Kidney and Dialysis

Background: Stress, anxiety and depression are phenomena that often accompany the onset of chronic illness. The development of psychosomatic medicine has led to the study of the influence of other emotional factors, including the presence of anxiety and depression, on a patient’s health status, in addition to quality of life. The aim of this study is to evaluate the relationship between vascular access function and the occurrence of stress, anxiety and depression in haemodialysis patients. Methods: A total of 202 haemodialysis patients were included in the analysis, and the severity of vascular access problems and levels of negative emotions (feelings of stress, anxiety, depression) were assessed using standardised questionnaires (VAQ, HADS-M, PSS-10). Results: The results show that an increase in vascular access function problems correlated with increased levels of stress (r = 0.262; p < 0.001), anxiety (r = 0.456; p < 0.001) and depression (r = 0.391; p < 0.001). Conclusions: The study confirms the significant impact of vascular access quality on patients’ emotional state, highlighting the need to monitor and optimise its functioning to improve the psychological well-being of dialysis patients. Full article

Bloodstream infections are a significant cause of morbidity and mortality among hemodialysis patients. These infections primarily involve Gram-positive bacteria and, less frequently, Gram-negative bacilli. Raoultella ornithinolytica is a Gram-negative bacillus which is known to be a rare opportunistic pathogen. It is found only occasionally in human infections; however, it has been noted as an emerging pathogen. Sepsis caused by this microorganism is very rare. A few cases have been reported among immunocompromised patients or those undergoing invasive procedures. Cases involving urinary catheters or port catheters have also been reported, as well as a single case of a patient on peritoneal dialysis. Here, we present a novel case of Raoultella ornithinolytica bloodstream infection in a patient with chronic renal failure undergoing hemodialysis who was successfully treated. We discuss the microbiology and clinical features of such infections, and consider aspects of treatment. Full article

Chronic kidney disease (CKD) remains a significant global health challenge, with its advanced stages necessitating timely and comprehensive patient education, particularly regarding kidney replacement therapy (KRT). Early initiation of education is crucial, as it enhances patient understanding and supports shared decision-making with healthcare teams, ultimately leading to better health outcomes. Evidence demonstrates that CKD education not only increases disease-specific knowledge, but also confers multiple benefits, including reduced healthcare utilization, greater adoption of self-management, delayed KRT initiation, improved survival, higher adherence to therapies, and increased transplant evaluation. Despite these advantages, a disconnect persists between the educational content desired by patients and what is prioritized by healthcare professionals. Structured educational interventions have been shown to improve patients’ ability to make informed decisions about KRT, with studies indicating that after targeted education, the vast majority of patients can articulate their therapy preferences. Furthermore, national and international guidelines highlight the necessity of embedding patient education as a core component of CKD care to empower patients and improve the quality of life. However, challenges remain, including disparities in access, health literacy, and the consistency of educational delivery. There is currently no standardized approach on how to effectively educate CKD patients. This review provides a comprehensive analysis of all aspects of pre-dialysis education and best practices for advanced CKD patient education. Full article

This review synthesizes current evidence on clinical nursing practices in the management of arteriovenous fistulas (AVFs) among patients undergoing hemodialysis (HD). It investigates the identification of risk factors and elements contributing to AVF dysfunction, emphasizing the crucial role of nursing professionals in maintaining, monitoring, and enhancing the long-term functionality of vascular access. The findings indicate that implementing upper limb exercise protocols can significantly support AVF maturation, enhance hemodynamic parameters, and improve vascular access outcomes. Notably, the review highlights the necessity of continuous education for nurses in AVF management, emphasizing their critical role in the successful preservation and optimization of vascular access, including the promotion of exercise interventions. These insights underscore the importance of equipping nursing staff with current knowledge and skills to improve patient outcomes in HD care. Full article

Resilience, the ability to adapt and thrive in the face of adversity, is an essential yet under-recognized determinant of outcomes in patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD), particularly those undergoing home-based peritoneal dialysis (PD). While studies have shown that PD can enhance autonomy and quality of life compared to in-center hemodialysis (IHD), it also places substantial emotional, physical and self-management demands on patients. Despite this, resilience is rarely assessed or systematically supported in PD care. This narrative review highlights the importance of resilience in CKD and dialysis populations and extends its application to the unique psychosocial challenges faced by PD patients. This review also introduces psychological frameworks of resilience, in particular the GROW model (Good emotions, Reason and purpose, Others and connections, Wellness flexibility), as tools for clinicians to support PD patients in developing optimism, purpose, strong social networks, and emotional adaptability. We also explore how routine, longitudinal assessment of resilience using validated tools can help improve patient well-being, treatment adherence, and long-term outcomes. Full article

