Controversy on the CONVINCE study findings: the PRO take / Controvérsia sobre os achados do estudo CONVINCE: a perspectiva PRO

ABSTRACT The CONVINCE study, recently published in the New England Journal of Medicine, reveals a groundbreaking 23% reduction in the relative risk of all-cause mortality among end-stage kidney patients undergoing high convective volume hemodiafiltration. This significant finding challenges the conventional use of high-flux hemodialysis and offers hope for improving outcomes in chronic kidney disease patients. While some controversies surround the study's findings, including concerns about generalizability and the causes of death, it is essential to acknowledge the study's design and its main outcomes. The CONVINCE study, part of the HORIZON 2020 project, enrolled 1360 patients and demonstrated the superiority of hemodiafiltration in reducing all-cause mortality overall, as well as in specific patient subgroups (elderly, short vintage, non-diabetic, and those without cardiac issues). Interestingly, it was shown that hemodiafiltration had a protective effect against infection, including COVID-19. Future research will address sustainability, dose scaling effects, identification of subgroups especially likely to benefit and cost-effectiveness. However, for now, the findings strongly support a broader adoption of hemodiafiltration in renal replacement therapy, marking a significant advancement in the field.

RESUMO O estudo CONVINCE, publicado recentemente no New England Journal of Medicine, revela uma redução inovadora de 23% no risco relativo de mortalidade por todas as causas entre pacientes renais em estágio terminal submetidos à hemodiafiltração de alto volume de convecção. Esse achado significativo desafia o uso convencional da hemodiálise de alto fluxo e oferece esperança de melhoria dos desfechos em pacientes com doença renal crônica. Embora algumas controvérsias cerquem os achados do estudo, incluindo preocupações sobre a generalização e as causas de óbito, é essencial reconhecer o desenho do estudo e seus principais desfechos. O estudo CONVINCE, parte do projeto HORIZON 2020, inscreveu 1.360 pacientes e demonstrou a superioridade da hemodiafiltração na redução da mortalidade por todas as causas em geral, bem como em subgrupos específicos de pacientes (idosos, HD de curta duração, não diabéticos e aqueles sem problemas cardíacos). Curiosamente, demonstrou-se que a hemodiafiltração teve um efeito protetor contra infecções, incluindo a COVID-19. Pesquisas futuras abordarão sustentabilidade, efeitos de escalonamento da dose, identificação de subgrupos especialmente propensos a se beneficiar e a relação custo-benefício. No entanto, por ora, os achados apoiam fortemente uma adoção mais ampla da hemodiafiltração na terapia renal substitutiva, marcando um avanço significativo na área.

Hemodiafiltration: a synergy yet to be convincing / Hemodiafiltração: uma sinergia ainda não convincente

ABSTRACT The desperate attempt to improve mortality, morbidity, quality of life and patient-reported outcomes in patients on hemodialysis has led to multiple attempts to improve the different modes, frequencies, and durations of dialysis sessions in the last few decades. Nothing has been more appealing than the combination of diffusion and convection in the form of hemodiafiltration. Despite the concrete evidence of better clearance of middle weight molecules and better hemodynamic stability, tangible evidence to support the universal adoption is still at a distance. Survival benefits seen in selected groups who are likely to tolerate hemodiafiltration with better vascular access and with lower comorbid burden, need to be extended to real life dialysis patients who are older than the population studied and have significantly higher comorbid burden. Technical demands of initiation hemodiafiltration, the associated costs, and the incremental benefits targeted, along with patient-reported outcomes, need to be explored further before recommending hemodiafiltration as the mode of choice.

RESUMO A tentativa desesperada de melhorar a mortalidade, morbidade, qualidade de vida e desfechos relatados pelos pacientes em indivíduos em hemodiálise levou a diversas tentativas de aprimorar os diferentes modos, frequências e durações das sessões de diálise nas últimas décadas. Nada foi mais atrativo do que a combinação de difusão e convecção na forma de hemodiafiltração. Apesar das evidências concretas de melhor depuração de moléculas de peso médio e melhor estabilidade hemodinâmica, evidências tangíveis para apoiar a adoção universal ainda estão distantes. Os benefícios de sobrevida observados em grupos selecionados que provavelmente toleram a hemodiafiltração com melhor acesso vascular e com menor carga de comorbidades precisam ser estendidos aos pacientes reais em diálise, que são mais velhos do que a população estudada e apresentam uma carga de comorbidades significativamente maior. As exigências técnicas do início da hemodiafiltração, os custos associados e os benefícios incrementais almejados, juntamente com os desfechos relatados pelos pacientes, precisam ser melhor explorados antes de se recomendar a hemodiafiltração como o modo de escolha.

