Kidney and Dialysis

Introduction: The association between anemia and peritoneal dialysis (PD) withdrawal in patients with stable PD remains poorly established. Herein, we investigated the relationship between anemia and PD withdrawal in patients with stable PD. Materials and Methods: We included 43 patients undergoing PD for at least 6 months between October 2011 and December 2022. Patients were categorized based on their hemoglobin (Hb) levels at the time of their first peritoneal equilibration test (PET) during the study period as follows: Hb ≥ 11 g/dL and Hb < 11 g/dL. The PD withdrawal rates were compared between these groups. Patients were followed up until death or 31 July 2023. Results: During the follow-up, 36 patients discontinued treatment. Patients with Hb < 11 g/dL had a significantly higher PD withdrawal rate than those with Hb ≥ 11 g/dL. Cox proportional hazards analysis identified Hb level as a risk factor for PD withdrawal. Furthermore, Hb levels negatively correlated with the annual decline in urine volume. Conclusions: Our findings suggest anemia as a predictor of PD withdrawal in patients with stable PD. The negative correlation between Hb levels and the annual decline in urine volume implies that anemia may contribute to PD withdrawal via the deterioration of residual renal function. Full article

Background: Chronic kidney disease-associated pruritus (CKD-aP) is a common condition in dialysis patients, and is associated with lower quality of life, depression, and sleep problems. CKD-aP is under-recognized and undertreated. While question 20 of the KDQOL is used for CKD-aP assessment in the clinical setting, recent studies testing novel drugs for CKD-aP have used the WI-NRS. Therefore, evaluating the correlation between KDQOL-Q20 and the WI-NRS may enable the identification of patients who could potentially benefit from these treatments. Methods: This was an observational cohort study of patients receiving in-center hemodialysis from the Mount Sinai Kidney Center. Patients completed a baseline survey on CKD-aP (KDQOL-Q20 and WI-NRS), depression, and sleep quality. A repeat survey was conducted at 4 weeks, with the order of the CKD-aP surveys reversed. We defined moderate/severe CKD-aP as a KDQOL-Q20 score ≥2 and a WI-NRS score ≥ 4. Our outcomes of interest were the correlations of KDQOL-Q20 with the WI-NRS, missed HD treatments, depression, and sleep quality. Correlation analysis was performed with Spearman correlation analysis. Association testing between CKD-aP and outcomes was conducted by relative risk estimation with robust error variance. Results: A total of 112 patients completed the study. According to the WI-NRS, 42% of patients reported itching (score of ≥4) while according to KDQOL-Q20, 57% of patients reported itching (score of ≥2). KDQOL-Q20 and the WI-NRS were strongly correlated (r = 0.7; p < 0.001). Patients who had moderate/severe CKD-aP according to KDQOL-Q20 had a non-statistically significant trend towards a lower risk of missed HD treatments and a higher risk of depression, and a statistically significantly higher risk of sleep-related problems, compared to those with no or mild CKD-aP. Conclusions: CKD-aP is a common condition, and is associated with various clinical outcomes. We found a strong correlation between two CKD-aP measures. These results can help to identify patients for CKD-aP treatment. Full article

Increased availability of dialysis services has led to both an increase in the number of elderly, frail, co-morbid patients with advanced chronic kidney disease now being offered dialysis and starting dialysis with residual kidney function. Traditionally, these patients would have been offered in-centre haemodialysis. However, the introduction of an assisted peritoneal dialysis service has allowed more of these elderly patients to be considered for peritoneal dialysis, a home-based treatment, with the exchanges performed by family members or visiting health care staff. It is now realised that the amount of dialytic clearance any individual requires varies, and as such, treatment targets have changed over time from achieving minimum clearance targets to a more holistic approach, considering patient lifestyles, and adapting dialysis prescriptions and schedules to the needs of the individual patient. As dietary intake is often lower in the elderly, coupled with the physiological loss of muscle mass, this results in a reduced generation of waste products of metabolism and consequently requires less dialytic clearance. Thus, this allows many elderly patients to benefit from an incremental approach to starting peritoneal dialysis, potentially beginning with only one or two continuous ambulatory peritoneal dialysis exchanges, or an overnight cycler for only a few nights/week. Full article

