Simultaneous analysis of caffeine and paraxanthine provides potentially useful indexes in the treatment of acute caffeine intoxication.

Caffeine (CFF) is efficiently absorbed after ingestion, and approximately 80% of ingested CFF is metabolized to paraxanthine (PXT). Although PXT has approximately twice the adenosine receptor antagonist activity of CFF, there are few reports measuring the metabolite concentrations during CFF intoxication. Furthermore, no studies have examined the efficacy of hemodialysis (HD) on PXT or the indicators that contribute to treatment strategies for patients with acute CFF intoxication. This study analyzed the association between CFF and PXT blood levels, the blood biochemical data, and the vital signs of 27 cases with information on CFF intake and elapsed time data. It was found that HD was not as effective as CFF against PXT in CFF intoxication; however, HD was effective in cases with relatively high PXT concentrations (>10 µg/mL). Simultaneous analysis of CFF and PXT would make it possible to estimate the time elapsed from CFF intake and the risk of hyperCKemia, which may develop in cases left untreated for a prolonged period after ingestion. Therefore, the measurement of PXT, in addition to CFF, is expected to provide useful information for understanding the pathogenesis of CFF intoxication and the development of treatment strategies of acute CFF intoxication.

A Rare Case of Tumoral Calcinosis in a Chronic Hemodialysis Patient.

Tumor calcinosis is a rare condition. It is characterized by the presence of calcified masses in the juxta-articular regions without joint involvement. It particularly affects young adults and adolescents. Its exact pathogenesis remains poorly defined. The diagnosis is suspected clinically and radiologically but confirmed by histological examination. The treatment is mainly surgical, and the prognosis is often good. We report the original case of a chronic hemodialysis patient presenting with tumoral calcinosis by discussing our diagnostic and therapeutic approach according to data from the recent scientific literature.

Peer-to-peer training among health care professionals working in dialysis clinics: an education approach from the GoodRENal project.

BACKGROUND: Lifestyle interventions aiming to improve dietary habits, increase physical activity level, and improve emotional well-being can positively impact clinical outcomes in patients with chronic kidney disease (CKD). Educational material for health care professionals working with CKD patients that focuses on why and how to promote lifestyle changes is lacking. The present study aims to depict the material and dissemination methods for the peer-to-peer training program developed for health care professionals working in the dialysis clinics of the four countries engaged in the GoodRENal project: Spain, Greece, Sweden, and Belgium. METHODS: This is an ERASMUS + project funded by the European Union (number 2020-1-ES01-KA2014-083141, http://goodrenal.eu/ ) named GoodRENal. The educational material was developed in English by a multidisciplinary team integrating the GoodRENal project (dietitian, physiotherapist, psychologist, and nephrologist). The material was then translated to Greek, Spanish, Swedish and Dutch and is available for download at the GoodRENal webpage ( https://goodrenal.es/results-3/ ). After training, the health care professionals filled in an anonymous questionnaire regarding their degree of satisfaction with the training. RESULTS: In total, 138 health care professionals in the four dialysis clinics joined the peer-to-peer training, representing 50% to 92% of the health care professionals in each clinic. From the total sample, 78 health care professionals responded to the satisfaction questionnaire. The answers showed that most participants were very satisfied or satisfied with the peer-to-peer training and that they found this approach useful in their clinical practice. CONCLUSION: The educational material developed for health care professionals working with patients on hemodialysis (HD) obtained good satisfaction scores from the participants.

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.

Calcified Maxillary Fibroma in a Patient on Hemodialysis for Seven Years.

Background: The presentation of mineral bone disorder (MBD) in individuals with chronic kidney disease (CKD) may vary. Consequently, physicians should be capable of recognising this condition when there is a suspicion of its existence. This case report will describe a calcified maxilla tumour as a manifestation of CKD-MBD. Case description: Initially asymptomatic, a 32-year-old female presented with progressive swelling of the upper left jaw. She had a history of routine haemodialysis. Further laboratory, radiological, and histopathological workup revealed the mass was indeed calcified maxillary fibroma arising from the manifestation of CKD-MBD. Conclusion: This study underscores the significance of clinical comprehension of the broad-spectrum manifestations of CKD-MBD, including an initially asymptomatic mass. In addition, the screening of the patient's biochemical was required to determine the necessity of early intervention and improve the patient's outcome. LEARNING POINTS: The case emphasises the importance of recognising atypical presentations of chronic kidney disease-mineral bone disorder (CKD-MBD), such as a calcified mass, which are rarely reported but critical for timely intervention.This report underscores the necessity for routine screening for secondary hyperparathyroidism in CKD patients, as early detection can significantly impact patient outcomes.Surgical management of the overlying mass and underlying parathyroid gland hyperplasia should always be considered in the management of the symptomatic CKD-MBD patient.

