Real world treatment of hypertension on hemodialyses-data from large Polish database.

INTRODUCTION: The prevalence of hypertension among patients with end stage kidney disease (ESKD) undergoing hemodialysis (HD) ranges from 72-88% depending on applied diagnostic criteria and chosen method of blood pressure measurement. Despite the guidelines recommending the widespread use of renin angiotensin system blockers (RASB) in patients with kidney disease, their utilization in patients on HD may be suboptimal, especially in patients with preserved diuresis. This hesitance often steams from concern is often due to fear of a decrease in eGFR and a subsequent decrease in diuresis. The aim of this study was to compare clinical characteristics, blood pressure, safety, and hemodialysis adequacy indices in hypertensive HD patients on multiple antihypertensive drug regimens, including diuretic treated with RASB (RASB group) or without RASB (no-RASB) with preserved residual diuresis. We sought to examine the real life use of RASB in hemodialysis patients in relation to their clinical characteristics, blood pressure, safety, and hemodialysis adequacy. METHODS: From a database of 5879 patients receiving hemodialysis (mean age 65.2±14.2 yrs., 60% of males) of the largest provider of HD in the country, we selected the subgroup treated with at least three antihypertensive medications including diuretics. We compared patients treated with RASB to counterparts without RASB (no-RASB). RESULTS: RASB group has similar age and gender proportions as well as BMI and bioimpedance,compared to counterparts. However, dry body mass was significantly lower in the RASB group (78.1±18.3 kg vs. 80.0±18.2 kg, p<0.017). Prevalence of diabetes mellitus was similar in both groups, but RASB-treated patients have cardiovascular diseases more frequently (70.1% vs. 60.8%; p<0.001). Systolic blood pressure and the number of antihypertensive drugs used were significantly higher in RASB patients than in counterparts (146±16 mmHg vs. 144±15 mmHg; p<0.001 and 4.1±0.9 vs. 3.5±0.5; p<0001 respectively). RASB-treated patients have significantly longer dialysis vintage (52.7±44.4 months vs. 40.2±40.9 months; p<0.001) and dialysis time (722±87.1 min./week vs. 713±93.4 min./week;p<0.017) than counterparts. Serum potassium was slightly but significantly higher in RASB (5.3±0.8 mmol/L vs. 5.1±0.7 mmol/L;p<0.01). CONCLUSIONS: In the real world setting, RASB can be safely used in HD patients treated with diuretics with preserved residual diuresis. Given that many HD patients present numerous multimorbidities, RASB should not only be considered as an additional hypotensive drug in poorly controlled hypertension but also in other compelling indications in HD patients. The tendency toward hyperkalemia in HD patients could be effectively managed with appropriate diet and HD prescription adjustments.

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.

[Contemporary opinions on the diagnosis and treatment of secondary hyperparathyroidism].

Secondary hyperparathyroidism is one of the most common hormonal disorders associated with a chronic kidney disease. The main causes of this disease are associated with renal failure hyperphosphatemia, hypocalcemia, and active form of vitamin D deficiency. The progressive secondary hyperparathyroidism leads to a series of complications known as a mineral and bone disorder in a chronic kidney disease. In the treatment of secondary hyperparathyroidism the most important role is played by stabilization of calcium-phosphate metabolism (through proper diet regimen, the use of phosphate binders) and reducing the synthesis and secretion of parathyroid hormone by the administration of calcimimetics and preparations of vitamin D. In the event of failure of conservative treatment complete or partial parathyroid resection should be considered.

[Treatment of secondary hyperparathyroidism in hemodialysed patients--paricalcitol with or without cinacalcet]. / Leczenie wtórnej nadczynnosci przytarczyc u chorych hemodializowanych--parykalcytol razem z cynakalcetem czy osobno?