Background: We observed a COVID-19 survivor with a ventriculoperitoneal shunt who developed increased intracranial pressure during hemodialysis. We hypothesized that post-SARS-CoV-2 infection, patients may have altered cerebral perfusion pressure regulation in response to intracranial pressure changes. Methods: From April to July 2021, we recruited dialysis patients with prior COVID-19 from two Madrid nephrology departments. We also recruited age- and sex-matched dialysis patients without prior SARS-CoV-2 infection. Transcranial Doppler ultrasound was used to measure the middle cerebral artery velocity before dialysis and 30, 60, and 90 min after the initiation of dialysis. Results: The final sample included 37 patients (16 post-COVID-19 and 21 without). The COVID-19 survivors showed a significant pulsatility index increase between 30 and 60 min compared to those without COVID-19. They also had lower heart rates. Conclusions: We propose two mechanisms: an increase in intracranial pressure or a decreased arterial elasticity. A lower heart rate was also observed in the COVID-19 survivors. This study highlights SARS-CoV-2’s multifaceted effects, including potential long-term vascular and cerebral repercussions. Full article

Chronic kidney disease of uncertain etiology (CKDu) has emerged with growing evidence linking it to environmental exposures. This case–control study aimed to evaluate serum and urine trace elements (TEs) in CKDu patients, comparing them with those from control groups from endemic and non-endemic regions. TEs were analyzed in 406 participants (CKDu = 75, endemic CKD (ECKD) = 82, non-endemic CKD (NECKD) = 85, endemic control (EC) = 79, non-endemic control (NEC) = 85 using Inductively Coupled Plasma Mass Spectrometry. Means ± standard deviations were compared via the t-test and categorical variables by the chi-square test. Compared to non-endemic groups, Al, Mn, Ni, Cu, Cd, and Ba in serum and urine were significantly higher in endemic areas. CKDu patients showed elevated serum V, Cr, Zn, As, and U and urinary Cr, Mn, Fe, Co, Ni, and Rb compared to ECKD. Compared to NEC, CKDu patients had higher serum Zn, As, and Ba and urinary Al, Cr, Mn, Fe, Co, Ni, and Cu. Significant increases in serum V, Zn, As, Cd, Ba, and U and urinary V, Cr, Mn, Co, Ni, Rb, and Sr were noted in CKDu vs. NECKD. Elevated serum Al, Cr, Mn, Fe, Co, etc., and urinary Be, V, Zn, Se, etc., were observed in EC vs. CKDu. Urinary TEs positively correlated with eGFR, suggesting tubular dysfunction or prolonged exposure. Serum Se, a known reno-protective TE, was low in CKDu and ECKD. This study highlights that TE levels were high not only due to exposure but also depending on kidney health. Identified group-specific TEs may be causative in CKDu, having adverse health outcomes in some groups while potentially being protective in healthy groups. Full article

Background: Steroid-resistant nephrotic syndrome (SRNS) in adults presents a significant therapeutic challenge, often leading to end-stage kidneys. This study aims to evaluate the clinical outcomes of rituximab (RTX) administration as an alternative to traditional cytostatic therapy in adults with SRNS, focusing on its effectiveness and safety profile. Methods: This multicenter, randomized study evaluates the effects of RTX for SRNS treatment, analyzing its clinical outcomes, safety, and efficacy across 52 adults (median age 47, 52% male) over 36 months. Amyloidosis and proliferative diseases were excluded by a kidney biopsy. Results: Complete remission rates improved from 50% to 66.7% by 36 months, with variations based on the morphological types of nephrotic syndrome experienced. The number needed to treat (NNT) for complete remission decreased from indeterminate to 12 by 36 months. RTX was well tolerated, with 17.3% experiencing allergic reactions and 25% developing hypogammaglobulinemia after one year. Severe infusion reactions were managed with omalizumab. Hypogammaglobulinemia and recurrent respiratory infections (21.5%) required additional treatments. Conclusions: RTX shows promise in achieving sustained remission in SRNS, especially in MN and FSGS, with increasing effectiveness over time. While its safety profile is encouraging, extended monitoring is essential for accurate treatment assessments. Further studies are needed to refine RTX protocols and outcomes. Full article

