Intradialytic Tolerance and Recovery Time in Different High-Efficiency Hemodialysis Modalities.

There are several forms of maintenance high-efficiency hemodialysis (HD), including hemodiafiltrations (HDF) in different technical modes and expanded HD, using dialyzers with medium cut-off membranes. The aim of the study was to assess the intradialytic tolerance and length of dialysis recovery time (DRT) in these modalities. This is an exploratory, crossover study in maintenance HD patients with low comorbidity and no clinical indications for the use of high-efficiency HD, who were exposed to five intermittent dialyses in random order: high-flux hemodialysis (S-HD), expanded HD (HDx), pre-dilution HDF (PRE-HDF), mix-dilution HDF (MIX-HDF) and post-dilution HDF (POST-HDF). Twenty-four dialysis sessions of each method were included in the analysis. Dialysis parameters, including blood flow rate, dialysis fluid flow rate and temperature, and pharmacological treatment were constant. Average total convection volume for post-HDF, pre-HDF and mix-HDF were 25.6 (3.8), 61.5 (7.2) and 47.1 (11.4) L, respectively. During all therapies, patients were monitored for the similarity of their hydration statuses using bioimpedance spectroscopy, and for similar variability over time in systemic blood pressure and cardiac output, while peripheral resistance was monitored using impedance cardiography. The lowest frequency of all intradialytic adverse events were observed during HDx. Delayed DRT was the shortest during PRE-HDF. Patients were also more likely to report immediate recovery while receiving PRE-HDF. These differences did not reach statistical significance; however, the study results suggest that intradialytic tolerance and DRT may depend on the dialysis method used. This supports the need of taking into account patient preferences and quality of life while individualizing high-efficiency therapy in HD patients.

Prevalence of cardiovascular diseases in kidney transplant recipients and its relationship with asymmetric dimethylarginine, fibroblast growth factor-23 and multiple inflammatory markers.

INTRODUCTION AND AIM: Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of endothelial nitric oxide synthase, a marker of endothelial damage and progression of atherosclerosis. Research confirms the association of ADMA with an increased risk of cardiac complications and an increased risk of death, graft loss among kidney transplant recipients (KTRs). The aim of our study was to establish the significance of ADMA and FGF-23 as biomarkers of cardiovascular risk as well as predictors of graft failure and progression of chronic transplant kidney disease in comparison to CKD subjects. In addition, an analysis of the relationship between ADMA, FGF23 and cardiovascular diseases in CKD subjects and KTRs was performed. MATERIAL AND METHODS: The study group included 132 KTRs. The control group consisted of age- and sex-adjusted 40 individuals with clinically stable CKD. ADMA, FGF-23, hs-CRP and IL-6 were measured by the enzyme-linked immunoassay method (ELISA). Parameters of body mass composition such as fat mass, FTI, lean tissue mass, LTI, body water and overhydration were assessed by multi-frequency bioimpedance analysis (BIA). RESULTS: Cardiovascular diseases (CVDs) were present in 31.8% of KTRs. Independent variables related to nutritional status (SGA, s-albumin), according to multivariate regression, may have an impact on the prevalence of CVD in the kidney transplant recipients' group. Our study findings suggested a correlation between ADMA and serum albumin (r=-0.41, p<0.05), oxLDL (r=-0.42, p<0.05) and overhydration (OH%, r=0.28, p<0.05). Moreover, administration of statins and/or angiotensin-converting-enzyme inhibitors was significantly related to a reduction of ADMA in KTRs. We have also identified a significant positive correlation between FGF-23 levels and inflammatory markers (hs-CRP, IL-6) and negative with overall index of renal function (eGFR-CKD EPI, eGFR-MDRD). CONCLUSION: Nutritional status, inflammation and endothelial dysfunction markers (ADMA, FGF-23) are considerably altered even in stable kidney transplant recipients.

Adherence to Caloric and Protein Recommendations in Older Hemodialysis Patients: A Multicenter Study.

