The role of oral dryness in interdialytic weight gain by diabetic and non-diabetic haemodialysis patients

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.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬.

Association of serum sodium levels with fractures and mortality in patients undergoing maintenance hemodialysis

BACKGROUND

Hyponatremia is implicated in pathological bone resorption and has been identified as a risk factor for bone fracture in the general population. However, there are limited data on the association between serum sodium levels and fracture risk in patients undergoing hemodialysis (HD).

METHODS

We analyzed a historical cohort of 2220 maintenance HD patients to examine the association between serum sodium levels and the risk of fracture and mortality. We also examined the association between serum sodium levels and osteoporosis, based on metacarpal bone mineral density, in a subcohort of 455 patients with available data. In addition, we examined the association between serum sodium levels and bone turnover markers in a separate cross-sectional cohort of 654 maintenance HD patients.

RESULTS

During a median follow-up of 5.4 years, 712 patients died, 113 experienced clinical fractures, and 64 experienced asymptomatic vertebral fractures. Lower serum sodium levels were associated with an increased risk of mortality (HR 1.06 per 1 mEq/L decrease; 95% CI 1.03-1.09) but not with the risk of clinical fracture (HR 1.04 per 1 mEq/L decrease; 95% CI 0.97-1.11). A similar lack of association was observed for asymptomatic vertebral fracture and any fracture. Serum sodium levels were also not associated with osteoporosis in a subcohort with available data (n = 455) or with bone alkaline phosphatase or tartrate-resistant acid phosphatase-5b in a separate cross-sectional cohort.

CONCLUSION

Serum sodium levels were associated with mortality but not with fracture risk, osteoporosis, or bone turnover markers in maintenance HD patients.

Is increased subjective thirst associated with greater interdialytic weight gains, extracellular fluid and dietary sodium intake?

BACKGROUND

Some previous studies have reported an effect of increasing subjective thirst and interdialytic weight gains (IDWG), and that this may be influenced by nonadherence to dietary sodium restrictions, whereas others reported no such association. As such we wished to review the effect of self-reported thirst on IDWGs and dietary sodium intake.

METHODS

Dialysis patients were asked to complete visual analogues thirst, distress thermometer (DT) scores and complete a sodium food frequency questionnaire (SFFQ). IDWG and pre and post dialysis volumes were measured with multifrequency bioelectrical impedance.

RESULTS

One hundred and eleven patients completed the questionnaires and had bioimpedance measurements: 63% male, mean age 63.8 ± 16.1 years, 33% diabetic with a median thirst score 3 (0-5) and SFFQ 52.0 ± 18, and IDWG 2.1 ± 1.3%. Thirst was associated with DT (r = 0.28, p = 0.004) and negatively with age (r = -0.31, p < 0.001), but not SFFQ, IDWG, extracellular water, or dialysate sodium, or dialysate to plasma gradient. Patients with higher thirst scores were younger (58.0 ± 15.2 vs. 69.4 ± 15.0 years, p < 0.001) with higher DT scores (5 [2-7] vs. 2 [0-5], p < 0.001). On multivariate logistic analysis, only age was associated with self-reported thirst (odds ratio 0.95, 95% confidence limits 0.92-0.98, p < 0.001).

CONCLUSION

We found that subjective thirst was greater for younger patients and those who reported higher levels of distress, but no association with IDWGs, dietary sodium intake, or dialysate sodium. However, most of our patients followed the dietary advice, as evidenced by the low SFFQ scores and % IDWGs. Whether thirst increases distress or distress increases subjective thirst remains to be determined.

World Workshop on Oral Medicine VIII: Development of a Core Outcome Set for Dry Mouth: A Systematic Review of Outcome Domains for Xerostomia

OBJECTIVE

The purpose of this study was to identify all outcome domains used in clinical studies of xerostomia, that is, subjective sensation of dry mouth. This study is part of the extended project "World Workshop on Oral Medicine Outcomes Initiative for the Direction of Research" to develop a core outcome set for dry mouth.

STUDY DESIGN

A systematic review was performed on MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases. All clinical and observational studies that assessed xerostomia in human participants from 2001 to 2021 were included. Information on outcome domains was extracted and mapped to the Core Outcome Measures in Effectiveness Trials taxonomy. Corresponding outcome measures were summarized.