Introduction: Diabetes mellitus, a chronic disease characterized by hyperglycemia, is a significant contributor to chronic kidney disease, particularly in patients with diabetic nephropathy undergoing renal replacement therapy. Variations in circadian rhythms can influence the progression of chronic diseases and treatment outcomes. Aims: This observational study evaluated gender-based chronobiological changes in biochemical, hemorheological factors, and cytokines in patients with dialysis-dependent diabetic nephropathy. Materials and Methods: A cross-sectional study was conducted in Barra do Garças, Brazil, involving 46 patients with type 2 diabetes mellitus who were on regular hemodialysis. Participants were divided into four groups for analysis according to gender and period of day. Inclusion criteria included individuals with type 2 diabetes mellitus undergoing periodic hemodialysis, receiving hemodialysis care at the service, and signing a consent form. Patients with an age under 18 years, diabetes mellitus type 1, or with autoimmune diseases were excluded. Blood samples were collected to assess melatonin, cortisol, biochemical and hemorheological parameters, and cytokines such as IFN-γ, TNF-α, IL-2, IL-4, IL-6, IL-10, and IL-17. Results: Men exhibited higher melatonin, urea, and creatinine levels in the morning and afternoon phases. At the same time, women showed lower melatonin, increased viscosity, and a decreased deformation rate in the afternoon. Additionally, levels of TNF-α, IFN-γ, and IL-17 were lower in morning serum samples from women. Conclusion: These findings suggest that both gender and circadian timing should be taken into account, when optimizing hemodialysis treatment for patients with diabetic nephropathy. A deeper understanding of these factors could lead to more personalized and effective treatment strategies, ultimately improving patient outcomes and enhancing their quality of life. Full article

Despite the high burden of fatigue in patients with advanced chronic kidney disease (CKD) stage 4–5 including dialysis, little is known about risk factors and treatments for fatigue. This paper provides an overview of measurement, associated risk factors and approaches to alleviate fatigue. Up to now, the 36-Item Short Form Health Survey (SF-36) is the most widely used tool to measure fatigue. Socio-demographic factors, including older age, female, white ethnicity, less education, unemployment and less social support, are risk factors for fatigue. More severe fatigue is related to anemia, protein energy wasting, inflammation, lactic acidosis, comorbidities (including diabetes, cardiovascular disease and chronic obstructive pulmonary disease), depression, anxiety, sleep disorders and uremic symptoms such as restless legs syndrome and pruritus. Dialysis treatment, dialysis-related low blood pressure and low dialysis adequacy, contribute to fatigue. Medication, such as β-blockers, antidepressant medication and medication for sleep disorders, are associated with fatigue, either as a result of the underlying condition or side effects. Currently, the principal treatments encompass pharmacological and nonpharmacological interventions. The utilization of erythropoiesis-stimulating agent (ESA) for anemia may alleviate fatigue. Physical exercise has been proved to be a promising therapeutic approach. Other potential treatments, such as L-carnitine, sodium bicarbonate, antidepressive medication (such as bupropion), psychological interventions and cold dialysis, require more research. To conclude, further research is needed to better understand the risk factors and underlying mechanism of fatigue, as well as to explore potential treatments for patients with advanced CKD. Full article

Hypercalcemia is defined as a serum calcium concentration higher than 10.5 mg/gL or 2.6 mmol/L. Only 50% of serum calcium is active, presented as ionized calcium. The remaining half is bound to albumin, phosphate, and other serum anions, and their changes can affect the serum calcium concentration. Thus, to discriminate true hypercalcemia from pseudo hypercalcemia, an ionized calcium concentration higher than 1.3 mmol/L might be more appropriate. Many variables can lead to hypercalcemia, and managing them is necessary to treat this ion disorder. Indeed, it can be caused by malignancies, hematologic disorders, or genetic diseases such as familial hypocalciuric hypercalcemia, or it can be related to hormone disorders involving parathormone or vitamin D. For this condition, the correct diagnostic algorithm should be followed. In this review, we summarize the diagnostic steps to follow and detail each clinical pathway is involved in hypercalcemia. Full article

