Publications by authors named "Sandip Mitra"

86 Publications

Home-based exercise for people living with frailty and chronic kidney disease: A mixed-methods pilot randomised controlled trial.

PLoS One 2021 1;16(7):e0251652. Epub 2021 Jul 1.

Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom.

Background: Frailty is associated with adverse health outcomes in people with chronic kidney disease (CKD). Evidence supporting targeted interventions is needed. This pilot randomised controlled trial (RCT) aimed to inform the design of a definitive RCT evaluating the effectiveness of a home-based exercise intervention for pre-frail and frail older adults with CKD.

Methods: Participants were recruited from nephrology outpatient clinics to this two-arm parallel group mixed-methods pilot RCT. Inclusion criteria were: ≥65 years old; CKD G3b-5; and Clinical Frailty Scale score ≥4. Participants categorised as pre-frail or frail using the Frailty Phenotype were randomised to a 12-week progressive multi-component home-based exercise programme or usual care. Primary outcome measures included eligibility, recruitment, adherence, outcome measure completion and participant attrition rate. Semi-structured interviews were conducted with participants to explore trial and intervention acceptability.

Results: Six hundred and sixty-five patients had an eligibility assessment with 217 (33%; 95% CI 29, 36) eligible. Thirty-five (16%; 95% CI 12, 22) participants were recruited. Six were categorised as robust and withdrawn prior to randomisation. Fifteen participants were randomised to exercise and 14 to usual care. Eleven (73%; 95% CI 45, 91) participants completed ≥2 exercise sessions/week. Retained participants completed all outcome measures (n = 21; 100%; 95% CI 81, 100). Eight (28%; 95% CI 13, 47) participants were withdrawn. Fifteen participated in interviews. Decision to participate/withdraw was influenced by perceived risk of exercise worsening symptoms. Participant perceived benefits included improved fitness, balance, strength, well-being, energy levels and confidence.

Conclusions: This pilot RCT demonstrates that progression to definitive RCT is possible provided recruitment and retention challenges are addressed. It has also provided preliminary evidence that home-based exercise may be beneficial for people living with frailty and CKD.

Trial Registration: ISRCTN87708989; https://clinicaltrials.gov/.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251652PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248609PMC
July 2021

Exercise programme to improve quality of life for patients with end-stage kidney disease receiving haemodialysis: the PEDAL RCT.

Health Technol Assess 2021 Jun;25(40):1-52

School of Health Sciences, Queen Margaret University, Edinburgh, UK.

Background: Whether or not clinically implementable exercise interventions in haemodialysis patients improve quality of life remains unknown.

Objectives: The PEDAL (PrEscription of intraDialytic exercise to improve quAlity of Life in patients with chronic kidney disease) trial evaluated the clinical effectiveness and cost-effectiveness of a 6-month intradialytic exercise programme on quality of life compared with usual care for haemodialysis patients.

Design: We conducted a prospective, multicentre randomised controlled trial of haemodialysis patients from five haemodialysis centres in the UK and randomly assigned them (1 : 1) using a web-based system to (1) intradialytic exercise training plus usual-care maintenance haemodialysis or (2) usual-care maintenance haemodialysis.

Setting: The setting was five dialysis units across the UK from 2015 to 2019.

Participants: The participants were adult patients with end-stage kidney disease who had been receiving haemodialysis therapy for > 1 year.

Interventions: Participants were randomised to receive usual-care maintenance haemodialysis or usual-care maintenance haemodialysis plus intradialytic exercise training.

Main Outcome Measures: The primary outcome of the study was change in Kidney Disease Quality of Life Short Form, version 1.3, physical component summary score (from baseline to 6 months). Cost-effectiveness was determined using health economic analysis and the EuroQol-5 Dimensions, five-level version. Additional secondary outcomes included quality of life (Kidney Disease Quality of Life Short Form, version 1.3, generic multi-item and burden of kidney disease scales), functional capacity (sit-to-stand 60 and 10-metre Timed Up and Go tests), physiological measures (peak oxygen uptake and arterial stiffness), habitual physical activity levels (measured by the International Physical Activity Questionnaire and Duke Activity Status Index), fear of falling (measured by the Tinetti Falls Efficacy Scale), anthropometric measures (body mass index and waist circumference), clinical measures (including medication use, resting blood pressure, routine biochemistry, hospitalisations) and harms associated with intervention. A nested qualitative study was conducted.

Results: We randomised 379 participants; 335 patients completed baseline assessments and 243 patients (intervention,  = 127; control,  = 116) completed 6-month assessments. The mean difference in change in physical component summary score from baseline to 6 months between the intervention group and control group was 2.4 arbitrary units (95% confidence interval -0.1 to 4.8 arbitrary units;  = 0.055). Participants in the intervention group had poor compliance (49%) and very poor adherence (18%) to the exercise prescription. The cost of delivering the intervention ranged from £463 to £848 per participant per year. The number of participants with harms was similar in the intervention ( = 69) and control ( = 56) groups.

Limitations: Participants could not be blinded to the intervention; however, outcome assessors were blinded to group allocation.

Conclusions: On trial completion the primary outcome (Kidney Disease Quality of Life Short Form, version 1.3, physical component summary score) was not statistically improved compared with usual care. The findings suggest that implementation of an intradialytic cycling programme is not an effective intervention to enhance health-related quality of life, as delivered to this cohort of deconditioned patients receiving haemodialysis.

Future Work: The benefits of longer interventions, including progressive resistance training, should be confirmed even if extradialytic delivery is required. Future studies also need to evaluate whether or not there are subgroups of patients who may benefit from this type of intervention, and whether or not there is scope to optimise the exercise intervention to improve compliance and clinical effectiveness.

Trial Registration: Current Controlled Trials ISRCTN83508514.

Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 25, No. 40. See the NIHR Journals Library website for further project information.
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http://dx.doi.org/10.3310/hta25400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256322PMC
June 2021

Is home hemodialysis a practical option for older people?

Hemodial Int 2021 Jun 16. Epub 2021 Jun 16.

