Prediction of hyperkalemia in ESRD patients by identification of multiple leads and multiple features on ECG

BACKGROUND

Patients with end-stage renal disease (ESRD) especially those undergoing dialysis have a high prevalence of hyperkalemia, which must be detected and treated immediately. But the initial symptoms of hyperkalemia are insidious, and traditional laboratory serum potassium concentration testing takes time. Therefore, rapid and real-time measurement of serum potassium is urgently needed. In this study, different machine learning methods were used to make rapid predictions of different degrees of hyperkalemia by analyzing the ECG.

METHODS

A total of 1024 datasets of ECG and serum potassium concentrations were analyzed from December 2020 to December 2021. The data were scaled into training and test sets. Different machine learning models (LR, SVM, CNN, XGB, Adaboost) were built for dichotomous prediction of hyperkalemia by analyzing 48 features of chest leads V2-V5. The performance of the models was also evaluated and compared using sensitivity, specificity, accuracy, accuracy, F1 score and AUC.

RESULTS

We constructed different machine models to predict hyperkalemia using LR and four other common machine-learning methods. The AUCs of the different models ranged from 0.740 (0.661, 0.810) to 0.931 (0.912,0.953) when different serum potassium concentrations were used as the diagnostic threshold for hyperkalemia, respectively. As the diagnostic threshold of hyperkalemia was raised, the sensitivity, specificity, accuracy and precision of the model decreased to various degrees. And AUC also performed less well than when predicting mild hyperkalemia.

CONCLUSION

Noninvasive and rapid prediction of hyperkalemia can be achieved by analyzing specific waveforms on the ECG by machine learning methods. But overall, XGB had a higher AUC in mild hyperkalemia, but SVM performed better in predicting more severe hyperkalemia.

Effects of sacubitril-valsartan in patients undergoing maintenance dialysis

OBJECTIVES

Data on angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril-valsartan (SV) in patients undergoing maintenance dialysis is scarce. Our study aimed to investigate the effect of SV on patients undergoing dialysis.

METHODS

We retrospectively reviewed the data of end-stage kidney disease (ESRD) patients undergoing either peritoneal dialysis (PD) or hemodialysis (HD) in our center. A total of 51 patients receiving SV treatment were enrolled in the SV group. Another 51 age and sex-matched patients on dialysis without SV treatment were selected as the control group. All the patients were regularly followed up in the dialysis clinic. Their clinical, biochemical, and echocardiographic parameters were all recorded at baseline and during follow-up. The effect and safety of SV were further analyzed.

RESULTS

A total of 102 ESRD patients on dialysis (51 patients in the SV group and 51 patients in the control group) were finally enrolled. The median follow-up time was 349 days (interquartile range [IQR]: 217-535 days). The level of B-type natriuretic peptide (BNP) (median [IQR] before and after SV treatment: 596.35 pg/ml [190.6-1714.85] vs. 188.7 pg/ml [83.34-600.35], p < 0.001) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) (median [IQR]: 6316.00 pg/ml [4552.00-28598.00] vs. 5074.00 pg/ml [2229.00-9851.00], p = 0.022) were significantly decreased after treatment with SV. The variant rate of left ventricular ejection fraction (LVEF) was significantly higher in the SV group compared to the control group, especially in the PD subgroup. No significant difference was found in other echocardiographic parameters between SV and control group. Subgroup analysis of the PD group showed an increase in daily PD ultrafiltration (median [IQR]: 400 ml/d [200-500] vs. 500 ml/d [200-850], p = 0.114) after SV treatment. Variant rate of overhydration (OH) measured by the body composition monitor (BCM) of the SV group were significantly different from the control group (median [IQR]: -13.13% [-42.85%-27.84%] vs. 0% [-17.95%-53.85%], p = 0.049). The rate of hyperkalemia was slightly higher but without significant difference before and after the introduction of SV (19.6% vs. 27.5%, p = 0.350). No event of hypotension and angioedema were observed.

