Search Results (3,951)

Background/Objectives: Nurses and dialysis technicians are primarily responsible for cannulation in in-center and satellite dialysis units. Despite being a core component of hemodialysis care, existing clinical guidelines offer limited standardization, resulting in practice variability across facilities. Therefore, clinical expertise and adherence to consistent standards are essential to ensure safe and effective vascular access management. The study aimed to investigate the variables related to patients and nurses that contribute to unsuccessful vascular access cannulations, as well as the actions taken in response to cannulation failure, in a tertiary dialysis center in the Eastern Region of Saudi Arabia. Methods: This retrospective analytic study reviewed the records of 228 adult hemodialysis patients at King Fahad Military Medical Complex from 2020 to 2024, analyzing demographic, clinical, vascular access, and nursing variables associated with cannulation failure using descriptive statistics, the chi-square test, and t-tests. Ethical approval was obtained, and data were de-identified and manually extracted from nursing and dialysis documentation. Results: Most patients had hypertension and diabetes, with significant comorbidity burdens. Infiltration (61%) and clot formation (30.7%) were the primary complications of cannulation failure. Significant associations emerged with recurrent stroke and peripheral vascular disease, but not with nurse or patient demographics, suggesting vascular factors outweigh staff variables in cannulation risk. Cannulation failures were most common in patients with vascular comorbidities, while staff experience and education had no significant impact. Conclusions: Recommendations include implementing tailored protocols, providing ongoing nurse education, conducting systematic vascular assessments, and holding regular team reviews to enhance access outcomes and patient safety. Full article

Background: Patients with kidney failure requiring dialysis experience a high burden of vaccine-preventable diseases, and vaccine hypo-responsiveness is a key contributor. Uraemic toxins and gut dysbiosis are potential causes of hypo-responsiveness. Aim: This study aimed to determine whether uraemic toxin concentrations or gut dysbiosis are associated with vaccine response in haemodialysis patients. Methods: This was a single centre, observational cohort study of maintenance dialysis patients receiving a conventional 2-dose primary COVID-19 vaccination course. Demographic, clinical and vaccination data were collected from the eMR. Vaccine response (Elecsys Anti-SARS-CoV-2 immunoassay), serum uraemic toxin concentrations (indoxyl sulphate, p-cresyl sulphate, and trimethylamine N-oxide by liquid chromatography), and stool microbiome (16S rRNA gene sequencing) were measured 8 weeks after the second dose of vaccine. Results: Forty participants (43% female, mean age 66 years; 59% Caucasian) were included, 70% of whom were classified as a vaccine responder. Antibiotic exposure, prednisolone use and lymphopenia were significantly associated with hypo-responsiveness. Microbiome profiling identified differences in beta diversity between responders and non-responders, positively correlated with short-chain fatty acid producers (Parabacteriodes) and negatively with pathobionts (Escherichia/Shigella). Differential abundance analysis identified lower levels of Tyzzerella, Gemmiger, and Hungatella and higher levels of Turicibacter in vaccine responders. Total uraemic toxin burden and individual toxin concentrations did not differ between responders and hypo-responders (all p > 0.05). Stratification by low versus high/very high toxin burden groupings was not associated with response (p > 0.99). Conclusions: Differences in gut microbial composition were observed between vaccine responder groups, while uraemic toxin concentrations were not associated with vaccine responsiveness. These findings suggest gut microbiota composition may contribute to vaccine hypo-responsiveness in individuals receiving dialysis and warrant further investigation in larger mechanistic studies. Full article

