Impact of different COVID-19 waves on kidney replacement therapy epidemiology and mortality: REMER 2020.

BACKGROUND: Kidney replacement therapy (KRT) confers the highest risk of death from coronavirus disease 2019 (COVID-19). However, most data refer to the early pandemic waves. Whole-year analysis compared with prior secular trends are scarce. METHODS: We present the 2020 REMER Madrid KRT registry, corresponding to the Spanish Region hardest hit by COVID-19. RESULTS: In 2020, KRT incidence decreased 12% versus 2019, while KRT prevalence decreased by 1.75% for the first time since records began and the number of kidney transplants (KTs) decreased by 16%. Mortality on KRT was 10.2% (34% higher than the mean for 2008-2019). The 2019-2020 increase in mortality was larger for KTs (+68%) than for haemodialysis (+24%) or peritoneal dialysis (+38%). The most common cause of death was infection [n = 419 (48% of deaths)], followed by cardiovascular [n = 200 (23%)]. Deaths from infection increased by 167% year over year and accounted for 95% of excess deaths in 2020 over 2019. COVID-19 was the most common cause of death (68% of infection deaths, 33% of total deaths). The bulk of COVID-19 deaths [209/285 (73%)] occurred during the first COVID-19 wave, which roughly accounted for the increased mortality in 2020. Being a KT recipient was an independent risk factor for COVID-19 death. CONCLUSIONS: COVID-19 negatively impacted the incidence and prevalence of KRT, but the increase in KRT deaths was localized to the first wave of the pandemic. The increased annual mortality argues against COVID-19 accelerating the death of patients with short life expectancy and the temporal pattern of COVID-19 mortality suggests that appropriate healthcare may improve outcomes.

The Impact of Immunosuppression and Autoimmune Disease on Severe Outcomes in Patients Hospitalized with COVID-19.

Immunosuppression (IS) and autoimmune disease (AD) are prevalent in patients with severe coronavirus disease 2019 (COVID-19), but their impact on its clinical course is unknown. We investigated relationships between IS, AD, and outcomes in patients hospitalized with COVID-19. Data on consecutive admissions for COVID-19 were extracted retrospectively from medical records. Patients were assigned to one of four cohorts, according to whether or not they had an AD (AD and NAD) or were immunosuppressed (IS and NIS). The primary endpoint was development of severe acute respiratory distress syndrome (ARDS); secondary endpoints included death, and a composite of mechanical ventilation (MV) or death. A total of 789 patients were included: 569 (72.1%) male, 76 (9.6%) with an AD, and 63 (8.0%) with IS. Relative to the NIS-NAD cohort, patients in the IS-AD cohort had a significantly reduced risk of severe ARDS (adjusted hazard ratio [aHR] 0.42; 95% confidence interval [CI] 0.23-0.80; p = 0.008). No significant relationships between IS or AD status and either death or the composite of MV and death were identified, although a trend towards higher mortality was identified in the IS-NAD cohort (aHR vs NIS-NAD 1.71; 95% CI 0.94-3.12; p = 0.081). Patients in this cohort also had higher median serum levels of interleukin-6 compared with IS-AD patients (98.2 vs 21.6 pg/mL; p = 0.0328) and NIS-NAD patients (29.1 pg/mL; p = 0.0057). In conclusion, among patients hospitalized with COVID-19, those receiving immunosuppressive treatment for an AD may have a reduced risk of developing severe ARDS.

Absolute blood volume variations and vascular refilling in hemodialysis patients.