CONCLUSIONS

SV might have a cardio-protective role in ESRD patients undergoing dialysis, especially in PD patients. Serum potassium should be monitored during the treatment.

manual fluid exchange alone

During urgent-start peritoneal dialysis (USPD) in end-stage renal disease (ESRD) patients, both adequate dialysis and skill training for fluid exchange are essential. However, automated peritoneal dialysis (APD) alone or manual fluid exchange peritoneal dialysis (MPD) alone could meet the above demands. Therefore, our study combined APD with MPD (A-MPD), and compared A-MPD with MPD, aiming to find the most appropriate treatment mode. This was a single-center, prospective, randomized controlled study. All eligible patients were randomized into the MPD and A-MPD groups. All patients underwent a five-day USPD treatment 48 h after catheter implantation, and they were followed up for six months after discharge. Overall, 74 patients were enrolled in this study. Among these, 14 and 60 patients quit due to complications during USPD and completed the study (A-MPD = 31, MPD = 29), respectively. Compared with MPD, the A-MPD treatment mode had a better effect on removing serum creatinine, blood urea nitrogen, and potassium and improving serum carbon dioxide combining power levels; it had less time expenditure on the fluid exchange by nurses (p < 0.05). In addition, patients in the A-MPD group had higher scores on the skill tests than those in the MPD group (p = 0.002). However, no significant differences in short-term peritoneal dialysis (PD) complications, PD technical survival rate, or mortality were found between the two groups. Therefore, the A-MPD mode could be recommended as an adoptable and suitable PD modality for USPD in the future.

Optimizing peritoneal dialysis initiation: A comparative cohort study of catheter placement methods for shortening break-in periods

INTRODUCTION

Peritoneal dialysis (PD) guidelines recommend a 14-day break-in period after catheter placement, yet this period could be shortened with new insertion techniques.

METHODS

We conducted a prospective cohort study to compare percutaneous vs. surgical catheter insertion in a newly established PD program. The break-in period was intentionally shortened to <24 h to start PD almost immediately.

RESULTS

We included 223 subjects who underwent percutaneous (34%) or surgical (66%) catheter placement. Compared to the surgical group, the percutaneous group had a higher proportion of early dialysis initiation within 24 h (97% vs. 8%, p < 0.001), similar successful initiation rates (87% vs. 92%, p = 0.34), and shorter lengths of stay (12 [9-18] vs. 18 [14-22] days, p < 0.001). Percutaneous insertion increased the likelihood of successful PD initiation within 24 h (OR 74, 95% CI 31-182), without increasing major complications.

CONCLUSION

Percutaneous placement could represent a cost-effective and efficient technique to shorten break-in periods.

Impact of sarcopenia on long-term survival after cardiac surgery for end-stage renal disease patients

BACKGROUND

The long-term mortality of end-stage renal disease (ESRD) patients is still unsatisfactory. Therefore, long-term risk assessments in ESRD patients undergoing cardiac surgery are needed. Recently, sarcopenia is major concern in cardiac surgery because of its association with poor long-term survival. However, the impact of sarcopenia on the long-term survival of ESRD patients undergoing cardiac surgery is not well understood.

METHODS

Eighty-two ESRD patients who underwent elective cardiac surgery were enrolled. Sarcopenia was identified based on noncontrast abdominal computed tomography. The impact of preoperative and intraoperative factors on long-term survival was investigated.

RESULTS

Forty-three patients (52%) were diagnosed with sarcopenia. The in-hospital mortality rate was 4.9%. The 5-year overall survival rate was 48%. The multivariate analyses revealed that STS score ≥ 4 (odds ratio, 6.0; confidence interval, 2.5-14.7; p < 0.01) and presence of sarcopenia (odds ratio, 2.4; confidence interval, 1.3-4.5; p  =  0.03) were independent risk factors for overall survival. The 5-year survival rates of low-risk (Society of Thoracic Surgeons score of < 4) patients without sarcopenia, low-risk with sarcopenia, more than intermediate-risk (Society of Thoracic Surgeons score of ≥ 4) without sarcopenia, and more than intermediate-risk with sarcopenia groups were 80%, 51%, 50%, and 26%, respectively.

CONCLUSIONS

Among the ESRD patients, the low risk without sarcopenia group showed an excellent long-term survival, in contrast to more than intermediate-risk patients with sarcopenia, who can expect poor long-term survival. Preoperative assessment of sarcopenia in addition to the surgical risk score can be useful in developing a therapeutic strategy.

INF2 and ROBO2 gene mutation in an Indian family with end stage renal failure and follow-up of renal transplantation

BACKGROUND

Accurate genetic diagnosis of end-stage renal disease patients with a family history of renal dysfunction is very essential. It not only helps in proper prognosis, but becomes crucial in designating donor for live related renal transplant. We here present a case of family with deleterious mutations in INF2 and ROBO2 and its importance of genetic testing before preparing for kidney transplantation.

