Effect of different dialysate temperatures on post dialysis fatigue in patients undergoing haemodialysis: a quasi-experimental study.

Objective: To compare the effects of warm and cold dialysate solutions on the duration of post-dialysis fatigue in patients undergoing maintenance haemodialysis. METHODS: The quasi-experimental study was conducted at the Department of Nephrology, Pak Emirates Military Hospital, Rawalpindi, Pakistan, from May 9 to September 10, 2023, and comprised adult patients of either gender undergoing maintenance haemodialysis for a minimum of 3 months. The patient initially underwent haemodialysis with a dialysate temperature of 36°C for 2 weeks. During the subsequent washout period of one week when the dialysate temperature was not monitored, they underwent haemodialysis with a dialysate temperature of 37°C for another 2 weeks. Blood pressure was monitored every 30 minutes to record any hypotensive episodes. Patients were asked if they felt fatigued after the last haemodialysis session, and the duration was noted down. Data was analysed using SPSS 24. RESULTS: Of the 92 patients with mean age 49.1±16.1 years, 57(62%) were males. Post-dialysis fatigue was seen in 67(72.8%) and 75(81.5%) patients with dialysate temperatures at 36°C and 37°C, respectively (p<0.001). The duration of post-dialysis fatigue was also significantly longer at dialysate temperatures 37°C p<0.001). There was no significant difference in the proportion of hypotensive episodes in the two groups (p=0.445). Conclusion: Dialysate temperature 36°C was found to be associated with less frequent and shorter duration of postdialysis fatigue compared to dialysate temperature 37°C.

Renal satellite units in Pakistan: Challenges, efforts, and recommendations.

This commentary delves into the complexities surrounding chronic kidney disease management in Pakistan, specifically examining the critical role played by renal satellite units in providing accessible dialysis services. Chronic kidney disease in Pakistan accounts for 3.9% of total deaths, warranting a focused exploration of challenges and potential solutions. RSUs, smaller entities affiliated with main renal units, emerge as key players in addressing issues of geographic accessibility and diminishing travel burdens for chronic kidney disease patients. Challenges such as financial constraints, limited resources, and staff shortages, particularly in rural settings, pose significant hurdles to the effective functioning of RSUs. This commentary emphasizes the importance of clear eligibility criteria, robust vascular access support, regular physician engagement, and the strategic integration of telemedicine. It explores diverse funding models, including government allocations, community contributions, and philanthropic partnerships, as potential solutions to alleviate cost-related concerns. The commentary advocates for a holistic, cost-effective approach to chronic kidney disease care, highlighting the transformative potential of renal satellite units in improving health outcomes across varied settings.

Spontaneous neck hematoma in a hemodialysis patient: A case report.

We present a 60-year-old maintenance hemodialysis patient who initially presented with neck swelling, which was diagnosed as a thyroid issue. Following a hemodialysis session, the swelling in the neck progressively enlarged, leading to respiratory distress and eventual cardiac arrest. During a life-saving tracheotomy, dark red blood was observed, and endotracheal intubation was urgently performed. Subsequent computed tomography examination identified multiple areas of slight high-density images in the nasopharyngeal cavity, oropharyngeal cavity, and esophagus. As time passed, the patient's hematoma underwent spontaneous absorption, but signs of recovery were absent. We discuss the rarity, etiology, diagnosis, and management of spontaneous neck hematoma in maintenance hemodialysis patients.

Bivalirudin as an anticoagulation strategy for acute hemodialysis in children: Two cases with a summary of recent literature.

Unfractionated heparin is the most used anticoagulative agent for extracorporeal settings in children, including acute hemodialysis modalities. In certain situations, such as heparin-induced thrombocytopenia, alternatives must be applied. The direct thrombin inhibitor bivalirudin has come forth as an attractive substitute. Bivalirudin is currently only approved for adult use in specific percutaneous coronary intervention settings. However, it has a growing off-label popularity in different contexts for both adult and pediatric patients. Experience with bivalirudin in children is mainly limited to extracorporeal membrane oxygenation, ventricular assist devices and during cardiopulmonary bypass surgery. Literature about its use as anticoagulation strategy for pediatric hemodialysis is very scarce. Here, we present two pediatric cases where bivalirudin was used during acute hemodialysis, followed by a short summary of recent literature.