[Diagnosis and treatment of gastrointestinal bleeding after kidney transplantation].

OBJECTIVE: To analyze the clinical characteristics of acute and chronic gastrointestinal bleeding in patients with end-stage renal disease (ESRD) after kidney transplantation, to improve the understanding of the causes, diagnosis, treatment and prevention of this complication, and to improve the management of patients with gastrointestinal bleeding after kidney transplantation. METHODS: The clinical, imaging and pathological data of patients with gastrointestinal bleeding after kidney transplantation in the Department of Urology of The First Affiliated Hospital of Anhui Medical University from August, 2015 to December, 2020 were collected. The etiology, early clinical manifestations, abnormal laboratory tests and examinations, treatment procedures, late prevention and treatment measures and outcomes of gastrointestinal bleeding were retrospectively studied, and the relevant literature was summarized and reviewed. RESULTS: A total of 17 patients were included in this study. Nine patients had chronic small amount of bleeding, hemoglobin gradually decreased, melena and fecal occult blood positive in the early stage, and the general condition was good, vital signs were stable, and were cured by drug treatment. Gastroscopy showed small ulcers with active bleeding foci in 2 cases, and the bleeding was stopped by titanium clips, and the prognosis was good. Gastroscopy showed that the anterior wall longitudinal ulcer at the junction of gastric antrum body was not effective in 1 case, and the small branch of right gastroepithelial artery was embolized, and the patient recovered and discharged after 2 weeks. Gastroscopy showed deep pit ulcer at the lesser curvature of gastric antrum in 1 patient, who underwent distal gastroduodenal artery embolization and had a good prognosis. Gastroscopy showed huge multiple ulcers in the stomach and duodenal bulb in 2 patients, who underwent subtotal gastrectomy and partial duodenectomy, duodenal stump exclusion and remnant gastrojejunostomy. One patient recovered and was discharged, and the other patient died of rebleeding on the 12th day after surgery. Two cases of diverticulum underwent surgical resection of diverticulum, and the prognosis was good. CONCLUSION: The onset of gastrointestinal hemorrhage in kidney transplant patients is insidious, and the condition is acute or slow, which can cause different degrees of damage to the patient and the transplanted kidney. Active prevention, early diagnosis, timely drug treatment, if the effect is not good, decisive endoscopic titanium clip hemostasis, transvascular interventional embolization, and even surgical treatment can minimize the harm of gastrointestinal bleeding.

Hyperparathyroidism presented as multiple pulmonary nodules in hemodialysis patient status post parathyroidectomy: A case report.

BACKGROUND: Primary hyperparathyroidism is typically caused by a single parathyroid adenoma. Ectopic parathyroid adenomas occur as well, with cases involving various sites, including the mediastinum, presenting in varying frequencies. Secondary hyperparathyroidism develops in the context of chronic kidney disease, primarily due to vitamin D deficiency, hypocalcemia, and hyperphosphatemia. It is frequently diagnosed in patients undergoing dialysis. This article presents a rare case of hyperparathyroidism involving multiple hyperplastic parathyroid glands with pulmonary seeding in a 50-year-old female patient undergoing hemodialysis (HD). CASE SUMMARY: The patient had a history of parathyroidectomy 10 years prior but developed recurrent hyperparathyroidism with symptoms of pruritus and cough with sputum during a period of routine dialysis. Radiographic imaging revealed multiple nodules in both lungs, with the largest measuring approximately 1.35 cm. Surgical histopathology confirmed the presence of hyperplastic parathyroid glands within the pulmonary tissue. After tumor resection surgery via video-assisted thoracic surgery with wedge resection, the patient was discharged in stable condition and in follow-up her symptoms showed improvement. CONCLUSION: This article describes hyperparathyroidism presenting as pulmonary nodules in a patient undergoing post-parathyroidectomy HD, highlighting diagnostic challenges and a positive outcome from tumor resection surgery.