CASE PRESENTATION

We report the case of a 29-year-female with end-stage renal disease and rapidly progressive renal failure. Mutational analysis revealed an Autosomal Dominant inheritance pattern and mutation in exon 4 of the INF2 gene (p. Thr215Ser) and exon 26 of the ROBO2 gene (p. Arg1371Cys). Her mother was diagnosed for CKD stage 4 with creatinine level of 4.3 mg/dL. Genetic variants (INF2 and ROBO2) identified in proband were tested in her sisters and mother. Her elder sister was positive for both heterozygous variants (INF2 and ROBO2). Her mother was positive for mutation in INF2 gene, and her donor elder sister did not showed mutation in INF2 gene and had mutation in ROBO2 gene without any clinical symptoms.

CONCLUSION

This case report emphasize that familial genetic screening has allowed us in allocating the donor selection in family where family member had history of genetic defect of Chronic Kidney Disease. Information of the causative renal disorder is extremely valuable for risk-assessment and planning of kidney transplantation.

Laparoscopic Inguinal Hernia Repair and Synchronous Peritoneal Dialysis Catheter Placement: A Single-Center Experience

Background: Peritoneal dialysis (PD) is a common method for treating end-stage renal disease (ESRD). Occurrence of inguinal hernia before and during PD is considered to be the main cause of treatment discontinuation, failure, and conversion to hemodialysis. In this study, we present a single-center experience about laparoscopic inguinal hernia repair and synchronous PD catheter placement and evaluated the feasibility and outcomes. Methods: During May 2018 to May 2022, a total of 216 consecutive patients with ESRD underwent laparoscopic PD catheter placement. Among them, 41 patients (27.7%) with coexistent inguinal hernia were included in this study. Individual information, complications, recurrent and new-onset hernias, and catheter survival were retrospectively analyzed. Results: Forty-one patients underwent laparoscopic inguinal hernia repair and synchronous PD catheter placement, 9 patients had bilateral inguinal hernia, and another 32 patients had unilateral inguinal hernia. The mean age was 46.49 years (range, 28-72 years), including 39 males and 2 females. There was no recurrent hernia and only 1 patient (2.4%) developed incisional hernia (trocar site hernia) which required hernia repair and discontinuation of PD. No postoperative complications were observed, such as bleeding, infection, and dialysate leakage. After a median follow-up of 37 months (20-58 months), there were no deaths and 97.6% (40/41) catheters were still working. Conclusions: Laparoscopic hernia repair and synchronous PD catheter placement is an effective and safe treatment for ESRD patients with coexisting inguinal hernia in virtue of low postoperative complications and high catheter survival.

Recent Evaluation by Nephrologists is Associated with Fewer Tunneled Dialysis Catheter Being Used at the Time of First Arteriovenous Access Creation

OBJECTIVE

Late primary care provider (PCP) or nephrologist evaluation of patients with progressive kidney disease may be associated with increased morbidity and mortality. Among patients undergoing initial arteriovenous (AV) access creation, we aimed to study the relationship of recent PCP and nephrologist evaluations with perioperative morbidity and mortality.

METHODS

We performed a retrospective review of patients from 2014-2022 who underwent initial AV access creation at an urban, safety-net hospital. Univariable and multivariable analyses identified associations of PCP and nephrologist evaluations <1 year and <3 months before surgery, respectively, with hemodialysis initiation via tunneled dialysis catheters (TDC), 90-day readmission, and 90-day mortality.

RESULTS

Among 558 patients receiving initial AV access, mean age was 59.7±14 years, 59% were female gender, and 60.6% were Black race. Recent PCP and nephrology evaluations occurred in 386 (69%) and 362 (65%) patients, respectively. On multivariable analysis, unemployed and uninsured statuses were associated with decreased likelihood of PCP evaluation (unemployment: OR .51, 95% CI .34-.77; uninsured status: OR .05, 95% CI .01-.45) and nephrologist evaluation (unemployment: OR .63, 95% CI .43-.91; uninsured status: OR .22, 95% CI .06-.83) (all P<.05). Social support was associated with increased likelihood of PCP evaluation (OR 1.81, 95% CI 1.07-3.08) (all P<.05). Hemodialysis was initiated with TDCs in 304 (55%) patients. Older age (OR .98, 95% CI .96-.99), obesity (OR .38, 95% CI .25-.58), and nephrologist evaluation (OR .12, 95% CI .08-.19) were independently associated with decreased hemodialysis initiation with TDCs in patients receiving an initial AV access (all P<.05). Ninety-day readmission occurred in 270 (48%) cases. Cirrhosis (OR 2.5, 95% CI 1.03-6.03, P=.04), coronary artery disease (OR 2.31, 95% CI 1.5-3.57), prosthetic AV access (OR 1.84, 95% CI 1.04-3.26), and impaired ambulation (OR 1.75, 95% CI 1.15-2.66) were independently associated with increased readmission (all P<.05). Older age (OR .98, 95% CI .97-.99), prior TDC (OR .65, 95% CI .45-.94), and unemployment (OR .58, 95% CI .39-.86) were associated with decreased readmission (all P<.05). Ninety-day mortality occurred in 1.6% patients. Neither PCP nor nephrologist evaluation was associated with readmission or mortality.