Percutaneous transluminal angioplasty is safe and feasible for reinsertion of tunneled cuffed catheters in the right internal jugular vein.

This study explores the feasibility, safety, and efficacy of percutaneous transluminal angioplasty (PTA) for reinserting tunneled cuffed catheters (TCC) with a Dacron sheath in the right internal jugular vein (RIJV) in hemodialysis patients with a history of prior RIJV catheterization and subsequent stenosis or occlusion of the RIJV, right innominate vein, and superior vena cava. Clinical data from 21 hemodialysis patients with dysfunctional vascular access who underwent PTA for reinsertion of TCC in the RIJVs from July 2020 to June 2023 at the First and Second Affiliated Hospitals of Bengbu Medical College were retrospectively analyzed. Clinical efficacy during hospitalization, postoperative TCC blood flow, and related complications during follow-up were observed. The procedure was successful in all 21 patients, with postoperative TCC blood flow meeting daily hemodialysis requirements. Only one case experienced acute bleeding with contrast agent extravasation at the intersection of the left and right innominate veins during sharp recanalization. No severe complications, such as arrhythmias, vascular rupture, pneumothorax, mediastinal hematoma, or pericardial tamponade, occurred during the procedures. Upon discharge, all patients exhibited satisfactory TCC blood flow (247.14 ± 11.46 ml/min). Postoperatively, TCC blood flow ranged between 200 and 260 ml/min, meeting the demands of regular hemodialysis. For patients with a history of repeated TCC or non-tunneled catheter (NTC) placement in the RIJV, reinserting TCC in the RIJVs through PTA is a safe and reliable technique. It effectively utilizes vascular resources and prevents vascular resource depletion associated with changing the venous catheter placement location.

Outcomes of Acute Kidney Injury in Patients Requiring Dialysis in a Tertiary Care Hospital of a Developing Country.

Acute kidney injury (AKI) requiring dialysis (AKI-D) is an important health care burden and is associated with very high in-hospital mortality. Timely initiation of dialysis in AKI is fundamental to achieve treatment goals and to provide solute clearance and removal of excess fluid while awaiting the recovery of kidney function. The primary outcome of interest of the study was recovery of sufficient kidney function to discontinue haemodialysis therapy and complete recovery of renal function. This prospective observational study has been conducted in Mymensingh Medical College Hospital, Bangladesh from September 2019 to February 2021. All adult patients with AKI-D were included in the study. All patients were followed up till death or complete recovery or for a maximum period of six month. A total of 134 patients of AKI-D were included in the study with the mean age of 42.3±15.7 years. Male (54.5%) were slightly more than female with a male to female ratio of 1.2:1. Diabetes and hypertension were present in 16 (11.9%) and 47 (35.1%) patients respectively. The causes of AKI were sepsis (35.1%), urinary tract infection (34.3%), acute watery diarrhoea (9.7%), leptospirosis (11.2%), obstetric (10.4%), malignancy (8.2%), post renal obstruction (8.2%), drugs (7.5%), surgery (18.7%), rapidly progressive glomerulonephritis (6%), COVID 19 (5.2%), rhabdomyolysis (4.5%), intestinal obstruction (3.7%), acute gastroenteritis (2.2%), wasp bite (2.2%), insecticide poisoning (1.5%), star fruit toxicity (1.5%), haemolytic uremic syndrome (0.7%) and unknown (1.5%). Mean number of dialysis requirement was 5.9±8.6 and length of hospital stay was 15.4±10.5 days. Out of 134 patients, 95(70.9%) were discharged from hospital and 39(29.1%) died in hospital. Total death of patients during the study period were 49(36.6%) including home death of 10(7.5%) patients. Complete recovery of kidney function was achieved in 70(52.2%) patients and partial recoveries of kidney function who can survive without dialysis were observed in 12(9%) patients. Three (2.2%) patients remain on dialysis and 85(63.4%) patients survived during the study period. Survival rate was significantly higher in patients with ≤40 years (72.6%) and significantly lower in patients with malignancy (18.2%) and post renal obstruction (27.3%). Outcomes of patients with AKI-D remain poor. Advanced stage of AKI, older age, late presentation, malignancy, nutritional deficiency and delay at initiation of dialysis were associated with high mortality and reduced survival.

