Kidney and Dialysis

Background: Oral frailty is a new concept, introduced in Japan in 2013. In our preliminary study, oral hypofunction was observed in more than half of patients undergoing maintenance hemodialysis (MHD). This allowed us to determine the exact prevalence of oral frailty in MHD patients and investigate the association between oral cavity function, findings obtained via comprehensive geriatric assessment, and motor features. Methods: We initiated a two-week hospitalization program for MHD patients to evaluate frailty including oral cavity functions. Along with a comprehensive geriatric assessment and evaluation of motor functions, seven items pertaining to oral cavity functions were assessed by a professional dentist to determine oral frailty. After the incidence of each item had been determined, the association between these factors was retrospectively analyzed to explore the factors that affect oral frailty. Results: Oral frailty was observed in 33 out of 50 patients (66%). In particular, tongue lip motor functions were frequently impaired in this population. Oral cavity function scores, which increased as oral function deteriorated, negatively correlated with cognitive function (r = −0.349; p = 0.0129; 1−β = 0.71) and grip strength (r = −0.364; p = 0.00933; 1−β = 0.75). Conclusions: Oral frailty was commonly observed in MHD patients. We are currently considering implementing exercise programs to improve tongue lip motor function, enhance cognitive function through interprofessional cooperation, and strengthen grip. Full article

Background: Diabetic ketoacidosis (DKA) in patients with kidney failure receiving dialysis presents a formidable clinical challenge. Standard DKA protocols, designed for patients with preserved renal function, often fail in this cohort and can be unsafe when applied without modification. Patients are at risk of iatrogenic fluid overload, dyskalaemia, and hypoglycaemia due to altered insulin kinetics, impaired gluconeogenesis, and the absence of osmotic diuresis. Purpose: This narrative review aims to synthesise current understanding of DKA pathophysiology in dialysis patients, delineate distinct clinical phenotypes, and propose individualised management strategies grounded in physiology-based reasoning, comparative guideline insights, and consensus-supported literature. Methods: We searched PubMed/MEDLINE, Embase, and Google Scholar (January 2004–June 2024) for adult dialysis populations, using terms spanning DKA, kidney failure, insulin kinetics, fluid balance, and cerebral oedema. Reviews, observational cohorts, guidelines, consensus statements, and physiology papers were prioritised; case reports were used selectively for illustration. Evidence was weighted by physiological plausibility and practice relevance. Nephrology-led authors aimed for a pragmatic, safety-first synthesis, seeking and integrating contradictory recommendations. Conclusions: Our findings highlight the critical need for a nuanced approach to fluid management, a tailored insulin strategy that accounts for glucose-insulin decoupling and prolonged insulin half-life, and careful consideration of potassium and acidosis correction. We emphasise the importance of recognising specific volume phenotypes (hypovolaemic, euvolaemic, hypervolaemic) to guide fluid therapy, and advocating the judicious use of variable-rate insulin infusions (‘dry insulin’) to mitigate fluid overload. We also show that service-level factors are critical. Dialysis-specific pathways, interdisciplinary training, and quality improvement metrics can reduce iatrogenic harm. By linking physiology with workflow adaptations, this review provides a physiologically sound, bedside-oriented map for navigating this complex emergency safely and effectively. In doing so, it advances an individualised model of DKA care for dialysis-dependent patients. Full article