CONCLUSIONS

Recent nephrology evaluation was associated with reduced hemodialysis initiation with TDCs among patients undergoing initial AV access creation. Unemployed and uninsured statuses posed barriers to accessing nephrology care.

Cannulation Technique of Vascular Access in Hemodialysis and the Impact on the Arteriovenous Fistula Survival: Systematic Review and Meta-Analysis

Adequate cannulation technique (CT) methods and successful puncture are essential for hemodialysis (HD) and arteriovenous fistula (AVF) maintenance. This systematic review and meta-analysis was designed to identify which CT allows better AVF primary patency and lower rates of complications in HD patients. The search was carried out on the CINAHL, MEDLINE, Cochrane Library, and Joanna Briggs Institute Library databases to identify all randomized controlled trials (RCTs) and observational studies comparing clinical outcomes of buttonhole (BH) versus rope ladder cannulation (RL) from 2010 to 2022. The Risk-of-Bias (Rob 2) tool was used for RCTs and the ROBINS-I was used for non-randomized studies. RevMan 5.4 was used for the meta-analysis. A total of five RCTs, one quasi-randomized controlled trial, and six observational studies were included. When compared with RL cannulation, BH cannulation significantly increased bacteremia (RR, 2.76, 95% CI (1.14, 6.67), p = 0.02) but showed no differences in AVF primary patency (HR, 1.06, 95% CI (0.45, 4.21), p = 0.90). There was no thrombosis reduction (RR, 0.51, 95% CI (0.23, 1.14), p = 0.10) or intervention number reduction (RR, 0.93, 95% CI (0.49, 1.80), p = 0.84) with BH. Outcomes like pain, hematoma, and aneurism could not be merged due to a lack of data, reported as medians, as well as due to different definitions. The quality in general was poor and the heterogeneity among the studies prevented us from merging the outcomes.

HCV Microelimination for High-risk Special Populations

The World Health Organization has set tremendous goals to eliminate viral hepatitis by 2030. However, most countries are currently off the track for achieving these goals. Microelimination is a more effective and practical approach that breaks down national elimination targets into goals for smaller and more manageable key populations. These key populations share the characteristics of being highly prevalent for and vulnerable to hepatitis C virus (HCV) infection. Microelimination allows for identifying HCV-infected people and linking them to care more cost-effectively and efficiently. In this review, we discuss the current obstacles to and progress in HCV microelimination in special populations, including uremic patients undergoing hemodialysis, people who inject drugs, incarcerated people, people living in hyperendemic areas, men who have sex with men with or without human immunodeficiency virus (HIV) infection, transgender and gender-diverse populations, and sex workers. Scaling up testing and treatment uptake to achieve HCV microelimination may facilitate global HCV elimination by 2030.

Clinical Outcomes of Drug-Coated Balloon Angioplasty in Peripheral Artery Disease Patients With End-Stage Renal Disease

PURPOSE

The objective was to determine the effectiveness and safety of paclitaxel-coated balloon angioplasty in hemodialysis patients with diabetic nephropathy (DN).

MATERIALS AND METHODS

The outcomes of end-stage renal disease (ESRD) patients with peripheral artery disease (PAD) and treated with drug-coated balloon (DCB) angioplasty were retrospectively evaluated. The effectiveness outcomes were clinical improvement of the Rutherford classification and target lesion revascularization (TLR). Safety outcomes were all-cause mortality and amputation.

RESULTS

Ninety-seven patients were treated with DCB angioplasty between December 2018 and December 2020. 87 (63.8±10.1 years) achieved technical success. Most patients had a Rutherford classification of at least grade 4. The mean lesion length was 169.8±73.8 mm, almost all had arterial calcification, and 31.0% had annular calcification. Wounds were present in 73.6% of the target limbs. The mean follow-up in this cohort was 13.4±7.4 months. The wound healing rate was 61.5% at the 12-month follow-up. All-cause mortality during 12 months of follow-up was 35.6%, amputation-free survival was 58.6%, and TLR was observed in 13 (15.3%) patients. At 3 and 12 months of follow-up, the Rutherford grade significantly improved (p<0.001). The Cox proportional hazards model revealed that wounds (hazard ratio [HR]=1.404, p=0.023) and annular calcification (HR=2.076, p=0.031) were independent predictors of amputation-free survival.