Systemic sclerosis (SSc) is a complex autoimmune connective tissue disease characterized by microvascular dysfunction, immune activation, and progressive fibrosis affecting multiple organs, including the heart. Myocardial involvement represents an important but frequently underrecognized manifestation of SSc and may develop even in the absence of overt clinical symptoms. Cardiac manifestations include ventricular dysfunction, arrhythmias, conduction abnormalities, and heart failure, contributing substantially to morbidity and mortality. The underlying pathophysiology involves coronary microvascular dysfunction, immune-mediated myocardial inflammation, and progressive myocardial fibrosis, which often precede clinically apparent cardiac disease. This review aims to summarize the current understanding of myocardial involvement in SSc and to provide a comprehensive overview of contemporary multimodality cardiovascular imaging techniques for its detection, characterization, and risk stratification. A comprehensive overview of the current literature was conducted focusing on established and emerging cardiovascular imaging modalities for the evaluation of myocardial involvement in SSc. Particular attention was given to echocardiography, cardiac magnetic resonance (CMR), nuclear imaging techniques including positron emission tomography (PET) and single-photon emission computed tomography (SPECT), and cardiac computed tomography (CT). Recent advances in imaging biomarkers, parametric mapping, myocardial strain analysis, and emerging technologies such as artificial intelligence (AI), radiomics, and molecular imaging were also considered. Multimodality cardiovascular imaging plays a central role in the early detection and comprehensive assessment of myocardial involvement in SSc. Advanced imaging techniques enable improved identification of subclinical myocardial dysfunction, microvascular impairment, inflammation, and fibrosis. An integrated imaging approach combining echocardiography, CMR, nuclear imaging, and CT may facilitate earlier diagnosis, enhance risk stratification, and ultimately improve cardiovascular outcomes in patients with SSc. Full article

Iodine is an essential micronutrient required for the synthesis of thyroid hormones and the maintenance of metabolic, neurodevelopmental and immune function. As iodine cannot be synthesized endogenously, adequate intake depends on dietary sources and environmental availability. Despite decades of progress in improving iodine supply, both iodine deficiency and excess remain significant global public health challenges. This review summarizes iodine physiology, covering both its role in thyroid hormone synthesis and emerging evidence for extrathyroidal immunomodulatory and antioxidant actions. It summarizes major dietary sources, global intake patterns and current approaches to iodine status assessment, including urinary biomarkers, salivary iodide measurement and dietary screening tools. The clinical consequences of iodine imbalance are examined, ranging from goiter, hypothyroidism and impaired neurocognitive development associated with deficiency, to iodine-induced thyroid dysfunction, autoimmunity and adverse systemic effects linked to excess intake. Special attention is given to vulnerable populations, particularly pregnant women and infants. This review further evaluates public health strategies, including salt iodization and targeted supplementation, while addressing the emerging challenge posed by salt-reduction initiatives. Achieving optimal iodine intake remains essential for thyroid health and population well-being, underscoring the need for coordinated monitoring and policy adaptation. Full article

Background/Objectives: Atypical hemolytic uremic syndrome (aHUS) is a rare, life-threatening thrombotic microangiopathy caused by dysregulation of the alternative complement pathway, often related to genetic mutations or autoantibodies. The introduction of complement C5 inhibitors, such as eculizumab and ravulizumab, has significantly improved renal and overall outcomes. However, complement inhibition impairs host defense against encapsulated bacteria, markedly increasing the risk of invasive infections, particularly Neisseria meningitidis. Vaccination against meningococcal groups ACWY and B, along with temporary antibiotic prophylaxis, is therefore recommended before initiating anti-C5 therapy. Methods: We report the clinical course of a 13-year-old boy with aHUS secondary to anti–complement factor H (CFH) autoantibodies and CFHR3–CFHR1 homozygous deletion, treated with C5 inhibitors. Results: Despite complete meningococcal vaccination and a previous course of antibiotic prophylaxis, the patient developed meningitis during ongoing complement inhibitor therapy. Conclusions: This case highlights that breakthrough invasive infections may occur despite adherence to recommended preventive strategies. It underscores the need for sustained clinical vigilance, timely vaccine boosters, and careful reassessment of the risk–benefit balance of continued complement inhibition therapy. Full article

