Hemodialysis (HD) catheters carry a high risk of life-threatening bloodstream infections and failure. Antimicrobial lock solutions (ALS) are used to reduce this risk, but their overall efficacy on key outcomes like infection rates and catheter survival requires comprehensive evaluation. This systematic review and meta-analysis assess the impact of ALS on preventing catheter-related bloodstream infections (including incidence and density) and on improving catheter survival. A systematic search was conducted across the databases of PubMed, Embase, Scopus, Cochrane Library, and Google Scholar. A meta-analysis was conducted using STATA software. A total of 1183 studies were screened based on title and abstract, and further 282 studies were evaluated in full text. Eventually, 14 studies with 15 treatment arms were included. Key outcomes including central line-associated bloodstream infection (CLABSI), exit infection, and catheter-free survival were conducted separately. ALS demonstrated statistically significant benefits on CLABSI infection and catheter-free survival compared to nonantimicrobial solutions, showing a reduction in CLABSI density with a pooled log odd ratio (logOR) of -1.29 (95% CI: -1.59 to -0.99), lower CLABSI rates (pooled logOR = -1.50, 95% CI: -1.85 to -1.15), and improved catheter-free survival with log hazard ratio (logHR) of -1.11 (95% CI: -1.41 to -0.8). Consistent treatment effects were observed across all lock types with no significant heterogeneity detected. ALS demonstrate statistically significant and clinically important efficacy in reducing CLABSI incidence and density while improving catheter survival in HD patients, establishing them as an essential preventive strategy in clinical practice.
INTRODUCTION:Depression is the third most disabling disease worldwide and is prevalent in patients undergoing hemodialysis. Given the greatly varied prevalence of depression in different regions, this meta-analysis was conducted to elucidate the status of depression in hemodialysis patients. METHODS:PubMed, Embase, Cochrane Library, and Web of Science databases were searched for relevant literature on depression in hemodialysis patients from inception to July 2023. Subgroup analyses and meta-regression were subsequently performed to determine the source of heterogeneity. RESULTS:A total of 137 cross-sectional studies were included, involving 21,608 hemodialysis patients. The random-effects analyses demonstrated that the prevalence of depression was 45.8% in hemodialysis patients (95% confidence interval [CI]: 42.0%-49.6%). Subgroup analysis of national income levels implied that high-income countries had the lowest prevalence of depression at 38.9% (95% CI: 34.1%-43.7%). Studies with a higher proportion of female hemodialysis patients reported a relatively higher prevalence of depression. Subgroup analysis by age revealed that patients under 40 years old had a depression prevalence of 50.8% (95% CI: 25.6%-76.0%), which was higher than that of other age groups. Different self-rating depression scales yielded different prevalence of depression in hemodialysis patients. CONCLUSION:Depressive symptoms are common in hemodialysis patients, so screening and identifying those at risk for depression and developing effective intervention strategies are of great value.
BACKGROUND:Improving physical function is essential for hemodialysis patients. Virtual reality-based methods are practical, well-tolerated, and easily integrated into care. METHODS:A meta-analysis aims to evaluate the effects of virtual reality-based interventions on physical function and their clinical feasibility for patients undergoing hemodialysis. Scientific literature published between January 2002 and June 2024 was searched in six databases. The standardized mean differences were determined using the upper and lower limits of 95% confidence intervals. Publication bias was evaluated using the Egger test and visualized using a funnel plot. RESULTS:Five studies were included in this meta-analysis. The types of virtual reality-based interventions were "treasure hunt" video games (n = 1), Wii Fit Plus games (n = 2), and A la Caza del Tesoro (ACT) video games (n = 2). The effects of virtual reality-based interventions on various measures of physical function, including the sit-stand test, 6-min walk test, timed stand-walk test, walking speed test, and handgrip strength test, were examined; significantly beneficial effects have been observed on many parameters. Furthermore, VR-based interventions did not cause any adverse effects on hemodynamic measurements. Methodological quality analysis revealed four good quality and one medium quality study. Egger testing showed no significant publication bias. CONCLUSIONS:This meta-analysis suggests that virtual reality-based interventions can enhance physical function and are feasible both physiological and behavioral. Nurses and other healthcare professionals can use virtual reality-based interventions to maintain or improve physical function by facilitating adherence.