Faculty of Medical and Human Sciences, Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK.

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.
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http://dx.doi.org/10.1111/hdi.12949DOI Listing
June 2021

Clinical triage of patients on kidney replacement therapy presenting with COVID-19: an ERACODA registry analysis.

Nephrol Dial Transplant 2021 Jun 15. Epub 2021 Jun 15.

Department Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands.

Rationale & Objective: Patients on kidney replacement therapy (KRT) are at a very high risk of COVID-19. Triage pathway for KRT patients presenting with varying severity of COVID-19 illness remains ill-defined. We studied clinical characteristics of patients at initial and subsequent hospital presentations and its impact on patient outcomes.

Study Design, Setting, Participants: European Renal Association COVID-19 Database (ERACODA) was analysed for clinical and laboratory features of 1423 KRT patients with COVID-19 either hospitalized or non-hospitalized during first presentation and those representing after non-admission at initial triage. Predictors of outcomes (Hospitalisation, 28-day mortality) were determined for those not hospitalized at first presentation.

Results: Amongst 1423 KRT patients with COVID-19 (Hemodialysis = 1017/Transplant = 406), 25% (n = 355) were not hospitalized at first presentation (30% Hemodialysis/13% Transplant). Of these non-hospitalized patients, 10% (n = 36) re-presented second time, with a 5-day median interval between two presentations (Interquartile interval 2-7 days). Patients who re-presented had worsening respiratory symptoms, a fall in oxygen saturation (97% vs. 90%) and rise in C-reactive protein between attendances (26 vs. 73 mg/L). Patients on second presentation were older (72 vs. 63 years), had early respiratory symptoms and lung imaging abnormalities compared with those who did not return second time. The 28-day mortality for those admitted at first or second presentations was not significantly different (25% vs. 29%, p = 0.6). Higher age, prior smoking history, higher clinical frailty score and self-reported shortness of breath at first presentation, were identified as predictors of mortality in those discharged at initial triage.

Conclusions: The study provides evidence that KRT patients with COVID-19 and mild pulmonary abnormalities with lack of pulmonary insufficiency can be safely discharged, with vigilance of respiratory symptoms, especially in those with risk factors for poor outcomes. Our findings support a risk-stratified clinical approach to admissions and discharges of KRT patients presenting with COVID-19, to aid clinical triage and optimise resource utilisation during the ongoing pandemic.
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http://dx.doi.org/10.1093/ndt/gfab196DOI Listing
June 2021

Patient perspectives of target weight management and ultrafiltration in haemodialysis: a multi-center survey.

BMC Nephrol 2021 May 20;22(1):188. Epub 2021 May 20.

School of Psychology, University of Leeds, Leeds, UK.

Background: Decisions around planned ultrafiltration volumes are the only part of the haemodialysis prescription decided upon at every session. Removing too much fluid or too little is associated with both acute symptoms and long-term outcomes. The degree to which patients engage with or influence decision-making is not clear. We explored patient perspectives of prescribing ultrafiltration volumes, their understanding of the process and engagement with it.

Methods: A questionnaire developed for this study was administered to 1077 patients across 10 UK Renal Units. Factor analysis reduced the dataset into factors representing common themes. Relationships between survey results and factors were investigated using regression models. ANCOVA was used to explore differences between Renal Units.

Results: Patients generally felt in control of their fluid management and that they were given the final say on planned ultrafiltration volumes. Around half of the respondents reported they take an active role in their treatment. However, respondents were largely unable to relate signs and symptoms to fluid management practice and a third said they would not report common signs and symptoms to clinicians. A fifth of patients reported not to know how ultrafiltration volumes were calculated. Patients responded positively to questions relating to healthcare staff, though with significant variation between units, highlighting differences in perception of care.

Conclusions: Despite a lack of formal acknowledgement in fluid management protocols, patients have significant involvement in decisions regarding fluid removal during dialysis. Furthermore, substantial gaps remain in patient knowledge and engagement. Formalizing the role of patients in these decisions, including patient education, may improve prescription and achievement of target weights.
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http://dx.doi.org/10.1186/s12882-021-02399-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138996PMC
May 2021

The PrEscription of intraDialytic exercise to improve quAlity of Life in patients with chronic kidney disease trial: study design and baseline data for a multicentre randomized controlled trial.

Clin Kidney J 2021 May 10;14(5):1345-1355. Epub 2020 Sep 10.

School of Health Sciences, Centre for Health, Activity and Rehabilitation Research, Queen Margaret University, Edinburgh, UK.

Background: Exercise interventions designed to improve physical function and reduce sedentary behaviour in haemodialysis (HD) patients might improve exercise capacity, reduce fatigue and lead to improved quality of life (QOL). The PrEscription of intraDialytic exercise to improve quAlity of Life study aimed to evaluate the effectiveness of a 6-month intradialytic exercise programme on QOL and physical function, compared with usual care for patients on HD in the UK.

Methods: We conducted a prospective, pragmatic multicentre randomized controlled trial in 335 HD patients and randomly (1:1) assigned them to either (i) intradialytic exercise training plus usual care maintenance HD or (ii) usual care maintenance HD. The primary outcome of the study was the change in Kidney Disease Quality of Life Short Form (KDQOL-SF 1.3) Physical Component Score between baseline and 6 months. Additional secondary outcomes included changes in peak aerobic capacity, physical fitness, habitual physical activity levels and falls (International Physical Activity Questionnaire, Duke's Activity Status Index and Tinetti Falls Efficacy Scale), QOL and symptom burden assessments (EQ5D), arterial stiffness (pulse wave velocity), anthropometric measures, resting blood pressure, clinical chemistry, safety and harms associated with the intervention, hospitalizations and cost-effectiveness. A nested qualitative study investigated the experience and acceptability of the intervention for both participants and members of the renal health care team.

Results: At baseline assessment, 62.4% of the randomized cohort were male, the median age was 59.3 years and 50.4% were white. Prior cerebrovascular events and myocardial infarction were present in 8 and 12% of the cohort, respectively, 77.9% of patients had hypertension and 39.4% had diabetes. Baseline clinical characteristics and laboratory data for the randomized cohort were generally concordant with data from the UK Renal Registry.