Brazilian Dialysis Survey 2022 / Censo Brasileiro de Diálise 2022

Abstract Introduction: The Brazilian Dialysis Survey (BDS) is an annual national survey about patients on chronic dialysis that contributes to health policies. Objective: To report the 2022 epidemiological data from the BDS of the Brazilian Society of Nephrology (BSN). Methods: A survey was carried out in Brazilian chronic dialysis centers using an online questionnaire that included clinical and epidemiological aspects of patients on chronic dialysis, dialysis therapy data, and dialysis center characteristics. Results: Overall, 28% (n = 243) of the centers answered the questionnaire. In July 2022, the estimated total number of patients on dialysis was 153,831. The estimated prevalence and incidence rates of patients per million population (pmp) were 758 and 214, respectively. Of the prevalent patients, 95.3% were on hemodialysis (HD, 4.6% of these on hemodiafiltration) and 4.7% on peritoneal dialysis (PD). Only 1.3% of patients were not vaccinated against COVID-19. The prevalence of anemia (Hb < 10g/dL) was 27% and hyperphosphatemia (P > 5.5mg/dL) reached 30%. The estimated overall crude annual mortality rate was 17.1%. Conclusions: The absolute number and prevalence rate of patients on chronic dialysis continue to increase. A growing number of patients were receiving hemodiafiltration. The mortality rate decreased, probably due to the end of COVID-19 pandemic. The conclusions were drawn in the context of relatively low voluntary participation, which imposed methodological limitations on our estimates.

Resumo Introdução: O Censo Brasileiro de Diálise (CBD) é uma pesquisa nacional anual sobre pacientes em diálise crônica que contribui para as políticas de saúde. Objetivo: Informar os dados epidemiológicos de 2022 do CBD da Sociedade Brasileira de Nefrologia (SBN). Métodos: Foi realizada uma pesquisa em centros brasileiros de diálise por meio de um questionário online que incluiu aspectos clínicos e epidemiológicos de pacientes em diálise crônica, dados da terapia dialítica e características do centro de diálise. Resultados: No total, 28% (n = 243) dos centros de diálise ativos cadastrados na SBN responderam ao questionário. Em julho de 2022, o número total estimado de pacientes em diálise era de 153.831. As taxas estimadas de prevalência e incidência de pacientes por milhão (ppm) de habitantes foram 758 e 214, respectivamente. Dos pacientes prevalentes, 95,3% estavam em hemodiálise (HD; 4,6% desses em hemodiafiltração) e 4,7% em diálise peritoneal (DP). Apenas 1,3% dos pacientes não foram vacinados contra a COVID-19. A prevalência de anemia (Hb < 10g/dL) foi de 27% e de hiperfosfatemia (P > 5,5mg/dL) alcançou 30%. A taxa bruta total anual de mortalidade estimada foi de 17,1%. Conclusões: O número absoluto e a taxa de prevalência de pacientes em diálise crônica continuam a aumentar. Um número crescente de pacientes estava em hemodiafiltração. A taxa de mortalidade diminuiu, provavelmente devido ao fim da pandemia da COVID-19. As conclusões foram de um contexto de participação voluntária relativamente baixa, o que impõe limitações metodológicas às nossas estimativas.

Predicting factors for early failure of vascular access in hemodialysis patients.

Purpose: This study aimed to investigate the incidence of early failure of vascular access for hemodialysis, and determine which factors measured in duplex ultrasound study could predict early failure. Methods: We performed a retrospective review of patients who underwent arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation for hemodialysis between September 2019 and January 2023. Early failure was defined as any event that required surgical or endovascular intervention within 6 months following AVF or AVG creation. Results: A total of 189 patients were included. Early failure occurred in 36 patients (19.0%), which included 22 AVFs and 14 AVGs. In the patients who underwent AVF, the preoperative venous diameter, postoperative venous and arterial diameters, and flow volume of AVF all were significantly smaller in the early failure group compared to the patent group. In AVG, the preoperative venous diameter was the only parameter that differed between the 2 groups. A sonographic score was defined based on these factors. In a multivariable analysis, male sex, a previous history of AVF or AVG creation, and sonographic score were found to be significantly associated with early failure. The postoperative venous diameter in AVF and the preoperative venous diameter in AVG were highly predictive of early failure (areas under the curves 0.92 and 0.82, respectively). Conclusion: Venous diameter measured 6 weeks following AVF operation and preoperative venous diameter in AVG were highly predictive of early failure among the duplex ultrasound parameters. Surveillance strategies in the early phase following vascular access creation can be based on these factors.

