The Clock Drawing Task reveals executive dysfunction in the dialysis population - an underrecognized and underestimated problem.

AIM OF THE STUDY: The study aimed to assess the prevalence of executive function impairment among patients with chronic kidney disease (CKD) undergoing dialysis, with no subjective cognitive problems and with normal global cognition on the Mini-Mental State Examination (MMSE). We also investigated the relationship between cardiovascular risk factors and cognitive test results. RATIONALE FOR THE STUDY: Patients with CKD, including those undergoing renal replacement therapy, are at a higher risk of developing cognitive impairment (CI) than the general population. Recent research has shown CI to be a growing problem among CKD patients worldwide. Yet, it remains underdiagnosed, even though it may significantly influence the lives of patients. MATERIALS AND METHODS: In this cross-sectional, prospective study, 58 dialysis patients with no cognitive decline on the MMSE screening were assessed for executive function impairment using the Executive Clock-Drawing Task (CLOX). Moreover, past medical history, demographic data, and laboratory test results were collected. RESULTS: The mean patient age was 59.47 ± 14.98 years, and the mean duration of dialysis was 45.93 ± 48.49 months. The prevalence of executive function impairment amounted to 8.6%. Moreover, remarkably similar pattern of clock drawing was observed, with numbers written outside the clock face in the CLOX1 test. CONCLUSIONS: Executive dysfunctions in dialysis patients may manifest itself before the onset of global cognitive impairment. There appear to be a deficit in the spatial domain as well. Better education may play a protective role.

Green Dialysis: Let Us Talk about Dialysis Fluid.

BACKGROUND: Hemodialysis is one of the most resources consuming medical intervention. Due to its concept, the proper amount of dialysis fluid passed through dialyzer is crucial to obtain the expected outcomes. The most frequent source of dialysis fluid is production from liquid concentrate (delivered in containers or plastic bags) in dialysis machine. Alternatively, concentrates for dialysis may be produced in dialysis center by dilution in mixing devices dry or semidry premixed compounds connected with system of central dialysis fluid delivery system. Dialysate consumption depends on various factors like type of hemodialysis machine, session duration, prescribed flow, etc. Summary: Modern hemodialysis machines are equipped with the modules which automatically reduce flow rate of dialysis fluid to the patient blood flow and minimize dialysate consumption during preparation and after reinfusion. Smart using of available options offered by manufacturers allows to save additional portion of acid concentrate and water. The weight of concentrates to be delivered to the dialysis center is the major factor influencing the cost (financial and environmental) of transportation from the manufacturer to the final consumer. The crisis on the energy carriers market and extremely high fuel prices made the transportation cost one of the significant costs of the treatment, which must be bear by supplier and finally influence on the price of goods. KEY MESSAGES: The careful choice of the concentrate delivery system can improve cost-effectiveness of dialysis. Such solutions implemented in dialysis unit helps make significant savings and decrease the impact on natural environment by carbon footprint reduction.

Lack or insufficient predialysis nephrology care worsens the outcomes in dialyzed patients - call for action.

The phenomenon of patients with advanced renal failure accepted for dialysis at a late stage in the disease process (late referral [LR]) is known almost from the beginning of dialysis therapy. It may also be associated with worse outcomes. The aim of the study was to assess the effect of referral time on the outcomes, such as number of hospitalizations, length of stay, kidney transplantation, and mortality. A study of 1303 patients with end-stage renal failure admitted for dialysis in the same period in Fresenius Nephrocare Poland dialysis centers was initiated. The type of vascular access during the first dialysis was accepted as the criterion differentiating LR (n = 457 with acute catheter) from early referral (ER; n = 846). The primary endpoint was the occurrence of death during the 13-month observation. By the end of observation, 341 (26.2%) of patients died. The frequency of death was 18.1 for ER and 37.9 for LR per 1000 patient-months. It can be estimated that 52.1% (95% CI: 40.5-61.5%) of the 341 deaths were caused by belonging to the LR group. Patients from LR group had longer hospitalizations, more malignancies, lower rate of vascular access in the form of a-v fistula, higher comorbidity index. It seems that establishing a nephrological registry would help to improve the organization of care for patients with kidney disease, particularly in the pandemic era.

Medical waste management - how industry can help us to protect environment and money?