CONCLUSIONS

Drug-coated balloon angioplasty in ESRD patients was effective and safe over the medium term. Wounds and annular calcification were independent predictors of amputation-free survival.

CLINICAL IMPACT

The effectiveness of DCB angioplasty in ESRD patients and the factors affecting major outcome prognosis in this population remain limited. This study contributes valuable insights into the effectiveness and safety of paclitaxel-coated balloon angioplasty for PAD in hemodialysis patients. Medical professionals can now regard DCB angioplasty as a viable treatment. Identifying wound presence and annular calcification as predictors of amputation-free survival equips medical practitioners with a more tailored approach to patient management, potentially resulting in enhanced outcomes and more precise treatment strategies.

A Novel Risk Score to Predict Hungry Bone Syndrome After Parathyroidectomy for Renal Hyperparathyroidism

OBJECTIVE

Hungry bone syndrome (HBS) is a known complication of parathyroidectomy. Patients with renal hyperparathyroidism are particularly vulnerable to HBS because of their prolonged exposure to electrolyte abnormalities and elevated parathyroid hormone (PTH). However, in-depth characterization of predictive factors for HBS in these patients is lacking.

METHODS

A retrospective analysis was performed of patients with renal hyperparathyroidism who underwent parathyroidectomy at a single institution from 2011-2021. Patient demographics, clinical characteristics, and biochemical data were collected and analyzed. Boruta and binary logistic regression analyses were used to develop a scoring system.

RESULTS

Thirty-three patients were identified; 16 (48%) developed HBS. Patients with HBS had significantly higher preoperative levels of serum PTH (mean difference [MS] = 2167.2 pg/mL, P <.001), phosphorus (MD = 3.5 mg/dl, P <.001), and alkaline phosphatase (ALP) (MD = 344.2 U/L, P =.002) and significantly lower levels of preoperative serum calcium (MD = -0.96 mg/dL, P =.004). Stepwise regression analysis identified elevated ALP (>150 U/L) and markedly elevated PTH (>1000 pg/mL) as positive predictors of HBS. A two-point scoring system with these 2 variables had overall diagnostic accuracy of 96.8% (sensitivity 100% and specificity 94.1%) with 1 point conferring 93.8% positive predictive value and 2 points conferring 100% positive predictive value.

CONCLUSION

Preoperative serum PTH and ALP are significantly associated with HBS in patients with renal hyperparathyroidism undergoing parathyroidectomy for renal hyperparathyroidism. A scoring system with these 2 variables may be of clinical utility in predicting patients at high risk of HBS.

Assessment of the Prognostic Value of MRI Left Ventricular Global Function Index (LVGFI) in Patients With End-Stage Renal Disease Under Maintenance Dialysis

BACKGROUND

Left ventricular global function index (LVGFI) integrates LV volumetric and functional parameters. In patients with end-stage renal disease (ESRD), cardiac injury manifests as LV hypertrophy and dysfunction. However, the prognostic value of LVGFI in this population remains unclear.

PURPOSE

To investigate the association of LVGFI with major adverse cardiac events (MACE) in patients with ESRD.

STUDY TYPE

Prospective.

POPULATION

One hundred fifty-eight ESRD patients (mean age: 54.1 ± 14.4 years; 105 male) on maintenance dialysis.

FILED STRENGTH/SEQUENCE

3.0 T, balanced steady-state free precession (bSSFP) cine and modified Look-Locker inversion recovery (MOLLI) sequences.

ASSESSMENT

LV volumetric and functional parameters were determined from bSSFP images. LVGFI was calculated as the ratio of stroke volume to global volume and native T1 was determined from MOLLI T1 maps. MACE was recorded on follow up. Models were developed to predict MACE from conventional risk factors combined with LVGFI, GLS, native T1, and LV mass index (LVMI), respectively. Subgroup analyses were further performed in participants with LVEF above median.

STATISTICAL TESTS

Cox proportional hazard regression and log-rank test were used to investigate the association between LVGFI and MACE. The predictive models were evaluated and compared using Harrell's C-statistics and DeLong tests. A P value <0.05 was considered statistically significant.

RESULTS

Thirty-four MACE occurred during the median follow-up period of 26 months. The hazard of MACE increased by 114% for each 10% decrease in LVGFI in univariable analysis. The predictive model consisting of LVGFI (C-statistic: 0.724) had significantly better predictive performance than the others (all P < 0.001). These results were consistent in patients (N = 79) with LVEF > median (63.54%).

