INTRODUCTION:Hemodialysis patients are exposed weekly to large volumes of dialysis water, making water quality a critical determinant of patient safety. Failures in dialysis water treatment systems may lead to chemical contamination, microbiological proliferation, endotoxin exposure, and biofilm formation, resulting in severe clinical complications. Despite the importance of risk prevention, few studies have applied failure mode and effects analysis (FMEA) to assess risks associated with hemodialysis water treatment. This study aimed to evaluate potential failures affecting dialysis water quality using a combined FMEA and cause-effect analysis approach. METHODS:A multidisciplinary risk assessment was conducted at the hemodialysis water treatment unit of Hassan II University Hospital in Fez, Morocco. The production chain was divided into four subprocesses: water feeding, pretreatment, treatment, and distribution. Potential failures, causes, and effects were identified through brainstorming sessions and root-cause analysis using an Ishikawa diagram. Each failure mode was scored according to frequency (F), severity (S), detectability (D), and management (M) using predefined five-level ordinal scales. Two indicators were calculated: the classical risk priority number (RPN1 = F × S × D) and a complementary management-adjusted indicator (RPN2 = (F × S)/M). RESULTS:Thirty-nine failure modes were identified across the dialysis water production process. Root causes were classified into three categories: Method and procedure, material and equipment, and physical and environmental factors. Based on classical RPN stratification, 30 failure modes were categorized as low priority, 8 as intermediate priority, and 1 as high priority. The highest-risk failure was a drop in water flow within the pretreatment circuit (RPN1 = 80). Intermediate-priority failures mainly involved alarm malfunctions, reverse osmosis maintenance issues, hydraulic disturbances, inadequate sampling, and temperature instability. The management-adjusted analysis highlighted electrical interruption of the water treatment unit as the failure mode with the greatest control-related concern (RPN2 = 15). CONCLUSION:The combined FMEA and cause-effect analysis effectively identified vulnerabilities affecting hemodialysis water quality and supported prioritization of corrective actions. The approach provides a practical framework for improving dialysis water safety and may be integrated into routine quality management practices, particularly in resource-limited healthcare settings.
BACKGROUND:Renal dialysis nursing is critical for improving survival and quality of life in patients with end-stage kidney disease (ESKD). This study systematically analyzed global research trends and frontiers in renal dialysis nursing from 1965 to 2025 using bibliometric methods. METHODS:A total of 608 peer-reviewed articles published between 1965 and 2025 were retrieved from the Web of Science Core Collection. CiteSpace software was employed for co-occurrence analysis, keyword clustering, and burst detection based on data from 2002 to 2025 to ensure analytical robustness. Temporal trends were divided into three phases (1988-2002, 2003-2012, and 2013-2025), and core themes were identified through keyword co-occurrence networks. DISCUSSION:Results revealed sustained growth in publications after 2003, peaking at 53 articles in 2015 and remaining at a high level through 2025. Core themes included social support systems, home dialysis, nurse-led case management, and nutritional risk assessment. Emerging frontiers focused on conservative management optimization, patient burden, and young adult care. The study highlights global shifts toward personalized, telemedicine-enabled care models and emphasizes the need for China to strengthen social support frameworks and remote care technologies.
INTRODUCTION:During hemodialysis, SpO2 is measured on the non-shunt side, restricting movement. This single-center, prospective, observational study evaluated shunt-side interchangeability. METHODS:Forty-five patients underwent double-sided finger-sensor SpO2 monitoring at five time points. Between-site agreement was assessed using Lin's concordance correlation coefficient (CCC), Deming regression, Bland-Altman analysis, and accuracy root mean square (Arms). Confidence intervals were calculated using subject-level cluster bootstrap resampling (2000 iterations; seed = 42). Using vector-type visualization, relationships between paired measurements were illustrated. RESULTS:SpO2 showed similar distributions between sites. The Spearman correlation was ρ = 0.705. CCC was 0.720 (95% CI: 0.590-0.811). Deming regression yielded y = 0.989x + 1.087. Bland-Altman bias was 0.060% (limits of agreement, ±3%). Arms were 1.41%, and the visualization showed minimal angular deviation (median |θ-45°| = 0.29°). CONCLUSION:Shunt-side SpO2 may be acceptable in selected clinical contexts, although interindividual variability warrants caution. These findings are not applicable to hypoxic states (SpO2 < 90%).