Conclusion: The results from this study will address a significant knowledge gap in the prescription of exercise interventions for patients receiving maintenance HD therapy and inform the development of intradialytic exercise programmes both nationally and internationally.

Trial Registration: ISRCTN N83508514; registered on 17 December 2014.
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http://dx.doi.org/10.1093/ckj/sfaa107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087141PMC
May 2021

Home haemodialysis: Providing opportunities to reimagine haemodialysis care.

Nephrol Ther 2021 Apr;17S:S60-S63

Department of Nephrology, Manchester University Hospitals, Oxford Road, M13 9WL Manchester, UK; Manchester Academy of Health Sciences Centre (MAHSC), Manchester, UK.

There has been a resurgence in home haemodialysis over the last decade and interest in its implementation in gaining momentum with advances in technology and healthcare policy initiatives. Both increasing haemodialysis frequency and treatment time have several potential benefits in improving dialysis efficiency and are ideally placed in the home setting. The paper describes the rationale, current status, controversies, challenges and future avenues for home haemodialysis.
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http://dx.doi.org/10.1016/j.nephro.2020.03.005DOI Listing
April 2021

Erratum: Frailty is independently associated with worse health-related quality of life in chronic kidney disease: a secondary analysis of the Frailty Assessment in Chronic Kidney Disease study.

Clin Kidney J 2021 Mar 4;14(3):1035. Epub 2020 May 4.

Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston,UK.

[This corrects the article DOI: 10.1093/ckj/sfz038.].
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http://dx.doi.org/10.1093/ckj/sfaa066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986437PMC
March 2021

Prognostic performance of clinical assessment tools following hip fracture in patients with chronic kidney disease.

Int Urol Nephrol 2021 Mar 8. Epub 2021 Mar 8.

Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK.

Purpose: People living with chronic kidney disease (CKD) are at a higher risk of hip fracture with an associated increased mortality risk compared to individuals without CKD. Our study aimed to evaluate the clinical assessment tools that best predict mortality risk following hip fracture for patients with CKD.

Methods: Patients with CKD G3b-5D admitted to Lancashire Teaching Hospitals NHS Foundation Trust, U.K. between June 2013 and Dec 2019 were included. The association between CKD and post-fracture mortality risk was evaluated. All patients were assessed using tools that evaluated frailty status, co-morbidity, pre-operative risk, functional status and cardiopulmonary fitness. Receiver operating characteristic curve analyses were performed to determine the prognostic accuracy of the assessment tools for 30 day and 1 year mortality following hip fracture in patients with CKD.

Results: 397 patients fulfilled inclusion criteria with a mean age of 83.5 ± 9.2 years. Older age, female sex, intracapsular fracture and more severe CKD, co-morbidity and frailty status were all associated with an increased mortality risk. Patients with dialysis-dependent CKD and severe/very severe frailty had a hazard ratio for mortality of 2.55 (95% Cl 2.11-2.98) and 3.11 (95% Cl 2.47-3.93), respectively. The Clinical Frailty Scale demonstrated the best prognostic accuracy for both 30 day [Area Under the Curve (AUC) 0.91, 95% Cl 0.84-0.97] and 1 year mortality (AUC 0.93, 95% Cl 0.87-1.00).

Conclusion: Patients with advanced CKD and severe frailty have a high mortality risk following hip fracture. The Clinical Frailty Scale is an excellent prognostic tool for mortality in this setting and could be easily incorporated into routine clinical practice.
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http://dx.doi.org/10.1007/s11255-021-02798-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7939449PMC
March 2021

A call to optimize haemodialysis vascular access care in healthcare disrupted by COVID-19 pandemic.

J Nephrol 2021 04 8;34(2):365-368. Epub 2021 Mar 8.

Manchester Academy of Health Sciences Centre, Manchester University Hospitals Foundation Trust and University of Manchester, Oxford Road, Manchester, UK.

The COVID-19 pandemic has resulted in major disruption to the delivery of both routine and urgent healthcare needs in many institutions across the globe. Vascular access (VA) for haemodalysis (HD) is considered the patient's lifeline and its maintenance is essential for the continuation of a life saving treatment. Prior to the COVID-19 pandemic, the provision of VA for dialysis was already constrained. Throughout the pandemic, inevitably, many patients with chronic kidney disease (CKD) have not received timely intervention for VA care. This could have a detrimental impact on dialysis patient outcomes in the near future and needs to be addressed urgently. Many societies have issued prioritisation to allow rationing based on clinical risk, mainly according to estimated urgency and need for treatment. The recommendations recently proposed by the European and American Vascular Societies in the COVID-19 pandemic era regarding the triage of various vascular operations into urgent, emergent and elective are debatable. VA creation and interventions maintain the lifeline of complex HD patients, and the indication for surgery and other interventions warrants patient-specific clinical judgement and pathways. Keeping the use of central venous catheters at a minimum, with the goal of creating the right access, in the right patient, at the right time, and for the right reasons, is mandatory. These strategies may require local modifications. Risk assessments may need specific "renal pathways" to be developed rather than applying standard surgical risk stratification. In conclusion, in order to recover from the second wave of COVID-19 and prepare for further phases, the provision of the best dialysis access, including peritoneal dialysis, will require working closely with the multidisciplinary team involved in the assessment, creation, cannulation, surveillance, maintenance, and salvage of definitive access.
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http://dx.doi.org/10.1007/s40620-021-01002-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938289PMC
April 2021

Development of a measure for patients preparing to start dialysis and their partners: The Starting Dialysis Questionnaire (SDQ).

Health Qual Life Outcomes 2020 Nov 7;18(1):358. Epub 2020 Nov 7.

School of Health Sciences, Division of Psychological Sciences and Mental Health, Manchester Centre for Health Psychology, Coupland Building I, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.