The imbalance between ultrafiltration volume (UF) and vascular refilling is considered a major cause for intradialytic hypotension. Recent studies report a noninvasive method to estimate vascular refilling (VREF ) by determining absolute blood volume (ABV). It was the aim of the study to analyze variations in ABV in a group of hemodialysis (HD) patients and examine VREF . Thirty one stable chronic HD patients were studied, aged 71.07 ± 13.31 years. Dialysis duration and UF requirements were based on physician prescription. VREF was calculated as: VREF  = VUF  - ΔV where ΔV is ABV variation during dialysis treatment. ABV at the beginning of the dialysis was 6.00 ± 2.39 L (92.82 ± 33.17 ml/kg) and at the end 5.38 ± 2.32 L (82.07 ± 31.41 ml/kg). Prescribed UF was 2.64 ± 0.83 L. Mean VREF was 2.05 ± 0.80 L, with a refilling fraction of 75.75 ± 12.79%. VREF was strongly correlated with UF volume (r2 0.877), and with pre-dialysis volume overload (r2 0.617). Patients under beta-blocker treatment showed significantly lower FREF . ABV measurement is an easy and noninvasive method that allows us to study VREF during HD. We found a strong correlation between VREF and UF.

Absolute blood volume variations during hemodialysis: Does dialysate temperature play a role?

BACKGROUND: Vascular refilling occurs to preserve hemodynamic stability during hemodialysis (HD). Recent studies report a feasible and noninvasive method to determine absolute blood volume (ABV), and estimate vascular refilling during HD. The objective of this study is to analyze if lowering dialysate temperature modifies variations in ABV during HD. METHODS: The study was performed in 50 patients under HD. During two different sessions, relative blood volume was assessed using dialysate temperatures of 35.5°C (cool dialysate) and 36.5°C (neutral dialysate). ABV and vascular refilling were calculated using Kron et al methodology. RESULTS: Thirty-nine intradialytic morbid events (IMEs) were observed in 30 patients, 14 under cool dialysate and 25 during neutral dialysate. We did not found statistically differences in ABV or in refilling volume between cool and neutral temperature. When analyzing apart only those patients who presented IME, we observed lower drop in ABV in the 35.5°C dialysate treatments (0.57 L) versus 36.5°C dialysate treatments (0.71 L). When cool dialysate was used, the vascular refilling fraction tended to be higher, but data did not turn statistically significant. CONCLUSIONS: In selected groups of patients the use of cool dialysate induces lower ABV variations that could improve hemodynamic stability during HD treatments.

Resuming peritoneal dialysis after catheter removal due to complicated peritonitis.

BACKGROUND: Causes of non-resuming peritoneal dialysis (PD) after complicated peritonitis requiring peritoneal catheter (PC) removal remain poorly studied. METHODS: We reviewed all peritonitis episodes in our center between 1997 and 2017. Patients who restarted PD after PC removal (Group 1) were compared to those who did not (Group 2), identifying the causes. RESULTS: Of 284 peritonitis episodes, PC was removed in 48 patients (16.9%). In 18 (37.5%) patients PC was reinserted, and PD successfully resumed in all, with a median duration of PD afterwards of 14.1 months. In other 30 (62.5%) reinsertion of PC was not attempted. Causes of non-reinsertion were: transfer to hemodialysis 76.6% (n = 23), death 16.7% (n = 5) and transplantation 6.7% (n = 2). Hemodialysis switch was due to non-medical reasons in 47.8% (n = 11) including fear of peritonitis, family decision and social dependence. Group 1 was younger (p = 0.041), with lower Charlson index (p = 0.045) and higher men proportion (p = 0.049). Group 1 had a better patient survival than group 2 (survival at 24 months: 67% and 53%, respectively; log-rank test p: 0.01). There were no differences in survival between groups when adjusted for significant basal characteristics. CONCLUSIONS: Resuming PD after severe peritonitis requiring PC removal is feasible but a high proportion of patients do not restart PD for non-medical reasons, usually older patients with higher Charlson index. A properly structured interview would be a useful tool that could improve return to technique in these patients.

Incremental hemodialysis and vascular access complications: a 12-year experience in a hospital hemodialysis unit.