Dialysis Modality Education Timing and Home Dialysis Uptake: A Quality Improvement Study.

Rationale & Objective: Investigating the effect of a quality improvement intervention aimed at enhancing the choice of home dialysis among patients through improved educational sessions on dialysis modalities. Study Design: A new referral protocol initiated on September 15, 2022, sought to direct patients with advanced kidney disease to modality education sessions. This protocol involved an updated referral form and process, requiring nephrologists to refer patients with an estimated glomerular filtration rate below 15 mL/min/1.73 m2 or specified Kidney Failure Risk Equation scores to modality educators for education. The impact was measured by the uptake of the education and the choice of home dialysis by patients. Setting & Participants: The study took place at Sunnybrook Health Sciences Centre in Toronto, Canada, involving 532 patients across 1,723 clinical encounters from October 2019 to June 2023. Predictor: The intervention was predicted to lead to an increase in both the number of patients receiving modality education and those choosing home dialysis. Outcomes: The primary outcome measured was the selection of home dialysis following modality education, with a secondary focus on the proportion of patients educated post intervention. Analytical Approach: Statistical process charts were used for monitoring changes in education uptake and home dialysis selection rates following the intervention. Results: After implementing the standardized referral system, the proportion of patients receiving modality education increased from 27.1%-56.7%. However, the rate of selecting home dialysis remained constant at 50.9%. Overall home dialysis prevalence at our center averaged 19.6%, remaining lower than the provincial average of 24.4% by the end of the study period. Limitations: The study was limited to 1 center, without evaluating patient satisfaction or dissecting the complexity of educational content and delivery. Conclusions: We succeeded in boosting education rates but failed to achieve higher home dialysis choice rates, possibly owing to the complexity involved in modality choices. We plan to further investigate the factors influencing patient choices during modality education to better promote home dialysis selection.

The study focused on whether teaching patients more about their dialysis options would encourage them to choose home dialysis. A new system was introduced at an academic hospital in Toronto, requiring doctors to refer patients with advanced kidney disease to educational sessions. The aim was to see if patients who learned more about dialysis would be more likely to manage their treatment at home. The result was more patients received these educational sessions, but this did not lead to more of them choosing home dialysis. Future research must investigate what other factors influence patients' decisions to consider dialysis treatments at home.

Capsule endoscopy in hemodialysis versus non-hemodialysis patients with suspected small bowel bleeding: a prospective cross-sectional study.

Background: Gastrointestinal (GI) bleeding is common among hemodialysis (HD) patients. Endoscopic examination of the upper and lower GI tract often fails to identify hemorrhagic lesions in anemic HD patients. The study aims to evaluate lesions of the small bowel mucosa in HD vs non-HD patients with suspected small-bowel bleeding (SSBB) using capsule endoscopy (CE) after negative upper and lower GI endoscopies. Methods: This prospective cross-sectional study included all consecutive patients presenting with occult GI bleeding at the Dialysis Unit (HD patients) and the Gastroenterology Outpatient Clinic (non-HD patients) of the University Hospital of Alexandroupolis. Within a pre-specified period of 13 months (01/07/2022 to 31/07/2023), we collected all relevant demographic data, laboratory parameters, comorbidity records, treatment profiles, and endoscopic findings. We used univariate and optimal scaling multivariate analyses to evaluate all parameters correlating with CE findings and Rhemitt score. Results: The study included 100 patients (25 HD and 75 non-HD). Considering any lesion (oozing blood, red spots, angiodysplasias, and erosive/ulcerative lesions) at any site (duodenum, jejunum, and ileum) as separate binary variables, the prevalence per patient was superior in HD patients (3.8 ± 1.6 vs 1.3 ± 1.4; p <0.001). More specifically, endoscopic capsule findings in HD vs non-HD patients identified oozing blood (28 % vs 15 %; p =0.133), red spots (96 % vs 44 %; p <0.001), angiodysplasias (32 % vs 9 %; p =0.006), and erosive/ulcerative lesions (64 % vs 24 %; p <0.001). In 25 non-HD patients, no findings were observed (p =0.001). The number of total endoscopic findings was independently correlated with dialysis (p <0.001), male sex (p =0.048), dyslipidemia (p =0.004), liver disease (p =0.001), and mean corpuscular volume (MCV) (p =0.015). Lastly, we found that HD patients rebleed more often (Rhemitt score 6.5 ± 1.4 vs 2.9 ± 2.1; p <0.001). The Rhemitt score was independently correlated with dialysis (p <0.001), body mass index (p =0.024), MCV (p <0.001), smoking (p <0.001), dyslipidemia (p =0.007), GI bleeding (p <0.001), Calcium channel blockers (p =0.023), and preparation (p =0.001). Conclusion: Compared with non-HD patients, HD patients who were investigated for potential GI bleeding demonstrated more severe and frequent small intestinal lesions with a higher probability of rebleeding. HIPPOKRATIA 2024, 28 (1):22-28.

