A Current State of the Art and Science of Exercise in Dialysis: A Narrative Review.

Purpose of the review: The purpose of the review is to discuss current proven benefits and problems of integrating exercise in the care of people receiving dialysis by reviewing literature from the last few years and identifying important questions that still need to be asked and answered. Methods: A focused review and appraisal of the literature were done. Original peer-reviewed articles, review articles, opinion pieces and guidelines were identified from PubMed and Google Scholar databases. Only sources in English were accessed. Search terms "exercise" and "dialysis" were used to find active recruiting randomized trials in various clinical trial registry platforms. Key findings: Numerous studies have demonstrated the benefits of exercise training in individuals receiving dialysis, limited by factors such as short duration of follow-up and inconsistent adverse event reporting and outcomes selected. Notable gaps in exercise research in dialysis include ways to maintain programs and patient motivation, studies in peritoneal dialysis and home hemodialysis patients, and how best to define and measure outcomes of interest. Implications: This review summarizes the current state of exercise in people receiving dialysis and serves as a call to action to conduct large, randomized controlled trials to improve the quality of evidence needed to implement and sustain innovative, exercise interventions, and programs for this population.

Objectif de la revue: Discuter des bienfaits et problèmes avérés de l'intégration de l'exercice physique dans les soins des personnes dialysées en examinant la littérature des dernières années et en identifiant les questions importantes auxquelles il faut encore répondre. Méthodologie: Une revue ciblée et une évaluation de la littérature existante. Des articles originaux évalués par des pairs, des articles-synthèses, des articles d'opinion et des lignes directrices ont été répertoriés dans les bases de données Pubmed et Google Scholar. Seuls les articles en anglais ont été consultés. Les termes de recherche « exercice ¼ et « dialyse ¼ ont été utilisés pour rechercher les essais randomisés en cours de recrutement dans diverses plateformes de registres d'essais cliniques. Principales observations: De nombreuses études ont démontré les bienfaits de l'exercice physique chez les personnes dialysées. Ces études étaient toutefois limitées par des facteurs tels qu'une courte durée du suivi et une incohérence dans le rapport des événements indésirables et la sélection des résultats. Les principales lacunes observées dans les recherches portant sur l'exercice physique en contexte de dialyse concernent les moyens de maintenir les programmes et la motivation des patients, les études sur les patients traités par dialyse péritonéale et hémodialyse à domicile, et les meilleures façons de définir les résultats d'intérêt et de les mesurer. Conclusion: Cette revue résume la situation actuelle en ce qui concerne l'exercice physique chez les personnes dialysées. Elle constitue un appel à l'action pour la tenue d'essais cliniques de grande envergure visant l'amélioration de la qualité des données nécessaires à la mise en œuvre et au maintien d'interventions et de programmes d'exercice novateurs destinés à cette population.

Comparison of Tetrasodium EDTA 4% with Sodium Citrate 4% as Line-Locking Solutions at 2 Tertiary Hemodialysis Centres.

Background: The patency of central venous catheters (CVCs) in patients undergoing hemodialysis (HD) is maintained by instilling sodium citrate 4% (SC 4%) locking solution. Alteplase, a thrombolytic agent, is administered to restore function if patency is lost. Objective: To compare SC 4% with a new line-locking solution, ethylenediaminetetraacetic acid 4% (EDTA 4%), in terms of CVC patency and alteplase use. Methods: This retrospective chart review included all HD patients who were switched from SC 4% to EDTA 4% locking solution at 2 tertiary HD centres between June and December 2021. Patients were switched to EDTA 4% if they had high usage of alteplase (receiving ≥ 2 doses of alteplase in a 2-week period). For each line-locking agent, HD pump speeds and alteplase use were analyzed over 2 consecutive 12-week periods. Mean serum calcium and ionized calcium values were recorded during each period. A cost analysis was also performed. Results: A total of 37 HD patients were switched to EDTA 4% during the study period. There was no difference in mean HD pump speed between SC 4% and EDTA 4% (307.7 vs 305.1 mL/min, p = 0.48). The number of catheter-use-days on which alteplase was required declined significantly, from 313 days with SC 4% to 94 days with EDTA 4% (p < 0.001), with an overall cost reduction of 34% ($13 183.21). The decrease in alteplase usage was primarily driven by 1 of the 2 sites. A statistically significant decrease in mean ionized calcium at site 2 (from 1.12 to 1.1 mmol/L, p = 0.037) was noted. As well, an intraluminal interaction between EDTA 4% and serum calcium caused 6 cases of low serum calcium. Conclusions: This study showed that use of EDTA 4% as a line-locking agent reduced alteplase usage in the CVCs of HD patients while maintaining adequate pump speed (i.e., ≥ 300 mL/min).

Contexte: La perméabilité des cathéters veineux centraux (CVC) chez les patients hémodialysés (HD) est maintenue en instillant une solution de verrouillage de citrate de sodium à 4 % (CS 4 %). L'alteplase, un agent thrombolytique, est administré pour rétablir la fonction en cas de perte de perméabilité. Objectif: Comparer la solution de CS 4 % et une nouvelle solution de verrouillage, l'acide éthylènediaminetétraacétique 4 % (EDTA 4 %), en termes de perméabilité du CVC et d'utilisation de l'alteplase. Méthodes: Cet examen rétrospectif des dossiers a été réalisé pour tous les patients HD qui sont passés de la solution de verrouillage de CS 4 % à la solution d'EDTA 4 % dans 2 centres d'hémodialyse tertiaires au cours de la période de juin à décembre 2021. Les patients sont passés à l'EDTA 4 % en cas d'utilisation élevée de l'alteplase (≥ 2 doses d'alteplase reçues sur une période de 2 semaines). Pour chaque agent de verrouillage, les vitesses de la pompe d'hémodialyse et l'utilisation de l'alteplase ont été analysées sur 2 périodes consécutives de 12 semaines. Les valeurs moyennes de calcium sérique et de calcium ionisé ont été enregistrées au cours de chaque période. Une analyse des coûts a également été réalisée. Résultats: Au total, 37 patients HD sont passés à l'EDTA 4 % au cours de la période de l'étude. Aucune différence dans la vitesse moyenne de la pompe d'hémodialyse n'a été constatée en cas d'utilisation de la solution de CS 4 % ou d'EDTA 4 % (307,7 c. 305,1 mL/min, p = 0,48). Le nombre de jours d'utilisation du cathéter qui ont nécessité l'utilisation de l'alteplase a diminué de manière significative, passant de 313 jours avec la solution de CS 4 % à 94 jours avec l'EDTA 4 % (p < 0,001); la réduction globale des coûts se montait à 34 % (économies de 13 183,21 $). L'utilisation moins importante de l'alteplase était principalement due à 1 des 2 sites. Une diminution significative du calcium ionisé moyen (1,12 c. 1,1 mmol/L, p = 0,037) a été observée au deuxième site. De plus, une interaction intraluminale entre l'EDTA 4 % et le calcium sérique a provoqué 6 cas d'hypocalcémie. Conclusions: Cette étude a montré que l'utilisation de l'EDTA 4 % comme agent de verrouillage réduisait l'utilisation de l'alteplase dans les CVC des patients HD tout en maintenant une vitesse de pompe adéquate (c'est-à-dire ≥ 300 mL/min).