Background: Despite efforts to rely on arteriovenous fistulas/grafts for maintenance hemodialysis, a significant number of patients still depend on tunnel hemodialysis catheters for treatment. This poses a risk factor for central line-associated bloodstream infection (CLABSI) and, subsequently, vascular access compromise. Method: We conducted a retrospective study in five dialysis centers to determine the potential factors resulting in vascular access loss, CLABSI incidence, and microbe distribution patterns in Saudi Arabia at centers under the Ministry of National Guard Health Affairs. Adults who regularly received hemodialysis and had positive blood cultures between January 2019 and December 2023 were the subjects of the study. Results: Our study identified the presence of tunnel infection (p < 0.001), the presence of a Gram-negative pathogen (p = 0.036), and a high body mass index (BMI > 30) (p = 0.04) as potential risk factors leading to the loss of tunnel central venous catheters. In contrast, there was a lower probability of central venous catheter loss due to Gram-positive pathogens (p = 0.01). The CLABSI rate was 1.55 per 100 patients per month over a five-year period. Patients with CVC required more hospital treatment and had a significantly higher rate of vascular access loss (p < 0.001). Both central and peripheral blood cultures had nearly identical microbe spectra. Methicillin-sensitive Staphylococcus aureus (MSSA), Methicillin-resistant Staphylococcus aureus (MRSA), and Staphylococcus epidermidis had the highest prevalence rates among Gram-positive organisms. Among the Gram-negative bacteria, Enterobacter cloacae was the most common, followed by Klebsiella pneumonia and Pseudomonas aeruginosa. Conclusions: Our findings indicate the need for rigorous measures and interventions to prevent Gram-negative infections and decrease the reliance on central venous catheters, to decrease infections in hemodialysis patients, and decrease morbidity and cost. Strict hand hygiene, patient education, and surveillance programs are recommended to monitor these patients. Full article

Introduction: Allogeneic hematopoietic cell transplantation (allo-HSCT)-associated thrombotic microangiopathy (TA-TMA) and pre-transplant renal dysfunction are recognized risk factors for mortality after allo-HSCT. Utilizing the data from the Center for International Blood and Marrow Transplant Research (CIBMTR), we investigated the association between onset of TA-TMA and pre-HSCT renal dysfunction on renal failure requiring dialysis (RFD). Methods: We evaluated TA-TMA as a time-dependent covariate in a multivariate Cox regression model for RFD in Allo-HSCT recipients aged ≥ 40 years between 2008 and 2016. Pre-HSCT patients were divided into two groups, estimated GFR (eGFR) < 60 mL/min/1.73 m² group and eGFR ≥ 60 mL/min/1.73 m². Cumulative hazards of RFD in patients with and without onset of TA-TMA were estimated. Results: TA-TMA was significantly associated with increased risk (6.6-fold compared to No TA-TMA) for RFD, the highest of all the significant risk factors. The estimated cumulative hazard for patients with TA-TMA in the two pre-HSCT renal function groups was significantly elevated when compared to similar patients with no TA-TMA (80% vs. 12% for eGFR < 60 mL/min and 50% vs. 5% for eGFR ≥ 60 mL/min group, respectively) at 12 months post-HSCT. Conclusions: Our results demonstrate that the adjusted HR of renal failure requiring dialysis and cumulative hazard was much higher in patients with onset of TA-TMA, especially among patients with pre-existing renal dysfunction, underscoring the importance of early recognition and risk-adapted management. Full article

The incidence of kidney diseases has been increasing in the last decade due to extended lifespan, which is often related to polymorbidity. Chronic kidney disease (CKD) and acute kidney injury (AKI) are associated with high morbidity and mortality, elevated costs for renal replacement therapy, and heavy psychosomatic burden. At the same time, therapeutic options are limited to prophylactic and renoprotective medications and measurements, and they often cannot restore the impaired kidney function. With the development of cellular therapies, new perspectives arise on the horizon with promising potential, including mesenchymal stem cells (MSCs) and induced pluripotent cells (iPSCs). Here we review the current possibility of both cell types in the field of nephrology and assess their cost implication. Full article

We report the case of a 44-year-old man with end-stage kidney disease (ESKD) who has been on chronic hemodialysis via a radio-cephalic arteriovenous fistula (RC-AVF) for one year. The patient arrived at the emergency department due to an inability to continue dialysis through the AVF. Clinical and ultrasound exams reveal an aneurysm in the cephalic vein, measuring 2.3 cm (cm) in diameter and 5 cm long, located in the middle third of the forearm, with intraluminal thrombosis. A surgical procedure is planned to exclude the aneurysmal segment and reconnect the vein, using a graft made from a bovine pericardium patch. Immediately after surgery, a thrill is detectable, and ultrasound shows a flow rate of 651 mL/min. On the second day, dialysis is performed through the distal cephalic vein segment under ultrasound guidance, avoiding the median forearm zone. At one month, the fistula remains functional, with no signs of thrombosis or stenosis. The bovine pericardium tubular graft has shown complete integration. This case supports the feasibility, safety, and potential advantages of using a tubularized bovine pericardial graft as an alternative conduit for RC-AVF reconstruction in select patients. However, further studies on larger cohorts and with extended follow-up are necessary to validate its reproducibility and long-term patency. Full article