Computational Fluid Dynamics (CFD) in Arteriovenous (AV) Graft Implantation Through End-to-Side Anastomosis with Varying Tube Diameters Across Different Vascular Access Locations for Dialysis Treatment.

Background/Objectives: Arteriovenous (AV) graft is a procedure for hemodialysis performed in the arm. Optimizing AV graft design is vital to enhance haemodialytic efficiency in patients with kidney disease. Despite being a standard procedure, making it work optimally is still difficult due to various graft diameters and anastomosis configurations, which have limited studies. This research aims to find the ideal AV graft tube diameter on blood flow and pressure gradients and the ideal body site for AV graft implantation and to study their angles for dialysate flow. Methods: Nine models were designed in Autodesk Fusion 360 with 40°, 50°, and 60° angles each having 2 mm, 5.1 mm, and 14.5 mm diameters, all following specific equations on continuity, momentum (Navier-Stokes Equation)), and the Reynolds Stress Model (RSM). The CFD simulation of these models was performed in ANSYS Fluent with an established parameter of 0.3 m/s inlet velocity and stiff/no-slip graft and artery wall boundary condition. Results: As a result, the design with a diameter of 14.5 mm and a 40° angle was overall the most ideal in terms of minimal wall shear stress and turbulence. Conclusions: Thus the brachiocephalic area or the forearm is calculated to be the most optimal implantation site. Additionally, varying angles do affect dialysate flow, as smaller values cause less stress.

Implementing a multisite shared haemodialysis care programme.

Adults receiving centre-based haemodialysis (HD) have low levels of patient activation which are associated with poorer outcomes. Shared haemodialysis care (SHC) describes an intervention whereby individuals are supported to undertake elements of their treatment to improve their activation levels and promote better self-care. This project aimed to increase the proportion of those performing SHC in seven HD centres within the Oxford Kidney Unit's catchment area. Sequential Plan-Do-Study-Act (PDSA) cycles effected change first in two central HD centres, in cycles 1 and 2, before rolling out to five satellite HD centres, in cycles 3 and 4. Cycle 1 explored and transformed staff perceptions regarding SHC using a questionnaire and teaching sessions while in cycle 2, staff partnered with patients to develop leaflets and noticeboards to improve awareness and participation. These interventions were then rolled out to the remaining HD centres in PDSA cycles 3 and 4. Other interventions included: Enrolling staff and patients in virtual training courses; designating SHC 'Champions'; engagement with a national SHC forum; and changes to the electronic patient record to enable the monitoring of patient SHC opportunity and to promote sustainable change. Outcome measurement data on the number of patients performing SHC and the number at different defined stages of SHC competency were captured monthly. In April 2022, only 4% (19/483) of those receiving centre-based HD performed any aspect of SHC. By the end of the project in December 2023, this had increased to 43% (220/511). There was a significant and sustained growth in the stage of patient SHC competency as well as the number of patients performing SHC in each HD centre. The project demonstrated that it is possible to implement, scale-up and maintain a multisite SHC programme even with little baseline staff and patient SHC experience.

Prediction of Arteriovenous Access Dysfunction by Mel Spectrogram-based Deep Learning Model.