BACKGROUND: Incremental hemodialysis (HD) is considered a valid alternative for patients with residual kidney function. Evidence concerning its effect on vascular access is scarce. We present our 12-year experience of an incremental hemodialysis program with the aim of evaluating survival and complications of arteriovenous fistula in these patients compared to the thrice-weekly scheme. METHODS: From January 1st, 2006 to December 31st, 2017, 220 incident patients started hemodialysis, 132 (60%) of whom began hemodialysis with two sessions per week and 88 (40%) with three sessions per week. Demographic and clinical variables were assessed at the start of treatment. Data regarding arteriovenous fistula survival and complications were collected. RESULTS: Both groups had similar baseline sociodemographic and clinical characteristics. A total of 188 (85%) patients were dialyzed with an arteriovenous fistula during follow-up. Eighty-three patients had one or more fistula complications, with no differences between incremental and conventional groups (p = 0.55). Fistula survival rates showed no significant difference between the two groups, whether analyzed from the date of fistula creation (Log Rank p = 0.810) or from the date of initial fistula cannulation (Log Rank p = 0.695). CONCLUSIONS: We found no differences in arteriovenous fistula survival or complication rate between patients who started HD with an incremental versus a conventional treatment scheme. Randomized controlled clinical trials may be warranted to achieve a higher degree of evidence.

Reversed diastolic intrarenal flow in page kidney following renal biopsy.

Page's kidney is a condition that occurs due to external renal compression, usually caused by a subcapsular haematoma, generating a renal compartmental syndrome with parenchymal damage and renal perfusion alteration. Classically associated with renal trauma, Page's kidney can also arise after invasive renal procedures, such as renal biopsies or percutaneous nephrostomies. Clinically, it can trigger hypertension due to activation of the renin-angiotensin system induced by hypoperfusion secondary to renal parenchymal compression and can also present with varying degrees of renal function impairment. Furthermore, severe acute renal failure may be found particularly in patients with solitary kidneys or renal transplants. We present two cases of Page's kidney after renal biopsy and their PoCUS ultrasound findings. We would like to highlight the reversed diastolic flow on Doppler ultrasound in this entity, a pattern we have found in all two cases.

Routine Kidney Graft Ultrasound After Elective Ureteric Stent Removal: Does it Help?

Transplantation (KTx) is considered to be the best renal replacement therapy, and improving its outcomes remains a primary challenge. KTx ureteral stenting has been used to prevent urological complications, but there is no consensus on the timing of stent removal, and literature regarding routine ultrasonography after ureteric stent removal (RUSUS) to detect complications is lacking. Point-of-care ultrasound has been gaining drive in the medical community in recent years, including nephrologists. We aimed to define the incidence of urological complications diagnosed with RUSUS, if those findings changed patient's management and ultrasound utility. Contrary to previously published data, in our cohort RUSUS allowed a timely diagnosis and early treatment of urological complications, a key factor for successful transplantation. KTx point-of-care ultrasound is a cost-effective and reproducible test that provides relevant information to guide clinical decisions, seeming most efficient when performed approximately 2 weeks post ureteral stent removal. Interventional nephrologists can promptly perform these examinations, reducing waiting times and improving graft and patient's survival.

Individually adjusted absolute blood volume feedback control: A promising solution for intradialytic hypotension.

INTRODUCTION: Intradialytic hypotension (IDH) remains one of the most frequent complications associated to hemodialysis (HD), frequently triggered by a reduction in absolute blood volume (ABV) not compensated by vascular refilling. A recently developed dilutional method allows routinary measurement of ABV and, by a simple algorithm, may turn blood volume monitor (BVM) guided UF (ultrafiltration) biofeedback into an ABV control, automatically adjusting UF rate to maintain ABV above a preset threshold. The aim of this study is to identify an individual critical ABV threshold and test the ability of an ABV feedback control to avoid IDH. METHODS: We studied 24 patients throughout three consecutive midweek HD treatments. ABV and blood pressure (BP) were measured every 30 min and anytime the patient referred any symptoms to identify each patient's critical ABV (ABV at the time of hypotension). A fixed bolus dilution approach at the start of HD was used to calculate ABV. Then, patients were followed through three additional HD treatments and IDH development was analyzed. FINDINGS: Seventy-one treatments performed in 24 patients. ABV monitoring showed a constant decrease as HD treatment progressed. Thirteen IDH events were observed in eight different patients, with a mean systolic BP drop in IDH treatments of 37.38 ± 4.31 mmHg and a mean adjusted ABV at hypotension of 71.07 ± 14.88 mL/kg. Critical ABV was individually set in patients prone to IDH. As expected, ABV feedback control successfully maintained ABV over preset critical ABV. IDH events were avoided in 21 out of 22 treatments performed. ABV drop was successfully reduced, as well as SBP drop (despite similar UF than prior to ABV feedback control implementation). DISCUSSION: ABV feedback control avoided IDH in 21 out of 22 treatments performed by maintaining blood volume above critical ABV, significantly reducing ABV variations without compromising prescribed UF.