Background/Objectives: Reports on seasonal influenza vaccine (SIV) coverage in Gulf Cooperation Council (GCC) countries showed lower than targeted coverage among high-risk populations both before and after the COVID-19 pandemic and subsequent COVID-19 vaccine release. This narrative review aims to synthesise SIV coverage following the introduction of COVID-19 vaccines among at-risk groups in the GCC region. Methods: Database searches included PubMed and Google Scholar for articles assessing SIV uptake, acceptance, hesitancy, and intention to vaccinate among adults in high-risk groups in GCC countries, with data collected after the introduction of COVID-19 vaccines. Results: SIV uptake ranged from 1.8% among pregnant women to 64.1% among dialysis patients in Saudi Arabia. Healthcare workers (HCWs) demonstrated the highest overall coverage, reaching 64.5% for annual uptake in Bahrain, with 79% of HCWs in Saudi Arabia intending to vaccinate. Prevalent barriers included low risk perception and consideration of influenza as a mild disease not necessitating SIV uptake, as well as vaccine effectiveness and safety concerns. Previous vaccination, physician advice, and policy or mandates for HCWs were identified as frequent facilitators of uptake. Conclusion: Suboptimal uptake was reported among most high-risk groups in GCC countries. Health Belief Model components and physician involvement appear to have a significant impact on vaccine uptake among the intended population. More emphasis should be directed toward effective risk communication and action cues methods to enhance uptake among high-risk groups. Future research is needed to cover understudied areas like the elderly aged ≥ 65 years, cancer and other high-risk groups, in addition to further studies for GCC countries other than Saudi Arabia in the post-COVID-19 vaccine period. Full article

Background/Objectives: Cardiovascular complications remain the leading cause of mortality among patients with end-stage renal disease (ESRD) treated with maintenance hemodialysis (HD). Global longitudinal strain (GLS) is a sensitive echocardiographic marker of left ventricular systolic dysfunction that enables the detection of transient contractile abnormalities consistent with intradialytic myocardial stunning. This study aimed to assess intradialytic GLS dynamics during a single HD session and to identify predictors of GLS deterioration. Methods: Forty-three patients were enrolled. Transthoracic echocardiography, electrocardiography, and pulse wave analysis were performed before HD, at mid-session, and after HD. Biochemical assessment included, among others, plasma osmolality, electrolytes, and biomarkers of oxidative stress and endothelial dysfunction. Results: Three distinct intradialytic GLS trajectories were identified: GLS worsening (GLSw, 46.5%), GLS stable (GLSs, 34.9%), and GLS improvement (GLSi, 18.6%). In the GLSw group, independent predictors of GLS deterioration included a decrease in left atrial volume index (LAVI, p = 0.0002), an increase in left ventricular end-systolic volume index (LVESVI, p = 0.0067), diabetes mellitus (p = 0.0094), and an increase in the malondialdehyde-to-creatinine ratio (MDA/CREA, p = 0.0055). In the GLSi group, GLS improvement was associated with a decrease in plasma osmolality (p = 0.0326) and asymmetric dimethylarginine (ADMA, p = 0.0279), as well as an increase in the subendocardial viability ratio index (SEVRI, p = 0.0004) and caspase-1 (p = 0.0005). Conclusions: Intradialytic GLS trajectories are heterogeneous and reflect individual susceptibility to GLS deterioration. Modifiable adverse factors likely include oxidative stress, osmotic stress, fluid overload, uremic toxin- and ion-disturbance-related stress, and impaired coronary microvascular reserve. Future prospective studies are needed. Full article