Hypomagnesaemia, a common complication ranging from 20% to over 90%, depending on the diagnostic criteria and population studied, significantly contributes to adverse outcomes, including new-onset diabetes after transplantation, cardiovascular complications, neurological dysfunction and increased infection risk. A total serum magnesium below 0.70 mmol/L is commonly used to define deficiency. In kidney transplant recipients, calcineurin inhibitors downregulate TRPM6 in the distal nephron, leading to early and persistent hypomagnesaemia with links to adverse metabolic and cardiovascular outcomes. Arrhythmia risk rises steeply at total magnesium of <0.50 mmol/L, while neuromuscular irritability and neuropsychiatric symptoms may appear at levels below 0.70 mmol/L. Severe manifestations, such as seizures or tetany, usually occur at ≤0.50 mmol/L and coma at <0.30 mmol/L. Normal ionised magnesium is typically ~0.48–0.65 mmol/L; transplant-specific intervention thresholds remain unvalidated. This narrative review addresses critical diagnostic gaps and explores emerging therapeutic strategies. It highlights three areas: the diagnostic accuracy of ionised magnesium over total magnesium, the critical role of pharmacogenomics in individualising immunosuppression to mitigate tacrolimus-induced hypomagnesaemia and the promising link between gut microbiome modulation and magnesium homeostasis. The implications of these insights are profound: enabling more precise diagnosis and personalised management, reducing the incidence and severity of hypomagnesaemia-related complications, and ultimately supporting more precise diagnosis and personalised management; prospective validation in transplant cohorts is required before outcome claims can be made. This review exposes current diagnostic and therapeutic limitations, advocating for more precise and personalised strategies to address this critical electrolyte imbalance. Identifying hypomagnesaemia as a mechanistically complex and clinically undertreated complication, this review proposes a thematic roadmap that serves as a scientific and clinical framework for advancing personalised electrolyte care in renal transplantation. It is emphasised that while these approaches appear promising, most remain under-evaluated or hypothesis-generating. Addressing hypomagnesaemia through validated thresholds, new research is required to test novel diagnostics and personalised strategies to improve patient and graft outcomes. Full article

Objective: This scoping review synthesized and mapped the breadth of the existing literature on technological resources used to support individuals undergoing hemodialysis treatment. Methods: Following the methodological guidelines of the Joanna Briggs Institute (JBI) for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist, comprehensive searches were conducted across the following databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Scientific Electronic Library Online (SciELO), MedicLatina, and the Cochrane Central Register of Controlled Trials, with no time restrictions. Results: Thirty-nine studies conducted between 2003 and 2023 met the inclusion criteria. These studies covered a range of technological innovations developed specifically for hemodialysis treatment, including virtual reality, exergames, websites, and mobile applications. These technologies were designed with diverse objectives: to facilitate physical exercise, optimize dietary and medication management, improve disease adherence and management, and promote self-efficacy and self-care in patients. Conclusions: The review revealed a wide range of technological resources available to hemodialysis patients. These digital solutions show great potential to transform care by promoting more engaged and personalized health practices. Although this study did not directly assess the impact of these technologies, it provides a solid foundation for future investigations that can explore in-depth how such innovations contribute to effective disease management and improvement in clinical outcomes. Full article