Magnesium and Fracture Risk in the General Population and Patients Receiving Dialysis: A Narrative Review.

Purpose of Review: Magnesium is an essential mineral for bone metabolism, but little is known about how magnesium intake alters fracture risk. We conducted a narrative review to better understand how magnesium intake, through supplementation, diet, or altering the concentration of dialysate magnesium, affects mineral bone disease and the risk of fracture in individuals across the spectrum of kidney disease. Sources of Information: Peer-reviewed clinical trials and observational studies. Methods: We searched for relevant articles in MEDLINE and EMBASE databases. The methodologic quality of clinical trials was assessed using a modified version of the Downs and Black criteria checklist. Key Findings: The role of magnesium intake in fracture prevention is unclear in both the general population and in patients receiving maintenance dialysis. In those with normal kidney function, 2 meta-analyses showed higher bone mineral density in those with higher dietary magnesium, whereas 1 systematic review showed no effect on fracture risk. In patients receiving maintenance hemodialysis or peritoneal dialysis, a higher concentration of dialysate magnesium is associated with a lower concentration of parathyroid hormone, but little is known about other bone-related outcomes. In 2 observational studies of patients receiving hemodialysis, a higher concentration of serum magnesium was associated with a lower risk of hip fracture. Limitations: This narrative review included only articles written in English. Observed effects of magnesium intake in the general population may not be applicable to those with chronic kidney disease particularly in those receiving dialysis.

Justification: Le magnésium est un minéral essentiel pour le métabolisme osseux, mais on en sait peu sur la façon dont un apport en magnésium modifie le risque de fracture. Nous avons procédé à un examen narratif afin de mieux comprendre comment les maladies liées à la densité minérale osseuse et le risque de fracture sont affectés par un apport en magnésium (supplémentation, régime alimentaire ou modification de la concentration de dialysat de magnésium) chez les personnes atteintes d'insuffisance rénale. Sources: Essais cliniques et études observationnelles examinés par des pairs. Méthodologie: Nous avons répertorié les articles pertinents dans les bases de données MEDLINE et EMBASE. Une version modifiée des critères de contrôle de la qualité des études de Downs et Black a servi à évaluer la qualité méthodologique des essais cliniques retenus. Principaux résultats: Le rôle d'un apport en magnésium dans la prévention des fractures n'est pas clair, tant dans la population générale que chez les patients sous dialyse d'entretien. Chez les personnes ayant une fonction rénale normale, deux méta-analyses ont montré que les personnes dont le régime alimentaire est riche en magnésium présentent une densité minérale osseuse plus élevée; alors qu'une revue systématique n'a montré aucun effet sur le risque de fracture. Chez les patients sous hémodialyse d'entretien ou dialyse péritonéale, une concentration plus élevée de dialysat de magnésium est associée à une plus faible concentration d'hormone parathyroïdienne, mais on en sait peu sur les autres effets liés aux os. Dans deux études observationnelles portant sur des patients sous hémodialyse, une concentration plus élevée de magnésium sérique a été associée à un risque plus faible de fracture de la hanche. Limites: Cet examen narratif ne comprend que des articles rédigés en anglais. Il est possible que les effets d'un apport en magnésium observés dans la population générale ne puissent s'appliquer aux personnes atteintes d'une néphropathie chronique, en particulier aux personnes sous dialyse.

Ultrasound-guided cutaneous nerve chemo-ablation for severe access site neuropathic pain-A case report.

Neuropathic pain at the cannulation site is challenging, both for the patient and the dialysis team. We present a case of a middle-aged man on chronic hemodialysis, who developed excruciating pain at the cannulation area without incident, limiting his dialysis sessions. Multidisciplinary collaboration allowed identification of the cutaneous nerve-the inferior lateral cutaneous nerve of the arm, relaying his pain. Subsequent ultrasound-guided phenol chemoablation resulted in the complete resolution of his pain and allowed continued use of the well-functioning fistula for dialysis.

A comparison of outcomes between open and endovascular arteriovenous access creation for hemodialysis.

OBJECTIVE: Preliminary outcomes for percutaneous endovascular autogenous access (endoAVF) have shown promising results; however, comparisons with surgical cohorts in dialysis populations are lacking. This study compares autogenous arteriovenous access created with the EverlinQ endoAVF system with accesses created by conventional surgical technique with respect to functional and patency related outcomes. METHODS: This is a multicenter, retrospective review of autogenous arteriovenous accesses entered into a prospective database. Patients receiving radiocephalic, brachiocephalic, or endoAVF arteriovenous accesses between 2014 and 2019 were included. Autogenous access maturation, primary patency, secondary patency, steal syndrome, and reinterventions were collected and analyzed using standard statistical and survival analyses. RESULTS: A total of 369 accesses were created during the study period, including 61 endovascular accesses, 171 radiocephalic accesses, and 137 brachiocephalic accesses (median follow-up, 17 months; range, 1-71 months). Maturation failure at the end of follow-up was 27% ± 6%, 27% ± 5%, and 18% ± 4% for endovascular, radiocephalic, and brachiocephalic accesses, respectively (P = .049 for brachiocephalic vs endovascular accesses). Primary patencies at 12 and 24 months were 42% ± 5% and 32% ± 7% for endovascular accesses, 43% ± 4% and 24% ± 4% for radiocephalic accesses, and 42% ± 4% and 29% ± 4% for brachiocephalic accesses (P = .906). Secondary patencies at 12 and 24 months were 68% ± 6% and 60% ± 7% for endovascular accesses, 75% ± 3% and 67% ± 4% for radiocephalic accesses, and 91% ± 3% and 81% ± 4% for brachiocephalic accesses (P = .006 for brachiocephalic vs endovascular accesses). There were no statistically significant differences in ischemic steal syndrome (3.3%, 4.1%, and 8.0%; P = .229) or total reinterventions/year (1.0 ± 3.1, 0.9 ± 1.8, and 1.2 ± 1.8; P = .289) for endovascular, radiocephalic, or brachiocephalic arteriovenous accesses, respectively. CONCLUSIONS: EndoAVF compare favorably with respect to maturation and patency compared with surgically created accesses in a real-world cohort. Outcomes and reintervention rates are similar to conventional radiocephalic arteriovenous accesses, but are inferior with respect to patency and maturation to brachiocephalic accesses.

