Impact of the vascular access on morbidity and mortality in chronic hemodialysis patients

Background Patients with endstage renal disease (ESRD) have high rates of mortality and morbidity. Adequate dialysis is essential to maintain a high quality of life and survival in these patients. Vascular access is also known as a ‘lifeline’ for patients receiving hemodialysis (HD). Complications associated with vascular access result in frequent hospitalizations and often require intervention. These complications have significant impacts on the morbidity and mortality of dialysis patients, while also leading to high medical costs. As a result, having a wellfunctioning point of vascular access is very important. We aimed to study the prevelance of different types of vascular access and practice patterns at Ain Shams university hospitals and to study the impact of vascular access related problems on morbidity and mortality. Patients and Methods This study is a prospective cohort study conducted in Ain shams university hospitals dialysis units in which all adults with end-stage kidney disease (ESRD) from the three units were included in the study. All patients were assessed as regard basic demographics, patient characteristics and vascular access characteristics. At the start of the study and then after one year data about vascular access related mortality and morbidity were collected. Statistical data analysis was done using SPSS (statistical package for the social sciences, version 2019, SPSS, Inc, Chicago, III, USA) Results In our HD population where the majority of catheters were temporary nontunneled catheters, dialysis catheter use was associated with higher mortality and increased hospitalization rates compared with AV access. These results emphasize the urgent need to minimize the use of dialysis catheters. Conclusion Using dialysis catheter carries a higher risk for life threatening complications compared to AV access.

Performance indicators of left ventricular strain, wall stress and serum brain natriuretic peptide levels in chronic hemodialysis patients

Background: Left ventricular (LV) global longitudinal strain (GLS) is a reliable determinant of LV systolic function. The precise relationship between LV wall stress and serum brain natriuretic peptide (BNP) concentrations in hemodialysis (HD) patients require clariϐication. BNP levels are raised in patients with endstage renal disease (ESRD) and could reflect LV impairment amongst HD patients. Objective: This study sought to evaluate the clinical utility of LV–GLS, wall stress and serum BNP levels in chronic HD patients. The correlations between BNP levels with both LV wall stress and LV–GLS were assessed. Methodology: A total of 30 ESRD patients on regular HD – divided into 15 patients with LV ejection fraction (EF) <50% and 15 patients with LV EF > 50% – and 15 agematched healthy subjects were assessed. LV function and structure were measured using conventional echocardiography, including LV meridional wall stress (LVMWS), LV mass index (LVM I) and two-dimensional speckle tracking echocardiography for determination of LV–GLS. Serum BNP levels were evaluated after HD sessions. Results: There were significant increases in LVM SW (189.2 ± 81 vs. 72.2 ± 20.6 dynes/cm 2 2 1000, P < 0.0001), higher levels of BNP (1238 ± 1085.5 vs. 71 ± 23.4 pg/ml, P<0.0001), w hilst LV–GLS was signiϐicantly reduced (15.1 ± 3.1 vs. 20.8 ± 1.7%, P <0.0001) in HD patients, when compared to the controls. Higher values of LVMWS (246.9 ± 67.5 vs. 131.5 ± 43.6 dynes/cm 2 2 1000, P <0.0001) and BNP (1925.4 ± 1087 vs. 550.5 ± 496.5pg/ml, P < 0.0005) with further impairment of LV–GLS (13.8 ± 2.5 vs. 16.4 ± 5.4%, P < 0.05) were found in patients with LV EF 0 50% than those with LV EF > 50%. Serum levels of BNP were positively correlated with LVM I (r = 0.896, P < 0.0001) and LVMW S (r = 0.697, P < 0.0001), but negatively correlated with LV–GLS (r = 0 0.587, P < 0.0001). Conclusion: LV–GLS and LVMWS are useful imaging markers for detection of LV dysfunction in HD patients. Serum BNP level is influenced by LV structural abnormalities, being regarded as a crucial hemodynamic biomarker in those patients.

Coronavirus Disease-2019, Diabetes and Dialysis: An Internal Medicine Conundrum Proposal for a Suitable and Easy-to-Handle Prevention Protocol

Background Frail populations burdened with chronic diseases can get more severe forms of coronavirus disease-2019 (COVID-19) and have a higher mortality rate. Aim To test the efficacy of a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) containment protocol in patients with endstage renal disease (ESRD) diabetes mellitus (DM) requiring dialysis, who are a typical example of the above category. Methods The protocol included: (i) daily telephone COVID-19 related triage for patients and their general practitioners (GPs); (ii) social distancing; (iii) environment sanitization, including ambulances, transfer vans, medical equipment, patient/health personnel clothing, and individual protection devices; (iv) adoption of quota systems for patients allowed to the dialysis room, and increased time lags among dialysis shifts. Eight hundred twenty-five (825) patients on dialysis (315 with and 510 without DM), and 381 healthcare providers (HCPs) were monitored continuously from the start of the pandemic until the end of the lockdown. Results No HCPs were infected, while only two patients on dialysis were positive for SARS-CoV-2: one with DM, who died in intensive care, and one without DM, who recovered at home. The adopted contagion containment protocol proved to be effective for both HCPs and patients. Conclusion Therefore, we propose it as a useful model for any internal medicine or ESRD specialized units dealing with patients on dialysisoriented with or without DM.