Background: The global climate change and its consequences force us to remodel our processes and rethink the current model of providing the HD treatments. Waste management have a massive impact on the environment and the economy. Every HD session produces above 1 kg of medical waste, which should be properly stored and destroyed. In particular in the pandemia time we should improve the dialysis unit budget as well as decrease CO2 emission produced during the waste elimination.Materials and Methods: The checked the weight of different dialyzers used regularly in dialysis centers in Poland. The Kern CM 320-IN scale was used for the measurement. The measurement accuracy was 0.1 g. Also the filling volume of each dialyzer has been taken into consideration.Results: The dialyzers were divided into four groups depending on the surface. 1,4m2 in group one, 1.5-1.6 m2 in group two, 1.7-1.8 m2 in group three and finally 2.0-2.2 m2 in group four. FX class dialyzers were lightest in every group. The heaviest ones were Polyflux dialyzers. The difference between the lightest and heaviest dialyzers was about 95 g. The filling volume was lowest in FX dialyzers and the highest in Elisio dialyzers. The difference was 20 mL.Conclusions: The weight of different dialyzers available on the market differs. The decision-makers should take into account this fact as the additional quality feature. In extreme cases the weight difference reaches 95 g. In yearly perspective, the usage of the lighter dialysis set can cause the 17 million kg decrease of medical waste and significant savings.

HOME DIALYSIS DURING COVID-19 OUTBREAK - IT IS WORTH TO CONSIDER.

The epidemic with the new SARS-CoV-2 virus poses a serious threat to patients treated with renal replacement therapy. Besides clinical risk factors (such as numerous comorbidities, immune disorders), dialysis patients are additionally exposed to the virus through regular stays for several hours in a dialysis center and ambulance journeys. In such an epidemiological situation, it seems that peritoneal dialysis and home hemodialysis are good alternatives for treatment. Currently available telemedicine and medical technologies allow for effective renal replacement therapy also outside dialysis centers. Thanks to this, it is possible to limit the stay of patients in a medical facility to clinically justified situations. For this reason, increasing the number of patients treated with peritoneal dialysis, which is carried out at home and without contact with medical personnel, seems to be a good solution. Enabling patients to undergo home hemodialysis treatment, nowadays unavailable in Poland and establishing it as a guaranteed benefit in the health care system will enable renal replacement therapy to be adapted to the clinical condition and the need for isolation.

[Ezetimibe as a treatment for dyslipidaemia in CKD].

Cardiovascular disease is the leading cause of death among patients with chronic kidney disease (CKD). Primary and secondary prevention of cardiovascular events is one of the major CKD patients' treatment targets. Dyslipidaemia is the important modifiable risk factor in general population. Each 1.0 mmol reduction in LDL cholesterol with statins reduces annual rate of heart attack, coronary revascularization or ischemic stroke by 20% leading to 10% reduction of all-cause mortality. Adding ezetimibe, an inhibitor of intestinal lipids absorption, further reduces LDL cholesterol by 20%. Optimal lipid lowering treatment for CKD patients remains unclear. Cardiovascular risk reduction observed with statins therapy decreases together with a progression of the disease, moreover patients with advanced CKD treated with high doses of statins have an increased risk of adverse events. These patients might benefit from adding ezetimibe to moderate dose statin therapy for prevention of cardiovascular events.

[The role of slow low efficiency dialysis (sled) in renal replacement therapy].

Slow low efficiency dialysis (SLED) is a hybrid technique of renal replacement therapy. It can be performed with a mobile single-pass batch dialysis system (Genius®) or the multifunctional hemodialysis machines, with reduced dialysate flow and the extended duration of the procedure. The present article reviews the recently published data comparing SLED to continuous renal replacement modalities in critically ill patients with acute kidney injury (AKI). The technical aspects as well as the practical advantages of SLED-Genius®are discussed, and our experience of using SLED for intraoperative renal replacement therapy during liver transplantation is shortly presented.

[Circulating bone turnover markers and their relationships in hemodialysis patients with vitamin D deficiency].