A Higher Concentration of Dialysate Magnesium to Reduce the Frequency of Muscle Cramps: A Narrative Review.

PURPOSE OF REVIEW: Strategies to mitigate muscle cramps are a top research priority for patients receiving hemodialysis. As hypomagnesemia is a possible risk factor for cramping, we reviewed the literature to better understand the physiology of cramping as well as the epidemiology of hypomagnesemia and muscle cramps. We also sought to review the evidence from interventional studies on the effect of oral and dialysate magnesium-based therapies on muscle cramps. SOURCES OF INFORMATION: Peer-reviewed articles. METHODS: We searched for relevant articles in major bibliographic databases including MEDLINE and EMBASE. The methodological quality of interventional studies was assessed using a modified version of the Downs and Blacks criteria checklist. KEY FINDINGS: The etiology of muscle cramps in patients receiving hemodialysis is poorly understood and there are no clear evidence-based prevention or treatment strategies. Several factors may play a role including a low concentration of serum magnesium. The prevalence of hypomagnesemia (concentration of <0.7 mmol/L) in patients receiving hemodialysis ranges from 10% to 20%. Causes of hypomagnesemia include a low dietary intake of magnesium, use of medications that inhibit magnesium absorption (eg, proton pump inhibitors), increased magnesium excretion (eg, high-dose loop diuretics), and a low concentration of dialysate magnesium. Dialysate magnesium concentrations of ≤0.5 mmol/L may be associated with a decrease in serum magnesium concentration over time. Preliminary evidence from observational and interventional studies suggests a higher dialysate magnesium concentration will raise serum magnesium concentrations and may reduce the frequency and severity of muscle cramps. However, the quality of evidence supporting this benefit is limited, and larger, multicenter clinical trials are needed to further determine if magnesium-based therapy can reduce muscle cramps in patients receiving hemodialysis. In studies conducted to date, increasing the concentration of dialysate magnesium appears to be well-tolerated and is associated with a low risk of symptomatic hypermagnesemia. LIMITATIONS: Few interventional studies have examined the effect of magnesium-based therapy on muscle cramps in patients receiving hemodialysis and most were nonrandomized, pre-post study designs.

CONTEXTE MOTIVANT LA REVUE: Les stratégies visant à atténuer les crampes musculaires sont parmi les principales priorités de recherche des patients hémodialysés. L'hypomagnésémie étant un possible facteur de risque, nous avons procédé à une revue de la littérature afin de mieux en comprendre l'épidémiologie, et d'examiner la physiologie et l'épidémiologie des crampes musculaires. Nous souhaitions également examiner les données probantes issues d'études interventionnelles portant sur l'effet des thérapies à base de dialysat de magnésium et de magnésium oral sur les crampes musculaires. SOURCES: Articles examinés par les pairs. MÉTHODOLOGIE: Nous avons cherché les articles pertinents dans les principales bases de données bibliographiques, notamment MEDLINE et EMBASE. La qualité méthodologique a été évaluée à l'aide d'une version modifiée des critères de contrôle de la qualité des études de Downs et Black. PRINCIPAUX RÉSULTATS: L'étiologie des crampes musculaires chez les patients hémodialysés est mal comprise et il n'existe aucune stratégie de prévention ou traitement clairement fondé sur des données probantes. Plusieurs facteurs pourraient jouer un rôle, notamment de faibles concentrations sériques de magnésium. La prévalence de l'hypomagnésémie (concentration inférieure à 0,7 mmol/L) chez les patients hémodialysés variait de 10 à 20 %. Une faible consommation de magnésium dans l'alimentation, la prise de médicaments inhibant l'absorption du magnésium (ex. les inhibiteurs de la pompe à protons), l'excrétion accrue du magnésium (ex. dose élevée de diurétiques de l'anse) et une faible concentration de dialysat de magnésium figuraient parmi les causes d'hypomagnésémie. Un taux de dialysat de magnésium inférieur ou égal à 0,5 mmol/L pourrait être associé à une diminution de la concentration sérique de magnésium au fil du temps. Les résultats préliminaires de certaines études observationnelles et interventionnelles suggèrent qu'une concentration sérique plus élevée de magnésium dans le dialysat augmenterait les concentrations sériques de magnésium et pourrait réduire la fréquence et la sévérité des épisodes de crampes musculaires. La qualité des preuves appuyant ce bienfait est cependant limitée. Des essais multicentriques et à plus vaste échelle sont nécessaires pour juger si un traitement à base de magnésium peut véritablement réduire les crampes musculaires chez les patients hémodialysés. Dans les études menées jusqu'à maintenant, l'augmentation de la concentration de dialysat de magnésium semblait bien tolérée et a été associée à un faible risque d'hypermagnésémie symptomatique. LIMITES: Peu d'études interventionnelles ont examiné l'effet de la prise de magnésium sur les crampes musculaires des patients hémodialysés, et la plupart de celles-ci constituaient des plans pré- ou post-études non randomisées.

Utility of Rapid Influenza Molecular Testing in an Outpatient Hemodialysis Unit: A Prospective Cohort Study.

BACKGROUND: Early initiation of antiviral therapy for individuals at risk for severe influenza infection is important for improving patient outcomes. Current guidelines recommend empiric antiviral therapy for patients with end-stage kidney disease presenting with suspected influenza infection. Rapid molecular influenza assays may reduce diagnostic uncertainty and improve patient outcomes by providing faster diagnostics compared to traditional batched polymerase chain reaction (PCR) testing. OBJECTIVE: To determine the utility of implementing a rapid influenza PCR assay compared to the standard of care in a hemodialysis unit. DESIGN: This is a prospective cohort study. SETTING: A hospital-based dialysis unit in a tertiary care hospital. PATIENTS: Adult patients with end-stage kidney disease on intermittent hemodialysis. MEASUREMENTS: Patient characteristics, influenza PCR swab results, antibiotic prescriptions, antiviral prescriptions, emergency room visits and hospitalizations. METHODS: From November 1, 2017 to March 31, 2018, we assigned samples collected from a single center, hemodialysis unit to be processed using a rapid influenza PCR (cobas® Influenza A/B & respiratory syncytial virus assay) or the standard of care (in-house developed multiplex PCR). Samples were assigned to the rapid PCR if the patient received dialysis treatment in the morning dialysis shift, while the remainder were processed as per standard of care. Study outcomes included the time from collection to result of nasopharyngeal swab, prescription of influenza antiviral therapy, time to receiving prescription, and the need for emergency department visit or hospitalization within 2 weeks of presentation. RESULTS: During the study period, 44 patients were assessed (14 with the rapid PCR and 30 with the standard of care assay). Compared to conventional testing, the time to result was shorter using rapid PCR compared to conventional testing (2.3 vs 22.6 hours, P < .0001). Individuals who were tested using the rapid PCR had a tendency to shorter time to receiving antiviral prescriptions (0.7 days vs 2.1 days, P = .11), and fewer emergency department visits (7.1% vs 30%, P = .13) but no difference in hospitalizations (14.3% vs 30%, P = .46) within 2 weeks of testing. LIMITATIONS: This is a single center non-randomized study with a relatively small sample size. Patients who were tested using the standard of care assay experienced a delay in the prescription of antiviral therapy which deviates from recommended clinical practice. CONCLUSIONS: Rapid influenza molecular testing in the hemodialysis unit was associated with a shorter time to a reportable result and with a tendency to reduced time to prescription of antiviral therapy. Rapid molecular testing should be compared with standard of care (empiric therapy) in terms of economic costs, adverse events, and influenza-related outcomes.

