Personalised cooler dialysate for patients receiving maintenance haemodialysis (MyTEMP): a pragmatic, cluster-randomised trial

Technical requirements and devices available for long-term hemodialysis in children-mind the gap!

Children requiring long-term kidney replacement therapy are a "rare disease" cohort. While the basic technical requirements for hemodialysis (HD) are similar in children and adults, key aspects of the child's cardiovascular anatomy and hemodynamic specifications must be considered. In this article, we describe the technical requirements for long-term HD therapy for children and the devices that are currently available around the world. We highlight the characteristics and major technical shortcomings of permanent central venous catheters, dialyzers, dialysis machines, and software available to clinicians who care for children. We show that currently available HD machines are not equipped with appropriately small circuits and sensitive control mechanisms to perform safe and effective HD in the youngest patients. Manufacturers limit their liability, and health regulatory agencies permit the use of devices, only in children according to the manufacturers' pre-specified weight limitations. Although registries show that 6-23% of children starting long-term HD weigh less than 15 kg, currently, there is only one long-term HD device that is cleared for use in children weighing 10 to 15 kg and none is available and labelled for use in children weighing less than 10 kg anywhere in the world. Thus, many children are being treated "off-label" and are subject to interventions delivered by medical devices that lack pediatric safety and efficacy data. Moreover, recent improvements in dialysis technology offered to adult patients are denied to most children. We, in turn, advocate for concerted action by pediatric nephrologists, industry, and health regulatory agencies to increase the development of dedicated HD machines and equipment for children.

Ten tips from the Swiss Working Group on Sustainable Nephrology on how to go green in your dialysis unit

The health-care system and particularly renal replacement therapy has a significant carbon footprint adding to global warming and extreme weather conditions. Improving sustainability has become the focus of national and international working groups. Many reviews underline the need for improvement of sustainability in nephrology, in particular dialysis, and provide recommendations on how to reduce waste, energy, and water consumption. However, how to implement these recommendations, and where to start, is not always clear. This paper summarizes discussions within the 'working group on sustainable nephrology' of the Swiss Society of Nephrology. We do not provide a detailed review of the topic but instead present a practical 10-point action plan to help health-care workers in nephrology make a start and improve the carbon footprint of their dialysis centres. We emphasize the importance of ongoing research, cooperation, and dialogue, and welcome additional ideas from the wider renal community.

The Ottawa Statement implementation guidance document for cluster randomized trials in the hemodialysis setting

Research teams are increasingly interested in using cluster randomized trial (CRT) designs to generate practice-guiding evidence for in-center maintenance hemodialysis. However, CRTs raise complex ethical issues. The Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials, published in 2012, provides 15 recommendations to address ethical issues arising within 7 domains: justifying the CRT design, research ethics committee review, identifying research participants, obtaining informed consent, gatekeepers, assessing benefits and harms, and protecting vulnerable participants. But applying the Ottawa Statement recommendations to CRTs in the hemodialysis setting is complicated by the unique features of the setting and population. Here, with the help of content experts and patient partners, we co-developed this implementation guidance document to provide research teams, research ethics committees, and other stakeholders with detailed guidance on how to apply the Ottawa Statement recommendations to CRTs in the hemodialysis setting, the result of a 4-year research project. Thus, our work demonstrates how the voices of patients, caregivers, and all stakeholders may be included in the development of research ethics guidance.

The Acute, Combined, and Separate Effects of Cold Hemodialysis and Intradialytic Exercise in Insulin Sensitivity and Glucose Disposal

Hemodialysis (HD) patients suffer from multiple health problems, including severe insulin resistance. Both cold dialysis and intradialytic exercise training could elicit health benefits; however, it is still unknown whether the combination of those two approaches could enhance overall health. The current study aimed to evaluate the separate and combined acute effects of a single session of cold dialysis and intradialytic exercise in parameters related to insulin sensitivity and glucose disposal. Ten HD patients (57.2 ± 14.9 years) participated in the study. Each patient participated in four different scenarios during HD: a) typical dialysis with dialysate temperature at 37°C (TD), b) cold dialysis with dialysate temperature at 35°C, c) typical HD combined with a single exercise bout, d) cold dialysis combined with a single exercise bout. Glucose disposal and insulin resistance were assessed immediately after the end of the HD session. None of the examined parameters significantly differed between the four scenarios ( p > 0.05). However, slight numerical changes and moderate to high effect size ( d : 0.50-0.85) were observed between TD versus cold dialysis and TD versus TD + exercise in glucose and insulin disposal rates. A single session of cold and TD with intradialytic exercise may provide an "acute" time-efficient stimulus for consecutively improving glucose disposal and insulin sensitivity.