Exit-site granuloma is a frequent and challenging complication in patients undergoing peritoneal dialysis, predisposing to exit-site infections. Recent evidence suggests a potential role for topical timolol in promoting regression of granulomatous tissue. We report two patients on continuous ambulatory peritoneal dialysis who developed exit-site granulomas. Both patients were treated with topical 0.5% timolol maleate ophthalmic solution applied locally to the exit site three times weekly as part of routine exit-site care. Clinical response was monitored using serial photographs. Complete resolution of the granuloma was achieved within 3 weeks in one patient and within 2 months in the other. Neither patient developed local or systemic adverse effects, and no exit-site infections occurred during treatment. Topical 0.5% timolol maleate may represent a safe, non-invasive, and effective treatment option for peritoneal dialysis exit-site granulomas. Larger studies are warranted to establish its efficacy in larger cohorts.
We planned a case presentation of right atrial hemodialysis catheter placement via minithoracotomy, an unusually good alternative in cases where venous access is exhausted and there is an associated ascending aortic aneurysm.
The details of four measures of "equivalent" clearances based on urea that have been proposed to monitor hemodialysis adequacy are reviewed. These measures fall into two groups: one based on urea nitrogen generation rate divided by the time-averaged serum urea nitrogen concentration, and the other based on urea nitrogen generation rate divided by the average predialysis serum urea nitrogen concentration. After the original variants were proposed, a potential problem regarding relative weights of dialysis and residual kidney clearances was identified, and revised equivalent urea clearances were proposed that give a higher weight to residual kidney clearance relative to dialysis clearance. These measures suggest that the target dialysis dose should be set to achieve dialysis solute concentrations typically found in patients at the point of needing dialysis, e.g., with a glomerular filtration rate of around 10 mL/min, corresponding to a urea clearance of approximately 6 mL/min and a creatinine clearance of 14. Despite the theoretical attractiveness of equivalent urea clearances to monitor hemodialysis adequacy, their utility has not been conclusively demonstrated in observational studies of incremental or more frequent hemodialysis.
BACKGROUND:Several case reports have linked low-dose methotrexate to serious adverse events, including death, in dialysis patients. We compared the risk of serious adverse events in dialysis patients initiating low-dose methotrexate versus hydroxychloroquine. METHODS:Using linked healthcare databases in Ontario, Canada (1997-2020), we identified 55 new users of low-dose methotrexate and 407 new users of hydroxychloroquine. The primary outcome was the 90-day risk of death or hospitalization with myelosuppression, sepsis, pneumotoxicity, or hepatotoxicity. Adjusting for age, sex, and a proxy for polypharmacy, a modified Poisson regression was used to estimate adjusted risk ratios (aRR), and a binomial regression was used to estimate adjusted risk differences (aRD). RESULTS:The median prescribed dose was 10 mg/week (IQR, 10-17.5) for methotrexate and 300 mg/day (IQR, 200-400) for hydroxychloroquine. The primary outcome occurred in 16/55 low-dose methotrexate users (29.1%) and in 29/407 hydroxychloroquine users (7.1%); aRR: 3.14 (95% CI, 1.75 to 5.63); aRD: 19.5% (95% CI, 7.5% to 31.4%). Findings were consistent across sensitivity analyses. CONCLUSION:Low-dose methotrexate should be avoided in dialysis patients whenever possible, and alternative DMARDs should be considered.