Doppler ultrasound surveillance of recently formed haemodialysis arteriovenous fistula: the SONAR observational cohort study.

Background: Arteriovenous fistulas are considered the best option for haemodialysis provision, but as many as 30% fail to mature or suffer early failure. Objective: To assess the feasibility of performing a randomised controlled trial that examines whether, by informing early and effective salvage intervention of fistulas that would otherwise fail, Doppler ultrasound surveillance of developing arteriovenous fistulas improves longer-term arteriovenous fistula patency. Design: A prospective multicentre observational cohort study (the 'SONAR' study). Setting: Seventeen haemodialysis centres in the UK. Participants: Consenting adults with end-stage renal disease who were scheduled to have an arteriovenous fistula created. Intervention: Participants underwent Doppler ultrasound surveillance of their arteriovenous fistulas at 2, 4, 6 and 10 weeks after creation, with clinical teams blinded to the ultrasound surveillance findings. Main outcome measures: Fistula maturation at week 10 defined according to ultrasound surveillance parameters of representative venous diameter and blood flow (wrist arteriovenous fistulas: ≥ 4 mm and > 400 ml/minute; elbow arteriovenous fistulas: ≥ 5 mm and > 500 ml/minute). Mixed multivariable logistic regression modelling of the early ultrasound scan data was used to predict arteriovenous fistula non-maturation by 10 weeks and fistula failure at 6 months. Results: A total of 333 arteriovenous fistulas were created during the study window (47.7% wrist, 52.3% elbow). By 2 weeks, 37 (11.1%) arteriovenous fistulas had failed (thrombosed), but by 10 weeks, 219 of 333 (65.8%) of created arteriovenous fistulas had reached maturity (60.4% wrist, 67.2% elbow). Persistently lower flow rates and venous diameters were observed in those fistulas that did not mature. Models for arteriovenous fistulas' non-maturation could be optimally constructed using the week 4 scan data, with fistula venous diameter and flow rate the most significant variables in explaining wrist fistula maturity failure (positive predictive value 60.6%, 95% confidence interval 43.9% to 77.3%), whereas resistance index and flow rate were most significant for elbow arteriovenous fistulas (positive predictive value 66.7%, 95% confidence interval 48.9% to 84.4%). In contrast to non-maturation, both models predicted fistula maturation much more reliably [negative predictive values of 95.4% (95% confidence interval 91.0% to 99.8%) and 95.6% (95% confidence interval 91.8% to 99.4%) for wrist and elbow, respectively]. Additional follow-up and modelling on a subset (n = 192) of the original SONAR cohort (the SONAR-12M study) revealed the rates of primary, assisted primary and secondary patency arteriovenous fistulas at 6 months were 76.5, 80.7 and 83.3, respectively. Fistula vein size, flow rate and resistance index could identify primary patency failure at 6 months, with similar predictive power as for 10-week arteriovenous fistula maturity failure, but with wide confidence intervals for wrist (positive predictive value 72.7%, 95% confidence interval 46.4% to 99.0%) and elbow (positive predictive value 57.1%, 95% confidence interval 20.5% to 93.8%). These models, moreover, performed poorly at identifying assisted primary and secondary patency failure, likely because a subset of those arteriovenous fistulas identified on ultrasound surveillance as at risk underwent subsequent successful salvage intervention without recourse to early ultrasound data. Conclusions: Although early ultrasound can predict fistula maturation and longer-term patency very effectively, it was only moderately good at identifying those fistulas likely to remain immature or to fail within 6 months. Allied to the better- than-expected fistula patency rates achieved (that are further improved by successful salvage), we estimate that a randomised controlled trial comparing early ultrasound-guided intervention against standard care would require at least 1300 fistulas and would achieve only minimal patient benefit. Trial Registration: This trial is registered as ISRCTN36033877 and ISRCTN17399438. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR135572) and is published in full in Health Technology Assessment; Vol. 28, No. 24. See the NIHR Funding and Awards website for further award information.