Introduction: The potassium removed by various dialysis methods (pre- and post-dilution on-line hemodiafiltration) is not clear in the literature. The aim of the study was to investigate the amount of potassium eliminated with each session of pre- or post-dilution on-line hemodiafiltration with collection of the total ultrafiltrate in a tank. Materials and Methods: We studied in 10 dialyzed patients the removal of potassium by a polyetherosulfone dialysis filter. We sought to investigate whether the amount removed is related to filter surface area and type of dialysis. We examined the removal of potassium by on-line hemodiafiltration and post-dilution with high-flux filters, surface areas 2.5 m² (Group A) and 2.1 m² (Group B). We repeated the same process with low-flux filters with conventional hemodialysis (Group C), as well as with pre-dilution on-line hemodiafiltration and 2.5 m² surface area filters (Group D). Results: Significantly higher potassium removal was noted with post-dilution on-line hemodiafiltration versus conventional haemodialysis, which was not affected by filter surface area, and also higher with pre-dilution on-line hemodiafiltration versus all other methods. The amounts of removed potassium even exceeded 300 mmol of potassium/dialysis session in some cases. Conclusions: It is concluded that, with on-line hemodiafiltration, much higher amounts of potassium are removed (mainly with pre-dilution) compared to conventional haemodialysis. The amount removed is not affected by the surface of the filter. The lower potassium levels of dialysate play an important role in this elimination. Full article

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease (ESKD). To date, no trial has been adequately powered to evaluate the effects of different dialysis modalities on cardiovascular events or mortality. To properly assess the risks and benefits of each modality for individual patients, it is crucial to understand the unique cardiovascular risk factors in patients undergoing dialysis. This review explores the existing literature on cardiovascular risk assessment in this population. It examines the mechanisms contributing to increased risk, including volume overload, blood pressure abnormalities, mineral bone disorder, vascular calcification, uremia, anemia, and chronic inflammation. Additionally, we discuss data from trials assessing cardiovascular outcomes and compare various dialysis modalities, including in-center hemodialysis, frequent dialysis, nocturnal dialysis, and peritoneal dialysis. Full article

Animated video could improve the reach of health education to kidney transplant (KT) seekers and their social network. Usage outcomes are rarely considered. This exploratory study aims to investigate use patterns of an animated video-based intervention (KidneyTIME) and examined associations with patient characteristics. Descriptive, quantitative analyses were conducted on user data (April 2022–March 2024) of KT-seekers allocated to the intervention arm of an ongoing randomized controlled trial of KidneyTIME. Of 195 KT-seekers allocated to KidneyTIME, optional use (defined as ≥1 video view or share) was 74% at 6 months follow-up and significantly higher among patients in the pre-evaluation phase (Odds Ratio [OR] 2.63, p = 0.0051) and with an active Facebook account (OR 2.93, p = 0036). Higher total video viewings were associated with single adult household (p = 0.0496). Not employed participants viewed more different videos (p = 0.0168). More days of viewing was significantly (p < 0.05) associated with older age, worse health, not employed, and single adult household. Video sharing was significantly associated with social media use (OR 2.86, p = 0.0264), active Facebook account (OR 2.55, p = 0.0411), and lower health literacy score (OR 2.80, p = 0.0274) and inversely associated with lower social support score (OR 0.35, p = 0098) and male sex (OR 0.48, p = 0.0394). Web-based animated video education promoted through email or text links is a viable modality to reach diverse KT-seekers. Full article

Primary aldosteronism (PA) is a major cause of hypertension, especially in younger patients. Early diagnosis and treatment are crucial to prevent damage to vital organs, including the heart and kidneys. Independent of blood pressure, aldosterone excess has direct deleterious effects on the kidneys, leading to tubulointerstitial fibrosis, glomerular hypertrophy, and glomerulosclerosis. Emerging biomarkers such as albuminuria and liver fatty acid-binding protein may have the potential to detect renal injury in PA, particularly in the setting of glomerular hyperfiltration. Comprehensive risk assessment of long-term renal dysfunction, based on both modifiable and non-modifiable risk factors, would aid clinicians in prediction and would even, in some cases, allow them to mitigate the risk of patients developing CKD in the setting of PA. Full article