OBJECTIVE: Introduction: Mineral homeostasis is achieved through a complex interplay of several feedback processes involving primarily the bone, intestine and kidney, regulated by different proteins acting on endocrine, paracrine or autocrine levels. The dysregulation of these processes in chronic renal failure, called kidney disease (CKD) - mineral and bone disorder (CKD-MBD), although apparent, is still poorly understood. The aim: The aim of the study was an analysis of potential relationships between selected biomarkers of CKD-MBD in maintenance hemodialysis (HD) patients. PATIENTS AND METHODS: Material and Methods: In the first part of this cross-sectional study, the 25(OH)D serum concentrations were measured in 115 HD vitamin D naïve patients from 5 dialysis units located in central Poland. Thereafter in 81 patients (49 men, 32 women, aged 67 ± 13 years) with vitamin deficiency (25(OH)D <20 ng/ml) serum concentrations of 25(OH)D, 1,25(OH)2D, intact parathyroid hormone (iPTH), intact FGF23, sclerostin (SCL), osteocalcin (OC), and C-terminal telopeptide of type I collagen (CTX1) were determined. RESULTS: Results: Serum levels of both 25(OH)D and 1,25(OH)2D were low (mean values 13.4±6.72 ng/ml and 12.9 ± 9.08 pmol/l, respectively). While serum 25(OH)D correlated only with a declared time spent outside (r= 0.411; p=0.000139), serum 1,25(OH)2D was related to diuresis (r= 0.289; p=0.009), and negatively to time on dialysis (r= -0.272; p=0.014) , serum phosphate (r= -0.393; p=0.000289), FGF23(r= -0.295; p=0.008), and SCL (r= -0.260; p=0.019). There was a marked dispersion of FGF-23 serum levels across the group (mean 823±5647, median 379 pg/ml) , and - as expected - they correlated highly with phosphate (r= 0.549, p=0.000), calcium (r= 0,328, p=0,003), OC (r=0.479; p=0.000), and negatively with z 1,25(OH)2D (r= -0.295, p=0.008). Mean serum SCL levels (89.2±46.7, median 81.9 pmol/l) were 3x higher than in general population, and correlated highly positively with dialysis vintage (r=0.402; p<0.001), age (r=0.356; p=0.001), as well as negatively with 1,25(OH)2D (r= -0.260; p=0.019) and CTX1 (r= -0.293; p=0.008). CONCLUSION: Conclusions: In our hemodialysis population, in addition to profoundly impaired 1,25(OH)2D synthesis, there is also a widespread prevalence of 25(OH)D deficiency. The patients have also markedly increased serum bone-secreted proteins, FGF23, and SCL, which regulate mineral and bone metabolism and are associated with the systemic side effects of uremia. All these hormones interact one with the other, creating a sophisticated cross-talk between the bone, intestine, and the kidney.

Stem cell mobilization in patients with dialysis-dependent multiple myeloma: Report of the Polish Myeloma Study Group.

INTRODUCTION: High-dose chemotherapy with autologous hematopoietic stem cell transplantation (auto-HSCT) improves the outcome of patients with multiple myeloma (MM). It seems that auto-HSCT is also a feasible therapeutic option in MM dialysis-dependent (MMDD) patients. However, to perform transplantation, a sufficient number of stem cells must be collected. MATERIALS AND METHODS: Given that data on mobilization of auto-HSC efficacy and safety in dialysis-dependent patients are limited, we report data from all Polish Centers belonging to the Polish Myeloma Study Group. Twenty-eight dialysis-dependent MM-patients were enrolled into this retrospective analysis. The study population comprised patients diagnosed between 2004 and 2015 in whom an attempt to collect auto-HSC was made (68%: women, median age: 56). Patients received granulocyte-colony stimulating factor (G-CSF) alone or in combination with chemotherapy and autologous peripheral blood stem cells (auto-PBSCs) were collected by leukapheresis. RESULTS AND CONCLUSIONS: The success rate in terms of obtaining sufficient number of CD34(+) cells/kg for an auto-HSCT (≥2 × 106 cells/kg body weight) during the first mobilization attempt was 92% (26/28 patients), and for 2 auto-HSCTs (≥4 × 106 cells/kg) - was 75% (21/28 patients). After the second mobilization attempt (undertaken in 8 patients), a sufficient number of CD34(+)/kg cells for an auto-HSCT was obtained for all patients and the number of CD34(+)/kg collected cells was sufficient for 2 auto-HSCT in 6 additional patients. Hematologic toxicity and infections were the most frequent complications. Higher doses of cytarabine (>1.6 g/m2 ) and cyclophosphamide (> 2 g/m2 ) should be avoided in MMDD patients due to toxicity. Further studies are needed to establish mobilization regimens, confirm their safety, and dosing in MMDD patients.

[Erythropoietin stimulating agents in chronic kidney disease: indications and contraindications].