BACKGROUND:Hematoma is a common complication following arteriovenous fistula (AVF) cannulation in hemodialysis patients; however, rapid progression to tension blister formation is rare. CASE REPORT:We describe a case involving a 62-year-old male on maintenance hemodialysis, who initially received treatment via a tunneled right internal jugular catheter with a polyester cuff. Approximately 10 weeks after the creation of a right forearm AVF, the patient underwent first-time AVF cannulation. After 2 h, he developed a hematoma at the puncture site, followed by extensive tension blisters the next day. Computed tomography angiography (CTA) revealed significant stenosis of the right subclavian vein. Conservative treatment, including antibiotics, microcirculation enhancement, and wound care, led to recovery. Based on this case, we revised our center's protocol for AVF assessment and early use during the first 3 months post-creation. CONCLUSIONS:In patients with newly matured AVFs-particularly those with a history of ipsilateral central venous catheterization-screening for thoracic outlet syndrome should be integrated into pre-cannulation assessments (e.g., AVF blood flow is dynamically evaluated with the arm in multiple positions). Standardizing AVF use during the activation period may reduce complications and help prolong fistula patency.
BACKGROUND:Studies suggest increased phosphate removal when using hemodiafiltration (HDF) compared with hemodialysis (HD), but a complete analytic comparison has not been reported. METHODS:We analyzed data from a 6-month prospective, multicenter, cross-sectional study that enrolled patients treated with high-flux HD or HDF and in whom residual kidney phosphate clearances (KrPhos) were measured. Modeling data and dietary survey data were available from 115 patients (59 treated with HD and 56 treated with HDF). RESULTS:Predialysis (midweek) serum phosphate values averaged 4.37 ± 1.00 and 4.60 ± 1.18 mg/dL in the HD and HDF groups (p = NS). Mean prescribed phosphate binder equivalent dose (PBED) (including zero values) was 3.33 ± 2.94 g/day in HD and 2.64 ± 2.68 g/day in HDF (p = 0.19). Mean modeled phosphate ingestion was similar in HD and HDF (911 ± 231 vs. 911 ± 300 mg/day, p = NS), but phosphate ingestion by dietary survey was higher in HDF vs. HD (1119 ± 520 vs. 801 ± 420 mg/day, p < 0.001). Mean predialysis serum phosphate values in patients with residual kidney function (defined as KrPhosWater > 1.0 mL/min) and anuric patients were similar (4.43 ± 0.73 vs. 4.50 ± 1.20 mg/dL, respectively), whereas mean prescribed PBED was lower in patients with KrPhosWater > 1.0 mL/min (1.83 ± 2.02 vs. 3.40 ± 2.96 g/day, p < 0.01). CONCLUSIONS:Predialysis serum phosphate is not always lower in patients treated with HDF compared with HD, and this can possibly be explained by a trend to a lower prescribed PBED and/or by a higher dietary phosphate intake.
Microinflammation and functional iron deficiency are major contributors to anemia and treatment burden in maintenance hemodialysis (HD). Medium cutoff (MCO) membranes enhance the removal of middle- and large-sized solutes implicated in these pathways, yet real-world data using routinely measured inflammatory and iron-related markers are scarce. This study examined the effects of MCO-based expanded HD on inflammatory indices, iron metabolism, and anemia-related treatment requirements. In this single-center retrospective study, 22 maintenance HD patients (11 who continued on high-flux dialyzers and 11 who were switched to MCO dialyzers) were followed for 24 weeks. Baseline and 24-week assessments included C-reactive protein (CRP), the CRP/albumin ratio, neutrophil count, and composite inflammatory indices, as well as serum iron, transferrin saturation (TSAT), total iron-binding capacity (TIBC), and ferritin. Monthly intravenous iron supplementation and weekly erythropoiesis-stimulating agent (ESA) doses were also documented. Baseline characteristics were comparable between groups. Over the 24-week period, the MCO group showed a significant decline in neutrophil count (p = 0.042) and downward trends in CRP and the CRP/albumin ratio, while both markers increased significantly in patients maintained on high-flux dialyzers. Serum albumin remained stable in all participants. Parallel to the improvement in inflammation, the MCO group demonstrated significant enhancements in iron-handling parameters, with higher serum iron (p = 0.008) and TSAT (p = 0.005), and lower TIBC (p = 0.007), none of which were observed in the high-flux group. Between-group Δ-differences were significant for CRP (p = 0.010), CRP/albumin ratio (p = 0.013), serum iron (p = 0.040), TIBC (p = 0.005), and TSAT (p = 0.005). Hemoglobin levels remained stable in both groups, while intravenous iron and ESA requirements showed modest within-group reductions in the MCO cohort. In this exploratory retrospective analysis, MCO membrane use was associated with favorable trends in inflammatory markers and iron-handling parameters, alongside modest within-group reductions in intravenous iron and ESA requirements, without compromising serum albumin. These findings suggest that MCO therapy may help mitigate microinflammation and support more efficient anemia management in real-world HD practice.