Chronic kidney disease (CKD) is prevalent throughout the world, and peritoneal dialysis (PD) has been a growing mode of renal replacement therapy (RRT) for over four decades. Peritoneal dialysis has several advantages in cost, patient satisfaction, and quality of life, despite accounting for only one in ten patients on dialysis in the United States. In spite of some contraindications and barriers to effective PD, the vast majority of renal failure patients are candidates, especially when in a high-volume program with surgical expertise readily available. Reliable access via an intraabdominal PD catheter is paramount for managing end-stage renal disease patients. Surgical approaches for PD catheter insertion have evolved substantially alongside innovations in catheter design. Recent data suggests that the advanced laparoscopic catheter placement offers the best results and long-term survival. However, image-guided fluoroscopic insertion can be performed without general anesthesia, is highly effective, and is growing in usage. Being able to start PD urgently is vital in avoiding hemodialysis (HD) and its complications, and this is a growing theme worldwide, despite slightly higher morbidity. Infectious and mechanical complications are relatively common and are frustrating to PD patients and the physicians who care for them. Peritonitis and exit site infections require antibiotic coverage and sometimes, surgical intervention. Catheter dysfunction is a frequent mechanical issue requiring a multidisciplinary approach: medical treatment, nurse-administered flushing and clot dissolvers, interventional radiology evaluation and wire manipulation, and surgical laparoscopy for catheter salvage. Full article

Asymptomatic bacteriuria (ASB) is a very frequent condition in kidney transplant recipients (KTRs). Guidelines advise against screening and treatment of ASB beyond the first month after renal transplantation. Here, we report the case of a 40-year-old female KTR with untreated ASB complicated with allograft pyelonephritis with urosepsis and acute kidney injury. The reported case highlights that ASB remains a grey area in the management of KTRs (after the first month), and there is a need for new ad hoc studies to identify which patients should be screened and eventually treated. Until new findings are available, it is suggested not to treat KTRs with ASB; however, if ASB is detected, stricter monitoring and non-antibiotic prophylaxis are necessary to favor prevention or prompt therapy of severe urinary tract infections. Full article

Background Socioeconomic factors significantly influence access to kidney transplantation, with socially vulnerable populations experiencing delays in receiving transplants, resulting in prolonged dialysis duration and poorer post-transplant outcomes. This study evaluates the relationship between social vulnerability and disparities in preemptive kidney transplantation using the Social Vulnerability Index (SVI), a composite measure developed by the Centers for Disease Control and Prevention (CDC). Methods Utilizing data from the Scientific Registry of Transplant Recipients (SRTR) from 2012 to 2020, we analyzed 155,424 adult kidney transplant recipients. The primary exposure was SVI, categorized into quartiles, while primary outcomes included preemptive transplant status and dialysis vintage. Multivariable regression models were adjusted for clinical covariates such as age, gender, BMI, diabetes, and peripheral vascular disease. Result Findings indicate that higher social vulnerability is significantly associated with a reduced likelihood of preemptive kidney transplantation (p < 0.0001) and an increased duration of dialysis prior to transplantation. Patients in the highest SVI quartile (0.75–1.00) were more than twice as likely to undergo dialysis before transplantation compared to those in the lowest quartile (OR = 2.21, 95% CI: 1.89–2.57). Similarly, increased SVI was strongly correlated with prolonged dialysis duration (OR = 3.43, 95% CI: 3.31–3.55, p < 0.0001). Conclusions These results highlight the impact of socioeconomic disparities on access to timely kidney transplantation. Addressing social vulnerability factors—such as poverty, education, and healthcare access—may help reduce inequities and improve transplantation outcomes. Future interventions should target high-SVI communities to facilitate earlier transplant access and reduce reliance on prolonged dialysis. Full article