Erythropoietin (EPO) deficiency is important complication of chronic kidney disease. It downregulates red cells maturation and production causing renal anemia. It is associated with reduced quality of life, increased risk of blood transfusions and cardiovascular morbidity. It is possible to substitute EPOwith recombinant human EPOor its derivatives - erythropoiesis stimulating agents (ESA). ESA therapy reduces blood transfusions, improves quality of life and can raise hemoglobin to 10-11.5 g/dl. Higher hemoglobin targets bring more harm than benefit - including increased risk for stroke, hypertension and vascular access thrombosis and mortality. Initiation of ESA therapy should be preceded by excluding the other causes of anemia and balancing ESA advantages and disadvantages in every patient. In patients with previous stroke, previous or current malignancy risks of ESA therapy may outweigh the risks of red cell transfusions.

[Paricalcitol - a selective vitamin D receptor activator for secondary hyperparathyroidism in patients with chronic kidney disease].

Secondary hyperparathyroidism is a frequently encountered complication of chronic kidney disease (CKD) attributable to altered phosphate/calcium homeostasis, increased synthesis of phosphaturic hormone (FGF-23) and profound active vitamin D deficiency. The disorder is associated with severe bone disease, progressive cardiovascular calcification and increased mortality. Calctriol and its analogs (alphacalcidol) can suppress parathyroid activity, however at the cost of hypercalcemia and hiperphosphatemia, thus aggravating the vascular disease. During the last decade, selective vitamin D receptor activators (VDRA) have been introduced, that reduce parathyroid activity with minimal changes in calcium and phosphate metabolism. Paricalcitol is the only selective VDRA registered in Europe for the management of patients with different stadia of CKD. For today, with its efficacy and safety confirmed in several clinical trials paricalcitol increases the vitamin D therapeutic window in this population. Furthermore, the clinical data on its possible positive effect on survival together with its reduced or even lacking experimental procalcifying effects on vessels, call for extensive research, since selective VDRA may provide additional clinical benefits going beyond mineral-bone disorder.

[Brief measure to assess patient perception of self-influence on the disease course-version for hemodialysis]. / Krótka metoda oceny poczucia wplywu pacjenta na przebieg choroby--wersja dla hemodializowanych.

INTRODUCTION: Self-influence on the disease course has a significant impact on coping with disease and adherence to medical recommendations. AIM: Elaboration of a brief scale for screening of patient perception of self-influence on the course of disease among hemodialysis, which could be used during usual medical practice. METHODS: In the first stage of the study, based on a group focus interview with 6 hemodialysis (mean age 65.2 ± 14.8 year)--5 women (83%) and 1 men (17%), mean time of dialysis 43.8 ± 38 months, a list of 51 characteristics of patients with low (LP) and high perception (HP) of self-influence on the curse of disease, was constructed. In the second stage 99 patients (mean age 66.1 ± 14.7 year)--51 men (52%) and 48 women (48%), mean time of dialysis 48.7 ± 48.1 months, assessed scale reliability. They were selected by their nephrologists to groups with LP and HP. Based on the results 11 items had the strongest power of discrimination of those two groups. 15 (13.2%) hemodialysis refused to participate at this part of study. In a third step 70 (mean age 68 ± 13.3 year) patients--40 men (57.1%) and 30 women (42.9%), mean time of dialysis 48.1 ± 45.6 months, assessed validity of the tool. RESULTS: The reliability alfa-Cronbach = 0.9 and validity tau-Kendall = 0.6. CONCLUSIONS: Scale has a very high reliability and satisfactory validity. It can be used for those of hemodialysis who have problems with adherence to medical recommendations or have difficulty in contact with the medical staff or other patients.

[Age-related kidney problems]. / Problemy nefrologiczne zwiazane z wiekiem.

Kidney diseases, with some exceptions, are diseases of the elderly. During last century mortality due to infections and injuries has gradually decreased and a longer life expectancy increased a rate of chronic diseases. Diabetes, hypertension and atherosclerosis have become most common causes of kidney diseases. A gradual nephrons loss in aging kidneys causes them more susceptible to acute injury as well as fastens the progression of their chronic disease. This leads to the rapid increase in the incidence of kidney diseases with aging. This paper discusses the process of kidney senescence and its influence on the course of kidney disease as well as the differences in the treatment of patients over 65 years.