DATA CONCLUSION

LVGFI is a novel marker for MACE risk stratification in patients with ESRD and was better able to predict MACE than native T1 mapping and GLS.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 3.

Risk of Thrombosis Following the First Dose of ChAdOx1 nCoV-19 Vaccine in Patients Undergoing Maintenance Hemodialysis: A Self-Controlled Case Series Study

Background

The ChAdOx1 nCoV-19 vaccine is associated with vaccine-induced thrombosis and thrombocytopenia (VITT). Patients with end-stage renal disease (ESRD) under hemodialysis are at elevated risk of heparin-induced thrombocytopenia, which shares similar mechanisms with VITT. We aimed to examine the risk of VITT after the first dose of ChAdOx1 nCoV-19 vaccine using a self-controlled case series analysis (SCCS) in the hemodialyzed ESRD population.

Methods

Drawing from the largest multi-center electronic medical records database in Taiwan, we identified adult patients, with or without hemodialysis, between 1st December, 2020, and 31st December, 2021, who received a first dose of ChAdOx1 nCoV-19 vaccine and had an outcome of thrombocytopenia, venous thrombosis, or arterial thrombosis. We calculated the incident rate ratios (IRRs) of outcomes in different periods at risk, compared to periods not at risk.

Results

 We identified 59 hemodialysis patients and 41 non-dialysis patients with an outcome. The SCCS analyses showed, for the hemodialysis group, a significantly increased risk of outcomes during the period 31 to 60 days post-exposure to ChAdOx1 nCoV-19 vaccine (IRR: 2.823; 95% CI: 1.423-5.600). However, in non-dialysis patients there was no increase in risks during any of the post-exposure risk periods.

Conclusion

For ESRD patients under hemodialysis, the first dose of ChAdOx1 nCoV-19 vaccine was associated with a 2.8-fold increase in risk of thrombosis.

Risk factors of foot ulcers in patients with end-stage renal disease on dialysis: A meta-analysis

The present study aims to assess the risk factors for foot ulcers in patients undergoing dialysis for end-stage renal disease (ESRD) and to provide evidence-based guidance for prevention and treatment. A systematic search was conducted on PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database and Wanfang Data from the database inception until May 2023 to identify relevant studies investigating the risk factors for foot ulcers in dialysis patients with ESRD. Two independent researchers conducted the literature screening and data extraction. The meta-analysis was performed using STATA 17.0 software. Ultimately, six articles comprising 1620 patients were included for analysis. The meta-analysis revealed that male (OR, 1.464; 95% CI: 1.082-1.980, p = 0.013), hypertension (OR, 1.781; 95% CI: 1.293-2.4550, p < 0.001), peripheral artery disease (PAD) (OR, 5.014; 95% CI: 2.514-9.998, p < 0.001), type 1 diabetes mellitus (T1DM) (OR, 2.993; 95% CI: 1.477-6.065, p = 0.002) and type 2 diabetes mellitus (T2DM) (OR, 2.498; 95% CI:1.466-4.256, p = 0.001) were risk factors for foot ulcers in dialysis patients with ESRD. Conversely, the female sex (OR, 0.683; 95% CI: 0.505-0.924, p = 0.013) was a protective factor against foot ulcers. Our analysis revealed that male sex, hypertension, PAD, T1DM and T2DM were risk factors for foot ulcers in patients undergoing dialysis for ESRD. Conversely, the female sex was a protective factor against foot ulcers. Therefore, it is crucial to strengthen health education that targets patients with these risk factors and regularly screen high-risk individuals. Early detection and treatment can help delay disease progression.

The Geriatric Nutritional Risk Index Is an Optimal Evaluation Parameter for Predicting Mortality in Adult All Ages Hemodialysis Patients: A Korean Population-Based Study

The Geriatric Nutritional Risk Index (GNRI) is a nutritional screening tool used for predicting mortality in patients undergoing hemodialysis (HD). This study investigated the cutoff values for the GNRI for predicting mortality in HD patients using Korean HD quality assessment data from 2015. To identify the optimal GNRI cutoff value, we used Harrell's C-index with multivariate Cox regression models. The highest value of C-index was identified as the cutoff value of GNRI for all-cause mortality in this population. In total, 34,933 patients were included; 90.8 of GNRI was the highest value of C-index, and it was used as a cutoff value to predict mortality; 3311 patients (9.5%) had GNRI values < 90.8, and there were 12,499 deaths during the study period. The mean follow-up period was 53.7 months. The crude mortality rates in patients with GNRI values < 90.8 and ≥ 90.8 were 160.4/1000 and 73.2/1000 person-years respectively. In the fully adjusted Cox model, patients with a GNRI < 90.8 had a 1.78 times higher risk of mortality than those with a GNRI ≥ 90.8. These findings suggest that the optimal GNRI cutoff value is 90.8 for predicting mortality in maintenance HD patients.