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.

Incidental diagnosis of gastric antral vascular ectasia in a case of chronic kidney disease from Nepal: a case report.

INTRODUCTION: Gastric antral vascular ectasia is an uncommon clinical disease that affects elder people and is characterized by severe chronic upper gastrointestinal bleeding mainly affecting the gastric antrum. It is generally unusual among patients undergoing maintenance hemodialysis for chronic kidney disease. CASE PRESENTATION: Here, we aim to present an uncommon case of incidental diagnosis of the gastric antral vascular ectasia and erosive gastritis in a 71-year-old Hindu male patient belonging to the Gurung ethnicity of Nepal undergoing maintenance hemodialysis due to chronic kidney disease. The patient presented with a history of melena and fatigue. On investigation, a low hemoglobin level of 7.3 gm% was used for blood transfusion. The patient was on regular hemodialysis after admission at our institution. Upper gastrointestinal bleeding was suspected after analyzing patient's history and investigations. Therefore, an upper gastrointestinal endoscopy was performed that showed linear ectatic punctuate lesions radiating from the body of the stomach to the antrum, and hence, an incidental diagnosis of the gastric antral vascular ectasia was made. Initial fluid resuscitation, iron therapy, and a triple regimen were administered. Proper management with argon plasma coagulation therapy was scheduled at another institution due to lack of respective facilities in our institution. DISCUSSION: Gastric antral vascular ectasia is an unusual cause of upper gastrointestinal bleeding, primarily affecting the gastric antrum and pylorus with rare cases affecting the duodenum, jejunum, and gastric fundus. It is generally associated with other chronic disease conditions. Several hypotheses have been proposed for the pathogenesis of gastric antral vascular ectasia, especially its association with chronic kidney disease, as in our case, which is considered to be rare. Management varies from medical to endoscopic interventions to even surgery. CONCLUSION: Prompt proper diagnosis and treatment for the gastric antral vascular ectasia should be sought, as it is frequently misdiagnosed or missed during upper gastrointestinal endoscopy. Our case report presents a case of gastric antral vascular ectasia in chronic kidney disease undergoing maintenance hemodialysis, which is quite uncommon, as literature has suggested the same point.

Comparative Analysis of Tools for Assessment of Protein-Energy Wasting in Chronic Kidney Disease Patients on Maintenance Hemodialysis.

Background: Patients with chronic kidney disease have muscle wasting, sarcopenia, and cachexia that contribute to frailty and morbidity. The present study assessed the prevalence of protein-energy wasting in dialysis-dependent chronic kidney disease population and evaluated the validity of various nutritional assessment tools in diagnosing protein-energy wasting. Materials and Methods: All patients above 18 years undergoing dialysis for more than 3 months without any active infection or malignancy were included in our study. Data from anthropometric measurements, dietary assessment, and blood investigations were collected. Protein-energy wasting was assessed by the International Society of Renal Nutrition and Metabolism 2008 criteria. Diagnostic validity of the nutritional assessment tools to predict protein-energy wasting was estimated by area under the curve, sensitivity, specificity, and accuracy statistics. Results: A total of 146 patients were studied. The prevalence of protein-energy wasting was 56.8%. Protein-energy wasting was significantly associated with socioeconomic status, hospitalization days, and catheter days. Normalized protein catabolism rate had the highest sensitivity (90.4%) for predicting protein-energy wasting. Malnutritional inflammatory score had the highest area under the curve (0.858), specificity (82.5%), and accuracy (82.2%). Mid-upper arm circumference, Dialysis Malnutrition Score, and albumin were also found to be significant predictors of protein-energy wasting. Conclusion: Lack of advanced equipment in suburban and rural centers to detect protein-energy wasting in India can be overcome by using the various stand-alone and combination nutrition assessment tools which have been validated in the present study.