For people with advanced kidney disease, haemodialysis is best provided by an 'arteriovenous fistula', which is created surgically by joining a vein onto an artery at the wrist or elbow. However, these take about 2 months to develop fully ('mature'), and as many as 3 out of 10 fail to do so. We asked whether we could use early ultrasound scanning of the fistula to identify those that are unlikely to mature. This would allow us to decide whether it would be practical to run a large, randomised trial to find out if using early ultrasound allows us to 'rescue' fistulas that would otherwise fail. We invited adults to undergo serial ultrasound scanning of their fistula in the first few weeks after it was created. We then analysed whether we could use the data from the early scans to identify those fistulas that were not going to mature by week 10. Of the 333 fistulas that were created, about two-thirds reached maturity by week 10. We found that an ultrasound scan 4 weeks after fistula creation could reliably identify those fistulas that were going to mature. However, of those fistulas predicted to fail, about one-third did eventually mature without further intervention, and even without knowing what the early scans showed, another third were successfully rescued by surgery or X-ray-guided treatment at a later stage. Performing an early ultrasound scan on a fistula can provide reassurance that it will mature and deliver trouble-free dialysis. However, because scans are poor at identifying fistulas that are unlikely to mature, we would not recommend their use to justify early surgery or X-ray-guided treatment in the expectation that this will improve outcomes.

Perioperative management of facial reconstruction surgery in patients with end-stage renal disease undergoing dialysis.

BACKGROUND: The rising incidence of dialysis-dependent end-stage renal disease (ESRD) has underscored the need for collaboration between plastic surgeons and nephrologists, particularly concerning preoperative and postoperative management for facial reconstruction. This collaboration is essential due to a scarcity of comprehensive information in this domain. METHODS: A study initiated in January 2015 involved 10 ESRD cases on dialysis undergoing Mohs micrographic surgery for facial skin cancer, followed by reconstructive surgery under general anesthesia. To ensure surgical safety, rigorous measures were enacted, encompassing laboratory testing, nephrology consultations, and preoperative dialysis admission. Throughout surgery, meticulous control was exercised over vital signs, electrolytes, bleeding risk, and pain management (excluding nonsteroidal anti-inflammatory drugs). Postoperative assessments included monitoring flap integrity, hematoma formation, infection, and cardiovascular risk through plasma creatinine levels. RESULTS: Adherence to the proposed guidelines yielded a notable absence of postoperative wound complications. Postoperative plasma creatinine levels exhibited an average decrease of 1.10 mg/dL compared to preoperative levels, indicating improved renal function. Importantly, no cardiopulmonary complications or 30-day mortality were observed. In ESRD patients, creatinine levels decreased significantly postoperatively compared to the preoperative levels (p< 0.05), indicating favorable outcomes. CONCLUSION: The consistent application of guidelines for admission, anesthesia, and surgery yielded robust and stable outcomes across all patients. In particular, the findings support the importance of adjusting dialysis schedules. Despite the limited sample size in this study, these findings underscore the effectiveness of a collaborative and meticulous approach for plastic surgeons performing surgery on dialysis-dependent patients, ensuring successful outcomes.

Privatization and Oligopolies of the Renal Replacement Therapy Sector on Contemporary Capitalism: A Systematic Review and the Brazilian Scenario.

Worldwide the assistance on renal replacement therapy (RRT) is carried out mainly by private for-profit services and in a market with increase in mergers and acquisitions. The aim of this study was to conduct an integrative systematic review on privatization and oligopolies in the RRT sector in the context of contemporary capitalism. The inclusion criteria were scientific articles without language restrictions and that addressed the themes of oligopoly or privatization of RRT market. Studies published before 1990 were excluded. The exploratory search for publications was carried out on February 13, 2024 on the Virtual Health Library Regional Portal (VHL). Using the step-by-step of PRISMA flowchart, 34 articles were retrieved, of which 31 addressed the RRT sector in the United States and 26 compared for-profit dialysis units or those belonging to large organizations with non-profit or public ones. The main effects of privatization and oligopolies, evaluated by the studies, were: mortality, hospitalization, use of peritoneal dialysis and registration for kidney transplantation. When considering these outcomes, 19 (73%) articles showed worse results in private units or those belonging to large organizations, six (23%) studies were in favor of privatization or oligopolies and one study was neutral (4%). In summary, most of the articles included in this systematic review showed deleterious effects of oligopolization and privatization of the RRT sector on the patients served. Possible explanations for this result could be the presence of conflicts of interest in the RRT sector and the lack of incentive to implement the chronic kidney disease care line. The predominance of articles from a single nation may suggest that few countries have transparent mechanisms to monitor the quality of care and outcomes of patients on chronic dialysis.