Residual kidney function (RKF) plays a crucial role in improving outcomes for dialysis patients. Enhanced middle molecular clearance has been proposed as one of the several benefits of preserved RKF. Most patients who start dialysis retain some residual kidney function, providing a rationale for using incremental dialysis. RKF has been associated with mortality benefit in both peritoneal dialysis (PD) and hemodialysis (HD). It also influences technique longevity and lowers peritonitis rates in patients on PD. In both dialysis modalities, RKF improves volume management and blood pressure control. Additional potential benefits include reduced dietary restrictions, improved nutritional status, better quality of life (QOL), reduced erythropoiesis-stimulating agent (ESA) requirements, lower inflammatory marker levels, and improved bone health. RKF is less frequently measured in HD patients primarily due to the lack of standardized methods and logistical challenges. Several equations for estimating RKF have been proposed, but none are widely adopted in clinical use. Historically, HD was believed to cause a rapid loss of RKF; however, more recent data have challenged this view. Future research should focus on identifying factors that affect RKF, standardizing measurement methods, and developing strategies for preservation. Efforts to preserve RKF should be made for all dialysis patients, regardless of modality. Full article

Several studies have shown an association of fibroblast growth factor-23 (FGF-23), 25-hydroxyvitamin D (25(OH)D), and asymmetric dimethylarginine (ADMA) with the pathogenesis of albuminuria. However, the direct relationship of these biomarkers with albuminuria independent of other risk factors for chronic kidney disease (CKD) remains controversial. FGF-23 and ADMA levels were associated with the progression of CKD, with a cutoff value of ≥100 RU/mL for FGF-23 and 0.69 μmol/L for ADMA. Background/Objectives: To analyze the correlation between FGF-23, 25(OH)D, and ADMA levels and albuminuria. Methods: This was an observational analytic study with a cross-sectional design conducted in patients with CKD with various disease stages (non-dialysis). The output is albuminuria. Statistical analysis was performed using multivariate logistic regression analysis. Results: This study included 107 patients with CKD stages 2–5 with an average age of 57.32 years. Their average FGF-23, vitamin D, ADMA, and uACR levels were 197.75 RU/mL, 23.44 ng/mL, 0.719 µmol/L, and 940 mg/g, respectively. FGF-23 was weakly correlated with uACR (r = 0.252; p = 0.009). Vitamin D was weakly correlated with uACR (r = −0.375; p = 0.000). ADMA was strongly correlated with uACR (r = 0.687; p = 0.00). Multivariate analysis showed an association of ADMA ≥ 0.69 µmol/L (p = 0.000) with albuminuria ≥ 300 mg/g (p = 0.003). Conclusions: ADMA was correlated with the presence of macroalbuminuria, strongly indicating its role in the progression of CKD. Full article

End-stage chronic kidney disease remains a global challenge, with dialysis and transplantation offering only partial or limited solutions. Recent advances in bioengineering have introduced modular strategies that aim to restore kidney function not by replicating the entire organ, but by rebuilding it one segment at a time. Platforms such as kidney organoids, implantable bioartificial kidneys, 3D-bioprinted tissues, and decellularized scaffolds each target specific nephron functions, from filtration to endocrine signaling. This Perspective examines how these technologies can be integrated into interoperable systems that reflect the nephron’s native structure and functional complexity. We assess translational readiness across key benchmarks, including vascular integration, hormonal responsiveness, immune compatibility, and implantability, and discuss the ethical, regulatory, and design considerations that will shape their clinical future. Collectively, these modular strategies offer a pathway toward more personalized, scalable, and physiologically relevant approaches to kidney replacement. Full article

New and emerging technologies are being developed to combat some of the most pressing issues regarding peritoneal dialysis training, delivery, and complication identification. Currently used peritoneal dialysis solutions are high-dextrose concentrated acidic solutions that can cause increased glucose absorption and peritoneal membrane degradation via a combination of pseudohypoxia and inflammation. Supply storage, the portability of the currently available devices, and the reactive approach to peritonitis identification and treatment are amongst the challenges facing peritoneal dialysis providers and patients. Technologic advancement to combat these issues are underway, and it is important that we study them comprehensively prior to widespread implementation. In this work, I discuss some of these advancements and technologies. Full article