Hemodialysis (HD) patients are characterized by malnutrition, which adversely affects their survival. The development of malnutrition is influenced, among other factors, by improper diet and the advanced age of patients. The study aimed to assess the nutritional status and adherence to dietary recommendations among older patients. The multicenter study included 179 stable HD patients. The nutritional status was assessed by a 7-point Subjective Global Assessment (SGA). Anthropometry and body composition was analyzed. The diet was assessed based on the 3-day food diary and the Food Frequency Questionnaire with 6 answers (FFQ-6). Blood laboratory tests were performed. Based on the 7-point SGA, malnutrition was diagnosed in 38.5% of HD patients. The decreased content of the muscle tissue (LTI < 14 kg/m2) was observed in 70.4% of the examined patients and the decreased concentration of s-albumin was observed in 44.1% of patients. Older patients had significantly lower LTI. 26% of patients consumed less than 25 kcal/kg body weight and less than 0.8 g protein/kg body weight. Older patients' diets contained significantly fewer calories. There were significant differences between nutrient intake on a weekday with dialysis, a weekday without dialysis, and a weekend day without dialysis. The lowest intake of nutrients was observed on the day of dialysis. Nutritional education and the determination of whether food is permitted during hemodialysis are necessary to improve patients' nutrition.

COVID-19 vaccination reduces mortality in patients on maintenance hemodialysis.

Patients with chronic kidney disease on maintenance hemodialysis (HD) have a very high risk of death in the course of COVID-19. The aim of the study was to assess the effectiveness of COVID-19 vaccination to reduce the incidence of COVID-19 and the fatality rate in HD patients. A retrospective registry-based cohort study was performed in all HD adult patients in the Pomeranian Voivodeship. Vaccinations were carried out from January to April 2021 with mRNA vaccines, either BNT162b2 or mRNA-1273 with two-dose schedule. In the first analysis (2nd pandemic wave), 1,160 unvaccinated patients were included (59.7% males, 25.7% diabetic). In the second analysis (4th pandemic wave), 1,131 (59.4% male, 30.7% diabetic) individuals were included, 1,042 (92.13%) were fully vaccinated. Three hundred and fifteen HD patients (27.2%) were COVID-19 positive during the 2nd wave, and 6.9% (78/1,131) during the 4th wave. Within the fully vaccinated patients of the 4th wave, 60 were COVID-19 positive, 5.8 vs. 20.2% of unvaccinated COVID-19 positive patients in 2nd wave, respectively. COVID-19 incidence rate ratio (IRR) was 0.21 (4th wave-vaccinated vs. 2nd wave-unvaccinated) indicating a 79% reduction. The IRR between vaccinated and unvaccinated patients of the 4th wave was 0.28 in favor of vaccinated patients with 72% reduction. In the 2nd wave, 93 patients died as a result of COVID-19 (fatality rate: 29.5%). The fatality rate of fully vaccinated patients during the 4th wave was 6.7% (p = 0.004), while the fatality rate in the 4th wave within unvaccinated patients accounted for 11.1%. Significant clinical effectiveness of COVID-19 vaccination was demonstrated in a multicenter study in HD patients.

Thyroid Function, Inflammatory Response, and Glucocorticoids in COVID-19.

The ongoing COVID-19 pandemic calls for extensive research on various medical topics. Since the beginning of the pandemic, multiple studies investigated the impact of SARS CoV-2 on thyroid function. However, crucial data, such as trend progression over time or influence of commonly used drugs, might still be missing. We checked the thyroid function in 174 patients with PCR-confirmed COVID-19. Our research covered three separate time points of hospitalization (days 1, 4, and 10). We did not exclude patients treated with glucocorticoids but, instead, compared them with patients not treated with steroids. We correlated the results of thyroid function tests with markers of systemic inflammation. We checked if abnormal thyroid function can predict unfavorable outcomes defined as combined primary endpoint and/or secondary endpoints; the combined primary endpoint was the occurrence of death, mechanical ventilation, non-invasive ventilation, vasopressor infusion, or prolonged hospital stay, and the secondary endpoint was any of the listed events. In general, 80.46% of evaluated patients displayed abnormalities in thyroid function tests over at least one time point throughout the observation. We noticed a high prevalence of features typical for thyroid dysfunction in non-thyroidal illness (NTI). Free triiodothyronine (fT3) concentration was significantly lower in the group requiring glucocorticoids. Patients displaying abnormal thyroid function were statistically more likely to meet the predefined combined primary endpoint. We found that fT3 measured at admission could be perceived as an independent predictor of endpoint completion for all analyzed groups. Thyroid involvement is common in COVID-19. Our study supports the idea of thyroid function abnormalities being important clinical tools and allowing early recognition of possible detrimental outcomes of the disease.