[Acute kidney injury in liver transplantation]. / Ostre uszkodzenie nerek u pacjentów poddawanych przeszczepieniu watroby.

Acute kidney injury (AKI) is a common complication in liver transplant recipients. Affecting ~25% of patients preoperatively, and up to 60% postoperatively significantly worsens the prognosis. Etiology differs depending on the time of its onset, from mostly prerenal before the transplantation, ischemic in the early postoperative period to toxic AKI later on. Liver transplantation is a lenghty and complex procedure with a significant risk of hemodynamic instability, metabolic acidosis and electrolyte disturbances. The article discusses the risk of AKI development in patients undergoing liver transplanation and the indications to renal replacement therapy in the perioperative period.

Long-term cholecalciferol administration in hemodialysis patients: a single-center randomized pilot study.

BACKGROUND: Data on the potent pleiotropic extraskeletal effects of vitamin D have renewed interest in its use in selected populations, including patients with chronic kidney disease, but the available data are still insufficient to make recommendations. This study assessed the long-term effect of small cholecalciferol doses on serum vitamin D, parathormone (PTH), and bone mineral density (BMD) in hemodialysis patients. MATERIAL/METHODS: Nineteen patients with serum 25(OH)D <20 ng/mL were randomized into cholecalciferol (2000 IU 3×/week) and no-treatment groups, then observed for 1 year. Patients with hypercalcemia, hyperphosphatemia, and receiving vitamin D/calcimimetics were excluded. Serum 25(OH)D, 1,25(OH)2D, PTH, and alkaline phosphatase activity were examined every 2 months and BMD was measured before and after the study. RESULTS: We observed normalization of serum 25(OH)D with an increase in medians from 11.3 to 44.9 ng/mL (P=0.02) in the cholecalciferol group and no change in the controls (P<0.001). Simultaneously, median serum 1,25(OH)2D increased from 18.2 to 43.1 pmol/L (P=0.02) in the cholecalciferol group and from 10.6 to 21.2 pmol/L (P=0.02) in controls (P=0.013). The treatment was associated with a small increase in serum calcium, but serum phosphate, PTH, alkaline phosphatase, and BMD remained unchanged in both groups. CONCLUSIONS: Oral cholecalciferol at a dose of 2000 IU/3×/week is an effective and safe way to treat vitamin D deficiency in hemodialysis patients, leading to a significant increase in serum 1,25(OH)2D. However, it was insufficient to suppress the activity of parathyroid glands or to significantly change BMD.

[The integrated renal replacement therapy]. / Koncepcja zintegrowanego leczenia nerkozastepczego.

The integrated renal replacement therapy (RRT) concept assumes that all its methods: kidney transplantation (Tx), hemodialysis (HD) and peritoneal dialysis (PD) can be applied in a complementary manner, according to the clinical situation of the particular patient and his preferences. Besides the integration of treatments this concept also emphasizes timely patient referral, predialysis education and timely start of RRT.

Left-Sided Pneumothorax in a Potential Kidney Transplant Recipient-A Surprise in the Surgical Ward: Case Report.

BACKGROUND: The risk of morbidity and mortality in the group of people qualified for kidney transplantation is high. Although currently, the qualification for kidney transplantation is very extensive and detailed, the final examination and assessment at the transplant center is crucial for the success of the transplantation. CASE REPORT: A 50-year-old woman with end-stage kidney disease was admitted to the Department of General, Vascular, and Transplant Surgery on July 21, 2023, for kidney transplantation. A month earlier, she had undergone surgery to create an arteriovenous fistula on the left forearm. The regional anesthesia was performed. Apart from temporary pain and cough, the postoperative course was uncomplicated. Upon admission to the Department, the patient was in good general condition, and only a dry cough was noted during the physical examination. Chest X-ray revealed pneumothorax on the left side with partial lung atelectasis. The patient was temporarily disqualified from kidney transplantation and the pneumothorax was cured. She is currently on the active list waiting for a kidney transplant. CONCLUSIONS: The analysis of the above case emphasizes the importance of a physical examination and final qualification at the transplant center. Detailed examination and evaluation at the above center can improve patients' quality of life and survival.

Patterns of Cognitive Impairment in Hemodialysis Patients and Related Factors including Depression and Anxiety.