Restoring Access in a Thrombosed Hemodialysis Reliable Outflow Graft Using the InThrill Thrombectomy System.

Arteriovenous grafts (AVGs) provide vascular access for hemodialysis in patients with end-stage renal disease (ESRD). However, vascular access thrombosis often occurs, requiring frequent reinterventions to maintain access patency. This report describes the successful use of the InThrill Thrombectomy System (Irvine, CA: Inari Medical) for macerating and removing thrombus from an occluded and heavily thrombosed AVG. A 47-year-old male was sent to our institute for a thrombosed right upper extremity arteriovenous access with a HeRO graft (South Jordan, UT: Merit Medical). The patient underwent interventions for the thrombosis of the same AVG two weeks prior using an Aspirex catheter (Franklin Lakes, NJ: BD Medical), and again two days prior with a Fogarty balloon catheter (Irvine, CA: Edwards Lifesciences). The patient presented with a recurrent completely occluded AVG. Using the InThrill Thrombectomy System and balloon angioplasty, the stenosis was reduced to less than 20%, resulting in brisk flow. The patient tolerated the procedure well without complication and recovered in the holding area with no acute distress. He was discharged the same day on anticoagulation therapy. This study highlights the successful use of the InThrill Thrombectomy System for the treatment of thrombosed AVG in a hemodialysis-dependent ESRD patient. The device was easy to use and efficient. Device and procedure times are unparalleled when compared with thrombolytic-based procedures. The patient's AVG remained patent at a 14-day follow-up.

Inspiratory Muscle Training in Patients Living with Chronic Kidney Disease and Receiving Hemodialysis: Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: People living with chronic kidney disease (CKD) and receiving hemodialysis (HD) have impaired respiratory muscle strength and endurance. The objective of this study was to systematically review the effects of inspiratory muscle training (IMT) on respiratory muscle strength, functional capacity, lung function, quality of life, endothelial function, and oxidative stress in people living with CKD and receiving HD. METHODS: An electronic search was conducted from inception to June 2023. Randomized controlled trials that evaluated the effects of IMT on respiratory muscle strength, functional capacity, lung function, endothelial function, quality of life, or oxidative stress in adults living with CKD and receiving HD, compared with control, placebo IMT, or conventional physical therapy, were included. RESULTS: Eight studies were included, totaling 246 people. The meta-analysis showed that IMT increased the maximum inspiratory pressure (MIP) by 22.53 cm H2O, the maximum expiratory pressure (MEP) by 19.54 cm H2O, and the distance covered in the 6-minute walk test by 77.63 m. Changes in lung function and quality of life were not observed. It was not possible to quantitatively analyze data on endothelial function and oxidative stress. CONCLUSIONS: IMT improves MIP, MEP, and functional capacity in people living with CKD and receiving HD. IMT did not demonstrate significant results for lung function and quality of life. Effects on endothelial function and oxidative capacity remain uncertain. IMPACT: Inspiratory muscle training improves MIP, MEP, and functional capacity in people living with CKD and receiving HD, compared with conventional physical therapy or controls or placebo intervention. Increases in functional capacity in this population are extremely important because of the relationship with the survival of these people.

Structural Equation Modelling to Identify Psychometric Determinants of Medication Adherence in a Survey of Kidney Dialysis Patients.

Purpose: Medication non-adherence in dialysis patients is associated with increased mortality and higher healthcare costs. We assessed whether medication adherence is influenced by specific psychometric constructs measuring beliefs about the necessity for medication and concerns about them. We also tested whether medication knowledge, health literacy, and illness perceptions influenced this relationship. Patients and Methods: This study is based on data from a cross-sectional in-person questionnaire, administered to a random sample of all adult dialysis patients at a teaching hospital. The main outcome was self-assessed medication adherence (8-Item Morisky Medication Adherence Scale). The predictors were: concerns about medications and necessity for medication (Beliefs About Medication Questionnaire); health literacy; medication knowledge (Medication Knowledge Evaluation Tool); cognitive, emotional, and comprehensibility Illness perceptions (Brief Illness Perception Questionnaire). Path analysis was performed using structural equations in both covariance and variance-based models. Results: Necessity for medication increased (standardized path coefficient [ß] 0.30 [95% CI 0.05, 0.54]) and concerns about medication decreased (standardized ß -0.33 [-0.57, -0.09]) medication adherence, explaining most of the variance in outcome (r2=0.95). Medication knowledge and cognitive illness perceptions had no effects on medication adherence, either directly or indirectly. Higher health literacy, greater illness comprehension, and a more positive emotional view of their illness had medium-to-large sized effects in increasing medication adherence. These were indirect rather and direct effects mediated by decreases in concerns about medications (standardized ß respectively -0.40 [-0.63,-0.16], -0.60 [-0.85, -0.34], -0.33 [-0.52, -0.13]). Conclusion: Interventions that reduce patients' concerns about their medications are likely to improve adherence, rather than interventions that increase patients' perceived necessity for medication. Improving patients' general health literacy and facilitating a better understanding and more positive perception of the illness can probably achieve this. Our study is potentially limited by a lack of generalizability outside of the population and setting in which it was conducted.