CONTEXTE: L'initiation précoce d'un traitement antiviral est essentielle pour améliorer les résultats de santé des personnes exposées à un grand risque d'infection grippale. Chez les patients atteints d'insuffisance rénale terminale (IRT) suspectés d'une infection grippale, les recommandations actuelles préconisent une approche empirique de traitement antiviral. Les tests moléculaires de dépistage rapide du virus influenza peuvent réduire l'incertitude diagnostique et améliorer les résultats pour les patients en posant un diagnostic plus rapidement que les tests PCR en lots traditionnellement utilisés. OBJECTIF: Mesurer l'intérêt de mettre en place un test PCR de dépistage rapide de la grippe comparativement à la norme de soins d'une unité d'hémodialyse. TYPE D'ÉTUDE: Étude de cohorte prospective. CADRE: Une unité de dialyze hospitalière de soins tertiaires. SUJETS: Des adultes atteints d'IRT et traités par hémodialyse intermittente. MESURES: Les caractéristiques des patients, les résultats de dépistage du virus influenza, les prescriptions d'antibiotiques et d'antiviraux, les visites à l'urgence et les hospitalisations. MÉTHODOLOGIE: Entre le 1er novembre 2017 et le 31 mars 2018, les échantillons prélevés à l'unité d'hémodialyse du center ont été répartis pour être analysés soit par la méthode PCR de dépistage rapide (cobas®Essai Influenza A/B & VRS), soit par la méthode traditionnellement utilisée (PCR multiplex mises au point à l'interne). Les prélèvements des patients dialysés pendant le quart de travail du matin ont été assignés à la méthode rapide, les autres ont été testés par la méthode traditionnelle. Les résultats incluaient le délai entre le prélèvement et le résultat de l'écouvillonnage naso-pharyngé, la prescription d'un traitement antiviral, le temps requis pour obtenir la prescription et la nécessité de se rendre à l'urgence ou d'être hospitalisé dans les deux semaines suivant la présentation des symptômes. RÉSULTATS: Au cours de l'étude, 44 patients ont été diagnostiqués avec la méthode rapide par PCR (n=14) ou la méthode traditionnelle (n=30). Comparativement à la méthode traditionnelle, la méthode rapide par PCR a permis de réduire le temps d'obtention du résultat (2,3 h contre 22,6 h pour la méthode traditionnelle; P < .0001). Les patients diagnostiqués avec la méthode rapide par PCR tendaient à obtenir une ordonnance d'antiviraux plus rapidement (0,7 jour contre 2,1 pour la méthode traditionnelle; P = .11) et à avoir visité l'urgence moins souvent (7,1 % contre 30 % pour la méthode traditionnelle, P = .13), mais ne présentaient aucune différence significative dans le nombre d'hospitalisations (14,3 % contre 30 % pour la méthode traditionnelle; P = .46) dans les deux semaines de suivi. LIMITES: Il s'agit d'une étude non répartie aléatoirement, qui s'est tenue dans un seul center et sur un échantillon relativement restreint. Les patients diagnostiqués avec la méthode traditionnelle ont subi un retard dans la prescription du traitement antiviral, ce qui s'écarte de la pratique clinique recommandée. CONCLUSION: Chez les patients d'une unité d'hémodialyse, le dépistage moléculaire rapide du virus influenza a été associé à un diagnostic plus rapide et à une tendance à une réduction du délai de prescription du traitement antiviral. Il serait pertinent de comparer le dépistage moléculaire rapide avec la norme standard de soin (traitement empirique) en ce qui concerne les coûts, les événements indésirables et les issues de santé liées à la grippe.

Cardiac MRI measurements of pericardial adipose tissue volumes in patients on in-centre nocturnal hemodialysis.

BACKGROUND: Conversion from conventional hemodialysis (CHD) to in-centre nocturnal hemodialysis (INHD) is associated with left ventricular (LV) mass regression, but the underlying mechanisms are not fully understood. Using cardiac MRI (CMR), we examined the effects of INHD on epicardial adipose tissue (EAT) and paracardial adipose tissue (PAT), and the relationships between EAT, PAT and LV remodeling, biomarkers of nutrition, myocardial injury, fibrosis and volume. METHODS: We conducted a prospective multicenter cohort study of 37 patients transitioned from CHD to INHD and 30 patients on CHD (control). Biochemical markers and CMR were performed at baseline and 52 weeks. CMR images were analyzed by independent readers, blinded to order and treatment group. RESULTS: Among 64 participants with complete CMR studies at baseline (mean age 54; 43% women), there were no significant differences in EAT index (60.6 ± 4.3 mL/m2 vs 64.2 ± 5.1 mL/m2, p = 0.99) or PAT index (60.0 ± 5.4 mL/m2 vs 53.2 ± 5.9 mL/m2, p = 0.42) between INHD and CHD groups. Over 52 weeks, EAT index and PAT index did not change significantly in INHD and CHD groups (p = 0.21 and 0.14, respectively), and the changes in EAT index and PAT index did not differ significantly between INHD and CHD groups (p = 0.30 and 0.16, respectively). Overall, changes in EAT index inversely correlated with changes in LV end-systolic volume index (LVESVI) but not LV end-diastolic volume index (LVEDVI), LV mass index (LVMI), and LV ejection fraction (LVEF). Changes in PAT index inversely correlated with changes in LVESVI, LVMI and positively correlated with changes in LVEF. There were no correlations between changes in EAT index or PAT index with changes in albumin, LDL, triglycerides, troponin-I, FGF-23, or NT-proBNP levels over 52 weeks (all p > 0.30). CONCLUSIONS: INHD was not associated with any changes in EAT index and PAT index over 12 months. Changes in EAT index were not significantly associated with changes in markers of LV remodeling, nutrition, myocardial injury, fibrosis, volume status. In contrast, changes in PAT index, which paradoxically is expected to exert less paracrine effect on the myocardium, were correlated with changes in LVESVI, LVMI and LVEF. Larger and longer-term studies may clarify the role of PAT in cardiac remodeling with intensified hemodialysis. CLINICALTRIALS. GOV IDENTIFIER: NCT00718848.