RESULTS

From a total of 34,922 records retrieved, 688 articles involving 122,151 persons with xerostomia were included. There were 16 unique outcome domains and 166 outcome measures extracted. None of these domains or measures were consistently used across all the studies. The severity of xerostomia and physical functioning were the 2 most frequently assessed domains.

CONCLUSION

There is considerable heterogeneity in outcome domains and measures reported in clinical studies of xerostomia. This highlights the need for harmonization of dry mouth assessment to enhance comparability across studies and facilitate the synthesis of robust evidence for managing patients with xerostomia.

When ESKD complicates the management of diabetes mellitus

Given the increased incidence and prevalence of ESKD (end-stage kidney disease) attributed to diabetes mellitus, it is important to consider the physiological and global sociodemographic factors that give rise to unique challenges in providing excellent care to this population. The individual with diabetes and ESKD faces alterations of glucose homeostasis that require close therapeutic attention, as well as the consideration of safe and effective means of maintaining glycemic control. Implementation of routine monitoring of blood glucose and thoughtful alteration of the individual's hypoglycemic drug regimen must be employed to reduce the risk of neurological, cardiovascular, and diabetes-specific complications that may arise as a result of ESKD. Titration of insulin therapy may become quite challenging, as kidney replacement therapy often significantly impacts insulin requirements. New medications have significantly improved the ability of the clinician to provide effective therapies for the management of diabetes, but have also raised an equal amount of uncertainty with respect to their safety and efficacy in the ESKD population. Additionally, the clinician must consider the challenges related to the delivery of kidney replacement therapy, and how inter-modality differences may impact glycemic control, diabetes, and ESKD-related complications, and issues surrounding dialysis vascular access creation.

Periodontal Disease in Patients Receiving Dialysis

Chronic kidney disease (CKD) is characterized by kidney damage with proteinuria, hematuria, and progressive loss of kidney function. The final stage of CKD is known as end-stage renal disease, which usually indicates that approximately 90% of normal renal function is lost, and necessitates renal replacement therapy for survival. The most widespread renal replacement therapy is dialysis, which includes peritoneal dialysis (PD) and hemodialysis (HD). However, despite the development of novel medical instruments and agents, both dialysis procedures have complications and disadvantages, such as cardiovascular disease due to excessive blood fluid and infections caused by impaired immunity. Periodontal disease is chronic inflammation induced by various pathogens and its frequency and severity in patients undergoing dialysis are higher compared to those in healthy individuals. Therefore, several investigators have paid special attention to the impact of periodontal disease on inflammation-, nutrient-, and bone metabolism-related markers; the immune system; and complications in patients undergoing dialysis. Furthermore, the influence of diabetes on the prevalence and severity of manifestations of periodontal disease, and the properties of saliva in HD patients with periodontitis have been reported. Conversely, there are few reviews discussing periodontal disease in patients with dialysis. In this review, we discuss the available studies and review the pathological roles and clinical significance of periodontal disease in patients receiving PD or HD. In addition, this review underlines the importance of oral health and adequate periodontal treatment to maintain quality of life and prolong survival in these patients.

The effects of Ramadan fasting on clinical and biochemical markers among hemodialysis patients: A prospective cohort study

Background

Ramadan fasting is compulsory for all healthy adult Muslims. Although sick people are exempted from Ramadan fasting, some patients such as hemodialysis patients prefer to fast during Ramadan. The effect of Ramadan fasting on clinical outcomes and biochemical markers among hemodialysis patients is not clear. The aim of this study was to examine the effects of daily Ramadan fasting and partial Ramadan fasting on key biochemical and clinical markers among hemodialysis patients as compared to hemodialysis patients who chose not to fast during Ramadan.

Methods

A prospective cohort study of 269 end stage renal disease patients were recruited from the hemodialysis unit in An-Najah National University Hospital, Nablus, Palestine. The participants were divided into three cohorts based on their plans for fasting during Ramadan in May 2018; Ramadan fasting group (RFG), Ramadan partial fasting group (RPFG) and Ramadan not-fasting group (RNFG). Key clinical and biochemical markers were measured before, during and after Ramadan.

Results

After adjustment for diabetic and hypertension status and other sociodemographic variables, RFG had higher mean inter-dialytic weight gain (IDWG) by 0.62 kg than RNFG (95% confidence interval (CI) 0.26, 0.99). RPFG also had slight increase in mean IDWG than RNFG by 0.35 kg (95% CI 0.11, 0.60). Additionally, RFG and RPFG had significant increase in mean serum potassium as compared to RNFG. Diabetes was independently associated with increased IDWG by 0.48 kg (0.25, 0.72). Diabetes and hypertension were associated with some independent changes in biochemical markers, but these were clinically negligible.