Background: The transition onto dialysis is a stressful time that affects both patients and their partners. Research suggests that psychological and interpersonal characteristics within the couple are related to how well they adapt to dialysis. The aim of this multi-phase, mixed methods study was to develop a measure, the Starting Dialysis Questionnaire (SDQ), that is applicable to both patients and their partners and assesses their own thoughts and feelings about these constructs.

Methods: Data from semi-structured interviews with patients and their partners (n = 22 couples) were analysed using theoretical thematic analysis to identify and define constructs related to quality of life (QOL). Next, items addressing these constructs were derived from the interviews. Then, cognitive interviews were conducted with patients with chronic kidney disease and their partners (n = 5 couples) to assess the face validity and comprehensibility of the items. Lastly, preliminary psychometric properties were evaluated in a sample of patients preparing to start dialysis and their partners (n = 83 couples).

Results: Three themes related to QOL were identified, namely dialysis expectations, accepting dialysis and dyadic relationship characteristics. The cognitive interviews refined the SDQ and established its face validity. Psychometric assessments indicated that overall the items performed well and did not show significant floor or ceiling effects. Good internal consistency was found within the three domains, and items correlated within the domains.

Conclusions: The SDQ is a measure (34 items) that assesses key psychological and interpersonal factors in patients and their partners as they start dialysis. It shows good preliminary psychometric properties; however, a large-scale field trial is needed to establish its validity. Once validated, it could offer a clinically useful tool to assist clinicians in preparing patients and partners for dialysis.
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http://dx.doi.org/10.1186/s12955-020-01610-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648298PMC
November 2020

Hemodialysis With the Quanta SC+: Efficacy and Safety of a Self-care Hemodialysis Machine.

Kidney Med 2020 Nov-Dec;2(6):724-731.e1. Epub 2020 Oct 21.

Quanta Dialysis Technologies, Alcester, United Kingdom.

Rationale & Objective: Most patients with kidney failure receive hemodialysis 3 times per week in a facility. More frequent and longer duration dialysis prescriptions improve a number of key outcome measures. These prescriptions are best suited to self-care and home regimens. The Quanta SC+ hemodialysis system is a novel device with demonstrated ease of use for patients and health care practitioners through human factors testing. The primary objective of this study is to report the efficacy and safety of the SC+ system using conventional hemodialysis prescriptions.

Study Design: Nonrandomized observational study.

Setting & Participants: Prevalent hemodialysis patients in 4 sites in the United Kingdom were recruited to switch from their current device to the SC+ system with no other changes to their prescription.

Interventions: SC+ hemodialysis system.

Outcomes: Efficacy data were collected in terms of dialysis adequacy, urea reduction ratios, and net fluid removal accuracy.

Results: 60 patients were enrolled in the study, resulting in 1,333 evaluable treatments. The threshold single-pool Kt/V of 1.2 was exceeded in 96.6% of treatments in patients receiving 3-times-weekly regimens, whereas the threshold standard Kt/V of 2.1 was exceeded in 94% of treatments and 97.6% of treatments in patients without significant residual kidney function. Ultrafiltration accuracy was determined by measuring net fluid removal and validated to be within acceptable limits. The adverse event profile during treatment was typical of hemodialysis. There were no serious adverse events.

Limitations: Few patients on high-frequency treatment regimens were enrolled.

Conclusions: The SC+ system delivers safe and effective hemodialysis across a range of patients and dialysis prescriptions. It is one of the smallest systems available and has validated usability for patients to perform self-care safely with minimal training. This device may encourage patients to feel empowered to take on home hemodialysis, unlocking beneficial clinical and patient-reported outcomes associated with these modalities.
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http://dx.doi.org/10.1016/j.xkme.2020.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577315PMC
October 2020

The reasons for a clinical trial on incremental haemodialysis.

Nephrol Dial Transplant 2020 11;35(11):2015-2019

Department of Nephrology, Dialysis and Transplantation, Azienda Ospedaliero-Universitaria Consorziale Policlinico, Bari, Italy.

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http://dx.doi.org/10.1093/ndt/gfaa220DOI Listing
November 2020

Implementation of a frailty screening programme and Geriatric Assessment Service in a nephrology centre: a quality improvement project.

J Nephrol 2020 Oct 10. Epub 2020 Oct 10.

Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK.

Introduction: The aims of this quality improvement project were to: (1) proactively identify people living with frailty and CKD; (2) introduce a practical assessment, using the principles of the comprehensive geriatric assessment (CGA), for people living with frailty and chronic kidney disease (CKD) able to identify problems; and (3) introduce person-centred management plans for people living with frailty and CKD.

Methods: A frailty screening programme, using the Clinical Frailty Scale (CFS), was introduced in September 2018. A Geriatric Assessment (GA) was offered to patients with CFS ≥ 5 and non-dialysis- or dialysis-dependent CKD. Renal Frailty Multidisciplinary Team (MDT) meetings were established to discuss needs identified and implement a person-centred management plan.

Results: A total of 450 outpatients were screened using the CFS. One hundred and fifty patients (33%) were screened as frail. Each point increase in the CFS score was independently associated with a hospitalisation hazard ratio of 1.35 (95% CI 1.20-1.53) and a mortality hazard ratio of 2.15 (95% CI 1.63-2.85). Thirty-five patients received a GA and were discussed at a MDT meeting. Patients experienced a median of 5.0 (IQR 3.0) problems, with 34 (97%) patients experiencing at least three problems.

Conclusions: This quality improvement project details an approach to the implementation of a frailty screening programme and GA service within a nephrology centre. Patients living with frailty and CKD at risk of adverse outcomes can be identified using the CFS. Furthermore, a GA can be used to identify problems and implement a person-centred management plan that aims to improve outcomes for this vulnerable group of patients.
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http://dx.doi.org/10.1007/s40620-020-00878-yDOI Listing
October 2020

Frontiers in hemodialysis: Innovations and technological advances.

Artif Organs 2021 Feb 9;45(2):175-182. Epub 2020 Sep 9.

Department of Nephrology, Colchester General Hospital, Colchester, UK.