Clinical evaluation of performance, biocompatibility, and safety of vitamin E-bonded polysulfone membrane hemodialyzer compared to non-vitamin E-bonded hemodialyzer.

The vitamin E-bonded polysulfone membrane hemodialyzer (ViE™-21) was evaluated in a clinical study for regulatory submission. Seventeen patients on hemodialysis were treated with conventional high-flux hemodialyzers for 2 weeks (Pre-ViE phase) and switched to the ViE-21 for 36 sessions (ViE phase) followed by an additional 2 weeks on conventional hemodialyzers (Post-ViE phase). Reduction ratios of urea, creatinine, beta-2-microglobulin, albumin, and ultrafiltration coefficients (KUF) were measured once during the Pre-ViE phase and twice during the ViE phase. Moreover, biocompatibility markers [leucocyte count, platelet count, and activated complement factor (C3a) levels] were evaluated pre-dialysis, 15 min after initiation, and post-dialysis. During the study, type and number of adverse events (AEs), and device malfunctions were recorded. ViE-21 reduction ratios and KUF were not noticeably different than those of conventional hemodialyzers. Fluctuations of leucocyte counts and C3a concentrations were similar using ViE-21 and conventional hemodialyzers; however, the platelet count fluctuation was lower in ViE-21 sessions. The frequency of episodes of hypotension occurring during the ViE phase was lower than that occurring during the Pre- and Post-ViE phases. In conclusion, this study provided performance and safety data of the ViE-21 for regulatory application. The data suggest that vitamin E-bonded hemodialyzers are beneficial in lowering platelet activation and frequency of intradialytic hypotension. Larger randomized controlled trials are needed to confirm these findings.

Left ventricular strain analysis using cardiac magnetic resonance imaging in patients undergoing in-centre nocturnal haemodialysis.

AIM: Intensified haemodialysis is associated with regression of left ventricular (LV) mass. Compared to LV ejection fraction, LV strain allows more direct assessment of LV function. We sought to assess the impact of in-centre nocturnal haemodialysis (INHD) on global LV strain (radial, circumferential, and longitudinal) and torsion by cardiac MRI (CMR). METHODS: In this prospective, two-centre cohort study, 37 participants on conventional haemodialysis (CHD, 3-4 h/session for three sessions/week) converted to INHD (7-8 h/session for three sessions/week) and 30 participants continued CHD. Participants underwent CMR using a standardized protocol and had biomarker measurements at baseline and 52 weeks. RESULTS: Among the 55 participants (mean age 55; 40% women) with complete CMR data, those who converted to INHD had a significant improvement in their global circumferential strain (GCS, P = 0.025), while those continuing CHD did not have any significant changes in LV strain. When the two groups were compared, there was significant improvement in torsion. LV strains were significantly correlated with each other, but not with troponin I, C-reactive protein, or brain natriuretic protein (NT-proBNP), except for global longitudinal strain (GLS) with troponin I (P = 0.001) and NT-proBNP (P = 0.038). CONCLUSION: Conversion to INHD was associated with significant improvement in GCS over one year of study, although comparisons with the CHD group were not significant. There was also a significant decrease in torsion in the INHD group compared with CHD. Improvement in LV regional function would support the notion that INHD has favourable effects on both LV structure and function.

Left Atrial Remodeling Assessed by Cardiac MRI after Conversion from Conventional Hemodialysis to In-Centre Nocturnal Hemodialysis.

BACKGROUND: Left atrial (LA) volume is a well-established cardiovascular prognosticator in patients with end-stage renal disease. Although dialysis intensification is associated with left ventricular mass regression, there are limited data regarding LA remodeling. Using cardiac magnetic resonance imaging (CMR), we examined changes in LA size and function relative to ventricular remodeling and cardiac biomarkers after dialysis intensification. METHODS: In this prospective 2-centre cohort study, 37 patients receiving conventional hemodialysis (CHD, 4 h/session, 3×/week) were converted to in-centre nocturnal hemodialysis (INHD 7-8 h/session, 3×/week); 30 patients remained on CHD. CMR and biomarkers were performed at baseline and repeated at 52 weeks. RESULTS: After 52 weeks, there were no significant changes in the LA volumes or LA ejection fraction (EF) within either the CHD or INHD group, and no significant differences between the two groups. Correlations existed between changes in LA and LV end-diastolic volume index (EDVi, Spearman's r = 0.69, p < 0.001), LA and LV end-systolic volume index (ESVi, r = 0.44, p = 0.001), LAEF and LVEF (r = 0.28, p = 0.04), LA and RV EDVi (r = 0.51, p < 0.001), LA and RV ESVi (r = 0.29, p = 0.039), and LA ESVi and LV mass index (r = 0.31, p = 0.02). At baseline, indexed LA volumes positively correlated with NT-proBNP, whereas LAEF negatively correlated with NT-proBNP and Troponin I. After 52 weeks, changes in biomarker levels did not correlate with changes in LA volume or EF. CONCLUSION: There was no significant change in LA size or systolic function after conversion to INHD. The significant correlations between LA and ventricular remodeling and cardiac biomarkers suggest common underlying pathophysiologic mechanisms. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00718848.

Multi-intervention management of calcific uremic arteriolopathy in 24 patients.

BACKGROUND: Calcific uremic arteriolopathy (CUA), also known as calciphylaxis, is a rare but life-threatening condition predominately occurring in patients with end-stage renal disease on dialysis. In the absence of randomized clinical trials to guide management, clinicians must rely on observational data. We have previously reported the outcomes of our multi-intervention management in seven patients and now present a larger series of patients with extended follow-up. METHODS: We performed a retrospective analysis of all patients diagnosed with CUA at a single academic center between 2008 and 2017. We identified 24 patients including 13 hemodialysis, 8 peritoneal dialysis and 3 predialysis Stage 5 chronic kidney disease patients. RESULTS: Mean age at diagnosis was 60.5 years (range 35-83) and mean follow-up 30.5 months (range <1-99). Patients were predominately female (71%) and Caucasian (83%) with diabetes mellitus diagnosed in 16 of 24 patients. Fifteen of 24 patients had ulcerating lesions suggestive of advanced disease and 20 of 24 had extensive involvement (bilateral disease or lesion size >5 cm). Treatment consisted of intensive hemodialysis (>20 h per week), sodium thiosulfate, wound care, analgesics and discontinuation of trigger medications including warfarin. Hyperbaric oxygen, cinacalcet, bisphosphonates and vitamin K were used in some cases. Overall 1 year mortality was 41% (9/22) and overall mortality at the end of follow-up was 64% (14/24). Cause of death was felt to be attributable to CUA in only four cases (16.7%). Complete or partial resolution of lesions occurred in 17 of 24 patients. One patient had recurrence of CUA 20 months after initial diagnosis. CONCLUSIONS: Although mortality remains high in this group, direct CUA-attributable mortality is lower than historic reports. We conclude that a multi-intervention approach can be successful in treating a group of patients with severe CUA lesions.