Objectives: Malperfusion is a major determinant of outcome in acute type A aortic dissection (ATAAD), yet its heterogeneous patterns and prognostic impact remain incompletely defined. We investigated the association between malperfusion burden, territory-specific involvement, and early outcomes after emergency ATAAD repair. Methods: We performed a retrospective single-center study including 483 consecutive patients undergoing emergency surgery for ATAAD (2010–2022). Malperfusion was classified by coronary, visceral, and peripheral territories and stratified as none, single-territory, or multidistrict (≥2 territories). The primary outcome was in-hospital mortality. Secondary outcomes included stroke, renal replacement therapy, peri-procedural myocardial infarction, major vascular events, and a composite endpoint of major adverse events (MAEs). Multivariable logistic regression identified independent predictors. Results: Overall, 68.5% of the population were male with a mean age of 65.4 ± 12.1 years. Malperfusion was present in 151 patients (31.3%), including 131 (27.1%) with single-territory and 20 (4.1%) with multidistrict involvement. In-hospital mortality increased stepwise with malperfusion burden (12.7%, 19.8%, and 50.0%; p < 0.001). MAEs occurred in 36.6% of patients, with a similar gradient (31.2%, 46.2%, and 65.0%, p < 0.001). In multivariable analysis, preoperative shock, neurological deficit, descending aortic involvement, and redo surgery were independent predictors of MAEs, whereas malperfusion burden showed an attenuated association after adjustment. Territory-specific analyses revealed strong associations between coronary malperfusion and peri-procedural myocardial infarction, visceral malperfusion and postoperative dialysis, and peripheral malperfusion and major vascular events. Conclusions: Malperfusion burden is associated with worse early outcomes after ATAAD repair but largely reflects underlying clinical severity. Distinct malperfusion territories confer specific postoperative risks, supporting a pattern-based approach to perioperative risk stratification. Full article

Gender medicine represents a key paradigm for advancing equitable and effective healthcare by systematically integrating sex- and gender-related differences into medical research and clinical practice. Despite regulatory efforts and international guidelines, significant gaps persist in the consideration of sex and gender across medical disciplines, including nephrology. Biological factors—including genetic, hormonal, and metabolic differences—interact with social, cultural, and environmental determinants to influence chronic kidney disease (CKD) susceptibility, clinical presentation, progression, and response to therapy. Insufficient consideration of sex and gender contributes to persistent disparities in CKD progression, cardiovascular outcomes, access to kidney transplantation, adverse drug reactions, dialysis outcomes, and pregnancy-related kidney complications. This narrative review outlines the historical development of gender medicine and critically appraises its relevance and unresolved challenges in kidney disease, with a focus on sex-specific differences in selected conditions, including autosomal dominant polycystic kidney disease, glomerular diseases, acute kidney injury, and pregnancy-associated kidney disorders. Integrating sex- and gender-informed approaches into nephrology is not merely an ethical requirement but a scientific necessity to improve risk stratification, personalize therapeutic strategies, and promote truly equitable and effective kidney care. Full article

Patients with chronic kidney disease (CKD) have a markedly increased cardiovascular risk that is not fully explained by traditional risk factors. Gut-derived uremic toxins, indoxyl sulfate (IS), indole-3-acetic acid (IAA), and p-cresyl sulfate (pCS), are poorly cleared by dialysis and may contribute to vascular damage. This cross-sectional observational study included 70 patients with CKD under different clinical conditions (pre-dialysis, peritoneal dialysis, hemodialysis, and kidney transplantation) and 17 healthy controls. Serum levels of IS, IAA, pCS and Klotho were measured, and vascular damage was assessed by carotid intima–media thickness (IMT) using ultrasound. CKD patients showed higher concentrations of IS, IAA, and pCS compared with controls, with the highest levels observed in hemodialysis patients. Peritoneal dialysis was associated with elevated IS and pCS, whereas in kidney transplantation, IS and IAA levels did not differ significantly from controls, and pCS remained elevated. Carotid IMT was higher in patients with diabetes and those undergoing hemodialysis. IAA correlated significantly with left/mean IMT, and mean IMT was the only parameter associated with previous cardiovascular events. These findings suggest that gut-derived uremic toxins, particularly IAA, might be associated with subclinical vascular damage in advanced CKD, although larger studies are needed to confirm these associations. Full article