BACKGROUND:Vascular calcification (VC) is prevalent among hemodialysis (HD) patients and represents a key factor contributing to high mortality rates. Therefore, there is a need for biomarkers capable of accurately and efficiently diagnosing VC. AIM:To investigate the predictive value of miR-3150b-3p for VC. METHODS:Clinically, we recruited 145 HD patients with VC and 120 without VC. Serum levels of miR-3150b-3p were evaluated by RT-qPCR. The predictive value of miR-3150b-3p for VC was assessed using ROC curves and logistic regression models. PTH and osteocalcin levels were measured by ELISA. Target gene prediction was performed using bioinformatics methods. RESULTS:Noncalcified and calcified HD patients showed significant differences in age, dialysis duration, ALP, calcium, and CRP. Furthermore, miR-3150b-3p was upregulated in the calcified group, with higher levels correlating to more severe calcification. Logistic regression analysis indicated that miR-3150b-3p, age, and CRP were independent risk factors for VC development, with miR-3150b-3p demonstrating good diagnostic performance for VC. Crucially, miR-3150b-3p positively correlated with PTH and osteocalcin levels. Bioinformatics analysis revealed that its target genes were extensively involved in processes such as transcriptional regulation, nervous system development, and cell differentiation. Furthermore, these target genes may participate in pathways including cancer, axon guidance, and thyroid hormone signaling. CONCLUSION:Overexpressed miR-3150b-3p participated in the VC process of HD patients. Furthermore, it exhibited potential predictive value for VC. Our study provides an alternative diagnostic biomarker for VC.
ABSTRACT Aim This study aimed to investigate the clinical background associated with extracorporeal circuit coagulation (ECC) with a specific focus on the impact of orthopedic surgery. Methods A single‐center retrospective observational study of 290 hospitalized adult hemodialysis patients (men/women: 204/86, median age: 70 years) was included. Univariate and multivariate negative binomial regression analyses were performed to identify factors associated with ECC. Results Twenty‐five ECC events were observed in a total of 20 (6.8%) patients (men/women: 14/6). In univariate negative binomial regression analysis, orthopedic surgery was significantly associated with ECC (incidence rate ratio, 4.16; 95% confidence interval, 1.68–10.0, p = 0.001). In multivariate analysis, the performance of orthopedic surgery emerged as a potent and independent factor for an increased frequency of ECC. Conclusion Orthopedic surgery is significantly associated with an increased frequency of ECC. This finding highlights the importance of considering orthopedic surgery as a potential clinical factor for ECC in perioperative hemodialysis management.
INTRODUCTION:Peritoneal dialysis (PD) is an established home-based kidney replacement therapy (KRT), but its uptake remains low in Japan. We evaluated whether individualized education in a dedicated outpatient clinic was associated with the initiation of PD. METHODS:In this retrospective cross-sectional study, 175 patients who initiated maintenance hemodialysis or PD between April 2021 and September 2024 were classified by attendance at a dedicated KRT modality selection clinic. Logistic regression and propensity score matching were performed. RESULTS:Among 175 patients, 40 attended the clinic. PD was initiated in 35.0% of attendees compared with 10.4% of nonattendees. Clinic attendance was independently associated with PD initiation (adjusted odds ratio, 4.51; 95% confidence interval, 1.89-10.77; p < 0.001), and this association remained significant after matching. CONCLUSIONS:Individualized education in a dedicated outpatient clinic was associated with a higher likelihood of PD initiation.