This study examined 112 CKD patients’ adherence to and satisfaction with treatment, and their quality of life, as mediated by the level of psychological stress experienced as well as their working alliance, resilience, and social support. The patients were receiving care at a public teaching hospital in the northeast region of the U.S. The results indicated a significant moderate negative correlation between psychological distress and quality of life (r = −0.34, p < 0.01). The results also indicated significant positive moderate to strong correlations between the physician–patient working alliance and adherence (r = 0.42, p < 0.001), satisfaction (r = 0.55, p < 0.001), and quality of life (r = 0.51, p < 0.001), between social support and quality of life (r = 0.39, p < 0.001), and significant moderate positive correlations between resilience and adherence (r = 0.35, p < 0.001) and satisfaction (r = 0.26, p < 0.01). Regression analyses indicated that the following predictors were significant: patient adherence was positively predicted by the working alliance (β = 0.42, p < 0.001); patient satisfaction was positively predicted by the working alliance (β = 0.51, p < 0.001) and negatively predicted by psychological distress (β = −18, p < 0.048); and quality of life was positively predicted by the working alliance (β = 0.38, p < 0.001) and social support (β = 0.28, p < 0.016) and negatively predicted by psychological distress (β = −0.34, p < 0.002). Moderation analyses indicated that the working alliance moderated the relationship between COVID impact and adherence (R² = 0.27, F(df1, df2) = 8.36, p < 0.001, 95% CI = 0.29–2.74), social support moderated the relationship between COVID impact and adherence (R² = 0.19, F(df1, df2) = 5.77, p < 0.001, 95% CI = 0.47–2.77), and resilient coping moderated the relationship between COVID impact and satisfaction (R² = 0.20, F(df1, df2) = 7.89, p < 0.001, 95% CI = 0.94–2.81). The present study provides evidence of the significant role of psychological stressors and social support in influencing CKD patients’ adherence to and satisfaction with treatment, as well as their quality of life. Full article

Chronic diseases are a growing concern in aging populations, with physical inactivity playing a major role in their onset and progression. Chronic kidney disease (CKD), which affects approximately 15% of U.S. adults and over 500 million people worldwide, is strongly associated with sedentary behavior. Despite mounting evidence supporting the benefits of exercise training in CKD management, current treatment approaches remain largely pharmacological, with exercise interventions receiving limited emphasis. One challenge is the uncertainty surrounding the most appropriate exercise modalities for CKD patients, particularly those undergoing dialysis. Recent guidelines from leading nephrology organizations advocate for integrating exercise training into CKD care, recommending at least 150 min of moderate-intensity exercise per week. This narrative review examines clinical studies on exercise interventions in dialysis patients, highlighting their impact on health outcomes and quality of life. Additionally, it explores the physiological mechanisms underlying these benefits and assesses nephrologists’ perspectives on prescribing exercise training. By addressing these critical aspects, this review aims to underscore the necessity of incorporating exercise into CKD treatment strategies. Full article

Background: Infections are a major cause of mortality in haemodialysis patients. The increasing antimicrobial resistance globally further exacerbates this concern. Procalcitonin has shown potential in aiding antimicrobial stewardship and reducing the mortality and morbidity associated with infections. This systematic review aims to synthesise the existing literature on the utility of procalcitonin as a diagnostic and monitoring tool for haemodialysis patients with suspected bacteraemia. Methods: Multiple electronic databases (EMBASE, MEDLINE, and the Cochrane Library) were systematically searched to identify primary studies evaluating procalcitonin use in haemodialysis patients with suspected bacteraemia. Using a narrative synthesis approach, along with other quality assessment tools, recommendations regarding procalcitonin usage in dialysis were formulated. Results: Eleven studies were identified. The review proposes a procalcitonin-guided antibiotic protocol aimed at facilitating antibiotic use in haemodialysis patients with suspected bacteraemia. Caution is, however, advised against relying solely on procalcitonin for diagnosis, emphasising the integration of procalcitonin with other clinical and biomarkers of infection. Conclusions: Procalcitonin shows promise as a valuable diagnostic and monitoring tool for suspected bacteraemia in haemodialysis patients. While caution is advised against relying solely on PCT for diagnosis, its integration with other clinical indicators can enhance infection management. To fully establish its clinical utility, more research is needed. Full article