Transfusion Management of Incident Dialysis Patients in Canada: A Prospective Observational Study.

BACKGROUND: Several studies have demonstrated harm associated with using erythropoiesis-stimulating agents (ESA) to achieve higher hemoglobin (Hb) levels. Subsequently, more conservative use of ESAs has changed anemia therapy in patients with chronic renal failure. OBJECTIVE: The objectives were to identify transfusion rates in hemodialysis (HD) patients during the first year of therapy, to identify factors associated with the probability of transfusion, describe reasons for the transfusions, and identify the Hb values associated with each transfusion. An exploratory objective was to describe the age of red blood cell transfusions. DESIGN: This was a multicenter prospective observational cohort study. SETTING: There were 12 study sites in 5 Canadian provinces. The study was performed from 2012 to 2014. METHODS: The study patients were adult incident chronic HD patients in these centers. Patients with acute kidney injury, peritoneal dialysis, and planned transfer to satellite units were excluded. Patients had to receive at least 1 month of chronic HD to be eligible. Data for 3 months prior to HD were obtained by retrospective chart review. Prospectively, charts were reviewed monthly for 12 months for data abstraction. RESULTS: There were 314 patients enrolled and 79.9% completed 12 month follow-up. Ninety-four (29.9%) patients received at least 1 unit of blood. During the first 90 days, the transfusion episode rate was 148.4 per 100 patient-years compared with 62.6 per 100 patient-years post 90 days. The most frequent indication was a low Hb value (92%) with gastrointestinal bleeding, surgical blood loss, and fatigue accounting for 9.9%, 8.6%, and 4.5%, respectively. Some patients had >1 indication. The mean Hb values prior to transfusion episodes ranged from 75.3 to 78.6 g/L. Cox regression analysis on time to first transfusion and time to first hospitalization/death both showed an association with inpatient initiation of HD. Some 37.5% initiated HD as an inpatient and differed from those starting as an outpatient. They had less predialysis care and laboratory data suggested more inflammation. The mean and median ages of the blood units transfused were 24.9 (SD = 10.0) and 23 days (interquartile range = 17-33). CONCLUSIONS: This work reported the blood transfusion rate in incident HD patients in Canada during a period associated with conservative ESA prescription. The major indication for transfusion was a low Hb rather than clinical symptoms. Initiation of HD as an inpatient was independently associated with the probability of receiving a blood transfusion. These findings require further investigation.

CONTEXTE: Plusieurs études ont fait état de lésions associées à l'utilisation d'agents stimulant l'érythropoïèse (ASE) pour hausser le taux d'hémoglobine (Hb). Dès lors, une utilisation plus conservatrice des ASE a modifié le traitement de l'anémie chez les patients atteints d'insuffisance rénale chronique. OBJECTIFS DE L'ÉTUDE: L'étude visait à i) établir les taux de transfusion sanguine chez les patients hémodialysés au cours de la première année de traitement; ii) cerner les facteurs associés à la probabilité de recourir à une transfusion sanguine; iii) connaître les raisons de la transfusion; et iv) caractériser le taux d'hémoglobine au moment de l'intervention. En outre, un objectif exploratoire consistait à déterminer l'âge des érythrocytes transfusés. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte observationnelle prospective multicentrique. CADRE DE L'ÉTUDE: L'étude s'est tenue entre 2012 et 2014 sur douze sites répartis dans cinq provinces canadiennes. MÉTHODOLOGIE: Les patients adultes hémodialysés des centres participants ont été recrutés pour l'étude. Ont été exclus les patients atteints d'insuffisance rénale aiguë, les patients traités par dialyse péritonéale et les patients à être transférés vers une unité satellite. Pour être admissible, le patient devait recevoir un traitement d'hémodialyse continu pendant au moins un mois. On a rétrospectivement tiré des dossiers médicaux les données des trois mois précédant l'hémodialyse, puis on a extrait les données des dossiers médicaux chaque mois sur un an. RÉSULTATS: Un total de 314 patients a participé à l'étude et 79,9 % d'entre eux ont complété les 12 mois de suivi. Sur cette période, 94 patients (29,9 %) ont reçu au moins une transfusion sanguine. Au cours des 90 premiers jours, le taux d'épisodes transfusionnels était de 148,4 pour 100 années-patients, comparativement à 62,6 pour 100 années-patients pour le reste de l'étude. La raison la plus fréquente de recourir à une transfusion était un faible taux d'Hb (92 % des cas); les cas de saignements gastro-intestinaux, de perte de sang périchirurgicale et de fatigue comptaient quant à eux pour 9,9 %, 8,6 % et 4,5 % respectivement. Certains patients cumulant plus d'une indication. Le taux d'Hb moyen prétransfusion variait de 75,3 à 78,6 g/L. Une analyse de régression de Cox sur le temps écoulé jusqu'à la première transfusion et jusqu'à la première hospitalisation (ou le décès) du patient a montré une corrélation avec l'initiation d'un traitement d'hémodialyse chez les patients hospitalisés. Les sujets qui avaient initié leur traitement d'hémodialyse alors qu'ils étaient hospitalisés (37,5 %) ont reçu moins de soins prédialyse et présentaient davantage d'inflammation que les sujets qui avaient commencé leurs traitements d'hémodialyse en tant que patient externe. Enfin, l'âge moyen et l'âge médian des érythrocytes transfusés étaient de 24,9 jours (ÉT : 10,0) et de 23 jours (EIQ : 17 à 23). CONCLUSION: Notre étude a permis de connaître le taux de transfusions sanguines dans une population de patients hémodialysés canadiens au cours d'une période correspondant à une prescription conservatrice d'ASE. On a observé que la principale raison de transfusion était un faible taux d'Hb et non des symptômes cliniques. Enfin, une hémodialyse amorcée en cours d'hospitalisation a été associée à une probabilité accrue de transfusion sanguine. Nos constatations devraient faire l'objet d'études plus approfondies.

Vascular Access Practice Patterns in Canada: A National Survey.