Cannabis Use, Perspectives, and Experiences Among Patients Receiving Hemodialysis: A Descriptive Patient Survey.

Background: Patients with chronic kidney disease experience high burden of symptoms, negatively affecting their quality of life. Medication therapy is often initiated to address these symptoms but is limited by variable efficacy and high pill burden. There is interest among clinicians and patients to explore cannabis and cannabinoids as an alternative treatment to manage symptoms related to kidney disease. Objective: The objectives were to characterize cannabis use among patients receiving maintenance hemodialysis (HD), to describe patient perspectives on cannabis, and to explore patient experiences with their kidney health care team related to cannabis. Design: This was a descriptive, cross-sectional paper-based patient survey. Setting/Participants: Patients receiving maintenance HD at Toronto General Hospital in the ambulatory setting between July and August 2020 were included. Methods: A 33-item questionnaire was developed to address the study questions based on existing cannabis questionnaires and input from kidney specialist physicians, pharmacists, kidney nurse practitioners, and patients. The questionnaire was distributed to patients during their in-center HD session. Patients who chose to participate in the study completed the questionnaire and returned it to the study team. Results: In total, there were 52 respondents, of which 11 (21%) reported cannabis use in the preceding 3 months, and 23 (44%) reported historical cannabis use. Baseline characteristics were similar between those who used cannabis and those who did not, with a possible trend of cannabis users being younger. The most commonly reported reasons for using cannabis were recreation and symptom management. Those who reported using cannabis for symptom management were doing so without medical authorization or documentation. Common symptoms that cannabis was used to self-treat were insomnia, anxiety, and/or non-neuropathic pain. Dried flower was the most common type of product used, and smoking was the most common route. Care gaps and opportunities to improve patient care related to cannabis use were identified, related to monitoring and management of adverse effects, management of drug interactions, harm reduction strategies, informed decision-making, and prescriber education. Limitations: The overall participation rate was low, at approximately 17%, possibly related to the COVID-19 pandemic, lack of interest, or fear of revealing cannabis use. Non-response bias is a possible limitation as this was a voluntary survey. The questionnaire was limited to multiple-choice and Likert scale questions, therefore limiting the depth of patient responses. Conclusions: Our study showed that cannabis use among patients receiving HD is common and comparable with the general population. Patients may be using cannabis to self-manage symptoms related to kidney disease, without the involvement of the health care team. Multiple opportunities to improve patient care related to cannabis use were identified.