Trial design of the MOTheR HDx study: a multicenter, open-label, prospective, randomized study to explore the morbidity and mortality in patients dialyzed with the Theranova HDx in comparison with online hemodiafiltration.

Background: Dialysis patients have been maintaining a high rate of cardiovascular morbidity and mortality. For this reason, it is to introduce necessary new technical advances in clinical practice. There is a relation between toxins retention and inflammation, mortality and morbidity. Medium cut-off (MCO) membranes are a new generation of membranes that allow the removal of a greater number of medium-sized molecules compared with high-flux hemodialysis (HF-HD), but retaining albumin. MCO membranes have an increased permeability and the presence of internal filtration. Because of these special properties, MCO generated a new concept of therapy called expanded HD (HDx). Until now, online hemodiafiltration (OL-HDF) has demonstrated its superiority, in terms of survival, compared with HF-HD. However, the comparison between OL-HDF and HDx remains an unsolved question. Methods: The MOTheR HDx study trial (NCT03714386) is an open-label, multicenter, prospective, 1:1 randomized, parallel-group trial designed to evaluate the efficacy and safety of HDx compared with OL-HDF in patients treated for dialysis in Spain for up to 36 months. The main endpoint is to determinate whether HDx is non inferior to OL-HDF at reducing the combined outcome of all-cause death and stroke (ischemic or hemorrhagic), acute coronary syndrome (angina and myocardial infarction), peripheral arterial disease (amputation or revascularization) and ischemic colitis (mesenteric thrombosis). Results: The trial has already started.

Impact of dialysate sodium concentration on vascular refilling.

BACKGROUND: Although relationship between dialysate sodium concentration and hemodynamic stability has been well studied over the years, outcomes of absolute blood volume (ABV) maintenance and vascular refilling volume (Vref ) modifications were not included, as its analysis has not been easily accessible to direct investigation. However, recent studies report a simple and feasible methodology to assess ABV and Vref during hemodialysis (HD) treatments. It is the aim of this study to analyze whether sodium concentration in dialysate modifies ABV drop and Vref . METHODS: The study was performed in 19 patients under HD. During three different sessions, sodium concentration in dialysate was randomized to three different profiles: low sodium concentration (LNa, 138 mEq/L), neutral sodium concentration (NNa, 140 mEq/L), and high sodium concentration (HNa, 143 mEq/L). ABV and Vref were calculated using Kron et al methodology. RESULTS: Predialysis values of the measured parameters showed similar results for the three profiles. Sodium concentration showed an effect on ABV drop, Vref, and vascular refilling fraction (Fref ). Pair-wise comparison revealed mean ABV decreased 0.21 L less when using HNa profile versus LNa profile (p = 0.027), a mean Vref increase of 0.39 L (p = 0.038), and a mean Fref increase of 9.94% (p = 0.048). CONCLUSIONS: This study shows that the use of HNa profiles increases Vref and Fref and reduces ABV drop during dialysis treatments when compared to LNa profiles.

Assisted peritoneal dialysis (asPD): age is not the key.