Background: Whether hemodialysis patients want caregivers to discuss spirituality is poorly studied, especially in Europe. The goal of this qualitative study was to explore the spirituality and spiritual expectations of hemodialysis patients in a Swiss dialysis center. Methods: Semi-structured, qualitative interviews were performed by an experienced sociologist with dialysis patients in the ambulatory dialysis unit of the University Hospital of Lausanne. The interviews included a set of open questions on the role that spirituality plays in patients’ lives, in coping with their illness and in the recent COVID-19 epidemic. All interviews were recorded, transcribed, coded and analyzed following the approach of content analysis. Findings: Twenty interviews were performed in 2022. In total, 14/20 patients practiced some form of religion (believers), four were agnostics, and two defined themselves as atheist. The majority (15/20) confirmed that spirituality plays a positive role to preserve hope and to manage the difficulties caused by the disease and its treatment; one out of four wishes to discuss spirituality in the hospital setting. The largest needs are related to social dimensions (isolation, loneliness, need to talk, financial problems). Their level of spirituality has not been impacted by the COVID-19 pandemic. Discussion: In this pilot study, spirituality in a broad sense was important for the majority of the patients, and a quarter of them would like it to be actively addressed by healthcare professionals. They also ask for more attention to social and socio-economic difficulties. Full article

Small interfering RNAs (siRNAs) are short, double-stranded RNA molecules that play a crucial role in the regulation of gene expression, particularly through a natural process called RNA interference (RNAi). Their discovery, about 25 years ago, paved the way for a whole series of research leading to synthetic molecules. The gene silencing potential of these siRNAs was initially oriented towards diseases resulting from genetic dysfunctions. This led to the development of the first synthetic siRNAs approved for human use in hereditary transthyretin amyloidosis. Subsequently, the field of application expanded beyond the confines of genetic diseases. The refinement of pharmacological techniques has led to the synthesis of a variety of siRNAs capable of blocking the production of individual proteins responsible for various disease conditions, thus expanding their field of therapeutic application. The kidney has also been affected by this new therapeutic tool, largely indirectly but also, with some difficulty, directly. The structural complexity of the kidney has made the search for siRNAs targeting its individual components very challenging. Nevertheless, the first results of the application of this new therapeutic technology to the kidney are beginning to be seen in experimental animals and in humans. siRNAs have been approved for the treatment of amyloidosis with patisiran and oxalosis with lumasiran and nedosiran. Studies are ongoing for the use of siRNAs as anti-complement drugs in IgA nephropathy, as angiotensinogen inhibitors in hypertension, or against some mediators of acute kidney injury. In this review, the biological mechanisms underlying the use of siRNAs are briefly exposed. The results of the therapeutic application of RNA interference to the kidney and its diseases are also analyzed and discussed. Full article

Follow-up studies evaluating the relationship between dyslipidemia and chronic kidney disease (CKD) in non-diabetic populations are limited. This longitudinal study (1998–2024) examined whether the prevalence of dyslipidemia is associated with the subsequent development of CKD in non-diabetic Japanese adult citizens of Zentsuji, Kagawa Prefecture, Japan. Dyslipidemia was defined as low-density lipoprotein cholesterol concentrations ≥ 140 mg/dL, high-density lipoprotein cholesterol concentrations < 40 mg/dL, and/or triglyceride concentrations ≥ 150 mg/dL. Participants were considered to have developed CKD if their estimated glomerular filtration rate was <60 mL/min/1.73 m². The proportional hazards assumption was violated. Therefore, the Weibull accelerated failure-time model was selected using the Akaike and Bayesian information criteria. The final cohort included 5970 participants, 41.6% of whom were men. The mean follow-up was 7.09 years. After the follow-up, 1890 (31.7%) participants developed CKD. Participants with dyslipidemia had a 5% shorter survival time (95% confidence interval: 3–7%) to incident CKD compared with those without dyslipidemia in the full model. High-density lipoprotein cholesterol concentrations < 40 mg/dL and triglyceride concentrations ≥ 150 mg/dL also reduced the survival time to CKD onset by 5–6%. Our results indicate that controlling the lipid profile to an appropriate range may contribute to reducing the risk of future onset of CKD. Full article