As increasing demand for hemodialysis (HD) treatment incurs significant financial burden to healthcare systems and ecological burden as well, novel therapeutic approaches as well as innovations and technological advances are being sought that could lead to the development of purification devices such as dialyzers with improved characteristics and wearable technology. Novel knowledge such as the development of more accurate kinetic models, the development of novel HD membranes with the use of nanotechnology, novel manufacturing processes, and the latest technology in the science of materials have enabled novel solutions already marketed or on the verge of becoming commercially available. This collaborative article reviews the latest advances in HD as they were presented by the authors in a recent symposium titled "Frontiers in Haemodialysis," held on 12th December 2019 at the Royal Society of Medicine in London.
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http://dx.doi.org/10.1111/aor.13798DOI Listing
February 2021

Correction to: Quality of life improved for patients after starting dialysis but is impaired, initially, for their partners: a multi-centre, longitudinal study.

BMC Nephrol 2020 Jul 6;21(1):254. Epub 2020 Jul 6.

School of Health Sciences, Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, UK.

An amendment to this paper has been published and can be accessed via the original article.
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http://dx.doi.org/10.1186/s12882-020-01858-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336627PMC
July 2020

The EX-FRAIL CKD trial: a study protocol for a pilot randomised controlled trial of a home-based EXercise programme for pre-frail and FRAIL, older adults with Chronic Kidney Disease.

BMJ Open 2020 06 22;10(6):e035344. Epub 2020 Jun 22.

Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK.

Introduction: Frailty is highly prevalent in adults with chronic kidney disease (CKD) and is associated with adverse health outcomes including falls, poorer health-related quality of life (HRQOL), hospitalisation and mortality. Low physical activity and muscle wasting are important contributors to physical frailty in adults with CKD. Exercise training may improve physical function and frailty status leading to associated improvements in health outcomes, including HRQOL. The EX-FRAIL CKD trial aims to inform the design of a definitive randomised controlled trial (RCT) that investigates the effectiveness of a progressive, multicomponent home-based exercise programme in prefrail and frail older adults with CKD.

Methods And Analysis: The EX-FRAIL CKD trial is a two-arm parallel group pilot RCT. Participants categorised as prefrail or frail, following Frailty Phenotype (FP) assessment, will be randomised to receive exercise or usual care. Participants randomised to the intervention arm will receive a tailored 12-week exercise programme, which includes weekly telephone calls to advise on exercise progression. Primary feasibility outcome measures include rate of recruitment, intervention adherence, outcome measure completion and participant attrition. Semistructured interviews with a purposively selected group of participants will inform the feasibility of the randomisation procedures, outcome measures and intervention. Secondary outcome measures include physical function (walking speed and Short Physical Performance Battery), frailty status (FP), fall concern (Falls Efficacy Scale-International tool), activities of daily living (Barthel Index), symptom burden (Palliative care Outcome Scale-Symptoms RENAL) and HRQOL (Short Form-12v2).

Ethics And Dissemination: Ethical approval was granted by a National Health Service (NHS) Regional Ethics Committee and the NHS Health Research Authority. The study team aims to publish findings in a peer-reviewed journal and presents the results at relevant national and international conferences. A summary of findings will be provided to participants, a local kidney patient charity and the funding body.

Trial Registration Number: ISRCTN87708989.
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http://dx.doi.org/10.1136/bmjopen-2019-035344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311028PMC
June 2020

Coronary artery disease in dialysis patients: evidence synthesis, controversies and proposed management strategies.

J Nephrol 2021 02 29;34(1):39-51. Epub 2020 May 29.

Nephrology Clinic, Dialysis and Renal Transplant Center-'C.I. Parhon' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania.

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD). Clustering of traditional atherosclerotic and non-traditional risk factors drive the excess rates of coronary and non-coronary CVD in this population. The incidence, severity and mortality of coronary artery disease (CAD) as well as the number of complications of its therapy is higher in dialysis patients than in non-chronic kidney disease patients. Given the lack of randomized clinical trial evidence in this population, current practice is informed by observational data with a significant potential for bias. Furthermore, guidelines lack any recommendation for these patients or extrapolate them from trials performed in non-dialysis patients. Patients with ESRD are more likely to be asymptomatic, posing a challenge to the correct identification of CAD, which is essential for appropriate risk stratification and management. This may lead to "therapeutic nihilism", which has been associated with worse outcomes. Here, the ERA-EDTA EUDIAL Working Group reviews the diagnostic work-up and therapy of chronic coronary syndromes, unstable angina/non-ST elevation and ST-elevation myocardial infarction in dialysis patients, outlining unclear issues and controversies, discussing recent evidence, and proposing management strategies. Indications of antiplatelet and anticoagulant therapies, percutaneous coronary intervention and coronary artery bypass grafting are discussed. The issue of the interaction between dialysis session and myocardial damage is also addressed.
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http://dx.doi.org/10.1007/s40620-020-00758-5DOI Listing
February 2021

Quality of life improved for patients after starting dialysis but is impaired, initially, for their partners: a multi-centre, longitudinal study.

BMC Nephrol 2020 05 18;21(1):185. Epub 2020 May 18.

School of Health Sciences, Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, UK.

Background: Quality of life (QOL) is important to patients with end stage renal disease and their partners. Despite the first 12 weeks being a critical time in the treatment pathway, limited research exists which examines how the transition onto dialysis impacts QOL. In this study we measured QOL in patients and their partners at pre-dialysis and over the first 12 weeks on dialysis to investigate QOL during this crucial period.

Methods: Patients and their partners, recruited from 10 renal units in England, completed questionnaires at pre-dialysis (n = 166 participants, 83 couples), 6 weeks (n = 90 participants, 45 couples) and 12 weeks (n = 78, 39 couples) after starting dialysis. On each occasion participants completed a QOL questionnaire (WHOQOL-BREF). Multilevel modelling accommodated the nested structure of couples with repeated measures within participants. Three-level random intercept models estimated changes in WHOQOL general QOL and its four domains (Physical, Psychological, Social and Environment). Two-level random intercept models assessed the relationship between baseline clinical and socio-demographic variables with changes in general QOL.