BACKGROUND: Peritoneal dialysis (PD) has multiple advantages over other dialysis modalities. As a home-based therapy, it allows patients to keep their autonomy, avoid frequent hospital visits and carry on with their usual lifestyle. However, as a self-care therapy, dependency has been traditionally considered a contraindication. However, assistance to perform PD (asPD) can be provided regardless of the patient's age and the duration of such help. This paper is aimed at reporting on assisted PD use in a Spanish Center, and is the first report on asPD from this country. METHODS: We retrospectively reviewed the electronic medical records of all patients consecutively treated with PD between May 1997 and December 2020 in our PD Unit. Assisted PD was defined as PD treatment requiring the help of another person. On the basis of the duration of dependency, we divided our cohort into: Group 1: Patients totally dependent at the start of PD treatment; Group 2: self-care patients that developed total dependency during follow up; Group 3: patients who needed short-term PD assistance. Group 4, consisting of 175 self-care PD, served as the control group. RESULTS: Seventy-three percent of patients who required asPD did so during their follow up, showing that an important proportion of patients may require some help even if they were autonomous at the beginning of PD. Even for short time periods, asPD should be an option, as up to 44% of autonomous PD patients became dependent for different reasons over time. Spouses were the most frequent caregivers and absence or loss of caregiver was a main reason for switching to hemodialysis. Fourteen percent of the patients received asPD as palliative care, with clinical symptoms and perceived well-being as the main treatment goals, with adequate results. The need for support and the quality of life were periodically discussed by patients, family members and hospital staff. CONCLUSION: Assisted PD is a safe option for dependent patients, young or elderly, and may result less expensive for our healthcare system, even when caregivers receive a financial incentive.

Spontaneous peritoneal dialysis catheter expulsion: A case series.

There are a significant number of mechanical complications related the peritoneal dialysis (PD) catheter and early diagnosis is key. Between them, the spontaneous extrusion of the catheter is quite uncommon but it should be included among the possible complications of the technique, given that it can be related to frequent situations in PD patients like abdominal wall issues, past immunosuppression or PD fluid leakage. In 25 years our Unit had three cases, probably related to peritoneal fluid leakage, exit site infection and past steroid treatment. Careful examination of abdominal wall preimplantation, adequate break-in period to allow maturation and early detection of exit site infection to start treatment in a timely fashion could help to prevent this rare complication. The complete extrusion of the catheter does not preclude from continuing PD treatment.

Lipid profile of patients treated with evolocumab in Spanish hospital nephrology units (RETOSS NEFRO).

BACKGROUND AND OBJECTIVE: To describe the clinical characteristics, the reasons for initiating therapy and the effects of treatment in the initial phase of evolocumab availability in the Nephrology Units of Spain. MATERIAL AND METHODS: Retrospective, observational and multicentric study that included patients initiating treatment with evolocumab (from February 2016 to August 2018), in 15 Nephrology Units in Spain. The demographic and clinical characteristics of the patients, the lipid lowering treatment and the evolution of the lipid profiles between 24 weeks pre-initiation and 12±4 weeks post-initiation of evolocumab were reviewed. RESULTS: 60 patients were enrolled: 53.3% women; mean (SD) age, 56.9 (12.8) years, 45.0% with familial hypercholesterolemia (FH) (5.0% homozygous and 40.0% heterozygous) and 65.0% with atherosclerotic cardiovascular disease. The mean (SD) eGFR was 62.6 (30.0) ml/min/1.73m2 (51.7% of patients had eGFR <60ml/min/1.73m2 [CKD stage>2]), 50.0% had proteinuria (>300mg/g) and 10.0% had nephrotic syndrome. Other CV risk factors were hypertension (75.0%), diabetes (25.0%), and smoking (21.7%). A 40.0% of patients were statin intolerant. At evolocumab initiation, 41.7% of patients were on a high intensity statin, 18.3% on moderate intensity statin and 50.0% were receiving ezetimibe. Mean (SD) LDL-c at evolocumab initiation was 179.7 (62.9) mg/dL (53.4% of patients with LDL-c ≥160mg/dL and 29.3% ≥190mg/dL). After 12 weeks, evolocumab resulted in LDL-c reductions of 60.1%. At week 12, 90.0% of patients reached LDL-c levels <100mg/dL, 70.0% <70mg/dL, and 55.0% <55mg/dL, while mean eGFR levels and statin use remained stable. CONCLUSION: In Nephrology Units of Spain, evolocumab was predominantly prescribed in patients with FH, chronic renal disease (CRD>2) and secondary prevention, with LDL-c levels above those recommended by the guidelines. Evolocumab used in clinical practice significantly reduced the LDL-c levels in all patients included in the study.