Secondary hyperparathyroidism (sHPT) is a common complication being a consequence of metabolic disorders associated with chronic kidney disease (CKD). Treatment of the sHPT should lead to calcium-phosphate management stabilization and parathyroid hormone levels reduction. The phosphate binders, synthetic vitamin D analogs and calcimimetics are used in sHPT treatment. In this paper we analyzed the results of three month paricalcitol treatment of 36 hemodialysis patients with sHPT (serum iPTH> 500 pg/ml). 11 patients have additionally received cinacalcet. Analysis of the results showes a statistically significant reduction in iPTH and alkaline phosphatase. Paricalcitol is effecitve in the tratment of SHPT with favourable profile of side effects. Alcaline phosphatase reduction may be a desirable additional therapeuctic effect. However, it appears that combined therapy with paricalcitol and cinacalcet shoud be offered to selected population of patients i.e. with hypocalcemia after calcimimetics.

Apparently Resistant Hypertension in Polish Hemodialyzed Population: Prevalence and Risk Factors.

BACKGROUND: The aim of this study was to assess the prevalence, characteristics, and determinants of apparent treatment-resistant hypertension (aTRH) in an unselected large population of patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) throughout the country. METHODS: A database of 5879 patients (mean age 65.2 ± 14.2 years, 60% of males receiving hemodialysis) was obtained from the biggest provider of hemodialysis in the country. Hypertension and aTRH were defined using pre- or/and post-dialysis BP values. Patients with and without aTRH (non-aTRH) were compared. RESULTS: Using pre- and post-dialysis criteria, hypertension was diagnosed in 90.7% and 89.1% of subjects, respectively. According to pre- and post-dialysis blood pressure criteria, aTRH incidences were 40.9% and 38.4%, respectively. The hypertensive patients with aTRH versus non-aTRH were younger, had a higher rate of cardiovascular disease, lower dialysis vintage, shorter time on dialysis, higher eKt/V, higher ultrafiltration, higher pre- and post-dialysis BP and HR, and higher use of antihypertensive drugs. Factors that increase the risk of aTRH according to both pre- and post-dialysis BP criteria were age-OR 0.99 [0.98-0.99] and 0.99 [0.98-0.99], the history of CVD 1.26 [1.08-1.46] and 1.30 [1.12-1.51], and diabetes 1.26 [1.08-1.47] and 1.28 [1.09-1.49], adjusted OR with 95% CI. CONCLUSIONS: In the real-life world, as much as 40% of HD patients may have aTRH. In ESKD HD patients, aTRH seems to be multifactorial, influenced by patient-related rather than dialysis-related factors. Various definitions of aTRH preclude easy comparisons between studies.

How COVID-19 Outbreak Influenced Transplantation in Poland.

Announced by the World Health Organization in early 2020, the pandemic caused by SARS-CoV-2 infections has had a huge impact on healthcare systems around the world. Local and international authorities focused on implementing procedures to safeguard the health of the population. All regular daily activities were disrupted. Similar factors related to the global fight against the COVID-19 epidemic also had a large impact on transplantation activity. In this article, the authors present the number of patients qualified for transplantation, transplanted and waiting on the waiting list in Poland during the 2-year period of the pandemic. In the first year of the epidemic (2020), all transplantation figures dropped drastically, by as much as 20-30% compared with 2019. The most disturbing fact is that the number of transplants performed in 2022 is still lower than before the outbreak of the epidemic (2019 and earlier).

Vaccination and COVID-19 in Polish Dialysis Patients: Results from the European Clinical Dialysis Database.