Results: Patients reported positive changes in general QOL from pre-dialysis to 6 weeks (β = 0.42, p < 0.001, 95% CI 0.19, 0.65) and from pre-dialysis to 12 weeks (β = 0.47, p < 0.001, 95% CI 0.24, 0.71). Partners' general QOL decreased significantly from pre-dialysis to 6 weeks (β = - 0.24, p = 0.04, 95% CI -0.47, - 0.01) but returned to its original level at 12 weeks. Patients reported improvements in the physical domain between pre-dialysis and 12 weeks (β = 6.56, p < 0.004, 95% CI 2.10, 11.03). No other domains changed significantly in patients or partners. Only in patients were there significant associations between moderator variables and general QOL. High comorbidity risk level and diabetes were associated with poorer QOL at pre-dialysis whereas being female and having an arteriovenous fistula were linked with improvements in general QOL.

Conclusions: Patients reported significant improvements in their general and physical QOL after starting dialysis. Partners' general QOL worsened after patients started dialysis but improved by 12 weeks. Both patients and partners may benefit from additional educational and counselling services in the lead up to, and immediately after starting dialysis, which could facilitate the transition onto dialysis and improve QOL in both.

Study Registration: This study was adopted on the NIHR Clinical Research Network (UK). The details of this study are registered on the Research Registry website (www.researchregistry.com). The identifier for this study is researchregistry2574.
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http://dx.doi.org/10.1186/s12882-020-01819-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236460PMC
May 2020

Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres.

Nephrol Dial Transplant 2020 05;35(5):737-741

Manchester Academy of Health Sciences Centre, Manchester University Hospitals Foundation Trust and University of Manchester, Manchester, UK.

COVID-19, a disease caused by a novel coronavirus, is a major global human threat that has turned into a pandemic. This novel coronavirus has specifically high morbidity in the elderly and in comorbid populations. Uraemic patients on dialysis combine an intrinsic fragility and a very frequent burden of comorbidities with a specific setting in which many patients are repeatedly treated in the same area (haemodialysis centres). Moreover, if infected, the intensity of dialysis requiring specialized resources and staff is further complicated by requirements for isolation, control and prevention, putting healthcare systems under exceptional additional strain. Therefore, all measures to slow if not to eradicate the pandemic and to control unmanageably high incidence rates must be taken very seriously. The aim of the present review of the European Dialysis (EUDIAL) Working Group of ERA-EDTA is to provide recommendations for the prevention, mitigation and containment in haemodialysis centres of the emerging COVID-19 pandemic. The management of patients on dialysis affected by COVID-19 must be carried out according to strict protocols to minimize the risk for other patients and personnel taking care of these patients. Measures of prevention, protection, screening, isolation and distribution have been shown to be efficient in similar settings. They are essential in the management of the pandemic and should be taken in the early stages of the disease.
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http://dx.doi.org/10.1093/ndt/gfaa069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7184437PMC
May 2020

Frailty is independently associated with worse health-related quality of life in chronic kidney disease: a secondary analysis of the Frailty Assessment in Chronic Kidney Disease study.

Clin Kidney J 2020 02 30;13(1):85-94. Epub 2019 Apr 30.

Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston,UK.

Background: Understanding how frailty affects health-related quality of life (HRQOL) in those with chronic kidney disease (CKD) could assist in the development of management strategies to improve outcomes for this vulnerable patient group. This study aimed to evaluate the relationship between frailty and HRQOL in patients with CKD Stages 4 and 5 (G4–5) and those established on haemodialysis (G5D).

Methods: Ninety participants with chronic kidney disease (CKD G4–5D) were recruited between December 2016 and December 2017. Frailty was assessed using the Frailty Phenotype, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), physical activity and self-perceived exhaustion. HRQOL was assessed using the RAND 36-Item Health Survey Version 1.0 (SF-36).

Results: Nineteen (21%) patients were categorized as frail. Frailty, when adjusted for age, gender, dialysis dependence and comorbidity, had a significant effect on five of the eight SF-36 domains: physical functioning, role limitations due to emotional problems, energy/fatigue, social functioning and pain. Regression modelling best explained the variation in the physical functioning domain (adj. R2 = 0.27, P < 0.001), with frailty leading to a 26-point lower score. Exhaustion was the only Frailty Phenotype component that had a significant effect on scores across all SF-36 domains.

Conclusions: Frailty is independently associated with worse HRQOL in patients with CKD G4–5D, with self-perceived exhaustion being the most significant Frailty Phenotype component contributing to HRQOL. Efforts should be made to identify frail patients with CKD so that management strategies can be offered that aim to improve morbidity, mortality and patient-reported outcomes, including HRQOL and fatigue.
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http://dx.doi.org/10.1093/ckj/sfz038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7025341PMC
February 2020

Salt and Water Retention Is Associated with Microinflammation and Endothelial Injury in Chronic Kidney Disease.

Nephron 2019 12;143(4):234-242. Epub 2019 Sep 12.

Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom.

Background: Progressive chronic kidney disease (CKD) inevitably leads to salt and water retention and disturbances in the macro-and microcirculation.

Objectives: We hypothesize that salt and water dysregulation in advanced CKD may be linked to inflammation and microvascular injury pathways.

Methods: We studied 23 CKD stage 5 patients and 11 healthy controls (HC). Tissue sodium concentration was assessed using 23Sodium magnetic resonance (MR) imaging. Hydration status was evaluated using bioimpedance spectroscopy. A panel of inflammatory and endothelial biomarkers was also measured.