Kidney Autotransplantation and Orthotopic Kidney Transplantation: Two Different Approaches for Complex Cases.

Introduction: Transplantation surgery teams often have to face complex cases. In certain circumstances, such as occlusion of the iliac vessels or prior pelvic surgery, heterotopic kidney transplantation may not be feasible and orthotopic kidney transplantation (OKT) could be a good alternative. Kidney autotransplantation (KAT) has been described as a potential treatment for complex renovascular, ureteral, or neoplastic conditions. There are scarce data regarding the complications and outcomes of these procedures; therefore, we present our experience. Materials and Methods: We retrospectively analysed the medical records of both 21 patients who had received OKT and 19 patients who underwent KAT between 1993 and 2020. We collected demographic features and data regarding surgical technique, complications, and graft outcomes. Kidney graft survival was calculated using Kaplan-Meier survival analysis. Results: Regarding OKT, in 15 (71.43%) cases, it was the first kidney transplantation. The most common indication was the unsuitable iliac region due to vascular abnormalities (57.14%). The early postoperative complication rate was high (66.67%), with 23.81% of Clavien grade 3b complications. During the follow-up period (mean 5.76 -SD 6.15- years), we detected 9 (42.85%) graft losses. At 1 year, the survival rate was 84.9%. Concerning KAT, the most frequent indication was ureteral pathology (52.63%), followed by vascular lesions (42.11%). The overall early complication rate was 42.11%. During the follow-up period (mean of 4.47 years), 4 (15.79%) graft losses were reported. Conclusions: Although OKT and KAT have high complication rates, these techniques can be considered as two valuable approaches for complex cases, in the absence of other therapeutic options.

Live donor kidney transplantation. Situation analysis and roadmap.

Living donor kidney transplantation (LDKT) is the best treatment option for end stage renal disease in terms of both patient and graft survival. However, figures on LDKT in Spain that had been continuously growing from 2005 to 2014, have experienced a continuous decrease in the last five years. One possible explanation for this decrease is that the significant increase in the number of deceased donors in Spain during the last years, both brain death and controlled circulatory death donors, might have generated the false idea that we have coped with the transplant needs. Moreover, a greater number of deceased donor kidney transplants have caused a heavy workload for the transplant teams. Furthermore, the transplant teams could have moved on to a more conservative approach to the information and assessment of patients and families considering the potential long-term risks for donors in recent papers. However, there is a significant variability in the LDKT rate among transplant centers and regions in Spain independent of their deceased donor rates. This fact and the fact that LDKT is usually a preemptive option for patients with advanced chronic renal failure, as time on dialysis is a negative independent factor for transplant outcomes, lead us to conclude that the decrease in LDKT depends on other factors. Thus, in the kidney transplant annual meeting held at ONT site in 2018, a working group was created to identify other causes for the decrease of LDKT in Spain and its relationship with the different steps of the process. The group was formed by transplant teams, a representative of the transplant group of the Spanish Society of Nephrology (SENTRA), a representative of the Spanish Society of Transplants (SET) and representatives of the Spanish National Transplant Organization (ONT). A self-evaluation survey that contains requests about the phases of the LDKT processes (information, donor work out, informed consent, surgeries, follow-up and human resources) were developed and sent to 33 LDKT teams. All the centers answered the questionnaire. The analysis of the answers has resulted in the creation of a national analysis of strengths, weaknesses, opportunities, threats (SWOT) of the LDKT program in Spain and the development of recommendations targeted to improve every step of the donation process. The work performed, the conclusions and recommendations provided, have been reflected in the following report: Spanish living donor kidney transplant program assessment: recommendations for optimization. This document has also been reviewed by a panel of experts, representatives of the scientific societies (Spanish Society of Urology (AEU), Spanish Society of Nephrology Nursery (SEDEN), Spanish Society of Immunology (SEI/GETH)) and the patient association ALCER. Finally, the report has been submitted to public consultation, reaching ample consensus. In addition, the transplant competent authorities of the different regions in Spainhave adopted the report at institutional level. The work done and the recommendations to optimize LDKT are summarized in the present manuscript, organized by the different phases of the donation process.