Conclusion

Our findings suggest that Ramadan fasting (fully or partially) is tolerable by hemodialysis patients and is not associated with important clinical complications. However, these patients should be made aware of the potential risk of fluid overload and hyperkalemia, if they decide to fast during Ramadan. Thus, they should be closely monitored and instructed to adhere to their dietary and fluid intake allowances. Further prospective cohort studies with comprehensive dietary measures and information on adverse clinical outcomes may provide more evidence about the tolerability and safety of Ramadan fasting by hemodialysis patients.

Patient-Centered Approach for Hypertension Management in End-Stage Kidney Disease: Art or Science?

Hypertension is present in most patients with end-stage kidney disease initiating dialysis and management of hypertension is a routine but challenging task in everyday dialysis care. End-stage kidney disease patients are uniquely heterogeneous individuals with significant variations in demographic characteristics, functional capacity, and presence of concomitant comorbid conditions and their severity. Therefore, these patients require personalized approaches in addressing not only hypertension but related illnesses, while also accounting for overall prognosis and projected longevity. There are only limited clinical trial data to guide individualized blood pressure management and current guidelines are based predominantly on observational evidence and expert opinions. Inthis review, we reflect on the shortcomings of peridialytic blood pressure recordings and discuss an important paradigm shift toward using out-of-dialysis blood pressure for evaluating hypertension control and for making treatment decisions. In addition, we provide our personal view on blood pressure goals and summarize nonpharmacologic and pharmacologic treatment options for individualized management of hypertension in end-stage kidney disease.

Xerostomia, thirst, sodium gradient and inter-dialytic weight gain in hemodialysis diabetic vs. non-diabetic patients

Background

In hemodialysis (HD) patients, xerostomia and hyposalivation may intensify sensations of thirst, and contribute to the intake of fluids and excessive inter-dialytic weight gain (IWG). Since IWG is regarded to be higher in diabetic patients than in non-diabetics HD enhancing their mortality, it is crucial to define plausible underlying causes. Therefore, the study investigates factors contributing to the increased IWG in diabetic HD patients.

Material and Methods

The study included 97 HD patients (38 diabetics) receiving hemodialysis. All participants completed surveys comprising the Dialysis Thirst Inventory (DTI) and Xerostomia Inventory. Unstimulated whole saliva flow rate (USWFR) was measured, with USWFR below 0.1 mL/min being regarded as hyposalivation. Additionally, pre- and post-dialysis serum sodium concentration, sodium gradient and IWG were assessed. In diabetic HD patients, hemoglobin A1c (HbA1c) level was measured.

Results

Significantly higher scores were found in diabetic than non-diabetic HD patients with regard to DTI (21.2±7.7 vs. 17.1±6.2: Z=2.44, p=0.03) and xerostomia (40.5±6.1 vs. 29.9±14.4: Z=4.15, p=0.003). Hyposalivation was observed more often in diabetic HD patients (Z=2.23, p=0.04). IGW was significantly higher in participants with diabetes (Z=2.44, p=0.03), as was the pre-dialysis sodium serum (Z=3.4, p=0.008). High levels of HbA1c were associated with lower levels of serum sodium (r=-0.67 p<0.05). HbA1c positively correlated with pre-dialysis sodium gradient (r=0.66 p<0.05). However, multiple regression analysis found that the only predictors of increased IWG (>4.8 IWG%) in diabetic patients remained saliva flow rate and pre-dialysis sodium gradient.

Conclusions

Concomitant diabetes in hemodialysis patients appears to intensify subjective xerostomia and thirst sensation. It also leads to excessive IWG by the increase of pre-dialysis serum sodium gradient.

Key words:Diabetes mellitus, hemodialysis, hyposalivation, inter-dialytic weight gain, sodium gradient.

Validity and reliability of the Turkish version of the thirst distress scale in patients on hemodialysis

PURPOSE

Thirst has been reported as an important source of distress for patients on hemodialysis. However, there is no instrument available that assesses thirst distress of Turkish patients on hemodialysis. Therefore, the aim of this study was to examine the psychometric properties of the Turkish version of the Thirst Distress Scale (TDS-T) for patients on hemodialysis.