Contexte: Les symptômes liés à l'insuffisance rénale représentent un lourd fardeau pour les patients qui en sont atteints, ce qui affecte négativement leur qualité de vie. Un traitement médicamenteux est souvent prescrit pour soulager les symptômes, mais il est limité par son efficacité variable et le nombre élevé de médicaments. Les patients et les cliniciens sont ouverts à explorer d'autres avenues pour gérer les symptômes de l'insuffisance rénale, notamment la consommation de cannabis et de cannabinoïdes. Objectifs: Caractériser la consommation de cannabis chez les patients recevant des traitements d'hémodialyse (HD) chronique; décrire les perspectives des patients sur le cannabis et examiner les expériences des patients avec leurs équipes de soins en lien avec la consommation de cannabis. Type d'étude: Enquête transversale descriptive sous forme d'un questionnaire papier remis aux patients. Cadre et sujets de l'étude: Les patients qui suivaient des traitements d'HD chronique en ambulatoire à l'Hôpital général de Toronto en juillet et août 2020. Méthodologie: Pour répondre aux objectifs de l'étude, un questionnaire en 33 points a été élaboré à partir de questionnaires existants sur la consommation de cannabis et des commentaires de néphrologues, pharmaciens, infirmières praticiennes en néphrologie et patients. Le questionnaire a été distribué aux patients pendant une séance d'HD en centre. Les personnes qui ont choisi de participer à l'étude l'ont rempli et l'ont renvoyé à l'équipe de recherche. Résultats: En tout, 52 personnes ont répondu au questionnaire, desquelles 11 (21%) ont déclaré avoir consommé du cannabis dans les trois mois précédents et 23 (44%) en avoir consommé dans le passé. Les caractéristiques initiales des consommateurs de cannabis étaient semblables à celles des personnes qui n'en consommaient pas; les consommateurs de cannabis ayant tendance à être plus jeunes. On consommait principalement du cannabis pour le côté récréatif et pour gérer les symptômes. Les personnes qui consommaient du cannabis pour gérer leurs symptômes le faisaient sans documentation ou indication médicale. Le cannabis était consommé pour l'auto-traitement de symptômes courants comme l'insomnie, l'anxiété et/ou la douleur non neurogène. Le plus souvent, le cannabis était fumé, et la fleur séchée était le produit le plus utilisé. Des lacunes dans les soins et des occasions d'améliorer les soins aux patients ont été identifiées en lien avec la consommation de cannabis, celles-ci concernaient la surveillance et la gestion des effets indésirables, la gestion des interactions médicamenteuses, les stratégies de réduction des risques, la prise de décisions éclairées et l'éducation des prescripteurs. Limites: Le taux de participation global a été faible (environ 17%), possiblement en raison de la pandémie de COVID-19, d'un manque d'intérêt ou de la réticence à révéler la consommation de cannabis. La participation était volontaire, un biais de non-réponse est donc possible. Le questionnaire n'était constitué que de questions à choix multiples et à échelle de Likert, ce qui limite la profondeur des réponses. Conclusion: Notre étude montre que la consommation de cannabis chez les patients sous HD est courante et comparable à celle de la population générale. Les patients peuvent consommer du cannabis pour soulager les symptômes liés à l'insuffisance rénale sans intervention de l'équipe de soins. Le sondage a permis d'identifier plusieurs occasions d'améliorer les soins aux patients en lien avec la consommation de cannabis.

Allopurinol, Febuxostat, and Nonuse of Xanthine Oxidoreductase Inhibitor Treatment in Patients Receiving Hemodialysis: A Longitudinal Analysis.

Rationale & Objective: Allopurinol and febuxostat, which are xanthine oxidoreductase inhibitors, have been widely used as uric acid-lowering medications. However, evidence regarding their cardiovascular effects in hemodialysis is insufficient. This study compared the effects of allopurinol and febuxostat on mortality and cardiovascular outcomes in patients receiving hemodialysis. Study Design: A retrospective observational cohort study. Setting & Participants: Data of 6,791 patients who had no history of topiroxostat usage and underwent maintenance hemodialysis between March 2016 and March 2019 at Yokohama Daiichi Hospital, Zenjinkai, and its affiliated dialysis clinics in Japan's Kanagawa and Tokyo metropolitan areas were collected. Exposure: Allopurinol, febuxostat, and nontreatment. Outcomes: All-cause mortality, cardiovascular disease (CVD) events, heart failure (HF), acute myocardial infarction (AMI), and stroke. Analytical Approach: For the main analyses, marginal structural Cox proportional hazards models were used to estimate HRs adjusted for time-varying confounding and selection bias because of censoring. Results: Allopurinol and febuxostat showed significantly better survival than nontreatment for all-cause mortality (HR, 0.40; 95% CI, 0.30-0.54 and HR, 0.49; 95% CI, 0.38-0.63, respectively), without significant difference between allopurinol and febuxostat. Allopurinol showed significantly better survival than nontreatment, whereas febuxostat did not for CVD events (HR, 0.89; 95% CI, 0.84-0.95 and HR, 1.01; 95% CI, 0.96-1.07, respectively), HF (HR, 0.71; 95% CI, 0.56-0.90 and HR, 1.03; 95% CI, 0.87-1.21, respectively), and AMI (HR, 0.48; 95% CI, 0.25-0.91 and HR, 0.76; 95% CI, 0.49-1.19, respectively). No comparisons showed significant results for stroke. Limitations: The ratio of renal or intestinal excretion of uric acid and uremic toxins could not be elucidated, and we could not investigate gene polymorphism because of the large number of cases. Conclusions: Allopurinol and febuxostat improved survival for all-cause mortality. Allopurinol and not febuxostat reduced the risk of CVD events, HF, and AMI.