Renin-angiotensin-system blockers and IgG antibodies in end-stage renal disease hemodialysis-receiving patients diagnosed with COVID-19 infection

OBJECTIVES

To evaluate the prevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections among patients receiving in-center hemodialysis (ICHD), the relationship between the IgG antibody levels against the virus and SARS-CoV-2-associated symptoms, hemodialysis adequacy, and the antihypertensives used in order to control blood pressure.

METHODS

A prospective observational study was carried out at a tertiary care center, King Fahad Kidney Center, Riyadh, Kingdom of Saudi Arabia, between November 2020 and January 2021. A total of 214 ICHD patients with end-stage renal disease (ESRD) were included, and the levels of their anti-SARS-CoV-2 IgG antibodies were assessed after obtaining their informed consent.

RESULTS

Our tests indicated that 15% of the patients in the study's population had detectable SARS-CoV-2 IgG antibodies, with more than half of them (53%) being asymptomatic. We also found that ESRD patients on angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) had higher levels of SARS-CoV-2 IgG antibodies than patients not receiving this group of medications.

CONCLUSION

More studies are required to assess whether patients with a SARS-CoV-2 infection that do not have an indication for being prescribed ACEIs/ARBs would benefit from receiving these medications.

Knee and hip arthroplasty joint surgical site wound infection in end-stage renal disease subjects who underwent dialysis or a kidney transplant: A meta-analysis

A meta-analysis study to assess the knee and hip arthroplasty joint surgical site wound infection (SSWI) in end-stage renal disease (ESRD) subjects who underwent dialysis or a kidney transplant (KT). A comprehensive literature examination till February 2023 was implemented and 1046 linked studies were appraised. The picked studies contained 5 471 898 subjects with total joint arthroplasty (TJA) at the baseline, 13 049 of them were haemodialysis or renal transplant, and 5 458 849 were control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of knee and hip arthroplasty SSWI in ESRD subjects who underwent dialysis or a KT by the dichotomous and continuous styles and a fixed or random model. Haemodialysis or renal transplant had a significantly higher postoperative SSWI (OR, 2.13; 95% CI, 1.73-2.62, P < .001) compared with control in TJA subjects. However, no significant difference was observed between haemodialysis and renal transplant in postoperative SSWI (OR, 0.93; 95% CI, 0.16-5.54, P = .94) and between haemodialysis or renal transplant and control in prosthetic joint infection (OR, 1.07; 95% CI, 0.25-4.55, P = .93) in TJA subjects. Haemodialysis had a significantly higher prosthetic joint infection (OR, 1.92; 95% CI, 1.21-3.03, P = .005) compared with renal transplant in TJA subjects. Haemodialysis or renal transplant had a significantly higher postoperative SSWI in TJA subjects. Also, haemodialysis had a significantly higher prosthetic joint infection compared with renal transplant in TJA subjects. Although precautions should be taken when commerce with the consequences because a low number of selected studies was picked for certain comparisons in this meta-analysis.

Risk Factors for Ulcer Recurrence in Diabetic Patients Managed by an Integrated Foot Care Protocol

The aim of our study was to identify risk factors for the recurrence of diabetic foot ulcers (DFUs) in a selected population of patients in secondary prevention treated, according to International Guidelines, with an integrated foot care protocol by a referral diabetic foot clinic. A retrospective study was performed with the inclusion of selected outpatients with diabetes at higher risk for ulceration with a history of previous ulcer and/or amputation followed in our diabetic foot clinic between January 2015 and December 2021. According to the presence or absence of recurrence, patients were divided into 2 groups: ulcer recurrence and without ulcer recurrence. One hundred twenty-seven (127) patients were included, 47 patients (37%) developed an ulcer recurrence while 80 patients (63%) did not. The mean age was 71.7 years; 65% were male; 97% were affected by type 2 diabetes with a mean duration of 21.1 years, the mean HbA1c was 63 + 21 mmol/mol. Both groups of patients had foot deformities, such as claw and hammertoes; hallux valgus, and prominent metatarsal heads (MTHs). The presence of deformity was significantly associated with ulceration. The group with ulcer recurrence showed a higher rate of prominence MTHs in comparison to a group without ulcer recurrence. The MTHs resulted as the only independent predictor for recurrence. This study shows that the presence of the prominent MTH is a significant risk factor for ulcer recurrence in a selected population of diabetic foot patients treated in the best way with integrated foot care.