Background: Cardiovascular disease is the leading cause of death in chronic kidney disease populations. The risk of major adverse cardiovascular events (MACE) is greater than that of progression to end-stage kidney disease. An exponential increase in mortality risk is associated with declining kidney function. This study aimed to review the current landscape of traditional and novel blood biomarkers in predicting MACE in ESKD patients. Methods: The systematic review was registered on PROSPERO (CRD42024497403). Standard and extensive Cochrane search methods were used. The latest search date was July 2023. Participants were aged ≥18 years with end-stage kidney disease. Descriptive analysis was performed and data was presented in tabular form. The hazard ratio or odds ratio was presented for potential biomarkers discovered. Results: Overall, 14 studies (4965 participants) were included for analysis; 12 focused on participants requiring haemodialysis and 2 on haemodialysis and peritoneal dialysis. The biomarkers analysed were Troponin I (n = 3), Troponin T (n = 3), B-type natriuretic peptide (n = 2), N-Terminal Pro-Brain-Natriuretic Peptide (n = 7), soluble receptors for advanced glycation end products (n = 2), Galectin 3 (n = 4), and the serum-soluble suppression of tumorigenicity-2 (n = 2). Reported study outcomes included all-cause mortality (n = 11), MACE (n = 5), cardiac specific mortality (n = 6), sudden cardiac death (n = 2), and first cardiovascular event (n = 3). Conclusions: This review outlines the potential role of traditional and novel biomarkers in predicting MACE in end-stage kidney disease. Further larger-scale research is required to establish the validity of the study outcomes to develop new methods of cardiovascular risk prediction in this high-risk population. Full article

Despite improvements in kidney transplantation rates, the shortage of donor kidneys remains a critical issue, exacerbated by non-utilization of recovered kidneys due to quality concerns, necessitating advancements in perfusion methods to enhance graft outcomes and usage. Although static cold storage remains the default standard for kidney preservation, newer methods like hypothermic machine perfusion have shown improved outcomes, including reduced delayed graft function and better survival rates. Hypothermic oxygenated machine perfusion and normothermic machine perfusion offer some potential clinical benefits but studies to date have demonstrated mixed results. In the United States, LifePort and the XVIVO’s Kidney Assist Transport are the most popular hypothermic perfusion devices, with NMP devices mostly in trials. Combining perfusion with biomarkers such as mitochondrial flavin mononucleotide, neutrophil gelatinase-associated lipocalin, and osteopontin shows promise in assessing kidney viability and predicting post-transplant outcomes, though further research is also needed. Emphasis on repair biomarkers, such as uromodulin and osteopontin, aims to better predict graft outcomes and develop new therapies. While notable advancements have been made in the use of machine perfusion and viability testing for liver transplantation, additional research with larger sample sizes is essential to substantiate these results and enhance kidney transplantation outcomes. Full article

The prevalence of early non-infectious peritoneal dialysis (PD) catheter complications makes performing PD challenging for patients and difficult for the healthcare team to manage. Three common patient scenarios are presented: catheter flow dysfunction, peri-catheter leaks, and catheter-related abdominal pain. Practice recommendations are integrated into each scenario and tailored to clinical presentation, patient need, and resource availability. The importance of including patients in the decision-making process is emphasized, and examples of how contextual factors modify the proposed approach to complications are given. Full article

The prevalence of end-stage renal disease has surged significantly in recent decades, with an 88% increase reported in the United States between 2002 and 2022. Peritoneal dialysis and home hemodialysis offer numerous advantages over in-center hemodialysis, including improved quality of life, increased treatment flexibility, and reduced healthcare costs. Despite strong preferences among healthcare professionals and the documented benefits of home-based therapies, utilization remains limited in the U.S. One of the many factors that play a role in the underutilization of home therapies is inadequate training and perceived incompetence among nephrology fellows in initiating and managing home dialysis patients. Here in this article, we highlight the current educational gaps in home dialysis training and ways to overcome the barriers. There is a need for a multifaceted approach that includes home dialysis rotations and continuity clinics; a dedicated one-year Home Dialysis Fellowship; and continued medical education through didactics, symposiums, and conferences. Here we emphasize the need for structured, longitudinal programs that combine didactic learning with hands-on clinical in fellowship trainings and the importance of dedicated one-year fellowships in cultivating future leaders and experts in the field. By enhancing training pathways and expanding fellowship opportunities, nephrology education can better equip physicians to meet the growing demand for home dialysis, ultimately improving patient outcomes and advancing public health objectives. Full article

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