A Pilot Study on the Safety and Adequacy of a Novel Ecofriendly Hemodialysis Prescription-Green Nephrology

Introduction

Hemodialysis (HD) units require large quantities of water. To reduce water consumption without compromising the adequacy and safety of dialysis, we studied a novel HD prescription with high temperature and low flow dialysate.

Methods

This was a single-center nonrandomized open-label cross-over pilot trial in patients with end-stage kidney disease on maintenance HD. Each participant was subjected to 3 different dialysis prescriptions for 1 month each as follows: (i) normal temperature with normal flow dialysate (NTNF prescription), (ii) high temperature with normal flow dialysate (HTNF prescription), and (iii) high temperature with low flow dialysate (HTLF prescription). The primary outcome, assessed at the end of each dialysis session, was the delivery of "adequate" dialysis, as defined by a single-pool Kt/V (spKt/V) ≥1.2. Outcomes were evaluated by comparing the NTNF and HTLF prescriptions.

Results

A total of 863 sessions of HD were performed in 30 patients over 3 months, with 287 to 288 sessions in each of the 3 dialysis prescriptions. The primary outcome was not significantly different between the NTNF prescription (202 sessions [70.14%]) and the HTLF prescription (198 sessions [68.75%]) (odds ratio, 1.07; 95% confidence interval, 0.75 to 1.52; P = 0.45). The mean spKt/V and urea reduction ratio (URR) were not significantly different. Clinically evident hemodynamic instability occurred in only 1 dialysis session in the HTNF prescription.

Conclusion

Increasing dialysate temperature while reducing dialysate flow rate (QD) can be used as a water conservation strategy without compromising the adequacy and safety of dialysis in young and hemodynamically stable patients. Reducing the QD from 500 ml/min to 300 ml/min reduces water consumption by 40%.

Update on Hemodialysis-Induced Multiorgan Ischemia: Brains and Beyond

Hemodialysis is a life-saving treatment for patients with kidney failure. However, patients requiring hemodialysis have a 10-20 times higher risk of cardiovascular morbidity and mortality than that of the general population. Patients encounter complications such as episodic intradialytic hypotension, abnormal perfusion to critical organs (heart, brain, liver, and kidney), and damage to vulnerable vascular beds. Recurrent conventional hemodialysis exposes patients to multiple episodes of circulatory stress, exacerbating and being aggravated by microvascular endothelial dysfunction. This promulgates progressive injury that leads to irreversible multiorgan injury and the well-documented higher incidence of cardiovascular disease and premature death. This review aims to examine the underlying pathophysiology of hemodialysis-related vascular injury and consider a range of therapeutic approaches to improving outcomes set within this evolved rubric.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬.

Digital Health Support: Current Status and Future Development for Enhancing Dialysis Patient Care and Empowering Patients

Chronic kidney disease poses a growing global health concern, as an increasing number of patients progress to end-stage kidney disease requiring kidney replacement therapy, presenting various challenges including shortage of care givers and cost-related issues. In this narrative essay, we explore innovative strategies based on in-depth literature analysis that may help healthcare systems face these challenges, with a focus on digital health technologies (DHTs), to enhance removal and ensure better control of broader spectrum of uremic toxins, to optimize resources, improve care and outcomes, and empower patients. Therefore, alternative strategies, such as self-care dialysis, home-based dialysis with the support of teledialysis, need to be developed. Managing ESKD requires an improvement in patient management, emphasizing patient education, caregiver knowledge, and robust digital support systems. The solution involves leveraging DHTs to automate HD, implement automated algorithm-driven controlled HD, remotely monitor patients, provide health education, and enable caregivers with data-driven decision-making. These technologies, including artificial intelligence, aim to enhance care quality, reduce practice variations, and improve treatment outcomes whilst supporting personalized kidney replacement therapy. This narrative essay offers an update on currently available digital health technologies used in the management of HD patients and envisions future technologies that, through digital solutions, potentially empower patients and will more effectively support their HD treatments.

Impact of Using Blood Warmer During Continuous Kidney Replacement Therapy in Patients With Acute Kidney Injury

PURPOSE

We investigated the impact of blood warmer use on hypotensive episodes in patients with acute kidney injury (AKI) receiving continuous kidney replacement therapy (CKRT).