Cortisol as an Independent Predictor of Unfavorable Outcomes in Hospitalized COVID-19 Patients.

Most cases of COVID-19 are non-severe, but some patients require urgent hospital care. In the past, it has been established that adrenal hyperactivity predicts poorer prognosis in severely ill patients. We wanted to verify if cortisol levels can be tied to clinical outcomes and the degree of inflammation in hospitalized COVID-19 patients. We recruited 180 adult patients with PCR-confirmed COVID-19. The group was divided into smaller subgroups based on the glucocorticoid treatment status; the subgroups were evaluated in three separate time points. The assessment involved hormonal function (cortisol, ACTH), inflammatory markers, and occurrence of the pre-selected endpoints (death, hospitalization ≥10 days, non-invasive ventilation or high-flow oxygenation, mechanical ventilation, vasopressors). In the evaluated group, 121 patients showed signs of abnormal adrenal function. There was a clear correlation between cortisol and IL-6 concentrations in all three time points regardless of glucocorticoid treatment. A total of 71.1% of patients displaying abnormal cortisol production met the preselected endpoints. Our analysis showed that a cutoff cortisol concentration prognosing endpoint occurrence could be set at 15.45 µg/dL for patients not treated with glucocorticoids. Cortisol concentration can be seen as an independent prognostic factor for unfavorable outcomes in selected adults hospitalized with COVID-19.

Angiotensin Converting Enzyme Inhibitors May Increase While Active Vitamin D May Decrease the Risk of Severe Pneumonia in SARS-CoV-2 Infected Patients with Chronic Kidney Disease on Maintenance Hemodialysis.

The group most at risk of death due to COVID-19 are patients on maintenance hemodialysis (HD). The study aims to describe the clinical course of the early phase of SARS-CoV-2 infection and find predictors of the development of COVID-19 severe pneumonia in this population. This is a case series of HD nonvaccinated patients with COVID-19 stratified into mild pneumonia and severe pneumonia group according to the chest computed tomography (CT) pneumonia total severity score (TSS) on admission. Epidemiological, demographic, clinical, and laboratory data were obtained from hospital records. 85 HD patients with a mean age of 69.74 (13.19) years and dialysis vintage of 38 (14-84) months were included. On admission, 29.14% of patients had no symptoms, 70.59% reported fatigue followed by fever-44.71%, shortness of breath-40.0%, and cough-30.59%. 20% of the patients had finger oxygen saturation less than 90%. In 28.81% of patients, pulmonary parenchyma was involved in at least 25%. The factors associated with severe pneumonia include fever, low oxygen saturation and arterial partial pressure of oxygen, increased C-reactive protein and ferritin serum levels, low blood count of lymphocytes as well as chronic treatment with angiotensin converting enzyme inhibitors; while the chronic active vitamin D treatment was associated with mild pneumonia. In conclusion, even though nearly one-third of the patients were completely asymptomatic, while the remaining usually reported only single symptoms, a large percentage of them had extensive inflammatory changes at diagnosis with SARS-CoV-2 infection. We identified potential predictors of severe pneumonia, which might help individualize pharmacological treatment and improve clinical outcomes.

Analysis of Experiences in Preventing COVID-19 in Hemodialysis Centers of the North of Poland before the Era of Vaccination.