Background: Anemia represents a significant complication in patients with advanced chronic kidney disease (CKD) on hemodialysis, primarily caused by reduced renal erythropoietin production. Despite erythropoiesis-stimulating agents (ESAs) being the cornerstone of treatment, hyporesponsiveness to these agents remains a clinical challenge with implications for patient outcomes. Objective: To identify and quantify risk factors associated with hyporesponsiveness to erythropoietin in patients with CKD on hemodialysis who present with anemia. Methods: This multicenter case–control study analyzed data from 784 hemodialysis patients receiving erythropoietin therapy across six dialysis centers in Ecuador between January and December 2019. Hyporesponsiveness was defined as requiring ≥ 200 IU/kg/week of erythropoietin alfa for ≥3 consecutive months to maintain target hemoglobin levels (10–12 g/dL). Demographic, clinical, and laboratory parameters were compared between hyporesponsive cases (n = 123) and responsive controls (n = 661). Bivariate and multivariate logistic regression analyses were performed to identify independent risk factors. Results: The prevalence of erythropoietin hyporesponsiveness was 15.69%. A multivariate analysis identified female sex (adjusted OR = 1.96; 95% CI: 1.20–3.20; p < 0.001), age < 50 years (adjusted OR = 4.25; 95% CI: 2.42–7.47; p < 0.001), serum albumin < 4.0 g/dL (adjusted OR = 10.53; 95% CI: 6.53–16.98; p < 0.001), ferritin ≥ 800 ng/mL (adjusted OR = 7.28; 95% CI: 4.22–12.57; p < 0.001), transferrin saturation < 20% (adjusted OR = 9.27; 95% CI: 5.47–15.69; p < 0.001), parathyroid hormone ≥ 500 pg/mL (adjusted OR = 1.89; 95% CI: 1.16–3.09; p = 0.011), and use of renin–angiotensin system blockers (adjusted OR = 2.25; 95% CI: 1.36–3.71; p = 0.002) as independent risk factors for erythropoietin hyporesponsiveness. Conclusions: Multiple demographic, clinical, and laboratory factors independently contribute to erythropoietin hyporesponsiveness in hemodialysis patients. Identification of these risk factors may guide clinicians in developing individualized treatment approaches, optimizing erythropoietin dosing, and implementing targeted interventions to improve anemia management in this vulnerable population. Full article

Background: Strategies are needed to address the elevated prevalence of chronic kidney disease (CKD) in socioeconomically disadvantaged regions where obesity, smoking, and type 2 diabetes rates are high. Methods: Recognising the inadequacy of generic health approaches in complex contexts, this study employed a participatory action research (PAR) framework to design and deliver five co-design community workshops in two stages over one year. Stage one workshops identified key matters of concern and stage two focussed on problem solving and co-creating solutions. The goal was to inform health service delivery in a region with high CKD prevalence and explore strategies to overcome barriers to individualised, collaborative care, and promote self-management. Results: The workshops identified three themes: 1. achieving person/family-centred care; 2. multimorbidity and siloed care (stage one); and 3. a kidney wellness framework (stage two). Conclusions: The findings reinforce the need for enhanced care coordination, and highlight the importance of consistent information sources, clear referral pathways, and centralised data sharing among health professionals. The proposed kidney healthcare framework aims to support various professionals, fostering linkages between primary and tertiary care, with an emphasis on professional development, especially in communicating complex information to individuals with multimorbidities. While co-designed healthcare models show promise, challenges persist in effective self-management amidst complex disease information and multimorbidity. Full article

Gitelman syndrome (GS) is a rare autosomal recessive renal tubulopathy characterized by hypokalemic metabolic alkalosis, hypomagnesemia, and hypocalciuria due to mutations in the SLC12A3 gene. This case report presents a 54-year-old African American female with near syncope and palpitations. The patient had a history of intermittent palpitations and generalized anxiety disorder and was previously diagnosed with GS. On presentation, the patient exhibited symptoms of severe hypokalemia and hypomagnesemia, attributed to medication non-adherence. Laboratory tests confirmed critically low potassium and magnesium levels, with elevated urine sodium and chloride. Treatment was initiated with oral and intravenous potassium and magnesium, leading to the normalization of electrolyte levels. This case highlights the challenges of managing GS, particularly in patients facing socioeconomic barriers that impede medication adherence and healthcare access. Personalized patient education, combined with comprehensive healthcare resources, is essential to mitigate complications and improve long-term outcomes in such cases. Full article

Artificial intelligence (AI) has become commonplace in our everyday lives and in healthcare. Peritoneal dialysis (PD) is a cost-effective method of treatment for kidney failure that is preferred by many patients, but its uptake is limited by several barriers. With the rapid advancements in AI, researchers are developing new tools that could mitigate some of these barriers to promote uptake and improve patient outcomes. AI has the capacity to assist with patient selection and management, predict patient technique failure, predict patient outcomes, and improve accessibility of patient education. Patients already have access to some open-source AI tools, and others are being rapidly developed for implementation in the dialysis space. For ethical implementation, it is essential for providers to understand the advantages and limitations of AI-based approaches and be able to interpret the common metrics used to evaluate their performance. In this review, we provide a general overview of AI with information necessary for clinicians to critically evaluate AI models and tools. We then review existing AI models and tools for PD. Full article