Background: Patients with end-stage kidney disease undergoing hemodialysis are particularly vulnerable to severe COVID-19 as a result of older age and multimorbidities. Objectives: Data are still limited and there are no published data on mortality in hemodialyzed patients in Poland, in particular when vaccines became available. We assessed the epidemiologic and clinical data of patients with laboratory-confirmed COVID-19 and assessed the mortality in 2019, 2020, and 2021, as well as the vaccination rate in 2021. Patients and Methods: Retrospectively collected data from 73 Fresenius Nephrocare Poland hemodialysis centers and one public unit were analyzed. Results: In 2021, the vaccination rate was 96%. The unadjusted mortality (number of deaths divided by number of patients) in 2019 was 18.8%, while the unadjusted (after exclusion of COVID-related deaths) mortality in 2020 was 20.8%, and mortality in 2021 was 16.22%. The prevalence of cardiovascular deaths in 2019 and 2020 was almost identical (41.4% vs. 41.2%, respectively), and in 2021, the figures increased slightly to 44.1%. The prevalence of sudden cardiac deaths in 2019 was higher than in 2020 (19.6% vs. 17.3%, respectively) and consequently decreased in 2021 (10.0%), as well as strokes (6.2% vs. 5.4%, and 3.31% in 2021), whereas deaths due to gastrointestinal tract diseases were lower (2.5% vs. 3.2%, and 2.25% in 2021), diabetes complications (0.5% vs. 1.3%, and 0.5% in 2021), sepsis (5.1% vs. 6.3%, and 8.79% in 2021), respiratory failure (1.2 vs. 1.6%, and 2.83% in 2021), and pneumonia (1.4% vs. 2.0%, and 0.82%). There were 1493 hemodialyzed COVID-19 positive patients, and among them, 191 died in 2020 (12.79%). In 2021, there were 1224 COVID-19 positive patients and 260 died (21.24%). The mortality of COVID-19 positive dialyzed patients contributed 13.39% in 2020 and 16.21% in 2021 of all recorded deaths. Conclusions: The mortality among HD patients was higher in 2021 than in 2020 and 2019, despite the very high vaccination rate of up to 96%. The higher non-COVID-19 mortality may be due to the limited possibility of hospitalization and dedicated care during the pandemic. This information is extremely important in order to develop methods to protect this highly vulnerable patient group. Prevention plays a key role; other measures are essential in the mitigation and spread of COVID-19 in HD centers.

SARS-CoV-2 mRNA Vaccine-Induced Cellular and Humoral Immunity in Hemodialysis Patients.

BACKGROUND/AIMS: Chronic kidney disease CKD patients on intermittent hemodialysis IHD are exposed to SARS-CoV-2 infection and carry a risk of developing severe symptoms. The aim of this study was to evaluate the humoral and cellular immunity induced by two doses of mRNA vaccines, the Pfizer-BioNTech (Comirnaty) COVID-19 Vaccine and the Moderna (mRNA-1273) COVID-19 vaccine. PATIENTS AND METHODS: The study included 281 patients from five dialysis centers in northern Poland. Within 2 weeks prior to the first dose of the vaccine, a blood sample was collected for an evaluation of SARS-CoV-2 antibodies. Thirty to forty-five days after the second dose of the vaccine, a blood sample was taken to evaluate humoral and cellular response. RESULTS: Patients with stage 5 CKD on IHD were characterized by a considerable SARS-CoV-2 vaccine-induced seroconversion rate. The strongest factors influencing the antibodies AB level after vaccination were a pre-vaccination history of SARS-CoV-2 infection, age, the neutrophil-to-lymphocyte ratio NLR, neutrophil absolute count, and the hemoglobin level. Cellular immunity was higher in patients with a pre-vaccination history of SARS-CoV-2 infection. Cellular immunity depended on the albumin level. Positive cellular response to vaccination was a positive factor reducing all-cause mortality, except for COVID-19 mortality (no such deaths were reported during our follow-up). Cellular immunity and humoral immunity were positively mutually dependent. High levels of albumin and hemoglobin, low neutrophil count, and a reduced NLR, translated into better response to vaccination. CONCLUSIONS: Patients with stage 5 CKD on IHD were characterized by a considerable SARS-CoV-2 vaccine-induced seroconversion rate and a good rate of cellular immunity. The factors that change with exacerbating inflammation and malnutrition (albumin, hemoglobin, neutrophil count, the NLR) affected the efficacy of the vaccination.

Eco-dialysis: fashion or necessity.