BACKGROUND:The transradial approach (TRA) is a critical access method for percutaneous transluminal angioplasty (PTA) in hemodialysis (HD) patients with arteriovenous fistula (AVF) dysfunction, yet its technical challenges remain unaddressed. Currently, no predictive tools exist to assess TRA feasibility. This study aimed to identify risk factors for difficult TRA and develop a predictive nomogram. METHODS:We retrospectively analyzed 160 HD patients undergoing ultrasound-guided TRA-PTA across three Chinese hospitals (May 2022-May 2024). A training cohort (n = 110) and validation cohort (n = 50) were established. Independent risk factors were identified via univariate and multivariate logistic regression. A nomogram was constructed and validated using ROC curves, calibration plots, and decision curve analysis (DCA). RESULTS:The cohort had a mean age of 59.7 ± 12.9 years, with 36.9% (59/160) experiencing difficult TRA. Radial artery diameter (OR = 2.1, p = 0.003), calcification (OR = 3.4, p < 0.001), and tortuosity (OR = 2.8, p = 0.002) were independent predictors. The nomogram demonstrated strong discrimination (AUC: 0.902), with sensitivity = 0.907 and specificity = 0.806 at a cutoff of 0.416. Calibration showed excellent agreement (mean absolute error = 0.022), and DCA confirmed clinical utility across threshold probabilities of 0.2-0.8. CONCLUSION:This nomogram demonstrates that for optimal puncture feasibility, the radial artery diameter should be ≥ 3 mm when both calcification and tortuosity are present, > 2.2 mm if either condition is present, and > 1.5 mm if neither is present. The nomogram effectively predicts difficult TRA during AVF-PTA in HD patients, offering clinicians a practical tool to preoperatively assess procedural feasibility and optimize vascular access planning.
BACKGROUND:Tunneled central venous catheter dysfunction is a frequent and clinically relevant complication in hemodialysis, with a direct impact on treatment efficacy and vascular access survival. Identifying modifiable risk factors is essential for optimizing prevention strategies and guide clinical decision-making. This study aimed to identify predictors of tunneled central venous catheter dysfunction through a retrospective multicenter cohort of hemodialysis sessions with repeated measures cross-sectional, while other cross-sectional approaches-such as the one presented here-focus on data collected during each HD session to detect early warning signs of dysfunction, following KDOQI 2019 guidelines for vascular access dysfunction definition. The secondary objective was to explore associations. METHODS:A multicenter retrospective cohort study with repeated measures was conducted using all hemodialysis sessions performed in 2021 in 18 public hospitals. The unit of analysis was the index session, and the primary outcome was catheter dysfunction in the subsequent session, defined as blood flow < 300 mL/min with associated arterial or venous pressure changes. A mixed-effects logistic regression with a random intercept for each patient was fitted to account for the repeated hemodialysis sessions. RESULTS:Significant associations were found between catheter dysfunction and lower blood flow rates, elevated venous pressures, line inversion, and catheter placement in the left internal jugular vein. Protective factors included urokinase locking and post-dilution hemodiafiltration. Higher risk was also linked to interstitial nephropathies and unknown etiologies, whereas prior vascular access reduced the risk of dysfunction. CONCLUSION:Tunneled central venous catheter dysfunction is a preventable complication when clinical, technical, and hemodynamic parameters are systematically monitored to identify risk factors and guide catheter management. Continuous session-based monitoring enables early detection and timely intervention. This comprehensive strategy, when combined with pharmacologic management, helps preserve vascular access and enhances treatment outcomes in hemodialysis patients.
