as follows: magnesium, 174.4 ± 94.3 mg; phosphorus, 842.6 ± 576.8 mg; calcium, 371.8 ± 363.7 mg; potassium, 1,616.2 ± 897.3 mg; and sodium, 1,350 ± 1,281 mg. Mean daily intakes of vitamins were as follows: vitamin A, 486.1 ± 544.6 µg; vitamin B1, 0.86 ± 0.7 mg; vitamin B2, 1.1 ± 0.7 mg; vitamin B3, 13.3 ± 8.1 mg; vitamin C, 47.8 ± 50.3 mg; and vitamin E, 9.5 ± 3.6 mg. The distribution of patients by daily intakes of vitamins showed most were under the recommended values. Daily intakes of trace elements and vitamins were similar among the three centers and did not differ between dialysis and non-dialysis days. CONCLUSIONS: Many HDP have daily dietary intakes of trace elements and vitamins below the recommended values, whereas the intake of copper is much higher.

Cognitive performance is associated with left ventricular function in older chronic hemodialysis patients: result of a pilot study.

BACKGROUND: Cognitive impairment is a common finding in end-stage renal disease patients on chronic hemodialysis, but data on the associated factors are still scanty. AIMS: The present study evaluated the association between cognitive function and left ventricular systolic function in hemodialysis patients. METHODS: We enrolled 72 patients admitted to the Hemodialysis Unit of the Catholic University, Rome. Cognitive performance was evaluated using the Mini Mental State Examination (MMSE); a cutoff of 24 was used to diagnose cognitive impairment. Left ventricular ejection fraction (LVEF) was assessed by echocardiography. Multivariable linear and logistic regressions were adopted to assess the adjusted association between cognitive performance and LVEF. Also, linear discriminant analysis was performed to ascertain the cutoff level of LVEF which best predicted cognitive impairment. RESULTS: Cognitive impairment was found in 37 (51 %) patients. According to linear regression, MMSE was independently associated with LVEF (B = 0.06; 95 % CI = 0.01-0.12; P = 0.040). Logistic regression confirmed the inverse association between LVEF and cognitive impairment (OR = 0.87; 95 % CI = 0.78-0.98; P = 0.022). In linear discriminant analysis, the LVEF cutoff level that best predicted cognitive impairment was ≤51 %. CONCLUSION: Cognitive impairment is a common finding in hemodialysis patients. Even mildly depressed LVEF is independently associated with cognitive impairment. This association and its potential therapeutic implications should be assessed in dedicated studies.

Intradialytic hypotension is associated with dialytic age in patients on chronic hemodialysis.

OBJECTIVE: Intradialytic hypotension (IDH) is common in patients on chronic hemodialysis, but knowledge on determinants is still unclear. The present study aims at evaluating the association between IDH and dialytic age (DA) in patients on chronic hemodialysis. METHODS: Between January 2012 and January 2013, 82 patients on chronic hemodialysis for at least 1 year were screened for inclusion in the present study. Of these, 14 were excluded because of advanced heart failure (n.9), history of alcohol/substance abuse (n.1), diagnosis of dementia (n.2), actual instability of clinical conditions requiring hospitalization (n.2). IDH was defined as a decrease in systolic blood pressure ≥20 mmHg or a decrease in mean arterial pressure (MAP) by 10 mmHg associated with clinical events and need for nursing interventions. The number of IDH episodes in 10 consecutive hemodialysis sessions was recorded for each patient. Linear and logistic regressions were adopted to assess the adjusted association between IDH and DA. RESULTS: The mean DA was 92 ± 81. Eleven patients (16%) experienced IDH. DA was associated with IDH (OR = 1.01; 95% CI = 1.01-1.02; p = 0.048), after adjusting for potential confounders. DA was associated with the numbers of IDH events in the unadjusted model (B = 0.02; 95% CI = 0.01-0.03; p = 0.042), after adjusting for age and sex (B = 0.01; 95% CI = 0.01-0.03; p = 0.042) as well as in the multivariable model (B = 0.02; 95% CI = 0.01-0.05; p = 0.045). CONCLUSION: DA is associated with an increased probability of IDH and with increased number of IHD events. Studies are needed to understand the underlying factors of such an association.