Background: Urgent-start peritoneal dialysis (UPD) has emerged as an alternative modality for initiating kidney replacement therapy when immediate hemodialysis is not available. However, early initiation after catheter placement may increase the risk of mechanical complications. Evidence from real-world settings, particularly in resource-limited healthcare systems, remains limited. Objective: To determine the frequency of early complications associated with urgent-start peritoneal dialysis and to identify clinical factors associated with their occurrence. Methods: We conducted a prospective observational cohort study including adult patients with chronic kidney disease who initiated peritoneal dialysis within 14 days after catheter placement at a public hospital in Mexico. Patients were followed for 30 days after dialysis initiation. The primary outcome was the occurrence of any dialysis-related complication within 30 days after initiation of peritoneal dialysis. Comparisons were performed according to dialysis initiation timing (<72 h vs. ≥72 h). Multivariable logistic regression was used to identify independent predictors of complications. Results: Sixty-five patients were included, of whom 29 (44.6%) developed complications within the first 30 days. Mechanical complications predominated, particularly pericatheter leakage (18.5%) and drainage failure (10.8%). Patients who initiated dialysis within 72 h after catheter placement experienced a significantly higher complication rate. In multivariable analysis, initiation of peritoneal dialysis within <72 h remained independently associated with complications (OR 5.75, 95% CI 1.06–31.29, p = 0.043). Conclusions: Initiating peritoneal dialysis within 72 h after catheter placement was associated with a significantly increased risk of early complications. When clinically feasible, delaying dialysis initiation beyond 72 h may reduce mechanical complications in urgent-start peritoneal dialysis programs. Full article

Background: Hemodialysis patients are particularly vulnerable to hepatitis B virus (HBV) due to immunosuppression and repeated vascular access. While universal childhood vaccination has reduced population-level HBV prevalence, dialysis units require tailored prevention and monitoring strategies. This study aimed to characterize HBV serologic profiles, evaluate immune responses, and assess the kinetics of antibody waning in a diverse hemodialysis population. Methods: We retrospectively analyzed 565 adult hemodialysis patients (2015–2024), assessing HBV seroprevalence, seroconversion, booster response, and antibody waning. Subgroup comparisons were made by ethnicity and birth cohort (pre- vs. post-1992 national vaccine rollout). Time-to-waning analyses were performed using Kaplan–Meier methods. Results: HBsAg and anti-HBc were positive in 4.1% and 31.7% of patients, respectively; 3.7% were HCV seropositive. No HBsAg seroconversions occurred, and 2.1% of initially anti-HBc-negative patients seroconverted. Among patients with isolated anti-HBc, 80.9% developed protective anti-HBs titers, and none became HBsAg- or HBV DNA-positive. Waning anti-HBs titers occurred in 67.5% (median: 7.3 months), with 87.4% demonstrating a serologic response following documented vaccine delivery. Patients born after 1992 showed higher isolated anti-HBs positivity and lower anti-HBc prevalence. Ethnic subgroup analysis showed higher exposure rates but similar booster response among minority patients. Conclusions: HBV serologic profiles in this hemodialysis cohort reflected the interplay of immunosuppression, vaccination practices, and evolving epidemiologic trends. Subgroups exhibited variable vaccine responses, differing patterns of antibody waning, and a low incidence of new infections. These findings support tailored, population-specific HBV monitoring and prevention strategies in dialysis care. Full article