Uric acid-lowering therapy has been used to prevent gout attacks and protect organs by reducing inflammation by lowering uric acid levels. However, uric acid-lowering medications have recently been found to have a side effect of inhibiting a channel responsible for excreting toxins, such as adenosine triphosphate-binding cassette transporter G2; the effects of medications with a strong inhibitory effect, such as febuxostat, are currently under investigation. Patients with kidney failure or dialysis excrete toxins through feces from their intestines in addition to removing toxins through dialysis. If uric acid-lowering medications suppress the channels responsible for intestinal toxin excretion, could this lead to the development of heart failure or stroke? This study investigated this question.

Can endogenous ethylene glycol production occur in humans? A detailed investigation of adult monozygotic twin sisters.

INTRODUCTION: To the best of our knowledge, clinically significant endogenous ethylene glycol production has never been reported in humans, very seldom reported in other animals or microorganisms, and then only under rare and specific conditions. We describe the detailed investigations we undertook in two adult monozygotic twin sisters to ascertain whether they were producing endogenous ethylene glycol. METHODS: Two previously healthy monozygotic adult twin sisters presented with recurrent episodes of apparent ethylene glycol poisoning beginning at age 35, requiring chronic hemodialysis to remove ethylene glycol and its metabolites as well as to restore metabolic homeostasis. The sisters denied ingestion or exposure to ethylene glycol. At their request, they were admitted to hospital under strict supervision to exclude surreptitious ingestion of ethylene glycol and to evaluate the need for treatment. Hemodialysis was withheld during this prospective study. Twin A was admitted for 14 days and twin B for 11 days. Serial biochemical analyses were performed in blood and urine. Clinical exome sequencing and mitochondrial deoxyribonucleic acid sequencing were also completed. RESULTS: In both twins, ethylene glycol was detected in urine, along with intermittent increases in concentrations of lactate, glycolate, and glycine in blood and/or urine. Blood ethylene glycol concentrations, however, remained <62 mg/L (<1 mmol/L) but became positive soon after discharge. The oxalate concentration remained normal in blood and urine. Plasma and urine amino acid profiles showed intermittent small increases in glycine, serine, taurine, proline, and/or alanine concentrations. Exome sequencing and mitochondrial deoxyribonucleic acid sequencing were non-diagnostic. Neither twin has been admitted with metabolic acidosis nor ethylene glycol poisoning since chronic hemodialysis was started. Twin A developed a calcium oxalate dihydrate lithiasis. DISCUSSION: Mitochondrial disease, methylmalonic/propionic/isovaleric aciduria, primary hyperoxaluria, and analyte error were all excluded in these twins, as were obvious common environmental exposures. CONCLUSION: Detailed investigations were performed in adult monozygotic twin sisters to ascertain whether they were producing endogenous ethylene glycol. Alternative explanations were excluded to the very best of our efforts and knowledge. Global metabolomics, gut microbiome analyses, and whole genome sequencing are pending.

Risk prediction models for autogenous arteriovenous fistula failure in maintenance hemodialysis patients: A systematic review and meta-analysis.

BACKGROUND: The aim of this study was to systematically retrieve and evaluate published risk prediction models for autogenous arteriovenous fistula (AVF) failure post-formation in maintenance hemodialysis (MHD) patients, with the goal of assisting healthcare providers in selecting or developing appropriate risk assessment tools and providing a reference for future research. METHODS: A systematic search of relevant studies was conducted in PubMed, Web of Science, Cochrane Library, CINAHL, Embase, CNKI, Wanfang Database, VIP Database, and CBM Database up to February 1, 2024. Two researchers independently performed literature screening, data extraction, and methodological quality assessment using the Prediction Model Risk of bias (ROB) Assessment Tool. RESULTS: A total of 4869 studies were identified, from which 25 studies with 28 prediction models were ultimately included. The incidence of autogenous AVF failure in MHD patients ranged from 3.9% to 39%. The most commonly used predictors were age, vein diameter, history of diabetes, AVF blood flow, and sex. The reported area under the curve (AUC) ranged from 0.61 to 0.911. All studies were found to have a high ROB, primarily due to inappropriate data sources and a lack of rigorous reporting in the analysis domain. The pooled AUC of five validation models was 0.80 (95% confidence interval: 0.79-0.81), indicating good predictive accuracy. CONCLUSION: The included studies indicated that the predictive models for AVF failure post-formation in MHD patients are biased to some extent. Future research should focus on developing new models with larger sample sizes, strict adherence to reporting procedures, and external validation across multiple centers.