Could Antioxidant Supplementation Delay Progression of Cardiovascular Disease in End-Stage Renal Disease Patients?

In end-stage renal disease patients, the leading causes of mortality are of cardiovascular (CV) origin. The underlying mechanisms are complex, given that sudden heart failure is more common than acute myocardial infarction. A contributing role of oxidative stress is postulated, which is increased even at early stages of chronic kidney disease, is gradually augmented in parallel to progression to endstage renal disease and is further accelerated by renal replacement therapy. Oxidative stress ensues when there is an imbalance between reactive pro-oxidants and physiologically occurring electron donating antioxidant defence systems. During the last decade, a close association of oxidative stress with accelerated atherosclerosis and increased risk for CV and all-cause mortality has been established. Lipid peroxidation has been identified as a trigger for endothelial dysfunction, the first step towards atherogenesis. In order to counteract the deleterious effects of free radicals and thereby ameliorate, or delay, CV disease, exogenous administration of antioxidants has been proposed. Here, we attempt to summarize existing data from studies that test antioxidants for CV protection, such as vitamins E and C, statins, omega-3 fatty acids and N-acetylcysteine.

The Frequency of Pulmonary Hypertension among End Stage Renal Disease Patients on Hemodialysis

Background: Chronic kidney disease is one of the global public health problem. It is a major cause of mortality and morbidity. Endstage renal disease patients will have either option of renal transplant or dialysis. Although dialysis is an effective form of renalreplacement therapy but it also have long term side effects. Pulmonary hypertension is one of them.Objective: To find frequency of pulmonary hypertension among end stage renal disease patients on hemodialysis in our populationMaterial and Methods: In this study a total of 163 patients were included, using 18.8% prevalence of pulmonary hypertension inend stage renal disease patients on hemodialysis, with 95% confidence interval and 6% margin of error, using WHO software. Moreover non-probability consecutive sampling technique was used for sample collection.Results: Our study shows that mean age was 52 years with SD ± 8.21. Fifty five percent patients were male and 73(45%) patientswere female. Forty eight percent patients had pulmonary hypertension.Conclusion: Our study concludes that the incidence of pulmonary hypertension was found to be one of the major contributingfactor among end stage renal disease patients on hemodialysis in our population.

Advanced Chronic Kidney Disease in Lupus Nephritis: Is Dialysis Inevitable?

Objective.Advanced chronic kidney disease (CKD) carries an increased risk for progression to endstage renal disease (ESRD). We aimed to determine the rate of progression and the factors that drive the decline of renal function in lupus nephritis (LN).Methods.Patients with advanced LN-related CKD were identified from our longterm longitudinal cohort. Advanced CKD was defined as stage 3b [estimated glomerular filtration rate (eGFR) = 30–44 ml/min/1.73 m2] and stage 4 (eGFR = 15–29 ml/min/1.73 m2). All individuals were followed until progression to ESRD or the last visit and were divided into “progressors” and “non- progressors.” Demographic, clinical, immunological, and therapeutic variables were compared at baseline. Multivariable Cox regression analysis (both time-dependent and independent) was performed to identify predictors for progression.Results.One hundred eighteen patients (74 CKD 3b and 44 CKD 4) were included. Forty-five patients progressed (29 to ESRD and 16 from CKD 3b to CKD 4) after 6 years on average. No significant decline in the renal function was observed in 73 patients (“non-progressors”) after 10 years on average. Active serology (high anti-dsDNA titers and low complements C3/C4) at the time of CKD diagnosis and any increase of the daily prednisone dose after baseline were strongly associated with progression. Treatment with renin angiotensin system (RAS) blockers was associated with less risk for progression.Conclusion.Dialysis is not inevitable in LN-related advanced CKD because 62% of our patients did not progress over 10 years of followup on average. Certain predictors were identified to affect progression to ESRD.

Investigation of Nutritional Status of Hemodialysis Patients in Istanbul/Turkey

Background: This study aims to determine protein, sodium, potassium, phosphorus consumptions and energy intake in endstage renal disease (ESRD) patients undergoing hemodialysis 3 times a week and compare these quantities with recommended requirements. Methods: This study was conducted with 198 end-stage renal disease patients between the ages of 20 and 65 who underwent hemodialysis 3 times a week. Data were obtained via a survey form and Food Frequency Questionnaire. Results: No significant relationship was identified between gender and protein consumption (p>0.05). However, a significant relationship was found between the body mass indices (BMI) and protein consumption of the patients (p<0.05); when groups were compared, protein consumption reduced while the BMI increased (p<0.01). When age and protein consumption were examined, protein consumption was found to be higher in patients aged 20-44 as compared to patients aged 56-65 (p<0.05). Conclusion: The protein consumption and energy intake of hemodialysis patients appears to be below the recommended level. This suggests that hemodialysis patients are receiving insufficient nutrition in Istanbul/Turkey. Hemodialysis patients should be given better nutritional education and their nutritional status should be optimized.