Background: The early detection of arteriovenous (AV) access dysfunction is crucial for maintaining the patency of vascular access. This study aimed to use deep learning to predict AV access malfunction necessitating further vascular management. Methods: This prospective cohort study enrolled prevalent hemodialysis (HD) patients with an AV fistula or AV graft from a single HD center. Their AV access bruit sounds were recorded weekly using an electronic stethoscope from three different sites (arterial needle site, venous needle site, and the midpoint between the arterial and venous needle sites) before HD sessions. The audio signals were converted to Mel spectrograms using Fourier transformation and utilized to develop deep learning models. Three deep learning models, (1) Convolutional Neural Network (CNN), (2) Convolutional Recurrent Neural Network (CRNN), and (3) Vision Transformers-Gate Recurrent Unit (ViT-GRU), were trained and compared to predict the likelihood of dysfunctional AV access. Results: Total 437 audio recordings were obtained from 84 patients. The CNN model outperformed the other models in the test set, with an F1 score of 0.7037 and area under the receiver operating characteristic curve (AUROC) of 0.7112. The Vit-GRU model had high performance in out-of-fold predictions, with an F1 score of 0.7131 and AUROC of 0.7745, but low generalization ability in the test set, with an F1 score of 0.5225 and AUROC of 0.5977. Conclusions: The CNN model based on Mel spectrograms could predict malfunctioning AV access requiring vascular intervention within 10 days. This approach could serve as a useful screening tool for high-risk AV access.

Safeguarding Patients with End-Stage Kidney Disease From Climate-driven Extreme Heat and Hurricanes.

5wPatients with end stage kidney disease (ESKD) who receive in-center hemodialysis are disproportionately vulnerable to extreme weather events, including hurricanes and heat waves, that may disrupt access to healthcare providers, and life-sustaining treatments. This current era of climate-driven compounding disasters is progressively elevating the level of threat to the health and well-being of patients with ESKD. This analysis brings together multi-disciplinary expertise to explore the contours of this increasingly complex risk landscape. Despite the challenges, important advances have been made for safeguarding this medically high-risk patient population. Hemodialysis services providers have devised innovative systems for preparing their patients and sustaining, or rapidly reestablishing, hemodialysis services in the aftermath of a disaster, and maintaining open lines of communication with their caseloads of ESKD patients throughout all phases of the event. A description of lessons learned along the path towards improved patient support in disasters, is provided. The article concludes with a detailed case example, describing dialysis providers' effective response throughout Hurricane Ian's passage across the State of Florida in 2022. Based on lessons learned, this analysis outlines strategies for protecting patients with ESKD that may be adapted for future climate-potentiated disaster scenarios.

Treatment-related Problems and Countermeasures for Patients Undergoing Maintenance Hemodialysis Following Tropical Cyclones: A Scoping Review.

BACKGROUND: Patients undergoing maintenance hemodialysis face heightened vulnerability during disasters like tropical cyclones, yet there is sparse research on their treatment-related challenges and countermeasures. This scoping review aims to highlight the issues maintenance hemodialysis patients encounter following tropical cyclones. METHODS: A systematic scoping review of 19 articles from 2000 to 2023 was conducted, evaluating eligibility against predefined criteria. RESULTS: Hemodialysis patients encounter substantial challenges during and after tropical cyclones in the United States, Puerto Rico, Australia, and Taiwan. Thematic analysis identified 3 themes related to "challenges" (Hemodialysis health-related challenges, socially relevant challenges, and challenges of management inefficiencies). "Recommendations" comprised 4 themes and 4 phases across the "mitigation phase" (fortifying healthcare infrastructure and mobilizing community-focused risk mitigation initiatives), "preparedness" (emergency plan development, training, and patient education), "response" (activation of emergency plans and providing emergency healthcare services), and "recovery" (intersectoral collaboration for recovery and rebuilding). CONCLUSION: This scoping review underscores challenges confronted by patients undergoing maintenance hemodialysis post-tropical cyclones, highlighting the urgent need for targeted strategies to ensure the continuity of dialysis care during and after such disasters.

Plasmapheresis in Severe Methemoglobinemia Following Naphthalene Ball Poisoning: A Case Report.