Vascular Access Perception and Quality of Life of Haemodialysis Patients.

Background: Patient quality of life is widely used as a non-clinical determinant of care. For patients undergoing hemodialysis, vascular access is vital to the delivery of hemodialysis and its function may affect not only the clinical outcome of treatment but also the overall quality of life of the patient, highlighting the need for increased efforts to improve the quality of hemodialysis vascular access care. The objective of this study was to evaluate the correlation between vascular access perception and quality of life in patients undergoing hemodialysis. Methods: A total of 202 patients with active hemodialysis vascular access were included in the study. Quality of life was assessed using the Kidney Disease Quality of Life Instrument (KDQOL™) questionnaire, while vascular access perception was evaluated using the Vascular Access Questionnaire (VAQ). Results: The study presented evidence on the influence of vascular access for hemodialysis patients on their quality of life. This impact is related to factors directly associated with vascular access, such as the type of access and the patient's subjective evaluation of the access. Conclusions: The perception of vascular access is one of the factors that determines the quality of life of hemodialysis patients. The quality of life of hemodialysis patients decreases as the number of vascular access-related problems increases.

Prevalence and clinical characteristics of hyperuricemia among patients with chronic kidney disease under haemodialysis in a tertiary care center: a cross-sectional study.

Background: Hyperuricemia is common in chronic kidney disease patients. This study aimed to investigate the prevalence and clinical characteristics of hyperuricemia in patients with chronic kidney disease undergoing haemodialysis. Materials and methods: This cross-sectional study was conducted among 104 patients with chronic kidney disease who visited the haemodialysis unit of a tertiary centre hospital from 11 September 2022, to 11 November 2022. A convenience sampling technique was used. The data were collected using a proforma form, entered into, and analyzed using the Statistical Package for Social Sciences version 21. Results: The mean age group of the study participants was 54.02 ± 14.03 years, and around two-thirds were male (n=70, 67.3%). Almost half of the participants (50, 48.07%) had hyperuricemia with a mean uric acid level of 6.76 ± 2.62 mg/dl. The majority of the participants had associated hypertension (n=100, 96.2%). More than three-fourths of the respondents (83, 79.8%) had haemoglobin levels below the target range. Conclusion: Nearly half of the study participants had hyperuricemia.

Effects of upper limbs' neuromuscular electrical stimulation (NMES) superimposed to voluntary contraction added to a protocol of intradialytic leg cycle ergometer exercise, in muscle strength, functional capacity and quality of life of adult patients with CKD: a randomized clinical trial protocol.

OBJECTIVE: To investigate the effects of unilateral upper limbs' (ULM) neuromuscular electrical stimulation (NMES) superimposed on a voluntary contraction added to a protocol of intradialytic leg cycle ergometer exercise on muscle strength, functional capacity and quality of life of adult patients with chronic kidney disease (CKD). METHODS: This randomized controlled clinical trial will be carried out at a Brazilian University Hospital. The patients will be evaluated and randomly allocated to an intervention group (i.e., unilateral NMES on the upper limb without hemodialysis fistula for 20 min and leg cycle ergometer for 30 min) or a control group (i.e., unilateral NMES-Sham on the upper limb without hemodialysis fistula for 20 min and leg cycle ergometer for 30 min). The patients will be treated for 8 weeks, with three weekly treatment sessions totaling 24 sessions. MEASUREMENTS: ULM muscle strength, functional capacity, quality of life and also the feasibility, safety and patient adherence to the exercise protocol. All physical measurements will be collected by trained researchers before treatment (week 0) and at the end of treatment (week 9), always in the second hemodialysis session of the week. It will be used in an intention-to-treat analysis. RESULTS/CONCLUSIONS: The outcomes of this clinical trial protocol may help to know the possible benefits of unilateral ULM' NMES superimposed on a voluntary contraction added to a protocol of leg cycle ergometer for patients with CKD and to aid clinical decisions about future implementation or not of this technique (NMES) in intradialytic physical training programs.