Background and Objectives: Hemodialysis (HD) patients represented a highly vulnerable population during the COVID-19 pandemic, both clinically and psychologically. Data regarding acute anxiety requiring pharmacologic treatment in this setting are limited. The aim of the study was to assess factors influencing clinical evolution, psycho-emotional disturbances reflected by “de novo” anxiolytic use, and vital prognosis of hospitalized COVID-19 patients on HD. Materials and Methods: The study included 211 patients followed between 2020 and 2023 (149 were COVID-19 positive and 80 required hospitalization) and comprised two sequential phases: an in-hospital phase during COVID-19, in which disease severity factors, in-hospital mortality, and the requirement for de novo anxiolytic therapy were assessed, and a follow-up phase, which evaluated overall mortality and the impact of vaccination on long-term outcomes. Results. Hospitalized patients were older, had lower dialysis adequacy, and a lower rate of COVID-19 vaccination. Severe COVID-19, associated with elevated inflammatory markers, prolonged hospitalization, and an increased need for anxiolytic therapy to control acute psychopathological disturbances, was significantly more frequent in patients with underlying oncological comorbidities. Patients who died from COVID-19 during hospitalization were older (69.364 ± 1.973 vs. 66.426 ± 1.546, p = 0.239), predominantly male (66.69% vs. 48.93%, p = 0.064), had similar BMI (26.836 ± 1.120 vs. 26.909 ± 0.943, p = 0.961), and had shorter duration on HD (5.182 ± 4.733 vs. 7.383 ± 6.060, p = 0.085). Patients who received anxiolytic therapy during hospitalization for COVID-19 were younger, predominantly male, and had a longer dialysis vintage as well as a higher body mass index. Although the de novo need for anxiolytics during COVID hospitalization was associated with multiple parameters in the linear regression analysis, the multivariable regression model showed a significant and strong association only with corticosteroid therapy (OR = 16.403, 95% CI = 4.433–62.111, p < 0.001). COVID-19 vaccination was associated with a significant reduction in mortality risk, with vaccinated patients exhibiting a 58% lower hazard of death compared with unvaccinated individuals (HR = 0.42; 95% CI: 0.28–0.62; p < 0.001). Conclusions: COVID-19 in HD patients is a multidimensional pathology, in which clinical severity and preventive strategies, such as vaccination, significantly influence survival. Acute anxiety requiring pharmacologic intervention was highly prevalent in hospitalized HD patients with COVID-19, but was not associated with worse survival (p = 0.903). Psychological burden should be recognized as an important component of care in this population. Full article

Background and Objectives: Appropriate antimicrobial dosing according to kidney function is essential to ensure therapeutic efficacy while minimizing toxicity and antimicrobial resistance. Despite established dosing guidelines and electronic prescribing systems, errors in renal dose adjustment of antimicrobials, particularly in the setting of acute kidney injury, remain common among hospitalized patients. Materials and Methods: A point-prevalence study was conducted on 31 October 2024 at a tertiary-care hospital in Greece to evaluate the appropriateness of antimicrobial dosing in relation to renal function. Patient characteristics, renal parameters, and antimicrobial prescriptions were extracted from electronic medical records. Glomerular filtration rate (GFR) was estimated using the MDRD formula. Comparative analyses were performed between correctly and incorrectly dosed cases, and between overdosing and underdosing episodes. Results: A total of 235 hospitalized patients were evaluated (mean age 64.8 ± 18.6 years; 43.4% female). Overall, 15.7% (37/235) received at least one antimicrobial dose inappropriate for their renal function. Among 37 patients where dosing errors were identified, overdosing was noted in 23 (62.2%), underdosing in 16 (43.2%), adding up to 39 prescriptions, while in 2 patients (5.4%), both mistakes were noted in different prescribed antimicrobials. Drug-specific error rates varied considerably: ceftazidime and cefuroxime showed the highest rates of inappropriate dosing (40% each), followed by colistin (33.3%) and acyclovir (33.3%). Piperacillin/tazobactam, the most frequently prescribed agent (n = 50), had a 14% error rate, mainly due to underdosing (10%). Patients with dosing errors were significantly older (71.5 vs. 64.1 years, p = 0.0220) and had worse renal function, including higher serum creatinine (1.68 vs. 1.19 mg/dL, p = 0.0174), lower GFR (58.5 vs. 75.9 mL/min/1.73 m², p = 0.0009), and more frequent dialysis (13.5% vs. 4.3%, p = 0.0422). They also received a higher median number of antimicrobials (2 vs. 1, p = 0.0185). Conclusions: Inappropriate antimicrobial dosing based on kidney function remains common in hospitalized patients, particularly among older individuals and those with impaired renal function or polypharmacy. Targeted antimicrobial stewardship strategies focusing on renal dose adjustment and agents that are more frequently dosed inappropriately, such as colistin, acyclovir, cefuroxime, and ceftazidime, as well as agents that are frequently prescribed despite a relatively lower rate of inappropriate dose, such as piperacillin/tazobactam, are needed to enhance prescribing safety and optimize therapeutic outcomes. Full article