INTRODUCTION:Reduced physical activity and prolonged sedentary behavior (SB) are associated with poor prognosis in patients undergoing hemodialysis. Although intradialytic exercise training (IET) is increasingly implemented, its effect on SB remains unclear. This study compared the effects of IET and cognitive training on SB. METHODS:In this multicenter pilot crossover study, patients aged 70-80 years undergoing maintenance hemodialysis completed 12 weeks of IET and 12 weeks of intradialytic cognitive training, separated by a 2-week washout period. Sedentary time (≤ 1.5 METs) and step counts were assessed using an accelerometer before and after each intervention. RESULTS:Nine participants completed the study. IET significantly reduced SB on all days and non-dialysis days (p = 0.02), whereas cognitive training showed no significant change. Reductions were significantly greater following IET. Step counts did not change. CONCLUSION:IET reduced SB, whereas cognitive training did not, suggesting its clinical relevance in dialysis care.
BACKGROUND:Whether cell-free and concentrated ascites reinfusion therapy (CART) improves renal function remains unclear. We investigated the effects of CART on renal function. METHODS:We retrospectively analyzed changes in renal function after CART in 157 patients (264 sessions) with or without chronic kidney disease (CKD) who underwent the treatment between June 1, 2010, and March 31, 2022. RESULTS:The most common underlying disease was malignant ascites (93.6%), most frequently caused by breast (n = 49, 31.2%) and ovarian (n = 31, 19.7%) cancers. The mean patient age was 61.6 ± 12.2 years (women, 82.1%). The median processed ascites volume was 4.26 [3.40-6.43] L, and the mean number of CART sessions per patient was 1.66 ± 1.38. No severe adverse events were observed. The estimated glomerular filtration rate (eGFR) significantly increased after CART (from 64.5 [47.5-82.9] to 65.1 [50.5-85.6] mL/min/1.73 m2; p = 0.004), particularly in patients with CKD stage G3b and G4 (G3b: from 35.4 [33.0-38.6] to 45.9 [36.1-52.5] mL/min/1.73 m2; p = 0.005, G4: from 25.1 [21.0-26.8] to 27.3 [21.1-35.3] mL/min/1.73 m2; p = 0.045). CONCLUSION:CART may be associated with an increase in eGFR, particularly in patients with CKD.
BACKGROUND:Patients with chronic kidney disease undergoing hemodialysis commonly experience reduced physical function, fatigue, poor sleep quality, and impaired health-related quality of life. Intradialytic exercise has been proposed as a non-pharmacological strategy to improve these outcomes. METHODS:Randomized clinical trial with 35 hemodialysis patients randomly allocated to a resistance group (RG) or aerobic group (AG). Exercises were performed during hemodialysis for 12 weeks. The primary outcome was handgrip strength (HGS). Secondary outcomes included the 30-second sit-to-stand test (30sec-STS), gait speed (GS), frailty, fatigue, sleep quality, and health-related quality of life (HRQL). RESULTS:In intragroup analyses, RG improved HGS (MD: 2.4; 95% CI: 0.3-4.5), 30sec-STS, GS, mental fatigue, and sleep quality, whereas AG improved 30sec-STS, GS, and HRQL measured by EQ-VAS. In intergroup analyses, AG was more effective than RG in reducing general fatigue (MD: 2.2; 95% CI: 0.4-4.0) and improving HRQL utility (MD: -0.04; 95% CI: -0.10 to -0.04). No significant between-group differences were observed for HGS or the other outcomes. No adverse events or harms were reported. CONCLUSIONS:Resistance and aerobic intradialytic exercise were both feasible and safe. Resistance exercise improved handgrip strength within-group; however, no significant between-group difference was observed for handgrip strength (the primary outcome). Aerobic exercise was more effective in improving general fatigue and health-related quality of life.
BACKGROUND:Diabetic nephropathy occurs in more than 20% of people with diabetes. Diabetic nephropathy has a high mortality rate and is one of the most common causes of end-stage renal disease in hemodialysis (HD) units. Analysis of survival rates and risk factors of mortality of HD patients with diabetic nephropathy is needed to determine patient prognosis, modify risk factors, and provide evaluation for HD quality, especially in a limited resource setting. METHODS:This study is a retrospective cohort study using data from the Indonesian Renal Registry (IRR) in Central Java during 2018-2022, followed by 1 year of monitoring until the patient died or dropped out of HD. The variables assessed in this study were age, sex, hypertension status, HD vascular access, and hemoglobin. RESULTS:There were 1184 patients who met the study criteria. All of the patients had a twice-weekly HD setting. The survival rate of HD patients with diabetic nephropathy was 90.7% for the first 90 days and 86.7% for 1-year survival. Hypertension status and initial vascular access affected the survival rate of HD patients with diabetic nephropathy. Based on the Cox proportional hazard regression model, the risk factors of mortality in HD patients with diabetic nephropathy were hypertension (HR = 1.530, 95% CI: 1.104-2.119) and femoral vein puncture (HR = 2.663, 95% CI: 1.777-3.990). CONCLUSION:The 1-year survival rate of HD patients with diabetic nephropathy in Central Java, Indonesia, is 86.7%. Risk factors of mortality in HD patients with diabetic nephropathy are hypertension and the use of femoral vein puncture as initial vascular access.