METHODS

This study was conducted methodologically. A convenience sample of 142 Turkish patients on hemodialysis participated in this study. Data were collected by using a questionnaire, the TDS-T and a visual analogue scale for thirst intensity. The analysis of data included descriptive statistics, the one-sample Kolmogorov-Smirnov test, Kruskal-Wallis test, Mann-Whitney U test, correlation coefficients and psychometric tests.

RESULTS

The TDS-T demonstrated acceptable internal consistency (Cronbach's alpha coefficient = .81), good test-retest reliability (intraclass correlation coefficient = .88), and correlations with interdialytic weight gain values and thirst intensity scores (measured by visual analogue scale) indicating concurrent and convergent validity, respectively. Construct validity was supported by known-group comparisons. The results revealed a one-component structure of the instrument.

CONCLUSIONS

The psychometric properties of the TDS-T were consistent with those reported in the original study. The TDS-T was found to be a valid and reliable tool for evaluating thirst distress in patients on hemodialysis.

Prevalence and severity of oral disease in adults with chronic kidney disease: a systematic review of observational studies

BACKGROUND

Oral disease may be increased in people with chronic kidney disease (CKD) and, due to associations with inflammation and malnutrition, represents a potential modifiable risk factor for cardiovascular disease and mortality. We summarized the prevalence of oral disease in adults with CKD and explored any association between oral disease and mortality.

METHODS

We used systematic review of observational studies evaluating oral health in adults with CKD identified in MEDLINE (through September 2012) without language restriction. We summarized prevalence and associations with all-cause and cardiovascular mortality using random-effects meta-analysis. We explored for sources of heterogeneity between studies using meta-regression.

RESULTS

Eighty-eight studies in 125 populations comprising 11 340 adults were eligible. Edentulism affected one in five adults with CKD Stage 5D (dialysis) {20.6% [95% confidence interval (CI), 16.4-25.6]}. Periodontitis was more common in CKD Stage 5D [56.8% (CI, 39.3-72.8)] than less severe CKD [31.6% (CI, 19.0-47.6)], although data linking periodontitis with premature death were scant. One-quarter of patients with CKD Stage 5D reported never brushing their teeth [25.6% (CI, 10.2-51.1)] and a minority used dental floss [11.4% (CI, 6.2-19.8)]; oral pain was reported by one-sixth [18.7% (CI, 8.8-35.4)], while half of patients experienced a dry mouth [48.4% (CI, 37.5-59.5)]. Data for kidney transplant recipients and CKD Stages 1-5 were limited.

CONCLUSIONS

Oral disease is common in adults with CKD, potentially reflects low use of preventative dental services, and may be an important determinant of health in this clinical setting.

Fluid intake and nutritional risk in non-critically ill patients at hospital referral

The association between hyporexia/anorexia, reduced food intake and disease-related malnutrition at hospital admission is well established. However, information on fluid intake according to nutritional risk has never been provided. Thus, we assessed the attitude and adequacy of fluid intake among case-mix hospitalised patients according to nutritional risk. A sample of 559 non-critically ill patients randomly taken from medical and surgical wards was evaluated. Nutritional risk was diagnosed by the Nutritional Risk Screening 2002. Usual fluid consumption the week before admission was assessed and categorised as < 5 and > or = 5 cups/d (1 cup = 240 ml), with the acceptable intake being > or = 5 cups/d. Prevalence of nutritional risk was 57.2%, and 46.2% of the patients reported a fluid intake < 5 cups/d. Multiple-adjusted logistic regression revealed that age > or = 65 years (OR: 1.88 (95% CI: 1.03, 3.43); P < 0.04), energy intake (for every 25% increase in food intake compared with estimated requirements, OR: 0.37 (95% CI: 0.25, 0.55); P < 0.001) and the number of drugs taken (every three-drug increase, OR: 0.63 (95 % CI: 0.44, 0.90); P < 0.02) were independently associated with inadequate fluid intake (< 5 cups/d). A significant independent association was also found with nutritional risk (OR: 0.64 (95% CI: 0.43, 0.95); P < 0.03). Nutritional risk appears to be positively associated with greater fluid intake in non-acute hospitalised patients, but both the reasons and the consequences of this relationship, as well as the impact on clinical practice, need to be explored. However, water replacement by oral nutritional support should take advantage of the patients' attitude to assuming a greater fluid intake, limiting at the same time fluid overload during the refeeding phase.