MATERIALS AND METHODS

We included patients with AKI undergoing CKRT between January 1, 2012, and January 1, 2021, at a tertiary academic hospital. Hypotensive episodes were defined as mean arterial pressure (MAP) <60 mm Hg or a decrease in MAP by ≥10 mm Hg, systolic blood pressure (SBP) < 90 mm Hg or a decrease in SBP by ≥20 mm Hg, or increased vasopressor requirement. These were analyzed by Poisson regression with repeated-measures analysis of variance using generalized estimation equation.

RESULTS

There were 669 patients with AKI that required CKRT. Use of blood warmer on first day of CKRT was in 324 (48%) patients. Incidence rate ratio of hypotensive episodes during the first 24-h of CKRT in patients where a blood warmer was used was 1.06 (95% confidence interval [CI]: 0.98-1.13) compared to those where blood warmer was not used. This did not change in adjusted model. Overall, the within-subject effect of temperature on hypotensive episodes showed that higher temperature was associated with fewer episodes (0.94, 95% CI: 0.9-0.99 per 10 degrees increase, P = .007).

CONCLUSION

Blood rewarming was not associated with hypotensive episodes during CKRT.

Capacity for the management of kidney failure in the International Society of Nephrology North America and the Caribbean region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

The International Society of Nephrology Global Kidney Health Atlas charts the availability and capacity of kidney care globally. In the North America and the Caribbean region, the Atlas can identify opportunities for kidney care improvement, particularly in Caribbean countries where structures for systematic data collection are lacking. In this third iteration, respondents from 12 of 18 countries from the region reported a 2-fold higher than global median prevalence of dialysis and transplantation, and a 3-fold higher than global median prevalence of dialysis centers. The peritoneal dialysis prevalence was lower than the global median, and transplantation data were missing from 6 of the 10 Caribbean countries. Government-funded payments predominated for dialysis modalities, with greater heterogeneity in transplantation payor mix. Services for chronic kidney disease, such as monitoring of anemia and blood pressure, and diagnostic capability relying on serum creatinine and urinalyses were universally available. Notable exceptions in Caribbean countries included non-calcium-based phosphate binders and kidney biopsy services. Personnel shortages were reported across the region. Kidney failure was identified as a governmental priority more commonly than was chronic kidney disease or acute kidney injury. In this generally affluent region, patients have better access to kidney replacement therapy and chronic kidney disease-related services than in much of the world. Yet clear heterogeneity exists, especially among the Caribbean countries struggling with dialysis and personnel capacity. Important steps to improve kidney care in the region include increased emphasis on preventive care, a focus on home-based modalities and transplantation, and solutions to train and retain specialized allied health professionals.

Implementing pragmatic clinical trials in hepatology

Patients with chronic liver disease would benefit from pragmatic trial designs. A pragmatic trial seeks to inform clinical decision-making by providing evidence for the adoption of an intervention into real-world clinical practice. A trial's pragmatism is based on the efficiency by which it identifies, recruits, and follows patients, the degree to which the interventions and design mirror the usual clinical care, and the importance of the outcomes to the patients. We review the promise, trade-offs, and purpose of pragmatic trials in hepatology.

Randomized trial comparing standard versus thermocontrolled haemodialysis using intradialytic cardiac, brain and renal magnetic resonance imaging

BACKGROUND

Ischaemic end-organ damage during haemodialysis (HD) is a significant problem that may be ameliorated by intradialytic cooling. A randomised trial was performed to compare standard HD (SHD; dialysate temperature 37°C) and programmed cooling of the dialysate [thermocontrolled HD (TCHD)] using multiparametric magnetic resonance imaging (MRI) to assess structural, functional and blood flow changes in the heart, brain and kidneys.

METHODS

Prevalent HD patients were randomly allocated to receive either SHD or TCHD for 2 weeks before undergoing serial MRI at four time points: pre-, during (30 min and 180 min) and post-dialysis. MRI measures include cardiac index, myocardial strain, longitudinal relaxation time (T1), myocardial perfusion, internal carotid and basilar artery flow, grey matter perfusion and total kidney volume. Participants then crossed to the other modality to repeat the study protocol.

RESULTS

Eleven participants completed the study. Separation in blood temperature between TCHD (-0.1 ± 0.3°C) and SHD (+0.3 ± 0.2°C; P = .022) was observed, although there was no difference in tympanic temperature changes between arms. There were significant intradialytic reductions in cardiac index, cardiac contractility (left ventricular strain), left carotid and basilar artery blood flow velocities, total kidney volume, longitudinal relaxation time (T1) of the renal cortex and transverse relaxation rate (T2*) of the renal cortex and medulla, but no differences between arms. Pre-dialysis T1 of the myocardium and left ventricular wall mass index were lower after 2 weeks of TCHD compared with SHD [1266 ms (interquartile range 1250-1291) versus 1311 ± 58 ms, P = .02; 66 ± 22 g/m2 versus 72 ± 23 g/m2, P = .004].