Association between Human Leukocyte Antigen and End-Stage Renal Disease in Patients from Transylvania, Romania

End-stage renal disease (ESRD) is the final stage of chronic kidney disease. This study explored the association between human leukocyte antigen (HLA) and ESRD. The interaction between genetic and environmental factors may also play a role in the development of ESRD. The study included 2392 ESRD patients who were awaiting renal transplantation. Blood samples were genotyped by SSOP and SSP-PCR methods. Multivariate logistic regression analysis showed that HLA-A*11 (p = 0.027), HLA-A*34 (p = 0.017), HLA-A*69 (p = 0.012), HLA-B*41 (p < 0.001), HLA-B*50 (p = 0.004), HLA-DRB1*10 (p = 0.027), and HLA-DRB1*14 (p = 0.004) were positively associated with ESRD (OR > 1); HLA-DRB1*07 (p < 0.001), HLA-DRB1*08 (p = 0.005), and HLA-DRB1*13 (p < 0.001) were protective against ESRD (OR < 1); and the three-locus haplotype HLA-A*02-B*41-DRB1*03, containing one susceptible allele, was strongly associated with ESRD (p < 0.001, OR = 3.15). In conclusion, this retrospective analysis of HLA typing in patients with ESRD of various etiologies suggests that molecular data on the HLA polymorphism should be collected in order to identify high-risk ESRD patients and to improve graft survival after kidney transplantation.

Safe and Efficient Use of Tocilizumab in Rheumatoid Arthritis Patient on Maintenance Hemodialysis: A Case Report

Background: Rheumatoid arthritis (RA) is a chronic systemic autoimmune and inflammatory disease. Conventional synthetic and biologic disease-modifying antirheumatic drugs (DMARDs), Janus kinase inhibitors, and rituximab are used to treat the disease. There are no recommendations or guidelines for the treatment of patients with both inflammatory arthritis and end-stage renal disease (ESRD), despite the safety and efficacy of the mentioned drugs. The anti-interleukin-6 receptor antibody tocilizumab (TCZ) has not been used as a long-term therapy for hemodialysis (HD) patients with RA, except in a few case reports. Case Description: We present the case of a 41-year-old patient with RA and ESRD on maintenance HD due to type 1 diabetes-related complications. Due to high RA disease activity, the patient was not a suitable candidate for a kidney transplant. Because TCZ is used to treat both RA and kidney transplant rejection, therapy with a full dose of TCZ was administered. The patient has achieved sustained clinical remission (for the past four years) with no adverse events reported. Conclusions: Herein, we present the safe and effective use of TCZ in an RA patient on HD who is also a candidate for kidney transplant. Consequently, TCZ could be the treatment of choice for RA patients with ESRD who have not achieved disease control (low activity or remission) with conventional synthetic DMARDs. Clinical studies are required to evaluate the efficacy and safety of biologic DMARDs and Janus kinase inhibitors in patients with both inflammatory arthritis and ESRD.

Association of Familial Fanconi Syndrome with a Novel GATM Variant

Fanconi syndrome is a disorder of the proximal renal tubule. Recently, advanced genetic analysis technology has revealed that several genes cause familial Fanconi syndrome. We identified a family with autosomal dominant Fanconi syndrome and chronic kidney disease with a novel glycine amidinotransferase (GATM) variant. Case 1 was a 57-year-old Japanese woman. Her father and two siblings had Fanconi syndrome or chronic kidney disease. She presented to our hospital at the age of 34 years with recurrent glucosuria. Her height and weight were 151 cm and 46.6 kg, respectively. Laboratory tests showed glucosuria, hypophosphatemia, hypouricemia, and normal renal function. Her serum creatinine level gradually increased over the following next two decades, and she developed end-stage renal disease. Case 2, the daughter of Case 1, was a 26-year-old woman. Her height and weight were 151 cm and 37.5 kg, respectively. Glucosuria was detected at the age of 13 years, which led to a referral to our hospital. Urinalysis showed low-molecular-weight proteinuria. She was diagnosed with Fanconi syndrome. At the age of 26 years, she had glucosuria, low-molecular-weight proteinuria, hypouricemia, and normal renal function. Genetic testing of both cases revealed a novel missense variant in GATM. The heterozygous missense variants in GATM have been reported to cause familial Fanconi syndrome, which manifests early in life and progresses to renal glomerular failure by mid-adulthood. The novel GATM variant detected in our cases was suspected to be associated with the development of Fanconi syndrome. GATM variants should be tested in patients with idiopathic Fanconi syndrome.