A retrospective study on outcome of microscopic polyangiitis in chronic renal replacement therapy.

BACKGROUND: Pauci-immune vasculitis is a heterogeneous disorder with an unfavourable prognosis. Renal involvement is frequently observed in antineutrophil cytoplasm autoantibody (ANCA)-associated small-vessel vasculitis and is an important cause of end-stage renal disease (ESRD). Renal replacement therapy (RRT) is frequently required. Although better prognosis under dialysis is well known, the long-term follow-up of pauci-immune renal vasculitis with RRT is rarely reported. METHODS: We described 24 patients with pauci-immune vasculitis and requirement of dialysis who were admitted in our institutions from January 1989 to December 2008. Mean age was 65 ± 12 years at the beginning of dialysis. There were 12 males and 12 females. Patients with Wegener's granulomatosis, Churg-Strauss syndrome or evidence of anti-glomerular basement membrane were excluded. The study group was formed by patients with a diagnosis of necrotizing extracapillary glomerulonephritis and microscopic polyangiitis. RESULTS: The distribution according to ANCAs was 14 p-ANCA (58%), 5 c-ANCA (21%) and 5 ANCA-negative (21%) pauci-immune renal vasculitis. Pulmonary renal syndrome (PRS) was observed in 10 patients at the onset of vasculitis. Corticosteroids and daily cyclophosphamide were administered to 18 patients, and one patient had intravenous cyclophosphamide. Five patients received isolated corticosteroid therapy. Early reduction in cyclophosphamide dosage was required in five patients due to leucopaenia. Mean follow-up after first dialysis was 89 ± 66 months (range 2-208). Twenty patients were included in haemodialysis (HD), and four patients were included in peritoneal dialysis (PD). At the end of the study, nine patients had received a cadaveric kidney transplant (KT). Relapses rate after the onset of dialysis was 0.03 episode/patient/year. PRS-associated relapses after beginning dialysis were observed in four patients. Main therapy in relapses was also corticosteroids and cyclophosphamide. Survival rates for year 1, 2 and 5 was 91%, 91% and 85%, respectively. Overall mortality at the end of the study was 31.8%. Five patients died in the PRS group, but only one death was associated with progressive pulmonary fibrosis. Higher mortality was observed in PRS vasculitis present at the onset of RRT (50% vs 16.7%, P = NS). Better outcome in patients who received a renal transplantation was observed (88.8% vs 53.8%, P = NS). Conclusions. Despite a low number of patients in this series, pauci-immune vasculitis prognosis under dialysis seems equal to other causes of chronic kidney disease. This study observed a low rate of relapses after beginning dialysis. Poor prognosis is related to severe complications at the beginning of RRT. Today, kidney transplantation is an important therapeutic option for these patients.

Effect of oral administration of docohexanoic acid on anemia and inflammation in hemodialysis patients: A randomized controlled clinical trial.