Hemodialysis (HD) is one of the resource hungry medical interventions. A huge volume of water (about 500 L) and significant amounts of energy (over 7 kW) are used for a hemodialysis session; over a kilogram of waste is produced during this procedure. Thus, HD contributes to global warming while saving patients' lives. In this paper, we showed these crucial points in HD treatment and possible ways (e.g. modifications in dialysate flow rate) to reduce environmental impact maintaining therapy standards.

Three Therapeutic Strategies: Cinacalcet, Paricalcitol or Both in Secondary Hyperparathyroidism Treatment in Hemodialysed Patients During 1-Year Observational Study-A Comparison.

Introduction: Secondary hyperparathyroidism (sHPT) is a common hormonal complication of chronic kidney disease. There are several therapeutic options for sHPT management aiming at calcium-phosphorus balance normalization and decrease of parathormone secretion. Objectives: The aim of this retrospective, observational study was the outcome assessement of three most common therapeutic strategies of secondary hyperparathyroidism treatment with vitamin D receptor activator-paricalcitol, calcimimetic-cinacalcet or both agents administered together during in 12-months period. Methods: One hundred and thirty-one haemodialysed patients with uncontrolled parathyroid hormone secretion have been treated with paricalcitol administered intravenously (group PAR-60 patients) or cinacalcet per os (group CIN-50 patients). The last group (group PAR+CIN-21 patients) received paricalcitol i.v. and oral cinacalcet administered simultaneously. Results: In all groups, the iPTH level decreased significantly, however in group 1 treated with paricalcitol administered intravenously iPTH level decrease was greater than in group 2 treated with cinacalcet and in group 3 treated with paricalcitol and cinacalcet in parallel. The most substantial change of iPTH level was noticed after 3-months of observation. After this period the iPTH level was stabilized and maintained till the end of observation. Safety level of all strategies was comparable. No severe hypercalcemia or hypocalcemia was observed during the whole period of observation. Conclusions: The results of observation show significant advantage of intravenous paricalcitol treatment. Complementing cinacalcet therapy with paricalcitol does not improve treatment outcomes. In case of unsatisfactory results after 3-months treatment, potential continuation should be considered carefully. Among three available therapeutic options, the treatment with paricalcitol i.v. should be considered in all haemodialysed patients with inadequate control of serum PTH level. The second option-with cinacalced administered orally should be considered in PD patients and when severe hypercalcemia occurs.

Treatment of secondary hyperparathyroidism with paricalcitol with or without cinacalcet in hemodialysis patients.

INTRODUCTION    Secondary hyperparathyroidism (SHPT) is a common hormonal disorder associated with chronic kidney disease (CKD). The treatment of SHPT should lead to a reduction in parathormone concentrations by calcimimetics or active vitamin D administration and stabilization of calciumand phosphate metabolism. In the event of failure of conservative treatment, complete or partial parathyroid resection should be considered. OBJECTIVES    The aim of the study was to assess the beneficial effects of a combination treatment with paricalcitol and cinacalcet in comparison with paricalcitol alone. PATIENTS AND METHODS    A total of 64 hemodialyzed patients (mean [SD] age, 58 [16] years) with inadequate control of serum parathyroid hormone levels were treated with intravenous paricalcitol, while 16 patients simultaneously received oral cinacalcet. Laboratory tests (intact parathormone [iPTH], calcium, phosphorus) were performed on a monthly basis. In the study, iPTH, calium, phosphorus, and alkaline phosphatase levels were assessed at baseline and after 24 weeks of treatment with paricalcitol alone or in combination with cinacalcet. RESULTS    In both groups, a significant decrease in the iPTH level was observed. Although paricalcitol affects calcium levels, no hypercalcemia was observed. The combination treatment did not result in a significant lowering of iPTH levels in comparison with paricalcitol alone. CONCLUSIONS    Treatment of SHPT with intravenous paricalcitol in patients on hemodialysis is effective and has a good safety profile. The combination of paricalcitol and cinacalcet does not improve the outcomes. Moreover, the combined treatment does not affect calcium and phosphorus concentrations. The cost­effectiveness of therapy should also be considered.