BACKGROUND: The appearance of very contagious SARS-CoV-2 variants and waning vaccine immunity may indicate the need to return to using universal methods of preventing the spread of COVID-19. METHODS: We performed a multicenter retrospective cohort survey study to describe the methods used in dialysis units to prevent and control the spread of SARS-CoV-2 and also the association between these methods and the incidence of COVID-19 among hemodialyzed (HD) patients before the era of vaccination. The study population included all maintenance HD patients (n = 1569) in 14 dialysis units in the Pomeranian Voivodeship. RESULTS: The group of 352 patients (199 men, 153 female) were confirmed for COVID-19. The absolute cumulative incidence in the studied period was 22.4%. It varied widely by dialysis units, ranging from 9.4% to 36.9%. Universal preventive methods were applied by all units. Different additional methods were implemented in some stations with varying frequency (36-86%). In order to quantify the scale of the applied additional preventive methods, we calculated a summary prevention index (PI), i.e., one point for one additional method. Lower incidence was found in centers applying dialysis in isolation of patients hospitalized due to diseases requiring hospitalization (17.42% ± 6.89 vs. 26.54 ± 6.34; p = 0.028) and higher incidence in medium-size dialysis centers (ANOVA F: p = 0.017). Significant inverse correlation between PI and incidence was demonstrated as well (r = -0.759; p = 0.002). CONCLUSIONS: The higher the number of implemented preventive measures, the lower the risk of COVID-19 infection in HD patients. Among applied procedures the isolation of hospitalized patients is of significant importance. The measures proved to be effective in prevention before the vaccination era should be continued, as the threat of SARS-CoV-2 still exists.

Predictors of Mortality in Hemodialyzed Patients after SARS-CoV-2 Infection.

INTRODUCTION: The determinants of COVID-19 mortality are well-characterized in the general population. Less numerous and inconsistent data are among the maintenance hemodialysis (HD) patients, who are the population most at risk of an unfavorable prognosis. METHODS: In this retrospective cohort study we included all adult HD patients from the Pomeranian Voivodeship, Poland, with laboratory-confirmed SARS-CoV-2 infection hospitalized between 6 October 2020 and 28 February 2021, both those who survived, and also those who died. Demographic, clinical, treatment, and laboratory data on admission, were extracted from the electronic medical records of the dedicated hospital and patients' dialysis unit, and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with 3-month all-cause mortality. RESULTS: The 133 patients (53.38% males) aged 73.0 (67-79) years, with a median duration of hemodialysis of 42.0 (17-86) months, were included in this study. At diagnosis, the majority were considered to have a mild course (34 of 133 patients were asymptomatic, another 63 subjects presented mild symptoms), while 36 (27.07%) patients had low blood oxygen saturation and required oxygen supplementation. Three-month mortality was 39.08% including an in-hospital case fatality rate of 33.08%. Multivariable logistic regression showed that the frailty clinical index of 4 or greater (OR 8.36, 95%CI 1.81-38.6; p < 0.01), D-Dimer of 1500 ng/mL or greater (6.00, 1.94-18.53; p < 0.01), and CRP of >118 mg/L at admission (3.77 1.09-13.01; p = 0.04) were found to be predictive of mortality. CONCLUSION: Very high 3-month all-cause mortality in hospitalized HD patients was determined mainly by frailty. High CRP and D-dimer levels upon admission further confer mortality risk.

Thyroglobulin levels in COVID-19-positive patients: Correlations with thyroid function tests, inflammatory markers, and glucocorticoid use.

COVID-19 often results in generalized inflammation and affects various organs and systems. Endocrine research focused on the possible sequelae of COVID-19, with special interest given to the thyroid gland. Clinical problems such as thyroid function in non-thyroidal illness (NTI), autoimmune thyroiditis, and COVID-19-related subacute thyroiditis (SAT) quickly gained wide coverage. Thyrotoxicosis of various origins leads to the release of peripheral thyroid hormones and thyroglobulin (TG), the main glycoprotein contained within the thyroid follicular lumen. In our study, we evaluated TG levels in COVID-19-positive patients and investigated the possible relationships between TG, thyroid function tests (TFTs), and inflammatory markers. Our approach included separate subanalyses of patients who received and those who did not receive glucocorticoids (GCs). In the entire population studied, the concentration of TG tended to decrease with time (p<0.001; p1,2 = 0.025, p1,3 = 0.001, p2,3 = 0.003), and this pattern was especially clear among patients treated with GCs (p<0.001; p1,2=<0.001; p1,3=<0.001; p 2,3=<0.001). The concentration of TG differed significantly between patients treated and those not treated with GC at the second and third time points of observation (p=0.033 and p=0.001, consecutively). TG concentration did not differ between the patients with normal and abnormal TFTs. The correlations between TG, TFTs, and inflammatory markers were very limited. 19 patients had elevated TG levels, but a TFT pattern suggestive of thyrotoxicosis was not common in this group. There were no statistically significant differences between patients who met and those who did not meet the predefined combined primary endpoint.