Results: CKD patients had fluid overload (FO) when compared to HC (overhydration index: CKD = 0.5 ± 1.9 L vs. HC = -0.5 ± 1.0 L; p = 0.03). MR-derived tissue sodium concentrations were predominantly higher in the subcutaneous (SC) compartment (median [interquartile range] CKD = 22.4 mmol/L [19.4-31.3] vs. HC = 18.4 mmol/L [16.6-21.3]; p = 0.03), but not the muscle (CKD = 24.9 ± 5.5 mmol/L vs. HC = 22.8 ± 2.5 mmol/L; p = 0.26). Tissue sodium in both compartments correlated to FO (muscle: r = 0.63, p < 0.01; SC: rs = 0.63, p < 0.01). CKD subjects had elevated levels of vascular cell adhesion molecule (p < 0.05), tumor necrosis factor-alpha (p < 0.01), and interleukin (IL)-6 (p = 0.01) and lower levels of vascular endothelial growth factor-C (p = 0.04). FO in CKD was linked to higher IL-8 (r = 0.51, p < 0.05) and inversely associated to E-selectin (r = -0.52, p = 0.01). Higher SC sodium was linked to higher intracellular adhesion molecule (ICAM; rs = 0.54, p = 0.02).

Conclusion: Salt and water accumulation in CKD appears to be linked with inflammation and endothelial activation pathways. Specifically IL-8, E-Selectin (in FO), and ICAM (in salt accumulation) may be implicated in the pathophysiology of FO and merit further investigation.
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http://dx.doi.org/10.1159/000502011DOI Listing
July 2020

Impact of Dialysis on the Dyadic Relationship Between Male Patients and Their Female Partners.

Qual Health Res 2020 02 3;30(3):380-390. Epub 2019 Sep 3.

Manchester Academic Health Science Centre, United Kingdom.

The objective of this study was to explore the impact of three early phases of renal dialysis, namely pre-dialysis, starting dialysis, and establishing dialysis, on dyadic relationships. Twenty UK-based dyads (20 male patients and their female partners) participated in semi-structured interviews and discussed the effects of dialysis on themselves and their relationship. Dyadic thematic analysis, facilitated by dyadic-level charting, integrated participants' experiences and enabled identification of patterns across dyads. We found that dialysis had positive and negative influences on identity, social relationships, and mental health, forming the themes: , and The final theme, , described how dyads prevented dialysis from negatively impacting their relationship. Dyadic-level charting provided a systematic examination of individual and dyadic experiences. These findings indicate that access to informational and support services for dyads as they prepare to start dialysis may minimize negative effects on their relationship.
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http://dx.doi.org/10.1177/1049732319869908DOI Listing
February 2020

Prospective Audit to Study urokinaSe use to restore Patency in Occluded centRal venous caTheters (PASSPORT 1).

J Vasc Access 2019 Nov 30;20(6):752-759. Epub 2019 Aug 30.

Institute of Translational Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK.

Objectives: Tunnelled central venous catheters dysfunction can be defined as failure to provide blood flow above 200 mL/min during dialysis often caused by thrombosis. Although urokinase is used routinely for thrombolysis, there is wide variation in dose regimens. A multidisciplinary group was formed to address this issue and offer guidance.

Methods: Dialysis centres that used urokinase in the United Kingdom took part in a prospective study to determine the safety and outcomes of thrombolysis using agreed protocols. Data were collected anonymously from September 2017 until February 2018. Catheter blood flow was measured before and after the following interventions: catheter dwell or push locks with 12,500-50,000 IU or catheter infusion with 100,000-250,000 IU of urokinase. Interventions were repeated if the blood flow remained below 200 mL/min.

Results: 10 centres took part and recruited 200 patients; 45.5% were female and 54.5% were male with mean age of 63.6 (±15.2) years. The cumulative success rate for thrombolysis was 90.5% after first intervention, 97% after second intervention, and 99% after more than 2 interventions. Although there was trend towards benefit with dose increments, the success rate between push/dwell locks and high-dose infusion of urokinase was not significantly different (p = 0.069). Seventeen (8.5%) tunnelled central venous catheters were removed due to failure of treatment. No urokinase-related adverse events were reported.

Conclusion: In this study, urokinase was safe and efficacious; there was no difference between dwell and push locks. There was some benefit with high-dose infusion of urokinase compared to the dwell and push lock.
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http://dx.doi.org/10.1177/1129729819869095DOI Listing
November 2019

Transcapillary Refilling Rate and Its Determinants during Haemodialysis with Standard and High Ultrafiltration Rates.

Am J Nephrol 2019 9;50(2):133-143. Epub 2019 Jul 9.

Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.

Background: Achieving euvolaemia using ultrafiltration (UF) during haemodialysis (HD) without inducing haemodynamic instability presents a major clinical challenge. Transcapillary refill is a key factor in sustaining the circulating blood volume (BV) during UF, which is in turn predicted by the rate of refilling. However, absolute plasma refilling rate (PRR), its determinants and variability with UF rate (UFR), have not been reported in the literature.

Method: We studied paired HD sessions (n = 48) in 24 patients over 2 consecutive mid-week HD treatments. Plasma refilling was measured using real-time, minute-by-minute relative BV changes obtained from the integrated BV monitoring device during UF. A fixed bolus dilution approach at the start of HD was used to calculate absolute BV. The first control HD session was undertaken with a standard UFR required to achieve the prescribed target weight, while during the second study session, a fixed (high) UFR (1 L/h) was applied, either in the first (n = 12 patients) or in the final hour (n = 12 patients) of the HD session. Participants' had their hydration status measured pre- and post-HD using multifrequency bioimpedance (BIS). Blood pressure was measured at 15-min intervals and blood samples were collected at 7 intervals during HD sessions.

Results: The mean PRR during a standard 4-hr HD session was 4.3 ± 2.0 mL/kg/h and varied between 2 and 6 mL/kg/h. There was a mean time delay of 22 min (range 13.3-35.0 min) for onset of plasma refilling after the application of UF irrespective of standard or high UFRs. The maximum refilling occurred during the second hour of HD (mean max PRR 6.8 mL/kg/h). UFR (beta = 0.60, p < 0.01) and BIS derived pre-HD overhydration index (beta = 0.44, p = 0.01) were consistent, independent predictors of the mean PRR (R2 = 0.49) in all HD sessions. At high UFRs, PRR exceeded 10 mL/kg/h. The total overall plasma refill contribution to UF volume was not significantly different between standard and high UF. During interventions no significant haemodynamic instability was observed in the study.