Introduction: The feasibility of enrolling and retaining diverse kidney transplant (KT) seekers in remote studies is sparsely reported. Aims: This study examined the use of a mobile communication strategy to enroll and retain participants within a clinical trial of an automated digital intervention to promote self-learning for kidney transplant access. Materials and Methods: Adult KT-seekers were identified from an administrative database at a transplant center and recruited by email or text supplemented by verbal prompts. Multivariable logistic regression was used to explore participant- and study-level characteristics associated with enrollment and response rates. Results: Between April 2022 and June 2023, 743 patients were invited to participate, and 422 were enrolled. Enrollers were more likely to be younger (aOR 1.02; p < 0.001). Early enrollment was associated with text message invitation (OR 2.69, p ≤ 0.014). Survey completion at 1 month was similar across patient sociodemographic, clinical, and study characteristics; however, participants self-reporting Black race were underrepresented at month 6 (OR 0.55, p = 0.015) and month 12 (aOR 0.37, p = 0008), and males were underrepresented at month 12 (aOR 0.45, p = 0.028). Conclusion: Mobile communication methods are viable for enrolling diverse KT-seeking patients and collecting survey data remotely. More work is needed to learn how to best recruit older people and retain diverse groups long-term. Full article

In the last decade, barriers to the growth and utilization of home dialysis have been described in mainstream and significant Nephrology journals. Since then, the suggested solutions have received little attention or have proven ineffective. This situation is even more significant because, in 2019, President Trump issued an executive order to increase the utilization of home dialysis and transplantation. The reasons for failing to achieve the stated goals of the executive order are numerous and can be attributed to barriers at many levels in the health care system. Some of the barriers are unique to the United States and learning from foreign systems would be beneficial. This correspondence attempts to describe and annotate these barriers. I classify them such that local institutions can identify and prioritize solutions. Home dialysis growth can only occur with all stakeholders committing to that end. Full article

Hyperphosphatemia in dialysis patients is associated with adverse outcomes including bone mineral disease, increased total mortality, and cardiovascular mortality. Therefore, maintaining serum phosphate levels within limits is an important aspect of the clinical care of peritoneal dialysis patients. Unfortunately, hyperphosphatemia is commonly seen in the majority of dialysis patients, at least in the USA, despite apparent optimal dietary and pharmacological intervention and adequate dialysis. Herein, we review major aspects of body phosphate homeostasis in healthy subjects and in dialysis patients in order to provide a good background understanding for a more rational approach to manage serum phosphate. Of note, the phosphate concentration measured in blood by clinical laboratories represents a minute portion of the total body phosphate content but the only one that we can easily access at present; this aspect is discussed in detail in this review. We emphasize the curtailment not only of the total oral phosphate intake but also the intake of highly bioavailable phosphate; this, together with the right use of oral phosphate binders and appropriate dialysis, is an important tool. Emerging therapies with agents that block intestinal absorption of phosphate may offer a promising four-pronged approach to phosphate management. Full article

Protein-energy wasting (PEW) increases the morbidity and mortality in maintenance hemodialysis (MHD) patients. The existing screening tools (e.g., Malnutrition-Inflammation Score (MIS)) are time-consuming and require expertise. Consequently, assessing a more practical and reliable tool such as handgrip strength (HGS) is important, as it strongly correlates with the PEW status in patients undergoing MHD, in whom increased protein and fat breakdown leads to muscle strength and function loss. A systematic search of five databases identified studies assessing HGS’s predictive value for PEW in patients undergoing MHD, using MIS as the reference. The quality of the studies was evaluated with the updated QUADAS tool. A diagnostic meta-analysis was carried out to estimate the pooled sensitivity, specificity, sROC, and sAUC using a two-level mixed-effects model. From 350 records, five studies were obtained which were included for analysis. The pooled sensitivity and specificity of the HGS among male patients were 68% (95%CI: 63–73%) and 66% (95%CI: 53–77%), respectively. Among female patients, the pooled sensitivity and specificity were 73% (95%CI: 62–82%) and 65% (95%CI: 48–79%), respectively. The positive likelihood ratio and negative likelihood ratio for male patients were 2.0 (95%CI: 1.4 to 2.9) and 0.48 (95%CI: 0.38 to 0.60), respectively. Meanwhile, among female patients, the positive likelihood ratio and negative likelihood ratio were 2.1 (95%CI: 1.4–3.1) and 0.41 (95%CI: 0.29–0.59), respectively. The sAUC for males and females was estimated to be 0.69 (95%CI: 0.65 to 0.73) and 0.75 (95%CI: 0.71–0.79). In summary, the sensitivity and specificity of the HGS were modest for all sexes, with females being more sensitive. HGS may be useful for triaging during daily screening and guiding further examination, but it requires supporting measurements to be employed as a diagnostic tool. PROSPERO: CRD42024595677 as of 1 October 2024. Full article