BACKGROUND: One of the mandates of the Canadian Society of Nephrology's (CSN) Vascular Access Working Group (VAWG) is to inform the nephrology community of the current status of vascular access (VA) practice within Canada. To better understand VA practice patterns across Canada, the CSN VAWG conducted a national survey. OBJECTIVES: (1) To inform on VA practice patterns, including fistula creation and maintenance, within Canada. (2) To determine the degree of consensus among Canadian clinicians regarding patient suitability for fistula creation and to assess barriers to and facilitators of fistula creation in Canada. DESIGN: Development and implementation of a survey. SETTING: Community and academic VA programs. PARTICIPANTS: Nephrologists, surgeons, and nurses who are involved in VA programs across Canada. MEASUREMENTS: Practice patterns regarding access creation and maintenance, including indications and contraindications to fistula creation, as well as program-wide facilitators of and barriers to VA. METHODS: A small group of CSN VAWG members determined the scope and created several VA questions which were then reviewed by 5 additional VAWG members (4 nephrologists and 1 VA nurse) to ensure that questions were clear and relevant. The survey was then tested by the remaining members of the VAWG and refinements were made. The final survey version was submitted electronically to relevant clinicians (nephrologists, surgeons, and nurses) involved or interested in VA across Canada. Questions centered around 4 major themes: (1) Practice patterns regarding access creation (preoperative assessment and maturation assessment), (2) Practice patterns regarding access maintenance (surveillance and salvage), (3) Indications and contraindications for arteriovenous (AV) access creation, and (4) Facilitators of and barriers to fistula creation and utilization. RESULTS: Eighty-two percent (84 of 102) of invited participants completed the survey; the majority were nurses or VA coordinators (55%) with the remainder consisting of nephrologists (21%) and surgeons (20%). Variation in practice was noted in utility of preoperative Doppler ultrasound, interventions to assist nonmaturing fistulas, and procedures to salvage failing or thrombosed AV-access. Little consensus was seen regarding potential contraindications to AV-access creation (with the exception of limited life expectancy and poor vasculature on preoperative imaging, which had high agreement). Frequent barriers to fistula utilization were primary failure (77% of respondents) and long maturation times (73%). Respondents from centers with low fistula prevalence also cited long surgical wait times as an important barrier to fistula creation, whereas those from centers with high fistula prevalence cited access to multidisciplinary teams and interventional radiology as keys to successful fistula creation and utilization. CONCLUSIONS: There is significant variation in VA practice across Canada and little consensus among Canadian clinicians regarding contraindications to fistula creation. Further high-quality studies are needed with regard to appropriate fistula placement to help guide clinical practice.

CONTEXTE: L'un des mandats du Groupe de travail en accès vasculaire (GTAV) de la Société canadienne de néphrologie consiste à informer la communauté en néphrologie des schémas de pratique actuels en accès vasculaire au Canada. Le GTAV a mené un sondage pancanadien pour mieux comprendre les schémas de pratique existants au pays en matière d'accès vasculaire. OBJECTIFS: (1) Informer la communauté des schémas de pratique canadiens (notamment en ce qui a trait à la création et au maintien fistulaire). (2) Déterminer le niveau de consensus parmi les cliniciens canadiens concernant l'admissibilité d'un patient à la création d'une fistule et les facteurs facilitant ou entravant la procédure. TYPE D'ÉTUDE: Il s'agit de la conception et de la réalisation d'un sondage. CADRE DE L'ÉTUDE: Programmes d'accès vasculaire en milieu universitaire ou communautaire. PARTICIPANTS: Ont été invités à participer néphrologues, chirurgiens et membres du personnel infirmier intervenant dans un programme d'accès vasculaire canadien. MESURES: Nous avons sondé les participants à propos de leur schéma de pratique concernant la création et l'entretien fistulaire, notamment les indications et contre-indications à la création d'une fistule, ainsi que des facteurs facilitant ou entravant la procédure dans leur milieu de pratique. MÉTHODOLOGIE: Quelques membres du GTAV ont défini le cadre du sondage et ont rédigé une série de questions. Cinq autres membres du GTAV (quatre néphrologues et un membre du personnel infirmier en accès vasculaire) ont ensuite validé la clarté et la pertinence des questions soumises. Finalement, le sondage a été testé auprès des autres membres du GTAV pour y apporter des ajustements. La version définitive du sondage a été envoyée électroniquement à des cliniciens (néphrologues, chirurgiens et membres du personnel infirmier) canadiens intervenant en accès vasculaire ou qui s'y intéressent. Les questions abordaient quatre thèmes : i) les schémas de pratique en création fistulaire (évaluation préopératoire, évaluation de la maturation fistulaire); ii) les schémas de pratique en entretien fistulaire (surveillance et rétablissement de l'accès vasculaire); iii) les indications et contre-indications à la création d'une fistule artérioveineuse; iv) les facteurs facilitant et entravant la création fistulaire et son utilisation. RÉSULTATS: Des 102 personnes invitées à participer au sondage, 84 (82 %) ont répondu au questionnaire. La majorité (55 %) était constituée de membres du personnel infirmier et de coordonnateurs en accès vasculaire. La différence se composait essentiellement de néphrologues (21 %) et de chirurgiens (20 %). On a noté une variabilité des habitudes de pratique quant au recours à une échographie Doppler en préopératoire, aux interventions en cas de fistules non formées et aux procédures de rétablissement d'un accès artériovasculaire défaillant ou thrombosé. Il n'existe pas de consensus sur les éventuelles contre-indications à la création d'un accès artériovasculaire, à l'exception de deux points : une espérance de vie limitée et une structure vasculaire faible (révélée par imagerie préopératoire). La défaillance primitive et un long délai de maturation ont été cernés comme obstacles au recours à la fistule par une majorité de répondants (77 % et 73 %, respectivement). Les répondants de centres où l'on pratique peu d'interventions fistulaires ont mentionné les longs délais d'attente préopératoire comme entrave; les répondants de centres où l'on pratique fréquemment l'intervention fistulaire ont quant à eux souligné deux facteurs facilitant la création fistulaire et son utilisation : l'accès à des équipes multidisciplinaires et à la radiologie interventionnelle. CONCLUSION: Au Canada, les schémas de pratique clinique en accès vasculaire varient fortement, et les indications et contre-indications à la création fistulaire ne font pas consensus au sein des cliniciens. D'autres études rigoureuses sur les conditions adéquates pour la pratique d'une intervention fistulaire sont nécessaires afin d'orienter la pratique clinique.

Extended Duration Nocturnal Hemodialysis and Changes in Plasma Metabolite Profiles.