Persistent Post-COVID-19 Syndrome in Hemodialyzed Patients-A Longitudinal Cohort Study from the North of Poland.

BACKGROUND: After recovery from COVID-19, patients frequently face so-called "Post-COVID-19 Syndrome" defined by clusters of persistent symptoms lasting for >12 weeks which may arise from any system in the body. The long-term health consequences of COVID-19 in maintenance hemodialyzed (HD) patients remain to be investigated. METHODS: In this longitudinal cohort study we described the health consequences in HD patients requiring hospitalization due to COVID-19. They were interviewed three and six months (M3 and M6) after discharge with a series of standardized questionnaires. RESULTS: Of 144 HD patients discharged from the 7th Naval Hospital in Gdansk, 79 participants were enrolled, 39 m (49.4%) and 40 f (50.6%) with a median age of 70.0 (64.0-76.5) and an HD vintage of 40 months (17.5-88). After discharge, 93.7% and 81% reported at least one persistent symptom at M3 and M6, respectively. The most common symptoms were fatigue or muscle weakness (60.76% and 47.04%) and palpitations (40.51% and 30.14%). Dyspnea with an mMRC scale grade of at least 1 was reported by 21.5% before infection, and by 43.03% and 34.25% at M3 and M6, respectively. A decrease in the quality of life was reported in all domains of the EQ-5D-5L questionnaire but mainly in the pain/discomfort and anxiety dimensions. Mean EQ-VAS scores were 69.05, 61.58 and 64.38, respectively. CONCLUSION: Our study showed that HD patients may still experience persistent symptoms six months after recovery from COVID-19, which can further reduce their already poor health-related quality of life. This study highlights the need for long-term follow-up on these patients for diagnostic and rehabilitation programs.

Extremely high mortality rates among hemodialysis patients with COVID-19 before the era of SARS-CoV-2 vaccination: results from a large database from the North of Poland.

INTRODUCTION: Preliminary reports suggested high incidence and mortality rates of SARS­ CoV 2 infection in patients receiving kidney replacement therapy. OBJECTIVES: We aimed to describe the incidence and outcomes of COVID­ 19 in hemodialysis patients. PATIENTS AND METHODS: We conducted a retrospective multicenter cohort study on the incidence and mortality of COVID­ 19 in hemodialysis patients as compared with the general adult population in the period from the beginning of the pandemic until the commencement of the SARS­ CoV 2 vaccination program. The study population included all patients who were receiving hemodialysis in any of the 14 dialysis units of Pomerania Province, Poland on December 31, 2019 and all individuals who were starting long­ term hemodialysis between January 1, 2020 and January 31, 2021, amounting to a total of 1567 patients. Data on the general population were obtained from reports of the health authorities. RESULTS: The absolute cumulative incidence of SARS­ CoV 2 infection in hemodialysis patients was 22.4%, and after standardization for age it was 3.98-fold higher compared with the general population (P <0.001). The epidemic trajectory of both groups ran in parallel, but the increase and decline in the number of new cases occurred earlier in hemodialysis patients. The fatality rate of COVID­ 19 among hemodialysis patients was 30.4%. It was the highest among the oldest patients, reaching 43.81% in individuals aged 75 years or older (P = 0.003). Age­ standardized fatality and mortality rates in hemodialysis patients were 5.5- and 10.9-fold higher than in controls, respectively (both P <0.001). CONCLUSIONS: The results of this study show the extremely high mortality rate of COVID­ 19 in hemodialysis patients during the first and second waves of the epidemic in Pomerania Province, before the vaccination era.