Naphthalene is a widely used industrial and household chemical in the form of mothballs, but it has rarely been an agent of poisoning worldwide. We describe a case of ingestional naphthalene poisoning with a good outcome after proper management. A 20-year-old boy with a history of seizure disorder and mental retardation presented with abdominal pain, vomiting, burning micturition, and blood in the urine for 2-3 days. On examination, it was found that he had ingested six to eight mothballs and presented 2 days later with hemolysis and methemoglobinemia. He was given intravenous methylene blue, N-acetylcysteine, and ascorbic acid, besides supportive treatment, but the condition did not improve. The patient then underwent plasmapheresis. After two sessions, he showed improvement in the form of decreasing hemolysis. Renal replacement therapy in the form of hemodialysis was performed. Gradually, his condition improved, and concurrent psychiatric assessment and treatment were also provided. The patient was discharged after 15 days.

Echocardiographic Indices in Patients with End-Stage Renal Disease and Their Association with Hemodialysis-to-Hemodiafiltration Transfer: A Prospective Observational Study.

Background and Objectives: The assessment of cardiac function in patients with end-stage renal disease (ESRD) is vital due to their high cardiovascular risk. However, contemporary echocardiographic indices and their association with hemodialysis-to-hemodiafiltration transfer are underreported in this population. Materials and Methods: This prospective cohort study enrolled 36 ESRD patients undergoing hemodialysis-to-hemodiafiltration transfer, with baseline and 3-month post-transfer comprehensive echocardiographic assessments. The key parameters included the global work index, global constructed work, global wasted work (GWW), global work efficiency (GWE), and global longitudinal strain (GLS), with secondary measures from conventional echocardiography. The baseline measures were compared to general population reference values and changes pre- to post-transfer were analyzed using the Mann-Whitney U test. Results: Patients exhibited significant deviations from reference ranges in GWW (179.0 vs. 53.0-122.2 mmHg%), GWE (90.0 vs. 53.0-122.2%), and GLS (-16.0 vs. -24.0-(-16.0)%). Post-transfer left ventricular myocardial work and longitudinal strain remained unchanged (p > 0.05), except for increased GWW (179.0, IQR 148.0-217.0 to 233.5, IQR 159.0-315.0 mmHg%, p = 0.037) and improved mid-inferior peak systolic longitudinal strain ((-17.0, IQR -19.0-(-11.0) to -18.7, IQR -20.0-(-18.0)%, p = 0.016). The enrolled patients also showed higher left atrial diameters, left ventricular volumes, and mass, with impaired systolic function in both ventricles compared to reference values. Conclusions: This study highlights baseline impairments in contemporary echocardiographic measures (GWW, GWE, GLS) in ESRD patients versus reference values, but found no association between hemodialysis-to-hemodiafiltration transfer and most myocardial work and strain parameters.

The effect of multiple single cannulation technique on complications of arteriovenous fistulae: A meta-analysis.

OBJECTIVE: To evaluate the effect of multiple single cannulation technique on the complications of arteriovenous fistula. METHODS: A comprehensive literature search was conducted to investigate the impact of multiple single cannulation technique on the complications of arteriovenous fistula. The search was performed in both Chinese and English databases including Wanfang Medicine, China National Knowledge Infrastructure, Vip, Pubmed, Embase, and The Cochrane Library, with a search period up to December 20, 2023. Following literature screening and data extraction, the quality of the included studies was assessed using the Cochrane Bias Assessment Tool for Randomized Controlled Trials. Statistical analysis was performed using Review Manager version 5.3. RESULTS: Thirteen papers, totaling 1299 patients, were included in the analysis. The experimental group consisted of 646 patients, while the control group had 595 patients. The meta-analysis revealed that the multiple single cannulation technique was more effective than rope ladder cannulation and buttonhole cannulation in reducing the incidence of angiomas (odds ratio [OR] = 0.19; 95% confidence interval [CI] = 0.10-0.35), stenosis (OR = 0.22; 95% CI 0.13-0.39), thrombosis (OR = 0.17; 95% CI = 0.07-0.39), and blood seepage (OR = 0.13; 95% CI = 0.08-0.21) of arteriovenous fistulas (P < .05). Additionally, it was found to increase the success rate of nurses' single cannulation (OR = 4.20; 95% CI = 1.78-9.95) of arteriovenous fistulas (P < .05). CONCLUSION: Multiple single cannulation technique could effectively reduce the incidence of complications of arteriovenous fistula, improve the success rate of cannulation, prolong the life span of arteriovenous fistula, and prolong the survival cycle of hemodialysis patients.