IgA nephropathy (IgAN), first described in 1968, is one of the most common forms of glomerulonephritis and can progress to end-stage kidney disease (ESKD) in 25 to 30 percent of patients within 20 to 25 years from the onset. It is histologically characterized by mesangial proliferation with prominent IgA deposition. The prognosis may be difficult to predict, but important risk factors for disease progression of kidney disease have been recognized: usually proteinuria above 0.75–1 g/day with or without hematuria, hypertension, high-risk histologic features (such as crescent formation, immune deposits in the capillary loops, mesangial deposits, glomerulosclerosis, tubular atrophy, interstitial fibrosis, and vascular disease), and a reduced Glomerular Filtration Rate (GFR). In the absence of reliable specific biomarkers, current standards of care are addressed to decrease proteinuria, as a surrogate endpoint, and control blood pressure. For a long time, corticosteroids have been considered the only cure for proteinuric patients or those at risk of progression to ESKF; however, unfortunately, like other immunosuppressive agents, they are burdened with high collateral risks. Therefore, optimal treatment remains a challenge, even if, to date, clinicians have many more options available. Here, we will review the main therapies proposed, such as the stronghold of RAAS inhibition and the use of SGLT2 inhibitors; it is expected that ongoing clinical trials may find other therapies, apart from corticosteroids, that may help improve treatment, including both immunosuppressive monoclonal antibodies and other strategies. At the current time, there are no disease-specific therapies available for IgAN, because no largescale RCTs have demonstrated a reduction in mortality or in major adverse kidney or cardiovascular events with any therapy. Full article

Background: Whether patients commence haemodialysis with a central venous catheter (CVC), or an arteriovenous fistula (AVF) is used to audit the quality of a vascular access service. However, this crude metric of measurement can miss the increasing nuance and complexity of vascular access planning. We aimed to understand whether commencing haemodialysis with a CVC represented an ‘optimal’ or ‘suboptimal’ outcome and how this could influence the assessment of a vascular access service. Methods: From a prospective clinical database, patients known to nephrology >90 days prior to initiating haemodialysis as first-ever renal replacement therapy (2011–2020) from a single centre were included. Results: A total of 158/254 patients started haemodialysis with a CVC, and 96 with arteriovenous fistula. For 91 patients, the CVC was deemed ‘optimal’ care due to factors such as unpredictable deterioration in renal function (n = 41) and inadequate veins for AVF creation (n = 24). For 67 patients, the CVC was ‘suboptimal’ due to factors such as no/late referral to access assessment (n = 25) and delays in the AVF creation pathway (n = 13). There was no difference in mean survival between the AVF and ‘suboptimal’ groups (2.53 vs. 2.21 years, p = 0.31). There was a survival difference between AVF versus CVC (2.53 vs. 1.97 years, p = 0.002) and ‘suboptimal’ versus ‘optimal’ CVC cohorts (2.21 vs. 1.40 years, p = 0.16). Conclusions: Understanding whether a CVC is ‘optimal’ or ‘suboptimal’ allows a more nuanced analysis of service provision. High mortality in the ‘optimal’ group suggests a frailer cohort where CVC is potentially the best care. Studying ‘suboptimal’ CVC starts helps identify practice and system issues preventing ‘optimal’ care. Full article

Background: For our society, chronic kidney disease is a major public health problem associated with high mortality, morbidity, reduced quality of life and a progressive increase in health costs. The aim of this study was to analyze and compare the current cost of kidney transplantation (KT) and kidney–pancreas transplantation (KPT) among the different Regional Health Services (RHS) in Spain. Methods: A descriptive comparative study analyzing the public prices of RHS in Spain. The Official Gazette of the different communities was consulted, where the latest available order on this type of cost was sought. A descriptive analysis was made of the stipulated cost of the KT and KPT, for each degree of severity, RHS, year of publication and cost calculation method. Mean cost and standard deviation were calculated. Results: KT prices were found for 15 of the 18 RHS (83.33%). The average cost of KT in Spain was EUR 33,926.53 ± 6950.053 (range from EUR 23,140.37 in the Canary Islands to EUR 48,205.75 in Catalonia). For KPT, costs were found for 5 of the 18 RHS (27.8%). The mean cost of KPT was EUR 65,792.38 ± 11,273.12 (ranging from EUR 49,418.81 in Navarra to EUR 78,363.20 in Andalusia). Conclusions: There is a large variability in KT and KPT costs in Spain between RHS. Our study underlines the importance of adopting standardized and updated costing methods for KT and KPT. Full article