BACKGROUND:Chronic micro-inflammation in patients with end-stage renal disease (ESRD) is a significant driver of cardiovascular complications and diminished quality of life. While standard hemodialysis (SHD) effectively manages small-molecule clearance, its ability to remove medium-to-large uremic toxins-the primary catalysts of systemic inflammation-remains limited. This study aimed to evaluate the comparative clinical benefits of hemodiafiltration (HDF) and hemoperfusion (HDP) relative to SHD, specifically focusing on inflammatory control, dialysis adequacy, and patient safety. METHODS:This was a 10-week, single-center, non-randomized prospective observational study evaluating 365 end-stage renal disease (ESRD) patients divided into three cohorts: standard hemodialysis (SHD, n = 145, thrice-weekly), online hemodiafiltration (HDF, n = 115, twice-weekly hemodialysis plus once-weekly HDF), and hemoperfusion (HDP, n = 105, twice-weekly hemodialysis plus once-monthly hemoperfusion). Primary endpoints were restricted to short-term surrogate outcomes, including shifts in serum inflammatory markers (interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP)) and clearance adequacy indices (Kt/V, URR). RESULTS:Baseline characteristics were well-balanced across all three cohorts. Following 10 weeks of treatment, the HDF (84.2%) and HDP (77.1%) groups demonstrated significantly higher effective treatment rates (defined by clinical symptom improvement and biochemical stability, a composite of symptomatic improvement and biochemical stability) compared to the SHD group (61.4%; p < 0.05). Advanced modalities achieved increased association with biomarker reduction of middle-molecule toxins, with HDF showing the most profound reductions in IL-6, TNF-α, and CRP (p < 0.001). Dialysis adequacy was significantly improved in the HDF group, which showed the highest increases in dialysis adequacy. While the incidence of acute complications such as hypotension and muscle cramps did not differ significantly between groups, both HDF and HDP cohorts reported a notable reduction in post-dialysis fatigue compared to SHD (14% and 16% vs. 19%, respectively). However, HDF and HDP cohorts experienced lower incidences of cognitive dysfunction. CONCLUSIONS:Over a 10-week observation framework, advanced hybrid modalities (HDF and HDP) are independently associated with superior clearance of middle-to-large molecular uremic toxins and attenuated systemic inflammation compared to SHD. However, these short-term surrogate improvements did not translate into a statistically significant reduction in clinical adverse events or post-dialysis fatigue, indicating the need for long-term longitudinal evaluation.
BACKGROUND:Arterial stiffness is an important cardiovascular risk marker in hemodialysis patients. The monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and triglyceride-glucose (TyG) index are laboratory-based markers related to inflammation, lipid metabolism, and insulin resistance. This study evaluated their association with arterial stiffness. METHODS:This cross-sectional study included 120 adults receiving maintenance hemodialysis. Arterial stiffness was assessed by pulse wave velocity (PWV), and patients were classified as PWV > 10 or ≤ 10 m/s. Correlation and multivariable linear regression analyses were performed to identify factors associated with PWV. RESULTS:A total of 29 patients had PWV > 10 m/s. PWV was associated with both the TyG index and MHR in unadjusted analyses. Patients with arterial stiffness were older and had higher systolic blood pressure. In multivariable analysis, only age and systolic blood pressure remained independently associated with PWV. CONCLUSIONS:Age and systolic blood pressure were the main determinants of arterial stiffness. Although MHR and the TyG index correlated with PWV, their independent predictive value appeared limited.