Effects of Internet Plus-Based Continuous Nursing on Hemodialysis Adherence in Patients with Chronic Renal Failure: A Retrospective Study.

Aims/Background Chronic renal failure (CRF) is the eventual outcome shared by various progressive renal diseases, posing a serious threat to the physical health of patients. CRF patients are required to undergo hemodialysis (HD), which imposes heavy psychological and mental burdens for most individuals. This study explores the effects of Internet Plus-based continuous nursing on the compliance of CRF patients with HD. Methods This study retrospectively analyzed the clinical data of 160 CRF patients undergoing HD in the Yantai Yuhuangding Hospital from March 2021 to April 2023, after excluding eight cases from an originally selected cohort of 168 cases. These patients were divided into two groups: 79 cases who received the routine nursing from March 2021 to March 2022 were categorized as the routine group, whereas 81 cases who were given Internet Plus-based continuous nursing from April 2022 to April 2023 were assigned into the observation group. The treatment adherence, self-management behaviors, quality of life and incidence of HD complications were compared in both groups. Results Both groups demonstrated no significant difference in the baseline information (p > 0.05). The scores of adherence in terms of HD attendance, medications, fluid restrictions and diet recommendations in the observation group were significantly higher than those in the routine group (p < 0.001). No significant difference in the Hemodialysis Self-Management Instrument (HDSMI) scores on the day of discharge between the two groups was found (p > 0.05). After 6 months of follow-up, the observation group showed significantly higher scores of partnership, problem solving, self-management execution and emotional processing than the routine group (p < 0.001). Both groups had no significant difference in the scores of Kidney Disease-Targeted Areas (KDTA) and 36-Item Short Form (SF-36) on the day of discharge (p > 0.05). After 6 months of follow-up, the scores of KDTA and SF-36 in the observation group were significantly higher than those in the routine group (p < 0.001). The incidence of HD complications in the observation group (7.41%) was significantly lower than that in the routine group (21.52%) (p < 0.05). Conclusion Internet Plus-based continuous nursing can effectively improve treatment adherence, self-management behaviors as well as quality of life in patients, and reduce the incidence of HD complications.

Pain management associated with arteriovenous fistula cannulation among children undergoing haemodialysis: Systematic review.

Objective: To evaluate studies related to pain management associated with arteriovenous fistula cannulation among children. METHODS: The systematic review comprised literature search on Embase, ProQuest, Science Direct, Scopus, SpringerLink and Wiley Online databases for studies published in English between 1998 and 2021. The search used key words, including pain management OR analgesia AND child OR paediatric AND haemodialysis OR dialysis AND arteriovenous fistula OR arteriovenous fistula cannulation OR fistula needle OR arteriovenous fistula insertion OR needle insertion. The quality of the studies was evaluated using the Joana Briggs Institute checklist. General characteristics of the and pain outcomes were noted. RESULTS: Of the 2,877 studies initially identified, 8(0.27%) were analysed; 7(87.5%) quasi-experimental and 1(12.5%) randomised controlled trial. Overall, there were 283 participants aged 6-18 years. The strategies used for reducing arteriovenous fistula puncture-related pain among children undergoing haemodialysis included cryotherapy, lidocaine agents, virtual reality (VR), guided visualisation, balloon inflation, aromatherapy, and other programmed distractions. The strategies had a positive effect on reducing arteriovenous fistula cannulation-related pain among children. Conclusion: Non-pharmacological pain management is an easier, simpler, inexpensive and more effective method of atraumatic care among children undergoing haemodialysis.