INTRODUCTION: Hemodialysis patients are at higher risk of developing cognitive impairment, but the pattern of affected cognitive domains is still undetermined. Little is also known about the symptoms of depression and anxiety in hemodialysis patients. METHODS: In this cross-sectional study, we included 74 consecutive adult patients undergoing hemodialysis. Cognitive functions were assessed using the Addenbrooke Cognitive Test III. In addition, all patients were screened for symptoms of depression and anxiety using the Hospital Anxiety and Depression Scale. RESULTS: The mean age of hemodialysis patients was 65.69 ± 14 years. Among the patients, there were 27% and 31% of patients with mild cognitive impairment and suspected dementia, respectively. In the group of patients with suspected dementia, all cognitive functions had significantly lower values compared to these functions in incognitively unimpaired and mild cognitive impairment patients. The most impaired domain was verbal fluency, which reflects impairments in executive function. Depression and anxiety symptoms were observed in 28% and 22% of patients, respectively. Patients with anxiety symptoms had higher levels of endogenous creatinine, parathyroid hormone, and hemoglobin, as well as decreased creatinine clearance, being younger and less educated. No factors contributing to the occurrence of depressive symptoms were found. CONCLUSION: Cognitive dysfunction is a significant problem in hemodialysis patients. Our study showed that the prevalence of cognitive impairment and depression and anxiety symptoms in hemodialysis patients was high. The domain of executive functions was most affected. Furthermore, creatinine, parathyroid hormone, hemoglobin levels, creatinine clearance, and education affected the anxiety scale score.

[Treatment of foot drop in orthopaedic practice]. / Leczenie stopy opadajacej w praktyce ortopedycznej.

Foot drop is a symptom of many diseases and leads to an unaesthetic limping gait, falls and injuries. The most common cause of foot drop is injury to the common peroneal nerve, which innervates ankle joint and foot extensors. Other causes of foot drop include: sciatic nerve injury, lumbar plexopathies, L4/L5 radiculopathy, central nervous system related neuropathies (anterior horn cell disease, brain tumor). Also compartment syndromes of the lower leg can lead to foot drop deformity. Ankle-foot orthoses (AFO) are helpful in the treatment of paralyzed extensor muscles of the foot. The surgical treatment should be connected with the etiology of the foot drop and can include: neurolysis of the nerve, "end to end" repair, autogenous nerve graft procedures, nerve transfers, direct neuromuscular neurotization and tendon transfers. In proximal sciatic nerve lesions, nerve transfers and one-stage nerve repair with concomitant tendon transfer are valuable methods of the treatment of drop foot. The aim of the paper is to present pathogenesis and modes of treatment of foot drop deformity encountered in any orthopedic unit.

Influence of formalized Predialysis Education Program (fPEP) on the chosen and definitive renal replacement therapy option.

BACKGROUND: It is widely accepted that patients with chronic kidney disease (CKD) should play an active role in the selection of renal replacement therapy (RRT) option. However, patients' knowledge about CKD and treatment options is limited. The implementation of structured education program and shared decision-making may result in a better preparation to RRT, more balanced choice of dialysis modalities and better access to kidney transplantation (TX). OBJECTIVES: The aim of this long-term study was to assess the impact of formalized Predialysis Education Program (fPEP) on knowlege on RRT options, as well as on selected and definitive therapy. MATERIAL AND METHODS: The study included 435 patients (53% men, mean age 60 years) with CKD stage 4 and 5, participating in fPEP at our center. The program included at least 3 visits, during which balanced information about all RRT options was presented and self-care and informed decision-making were encouraged. The knowledge about RRT options before and after fPEP attendance, and selected and definitive RRT options were assessed. RESULTS: Ninety-two percent of patients received prior nephrology care. After fPEP completion, in most patients, the knowledge about CKD and RRT options and selected preferred modality improved - 40% of participants chose hemodialysis (HD), 32% peritoneal dialysis (PD) and 18% TX. During the observation period, 4% of patients died before commencement of dialysis, 2.7% received preemptive kidney transplant, 8.6% were placed on transplant waiting list, and 94% started dialysis (30% PD and 70% HD). Among those who chose PD, 69% started PD and 24% started HD; the leading causes of the discrepancy between choosing and receiving PD was the deterioration in clinical condition (50%) and change of decision (32%). CONCLUSIONS: The fPEP increases CKD patients' knowledge on RRT methods. The implementation of a decision-making process based on fPEP leads to a satisfying distribution between modalities, with a good concordance between chosen and definitive modality.