Factors that Influence Attitudes toward Advance Directives among Hemodialysis Patients.

Purpose: Advance directives (ADs) are legal documents that outline a person's preferences or decisions regarding end-of-life care ahead of time. In Korea, there is insufficient awareness and knowledge about ADs among patients undergoing hemodialysis. This study explored the relationship between perceptions of a good death, knowledge about ADs, and attitudes toward ADs in this patient population. Methods: This cross-sectional survey enrolled 119 hemodialysis patients from a secondary hospital in 2021. The participants completed a self-administered questionnaire, and the data were analyzed using the t-test, analysis of variance, Pearson correlation coefficients, Spearman rank correlation coefficients, and multiple regression analysis. Results: The average score for perceptions of a good death among hemodialysis patients was 2.80 out of 4, with clinical symptoms identified as the most critical factor. The average scores for knowledge about ADs and attitudes toward ADs were 5.69 out of 9 and 2.79 out of 4, respectively. There was a positive correlation between perceptions of a good death and attitudes toward ADs (r=0.34, P<0.001), as well as between knowledge about Ads and attitudes toward ADs (r=0.19, P=0.037). Factors influencing attitudes toward Ads included employment status (ß=0.22, P=0.011), education level (ß=0.22, P=0.013), and perceptions of a good death (ß=0.29, P=0.001), which accounted for 24.8% of the variance in attitudes toward ADs. Conclusion: A positive perception of a good death among patients undergoing hemodialysis was associated with a positive attitude toward ADs. Educational programs are needed to improve individuals' understanding of a good death and encourage the development of end-of-life care plans.

Palliative Care for Adult Patients Undergoing Hemodialysis in Asia: Challenges and Opportunities.

This article underscores the importance of integrating comprehensive palliative care for noncancer patients who are undergoing hemodialysis, with an emphasis on the aging populations in Asian nations such as Taiwan, Japan, the Republic of Korea, and China. As the global demographic landscape shifts towards an aging society and healthcare continues to advance, a marked increase has been observed in patients undergoing hemodialysis who require palliative care. This necessitates an immediate paradigm shift to incorporate this care, addressing the intricate physical, psychosocial, and spiritual challenges faced by these individuals and their families. Numerous challenges impede the provision of effective palliative care, including difficulties in prognosis, delayed referrals, cultural misconceptions, lack of clinician confidence, and insufficient collaboration among healthcare professionals. The article proposes potential solutions, such as targeted training for clinicians, the use of telemedicine to facilitate shared decision-making, and the introduction of time-limited trials for dialysis to overcome these obstacles. The integration of palliative care into routine renal treatment and the promotion of transparent communication among healthcare professionals represent key strategies to enhance the quality of life and end-of-life care for people on hemodialysis. By embracing innovative strategies and fostering collaboration, healthcare providers can deliver more patient-centered, holistic care that meets the complex needs of seriously ill patients within an aging population undergoing hemodialysis.

Oral anticoagulation for stroke prevention in atrial fibrillation and advanced kidney disease.

Background: The net benefit of oral anticoagulation (OAC) with vitamin K antagonists or direct oral anticoagulants in patients with advanced chronic kidney disease and atrial fibrillation remains uncertain. Objectives: We examined the use, efficacy, and safety of OAC in patients with estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m2 (including dialysis-treated patients) and atrial fibrillation. Methods: In a retrospective cohort study, patients diagnosed with atrial fibrillation and eGFR of <30 mL/min/1.73 m2 were identified in national Danish registers between 2010 and 2022. Initiation of OAC was identified based on redemption of a relevant prescription. One-year risks of thromboembolic event, major bleeding, and death associated with OAC and no treatment were computed and standardized to the distribution of risk factors in the sample based on hazards determined in multiple Cox regression models adjusted for age and sex. Results: A total of 3208 patients were included (mean age 80 years, 52.8% males, 20.9% chronic dialysis). OAC was initiated in 1375 (42.9%) patients, of whom 48.1% were vitamin K antagonists and 51.9% were direct oral anticoagulants. One-year risks in nontreated and anticoagulated patients were 4.8% (95% CI, 3.8%-5.7%) and 3.6% (95% CI, 2.8%-4.6%; P = .028) for thromboembolic event, 7.6% (95% CI, 6.6%-8.7%) and 10.5% (95% CI, 9.3%-12.1%; P < .001) for major bleeding, and 36.3% (95% CI, 34.2%-38.3%) and 29.6% (95% CI, 27.6%-31.6%; P < .001) for death, respectively. Conclusion: In a retrospective study on patients with advanced chronic kidney disease and atrial fibrillation, OAC was associated with overall decreased 1-year risk of thromboembolic event and death offset by increased 1-year risk of major bleeding.