BACKGROUND:Maintenance hemodialysis (MHD) patients frequently suffer from frailty, characterized by reduced physical function and poor prognosis. Myokines, such as myonectin, secreted by muscle, are emerging regulators of systemic health. This study investigated the relationship between serum myonectin, adipokines (adiponectin, omentin), and objective measures of physical function in MHD patients, excluding previously planned cardiac data. METHODS:This cross-sectional study included 23 MHD outpatients. We assessed physical function using the Short Physical Performance Battery (SPPB) score and the 5-Sit-to-Stand Test (5-SST). We also measured body composition, physical activity (accelerometer-derived step count), and serum concentrations of myonectin, adiponectin, and omentin. Correlation analysis and comparison between high (≧ median) and low (< median) myonectin groups were performed. RESULTS:Serum myonectin was positively correlated with Body Mass Index (BMI) and the SPPB score. No significant correlations were observed between myonectin and other physical function or physical activity indicators. Furthermore, the high myonectin group showed significantly better performance compared to the low group, completing the 5-SST in a shorter time and achieving a higher SPPB score. Adiponectin showed significant inverse correlations with BMI, muscle mass, and fat mass. CONCLUSION:Serum myonectin levels are positively associated with superior physical function (SPPB) and faster lower-extremity performance (5-SST) in MHD patients. Myonectin may serve as a simple, novel biomarker to identify MHD patients with better preserved functional capacity and potentially less frailty-related limitation. These findings underscore the critical role of muscle health in maintaining function in this vulnerable population.
BACKGROUND:Establishing a comprehensive apheresis medicine program in a resource-constrained setting presents significant structural, financial, and logistical challenges. Despite the growing clinical importance of apheresis services globally, published experience from sub-Saharan Africa remains sparse. This study describes the 5-year operational experience of building and sustaining an Apheresis Medicine program at Next Hematology Medicare, a private hematology center in Lagos, Nigeria, including the challenges encountered, solutions implemented, and clinical outcomes achieved. METHODS:A retrospective review of all apheresis procedures performed between May 2020 and December 2025 was conducted. Therapeutic apheresis procedures included automated red cell exchange transfusion (RCE), therapeutic plasma exchange (TPE) and leukocytapheresis. Donor apheresis procedures comprised single-donor apheresis platelet collections for transfusion and stem cell collection (SCC) by donors. Data on patient demographics, clinical indications, procedural outcomes, and geographic distribution of platelet delivery were collected and analyzed. RESULTS:A total of 2405 apheresis procedures were performed over the 5-year period. Donor apheresis platelet (AP) collection was the most frequently performed procedure (n = 1772; 73.7%), followed by RCE (n = 617; 25.7%) as the most common therapeutic apheresis modality. TPE accounted for 12 procedures (n = 12; 0.5%), while leukocytapheresis (n = 2; < 0.1%) and SCC (n = 1; < 0.1%) were performed infrequently. For AP, Sepsis/DIC was the leading transfusion indication (n = 968; 54.6%). RCE was performed predominantly for patients with sickle cell anemia (SCA), with intractable recurrent vaso-occlusive crises (VOC) being the most common indication (n = 382; 61.9%). RCE significantly reduced hemoglobin S (HbS%) from 93.13% ± 12.4% to 18.74% ± 4.2% (p < 0.001) and improved hematocrit from 16.34% ± 3.5% to 26.01% ± 4.2% (p < 0.001). TPE was primarily indicated for neurological and transplant-related conditions. Apheresis platelets were distributed nationally across all six geopolitical zones and internationally. CONCLUSION:A fully functional Apheresis Medicine program can be successfully established and sustained in a resource-constrained low- and middle-income country (LMIC) setting, delivering outcomes comparable to high-income country benchmarks. RCE showed significant hematological benefits for patients with SCA, and donor apheresis platelet delivery extended care across all Nigerian geopolitical zones. The operational framework described here, addressing funding, infrastructure, staffing, licensing, and blood safety, provides a possibly replicable model for Apheresis Medicine program development across sub-Saharan Africa.