Proximalization of arterial inflow with adjunctive arterial pressure measurements for management of hemodialysis access-induced distal ischemia.

Hemodialysis access-induced distal ischemia (HAIDI) is an uncommon, yet potentially devastating, complication of hemodialysis access surgery. Management of HAIDI depends on the access' volume flow and may involve banding, proximalization of arterial inflow, revision using distal inflow, distal revascularization interval ligation, or access ligation. Various adjunctive techniques have been used to confirm improved distal arterial flow intraoperatively. Here, we present a case of a patient with grade 3 HAIDI treated with proximalization of arterial inflow technique with the adjunctive use of intra-arterial pressure gradient measurements.

Telomere Length Is Associated with Increased Risk of Cardiovascular Events in Patients with End-Stage Kidney Disease on Hemodialysis.

INTRODUCTION: Patients with chronic kidney disease, especially those with end-stage kidney disease (ESKD) on hemodialysis (HD), are at increased risk for cardiovascular disease (CVD), including myocardial infarction and ischemic stroke. A shortening in telomere length, as a parameter for accelerated vascular aging, is an established biomarker for CVD in the general population. We aimed to elucidate the role of telomere length in ESKD patient on HD and its association with cardiovascular outcomes. METHODS: Telomere length was measured in a prospective population-based cohort study of prevalent HD patients. DNA was isolated from whole blood, sampled at baseline, and analyzed for telomere length via a qPCR-based approach. The risk for the occurrence of the independently adjudicated three-point major adverse cardiovascular event outcome (myocardial infarction, ischemic stroke, and cardiovascular death) was statistically analyzed considering the competing risk of non-cardiovascular death. RESULTS: In the cohort of 308 patients with ESKD (115 [37.3%] women, median [25th-75th percentile] age: 67.0 [56.8-76.0]), the median telomere length was 1.51 kb (25th-75th percentile 0.6-3.2 kb). The 3P-MACE outcome occurred with an incidence rate of 9.4 per 100 patient-years. Patients with longer telomere length more frequently had vascular nephropathy compared to patients with shorter telomere length. Interestingly, patients in the highest quartile of telomere length had a 1.8-fold increased risk for 3P-MACE (95% CI: 1.051-3.201, p = 0.033), after multivariable adjustment for age, history of stroke, myocardial infarction, venous thromboembolism, presence of heart valve replacement, atrial fibrillation, smoking, anticoagulation, or immunosuppressive use. CONCLUSION: Surprisingly, in this high-risk cohort of patients with ESKD on HD, longer telomere lengths were associated with increased risk of cardiovascular events.

From Smoothies to Dialysis: The Impact of Oxalate Nephropathy.

Oxalate nephropathy is a rare cause of acute kidney injury that can lead to end-stage renal disease. This case report describes a 54-year-old male with type 2 diabetes mellitus and chronic kidney disease who presented for a routine clinic follow-up. Laboratory tests revealed significant deterioration in renal function with an unrevealing history and symptoms suggestive of the process. Initial investigations for worsening renal function were inconclusive, prompting a renal biopsy that confirmed acute tubular injury with abundant calcium oxalate deposits. Further investigation into dietary history revealed that the patient regularly consumed high-oxalate foods, such as spinach and kale smoothies, under the impression they were beneficial for his diabetes. Despite the initiation of hemodialysis, the patient did not recover renal function and remains dialysis-dependent. This case underscores the need for a high index of suspicion for oxalate nephropathy in chronic kidney disease patients presenting with unexplained acute kidney injury. Diagnosis is confirmed through renal biopsy and should be considered in patients with relevant dietary histories.