Cross-cultural validation of the Portuguese version of the Dialysis Symptom Index for haemodialysis patients.

Background: Patients with end-stage renal disease (ESRD) undergoing haemodialysis (HD) are associated with low quality of life (QoL) and high disease-related symptoms. The patient self-report instruments can assess the burden of physical and psychological symptoms. The Dialysis Symptom Index (DSI) is a specific instrument to evaluate the multidimensional reported symptoms by patients undergoing HD. Aims: To translate, validate and assess the psychometric properties of the Portuguese version of the DSI. Methods: A cross-cultural adaptation process from English to Portuguese and a validation study (n = 156) were conducted. Reliability, validity and responsiveness were assessed. Results: The patients' most reported symptoms were, nausea (n = 86, 55%), muscle cramps (n = 92, 59%), feeling tired or lack of energy (n = 92, 59%), bone or joint pain (n = 88, 56%) and trouble staying asleep (n = 95, 60%). Cronbach's alpha of the DSI was 0.87, and intraclass correlation coefficient was 0.868 (95%CI 0.836-0.896). The smallest detectable change was 28.32. Conclusion: The Portuguese DSI demonstrates excellent psychometric properties for assessing HD patients' reported symptoms. It highlights symptom severity and impact, providing valuable insights for healthcare practitioners. Nurses can use the DSI to tailor interventions and enhance patient-centred care.

A case of complete response to avelumab plus axitinib combination therapy for metastatic clear cell renal cell carcinoma in a kidney undergoing dialysis.

Introduction: Combination therapies of immune checkpoint and tyrosine kinase inhibitors for end-stage kidney disease and patients on hemodialysis need careful consideration as few case reports provide suitable management decisions. Case presentation: A 70-year-old man who had undergone hemodialysis for 6 years due to nephrosclerosis. Avelumab plus axitinib combination therapy was performed for repeated lung metastasis, and a complete response was achieved without major side effects. Conclusion: A complete response was achieved after Ave plus Axi combination therapy for clear cell renal cell carcinoma in a patient undergoing dialysis. This suggests that Ave plus Axi combination therapy may be safe and effective for dialysis patients.

Hemodialysis Patients with High-Flow Arteriovenous Fistulas: An Evaluation of the Impact on Cardiac Function.

Purpose: : Patients undergoing hemodialysis often experience changes in cardiac function when they have a high-flow arteriovenous fistula (AVF). This study aimed to assess the effect of high-flow AVFs on cardiac function in patients undergoing hemodialysis. Materials and Methods: : A longitudinal study was conducted on hemodialysis patients with high-flow AVFs. Echocardiographic parameters, such as left ventricular ejection fraction (LVEF), left atrial diameter (LAD), left ventricular end-diastolic dimension (LVEDD), right ventricular end-diastolic dimension (RVEDD), inferior vena cava diameter (IVCD), systolic blood pressure, and diastolic blood pressure, were measured and compared before and after AVF creation. Results: : One hundred hemodialysis patients with high-flow AVFs (mean age: 55.95±13.39 years, mean body mass index: 24.71±3.43 kg/m²) were studied. LVEF significantly decreased (51.10%±5.39% to 47.50%±5.79%), while LAD, LVEDD, and IVCD significantly increased after AVF creation (P<0.05). Systolic (132.49±16.42 mmHg to 146.60±17.43 mmHg) and diastolic (79.98±8.40 mmHg to 83.33±9.68 mmHg) blood pressure substantially rose post-fistularization (P<0.001). Notably, LVEF reduction was more significant in brachio-cephalic AVFs (46.29%±4.24%) compared to distal radio-cephalic or snuffbox AVFs (49.17%±7.15%) (P=0.014). Conclusion: : High-flow AVFs can significantly affect echocardiographic parameters in hemodialysis patients, thereby increasing the risk of cardiac failure. Close cardiac monitoring may be necessary for early intervention. Distal AVFs may be preferable in patients with decreased cardiac function.