BACKGROUND AND OBJECTIVES: In-center, extended duration nocturnal hemodialysis has been associated with variable clinical benefits, but the effect of extended duration hemodialysis on many established uremic solutes and other components of the metabolome is unknown. We determined the magnitude of change in metabolite profiles for patients on extended duration nocturnal hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In a 52-week prospective, observational study, we followed 33 patients receiving conventional thrice weekly hemodialysis who converted to nocturnal hemodialysis (7-8 hours per session, three times per week). A separate group of 20 patients who remained on conventional hemodialysis (3-4 hours per session, three times per week) served as a control group. For both groups, we applied liquid chromatography-mass spectrometry-based metabolite profiling on stored plasma samples collected from all participants at baseline and after 1 year. We examined longitudinal changes in 164 metabolites among those who remained on conventional hemodialysis and those who converted to nocturnal hemodialysis using Wilcoxon rank sum tests adjusted for multiple comparisons (false discovery rate <0.05). RESULTS: On average, the nocturnal group had 9.6 hours more dialysis per week than the conventional group. Among 164 metabolites, none changed significantly from baseline to study end in the conventional group. Twenty-nine metabolites changed in the nocturnal group, 21 of which increased from baseline to study end (including all branched-chain amino acids). Eight metabolites decreased after conversion to nocturnal dialysis, including l-carnitine and acetylcarnitine. By contrast, several established uremic retention solutes, including p-cresol sulfate, indoxyl sulfate, and trimethylamine N-oxide, did not change with extended dialysis. CONCLUSIONS: Across a wide array of metabolites examined, extended duration hemodialysis was associated with modest changes in the plasma metabolome, with most differences relating to metabolite increases, despite increased dialysis time. Few metabolites showed reduction with more dialysis, and no change in several established uremic toxins was observed.

Effectiveness and Cost of Weekly Recombinant Tissue Plasminogen Activator Hemodialysis Catheter Locking Solution.

BACKGROUND AND OBJECTIVES: Evidence to guide hemodialysis catheter locking solutions is limited. We aimed to assess effectiveness and cost of recombinant tissue plasminogen activator (rt-PA) once per week as a locking solution, compared with thrice weekly citrate or heparin, in patients at high risk of complications. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used a prospective design and pre-post comparison in three sites across Canada. Pre-post comparisons were conducted using multilevel mixed effects regression models accounting for cluster with site and potential enrollment of patients more than once. In the pre period, catheter malfunction was managed as per site-specific standard of care. The intervention in the post period was once weekly rt-PA as a locking solution (with citrate or heparin used for other sessions). The primary outcome was rate of rt-PA use for treatment of catheter malfunction. Secondary outcomes included rates of bacteremia, management of catheter malfunction, and cost. RESULTS: There were 374 patients (mean age 68 years; 52% men) corresponding to 506 enrollments. Mean length of enrollment was 200 days (SD 119) in the pre period and 187 days (SD 101) in the post period. There was a significant decline in rate of rt-PA use for treatment of catheter malfunction in the post compared with pre period (adjusted incidence rate ratio, 0.39; 95% confidence interval, 0.30 to 0.52); however, there was no difference in the rate of bacteremia, or catheter stripping or removal/replacement. The increase in mean total health care cost in the post period was CAD$962 per enrollment, largely related to costs of rt-PA as a locking solution. CONCLUSIONS: Once weekly rt-PA as a catheter locking solution was associated with a reduction in rt-PA use for treatment of catheter malfunction. Our results showing a reduction in rescue rt-PA use are consistent with a prior randomized trial, although we did not observe a reduction in bacteremia or catheter stripping/removal and did observe an increased incremental cost of this strategy primarily accounted for by the cost of the rt-PA.

Comparison of hypoalbuminemia-corrected serum calcium using BCP albumin assay to ionized calcium and impact on prescribing in hemodialysis patients
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BACKGROUND: Albumin-corrected calcium (cCa) is recommended over ionized calcium (iCa) in hemodialysis (HD) patients per the Kidney Disease: Improving Global Outcomes position statements due to cost and feasibility. Two common albumin assays, bromocresol green (BCG) and bromocresol purple (BCP), produce differing results in uremic patients. All previous studies compared iCa to cCa from a BCG assay. This study, using the BCP assay, aimed to compare cCa and total calcium, respectively, to iCa. We also sought to assess phosphate binders and dialysis prescribing patterns following abnormal calcium measurements. MATERIALS AND METHODS: Retrospective review of 122 stable chronic HD patients with iCa, serum calcium, and albumin measured together throughout 6 blood work periods for a total of 338 sets of comparison values. Payne and Jain calcium correction equations were used. Prescription changes within 2 weeks of abnormal iCa values were recorded. RESULTS: Mean iCa, cCa, and total calcium were 1.17 ± 0.08, 2.37 ± 0.16, and 2.28 ± 0.15 mmol/L, respectively. Total calcium and cCa compared to iCa had κ-coefficients of 0.19 and 0.08, respectively, for hypocalcemia, 0.19 and -0.02 for normocalcemia and 0.59 and 0.46 for hypercalcemia. 21 interventions were made in hypocalcemic patients using iCa as reference; however, if total or corrected calcium values were used, only 8 and 5 interventions, respectively, would result. CONCLUSION: When BCP assay is used, conventional correction equations should not be utilized in hemodialysis patients; uncorrected serum calcium has a better predictive value.
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Association between conversion to in-center nocturnal hemodialysis and right ventricular remodeling.

Background: In-center nocturnal hemodialysis (INHD) is associated with favorable left ventricular (LV) remodeling. Although right ventricular (RV) structure and function carry prognostic significance, the impact of dialysis intensification on RV is unknown. Our objectives were to evaluate changes in RV mass index (MI), end-diastolic volume index (EDVI), end-systolic volume index (ESVI) and ejection fraction (EF) after conversion to INHD and their relationship with LV remodeling. Methods: Of 67 conventional hemodialysis (CHD, 4 h/session, three times/week) patients, 30 continued on CHD and 37 converted to INHD (7-8 h/session, three times/week). Cardiac magnetic resonance imaging was performed at baseline and 1 year using a standardized protocol; an experienced and blinded reader performed RV measurements. Results: At 1 year there were significant reductions in RVMI {-2.1 g/m2 [95% confidence interval (CI) -3.8 to - 0.4], P = 0.017}, RVEDVI [-9.5 mL/m2 (95% CI - 16.3 to - 2.6), P = 0.008] and RVESVI [-6.2 mL/m2 (95% CI - 10.9 to - 1.6), P = 0.011] in the INHD group; no significant changes were observed in the CHD group. Between-group comparisons showed significantly greater reduction of RVESVI [-7.9 mL/m2 (95% CI - 14.9 to - 0.9), P = 0.03] in the INHD group, a nonsignificant trend toward greater reduction in RVEDVI and no significant difference in RVMI and RVEF changes. There was significant correlation between LV and RV in terms of changes in mass index (MI) (r = 0.46), EDVI (r = 0.73), ESVI (r = 0.7) and EF (r = 0.38) over 1 year (all P < 0.01). Conclusions: Conversion to INHD was associated with a significant reduction of RVESVI. Temporal changes in RV mass, volume and function paralleled those of LV. Our findings support the need for larger, longer-term studies to confirm favorable RV remodeling and determine its impact on clinical outcomes.