BACKGROUND & AIMS: Docohexanoic acid (DHA), a dietary n-3 polyunsaturated fatty-acid omega-3 (n-3, PUFA), showed potential beneficial effects in reducing all-cause mortality in hemodialysis (HD) patients. This randomized trial aimed to analyze whether DHA supplementation was a modulator of erythropoietin (EPO) response and inflammation in hemodialysis (HD) patients. METHODS: In this controlled clinical trial, 52 HD patients were randomized to either DHA supplementation (650 mg DHA/3 times/wk/post-HD session) or controls (usual care), with 8-weeks of follow-up. The primary outcome was to determine the correction of anemia measured by changes in the erythropoiesis-resistance index (ERI) to keep the hemoglobin level at recommended target value. Secondary outcomes include changes in inflammatory biomarkers: serum C-reactive protein, total homocysteine (tHcy) and expression of miR-146a. Laboratory measures were determined at baseline and at 8-weeks after the DHA supplementation or usual care in controls. Linear regression analysis was used to assess the effect of DHA supplementation, adjusting for baseline values and intervention. RESULTS: Forty-two HD patients (men: 69%; aged:66.7 ± 15.5 yrs; DM:19%), completed this study. The DHA effect significantly decreased EPO doses (-4158.7 UI/weekly; CI95%:-8123.7 to 193,6; p = 0.04), ERI (-9.25 UI weekly/kg BW/g/dL; CI95%:-15.5 to -2.9; p = 0.006), tHcy (-5.1 µmol/L; CI95%:-9.7 to -0.3; p = 0.03), and levels of miR-146a (-1.43; CI95%:-2.7 to -0.19; p = 0.03) in regression model. No adverse effects were found. CONCLUSION: The DHA supplementation enhances anemia management and attenuates inflammation response in this controlled trial in HD patients, when provided as coadjutant therapy together with usual medical care. REGISTERED UNDER CLINICALTRIALS. GOV IDENTIFIER NUMBER: 04536636.

Incoercible Vomiting in a Polycystic (ADPKD) Patient on Peritoneal Dialysis.

Although gastrointestinal symptoms are not uncommon in PD patients due to several causes, such as infusion volume with early satiety, constipation, or peritonitis, sometimes the differential diagnosis is more challenging for nephrologists. We present the case of a woman with end-stage renal disease due to autosomal dominant polycystic kidney disease on PD who presented with swollen legs and incoercible vomiting. After ruling out constipation and infection, an abdominal CT was done, revealing extrinsic compression of the intrahepatic inferior cava vein (ICV) and massive venous thrombosis from ICV to bilateral iliofemoral deep veins. In addition, CT also showed displacement and extrinsic compression of the stomach, pylorus, and duodenum due to an enlarged liver cyst. Percutaneous drainage and sclerosis of the cyst compressing the stomach was performed, anticoagulation was started, and the patient clinically improved with complete resolution of symptoms.

Effect of Beta-Blocker Cardioselectivity on Vascular Refilling in Hemodialysis Patients.

BACKGROUND: ß-Blockers are the most frequently prescribed cardioprotective drugs in hemodialysis (HD) patients, despite their weak evidence. We sought to evaluate the effects of ß-blockers on vascular refilling during HD treatments and examine whether carvedilol, for being noncardioselective and poorly dialyzable, associates more impact than others. METHODS: The study was performed in a cohort of maintenance HD patients from a tertiary center. All patients had previous ß-blocker prescription. We conducted a prospective crossover study and measured vascular refilling volume (Vref) and vascular refilling fraction (Fref) in 2 circumstances: under ß-blocker treatment (ßb profile) and without ß-blocker effect (non-ßb profile). RESULTS: Twenty patients were included, 10 of whom were treated with carvedilol. Predialysis values were comparable between the 2 profiles. Although the ßb profile showed lower Vref and higher ABV drop, these differences did not reach statistical significance. Data showed an increase in Fref in the non-ßb profile (70.01 ± 6.80% vs. 63.14 ± 11.65%; p = 0.015). The ßb profile associated a significantly higher risk of intradialytic hypotension (IDH) (risk ratio 2.40; 95% CI: 1.04-5.55). When analyzing separately the carvedilol group, patients dialyzed under drug effect experienced a significant impairment in Vref, Fref, and refilling rate. CONCLUSIONS: Administering ß-blockers before HD associated a higher risk of IDH and a decrease in Fref. Patients dialyzed under carvedilol effect showed an impaired refilling, probably related to its noncardioselectivity and lower dializability.