CONCLUSIONS

HD adversely affects cardiac function, reduces carotid and basilar artery blood flow and total kidney volume, but mild dialysate cooling using a biofeedback module did not result in differences in intradialytic MRI measures compared with SHD.

Does cooled dialysate still have a role in reducing intradialytic stress? Implications of the MyTEMP trial

PURPOSE OF REVIEW

There is an excess of cardiovascular morbidity and mortality in the maintenance haemodialysis population. Targeting traditional risk factors (e.g. hypercholesterolaemia) do not improve cardiovascular outcomes. Repeated myocardial stunning during haemodialysis is an important nontraditional risk, resulting in pathological cardiac remodelling and fibrosis. This review explores dialysate cooling as a management strategy to promote haemodynamic stability, reduce myocardial injury, and improve cardiovascular disease outcomes for individuals receiving maintenance haemodialysis.

RECENT FINDINGS

Observational data and small interventional studies demonstrate dialysate cooling has the potential to reduce end-organ damage and provide cardioprotection, renal protection and neuroprotection compared with standard care. These data are limited by the small sample sizes, short follow-up times and lack of long-term patient important outcomes. The MyTEMP study, a multicentre pragmatic randomized controlled trial, demonstrated cooled dialysate (0.5°C below body temperature) vs. standard care did not improve cardiovascular outcomes for prevalent haemodialysis patients.

SUMMARY

Dialysate cooling has been widely adopted into routine clinical practice; the MyTEMP study challenges the unit-level approach to implementing dialysate cooling. Due to methodological limitations, the absence of other important patient outcome measures, and lack of granularity of patient-level data, dialysate cooling should not be hastily removed from all dialysis care and warrants further research.

Fatigue in Patients Receiving Maintenance Hemodialysis: A Review

Fatigue surrounding hemodialysis treatments is a common and often debilitating symptom that impacts patients' quality of life. Intradialytic fatigue develops or worsens immediately before hemodialysis and persists through the dialysis treatment. Little is known about associated risk factors or pathophysiology, although it may relate to a classic conditioning response. Postdialysis fatigue (PDF) develops or worsens after hemodialysis and may persist for hours. There is no consensus on how to measure PDF. Estimates for the prevalence of PDF range from 20%-86%, likely due to variation in methods of ascertainment and participant characteristics. Several hypotheses seek to explain the pathophysiology of PDF, including inflammation, hypothalamic-pituitary-adrenal axis dysregulation, and osmotic and fluid shifts, but none is currently supported by compelling or consistent data. PDF is associated with several clinical factors, including cardiovascular and hemodynamic effects of the dialysis procedure, laboratory abnormalities, depression, and physical inactivity. Clinical trials have reported hypothesis-generating data about the utility of cold dialysate, frequent dialysis, clearance of large middle molecules, treatment of depression, and exercise as potential treatments. Existing studies are often limited by sample size, lack of a control group, observational design, or short intervention duration. Robust studies are needed to establish the pathophysiology and management of this important symptom.

Could cooling dialysate improve inflammatory and nutritional status of hemodialysis patients?

BACKGROUND

It has been shown that dialysate cooling (lowering the dialysate temperature to 0.5 °C below central body temperature) reduces the incidence of intradialytic hypotension. Other influences on hemodialysis patients, however, have not been adequately investigated. The purpose of this study was to determine the impact of individualized dialysate cooling on nutritional and inflammatory parameters in chronic hemodialysis (HD) patients.

METHODS

Seventy HD patients were separated into two groups: group A: (control group) standard dialysate temperature was 37 °C, and group B: (intervention group) dialysate temperature was 0.5 °C below core body temperature. In addition to routine laboratory tests, blood pressure, anthropometric measurements, inflammatory markers, and the malnutrition inflammation score (MIS) were calculated.

RESULTS

After six months of dialysate cooling, intradialytic hypotension episodes were much less prevalent in the intervention group (p = 0.001). Serum ferritin, transferrin saturation (TSAT), high sensitive C-reactive protein (HS-CRP), and Interleukin-6 (IL-6) reduced following dialysate cooling, whereas serum albumin rose. In the control group, IL-6 dropped but serum ferritin, TSAT, albumin, and HS-CRP rose. In both groups, hemoglobin levels dropped, and erythrocyte sedimentation rate (ESR) rose, both groups' midarm muscle circumference and MIS worsened.