Conclusion: We describe absolute transcapillary refilling rate and its profile during HD with UF. The findings provide the basis for the development of UF strategies to match varying PRRs during HD. An approach to fluid removal, which is tailored to patients' refilling rates and capacity, provides an opportunity for more precision in the practice of UF.
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http://dx.doi.org/10.1159/000501407DOI Listing
August 2020

Reasons for Underreporting of Uremic Pruritus in People With Chronic Kidney Disease: A Qualitative Study.

J Pain Symptom Manage 2019 10 19;58(4):578-586.e2. Epub 2019 Jun 19.

Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK. Electronic address:

Context: Uremic pruritus, or itch, is common in people with chronic kidney disease (CKD) and has a negative impact on their lives and well-being. However, for reasons currently unknown, itch often remains unreported and therefore untreated.

Objectives: To explore reasons for underreporting of itch to provide pointers for improving itch reporting and management in people with CKD.

Methods: We interviewed adult patients with CKD who self-reported experiencing itching in the last three years (n = 25), nephrologists (n = 10), and nurses (n = 12) from three kidney services in the U.K. Topic guides were informed by previous studies and a theoretical model of self-regulation. We conducted a thematic analysis of verbatim transcripts using framework analysis.

Results: We identified the following three main themes reflecting factors that may influence whether itch is reported: knowledge on causes and treatment of itch (lack of awareness of the relationship between itch and CKD, and lack of knowledge of treatment options); attitudes toward importance of itch as a health issue (patients' and clinicians' attitudes); and prompts for itch assessment during consultations (routine practice, itch as a marker, and itch severity).

Conclusion: Underreporting of itch is related to patients being unaware of its causes, accepting it as something to live with, prioritizing other health issues, and the length and timing of consultations. Health care professionals' assessment and management of itch vary widely and are not necessarily evidence-based. Better patient information, development of clinical practice guidelines, and incorporation of routine symptom assessments into care may improve itch reporting and management in people with CKD.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.06.010DOI Listing
October 2019

Extracellular resistance is sensitive to tissue sodium status; implications for bioimpedance-derived fluid volume parameters in chronic kidney disease.

J Nephrol 2020 Feb 18;33(1):119-127. Epub 2019 Jun 18.

Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.

Multifrequency bioimpedance spectroscopy (BIS) is an established method for assessing fluid status in chronic kidney disease (CKD). However, the technique is lacking in predictive value and accuracy. BIS algorithms assume constant tissue resistivity, which may vary with changing tissue ionic sodium concentration (Na). This may introduce significant inaccuracies to BIS outputs. To investigate this, we used Na magnetic resonance imaging (MRI) to measure Na in muscle and subcutaneous tissues of 10 healthy controls (HC) and 20 patients with CKD 5 (not on dialysis). The extracellular (Re) and intracellular (Ri) resistance, tissue capacitance, extracellular (ECW) and total body water (TBW) were measured using BIS. Tissue water content was assessed using proton density-weighted MRI with fat suppression. BIS-derived volume indices were comparable in the two groups (OH: HC - 0.4 ± 0.9 L vs. CKD 0.5 ± 1.9 L, p = 0.13). However, CKD patients had higher Na (HC 21.2 ± 3.0, CKD 25.3 ± 7.4 mmol/L; p = 0.04) and significantly lower Re (HC 693 ± 93.6, CKD 609 ± 74.3 Ohms; p = 0.01); Ri and capacitance did not vary. Na showed a significant inverse linear relationship to Re (r = - 0.598, p < 0.01) but not Ri. This relationship of Re (y) and Na (x) is described through equation y = - 7.39x + 814. A 20% increase in tissue ionic Na is likely to overestimate ECW by 1.2-2.4L. Tissue Na concentration has a significant inverse linear relationship to Re. BIS algorithms to account for this effect could improve prediction accuracy of bioimpedance derived fluid status in CKD.
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http://dx.doi.org/10.1007/s40620-019-00620-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7007413PMC
February 2020

Vascular access in children requiring maintenance haemodialysis: a consensus document by the European Society for Paediatric Nephrology Dialysis Working Group.

Nephrol Dial Transplant 2019 10;34(10):1746-1765

Mitera Children's Hospital, Athens, Greece.

Background: There are three principle forms of vascular access available for the treatment of children with end stage kidney disease (ESKD) by haemodialysis: tunnelled catheters placed in a central vein (central venous lines, CVLs), arteriovenous fistulas (AVF), and arteriovenous grafts (AVG) using prosthetic or biological material. Compared with the adult literature, there are few studies in children to provide evidence based guidelines for optimal vascular access type or its management and outcomes in children with ESKD.

Methods: The European Society for Paediatric Nephrology Dialysis Working Group (ESPN Dialysis WG) have developed recommendations for the choice of access type, pre-operative evaluation, monitoring, and prevention and management of complications of different access types in children with ESKD.

Results: For adults with ESKD on haemodialysis, the principle of "Fistula First" has been key to changing the attitude to vascular access for haemodialysis. However, data from multiple observational studies and the International Paediatric Haemodialysis Network registry suggest that CVLs are associated with a significantly higher rate of infections and access dysfunction, and need for access replacement. Despite this, AVFs are used in only ∼25% of children on haemodialysis. It is important to provide the right access for the right patient at the right time in their life-course of renal replacement therapy, with an emphasis on venous preservation at all times. While AVFs may not be suitable in the very young or those with an anticipated short dialysis course before transplantation, many paediatric studies have shown that AVFs are superior to CVLs.

Conclusions: Here we present clinical practice recommendations for AVFs and CVLs in children with ESKD. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system has been used to develop and GRADE the recommendations. In the absence of high quality evidence, the opinion of experts from the ESPN Dialysis WG is provided, but is clearly GRADE-ed as such and must be carefully considered by the treating physician, and adapted to local expertise and individual patient needs as appropriate.
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http://dx.doi.org/10.1093/ndt/gfz011DOI Listing
October 2019
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