CONCLUSION

Cold dialysate decreased intradialytic hypotension with no significant improvement of the nutritional and inflammatory surrogates. However, more studies including larger number of patients with longer duration of follow up are required to adequately assess its effect on inflammation and nutrition in chronic hemodialysis patients.

Physical intradialytic patient-reported outcome measures in haemodialysis and haemodiafiltration: A cross-over study

AIM

Standard haemodialysis (sHD) is associated with a poor survival and marked adverse intradialytic patient-reported outcome measures (ID-PROMs). Whereas physical ID-PROMs (PID-PROMs) are alleviated by cool dialysate (cHD), survival is prolonged by haemodiafiltration (HDF). So far, PID-PROMs are not prospectively compared between HD and HDF.

METHODS

To assess whether PID-PROMs and thermal perception differ between sHD, cHD, low volume HDF (lvHDF) and high volume HDF (hvHDF), 40 patients were cross-over randomized to each modality for 2 weeks. Dialysate temperature (T_d ) was 36.5°C, except in cHD (T_d 35.5°C). Target convection volumes were 15 L in lvHDF and ≥ 23 L in hvHDF. PID-PROMs were evaluated with a modified Dialysis Symptom Index (mDSI) and thermal perception with the Visual Analogue Scale Thermal Perception (VAS-TP). T_b and room temperature were measured as well.

RESULTS

Except for the item 'feeling cold' during cHD (p = .01), PID-PROMs did not differ between modalities, but varied markedly between patients (11/13 items, p < .05). T_b increased in sHD, lvHDF, and hvHDF (+0.30, 0.35, 0.38°C, respectively, all p < .0005), but remained stable in cHD (+0.04°C, p = .43). Thermal perception remained unaltered in sHD and both HDF modalities, but shifted towards cold in cHD (p = .007).

CONCLUSION

(1) PID-PROMs did not differ between modalities, but varied markedly between patients. Hence, PID-PROMs are largely patient-dependent. (2) While T_b increased in sHD, lvHDF and hvHDF, thermal perception did not change. Yet, whereas T_b remained unaltered in cHD, cold perception emerged. Hence, as for bothersome cold sensations, cHD should be avoided in perceptive individuals.

Health Services Use and Outcomes for Hospital Admissions With a Major Cardiovascular Event Recorded in Health Care Administrative Data in Patients Receiving Maintenance Hemodialysis: A Retrospective Cohort Study

Background

Administrative data are used in studies of hemodialysis care to report cardiovascular-related hospitalizations. Showing recorded events are associated with significant health care resource use and poor outcomes would confirm that administrative data algorithms identify clinically meaningful events.

Objective

The objective of this study was to describe the 30-day health service use and outcomes when a hospital admission with myocardial infarction, congestive heart failure, or ischemic stroke is recorded in administrative databases.

Design

This is a retrospective review of linked administrative data.

Patients and Setting

Patients receiving maintenance in-center hemodialysis in Ontario, Canada, between April 1, 2013, and March 31, 2017, were included.

Measurements

Records from linked health care databases at ICES in Ontario, Canada were considered. We identified hospital admission with the most responsible diagnosis recorded as myocardial infarction, congestive heart failure, or ischemic stroke. We then assessed the frequency of common tests, procedures, consultations, post-discharge outpatient drug prescriptions, and outcomes within 30 days following the hospital admission.

Methods

We used descriptive statistics to summarize results using counts and percentages for categorical variables and means with standard deviations or medians with quartile ranges for continuous variables.

Results

There were 14 368 patients who received maintenance hemodialysis between April 1, 2013, and March 31, 2017. The number of events per 1000 person-years was 33.5 for hospital admissions with myocardial infarction, 34.2 for congestive heart failure, and 12.9 for ischemic stroke. The median (25th, 75th percentile) duration of hospital stay was 5 (3-10) days for myocardial infarction, 4 (2-8) days for congestive heart failure, and 9 (4-18) days for ischemic stroke. The chance of death within 30 days was 21% for myocardial infarction, 11% for congestive heart failure, and 19% for ischemic stroke.

Limitations

Events, procedures, and tests recorded in administrative data can be misclassified compared with medical charts.

Conclusions

In patients receiving maintenance hemodialysis, hospital admissions of major cardiovascular events routinely recorded in health administrative databases are associated with significant use of health service resources and poor health outcomes.