BACKGROUND:Dialysis is a life-sustaining therapy for patients with end-stage renal disease, yet it is among the most resource-intensive treatments in modern healthcare. Hemodialysis requires large volumes of treated water, substantial energy input, and extensive single-use consumables, resulting in significant greenhouse gas emissions and clinical waste when scaled to millions of treatments performed annually. Climate change further threatens kidney health through heat stress, dehydration, and climate-related disruptions, creating a bidirectional relationship in which kidney care both contributes to and is adversely affected by environmental degradation. METHODS:This white paper synthesizes current evidence surrounding environmentally sustainable dialysis practices, collectively termed "green dialysis," reviewing technical and system-level interventions across water stewardship, energy management, waste reduction, and clinical practice innovation. RESULTS:Green dialysis strategies, including dialysate flow optimization, improved reverse-osmosis efficiency and water reuse, energy-efficient infrastructure, renewable energy integration, waste segregation, central concentrate delivery systems, and incremental dialysis, have been shown to reduce water consumption, energy use, waste generation, and operational costs while maintaining dialysis adequacy and clinical outcomes. Adoption remains uneven due to operational complexity, regulatory gaps, and financial constraints, particularly in low- and middle-income countries. CONCLUSIONS:Context-sensitive implementation, staff education, standardized monitoring, and transparent reporting are essential for overcoming these barriers. Broader integration of sustainability into routine dialysis care represents a critical opportunity to reduce the environmental footprint of kidney replacement therapy without compromising patient safety or treatment efficacy.
Comamonas testosteroni is a gram-negative aerobic bacillus commonly found in environmental sources and known for its bioremediation potential. Although it is widely distributed in nature, human infection is rare, but it is increasingly being recognized as a nosocomial pathogen. A 68-year-old female with stage 5 chronic kidney disease (CKD V) on maintenance hemodialysis since 2017 presented with fever and decreased consciousness. On examination, a tunneled cuffed catheter (TCC) was noted in the right internal jugular vein. Two sets of blood cultures, one drawn from the TCC and the other from a peripheral vein, grew C. testosteroni after 48 h. The organism was identified using API ID strips and was sensitive to amikacin, gentamicin, ceftazidime, imipenem, and meropenem but resistant to ciprofloxacin. She was treated with catheter removal and intravenous ceftazidime. The patient recovered completely after 5 days of hospitalization, with resolution of fever and improved consciousness. This case highlights C. testosteroni as an emerging nosocomial pathogen in immunocompromised patients undergoing invasive procedures. It underscores the importance of vigilant surveillance and strict catheter management protocols.
BACKGROUND:Value-based medicine (VBM) seeks to maximize patient-relevant outcomes per unit cost. In end-stage kidney disease (ESKD), vascular access (VA) is a dominant, modifiable driver of morbidity, mortality, and expenditure. METHODS:We performed a narrative review of published studies and gray literature on VA creation, maintenance, and salvage in ESKD, focusing on clinical outcomes, patient experience, and economic impact. Findings were synthesized within a VBM framework relevant to clinicians, health-system leaders, and policymakers. RESULTS:Contemporary data confirm that tunneled dialysis catheters (TDCs) are associated with high rates of bloodstream infection, central venous injury, and mortality, and substantially higher costs than autogenous access. Arteriovenous fistulas (AVFs) offer the best long-term value when creation is risk-based, maturation is supported, and the access is actually used; nonmaturation, nonuse, and prolonged catheter dependence erode this advantage. Endovascular AVF and external support devices improve technical success and early patency but have uncertain cost-effectiveness at current device prices. Arteriovenous grafts (AVGs) can provide greater net value than AVFs in selected patients (older, frail, or with poor veins) by shortening catheter exposure, at the expense of higher reintervention rates and maintenance costs. Across access types, circuit failure and recurrent interventions drive a substantial share of hemodialysis admissions and Medicare spending. Selective preoperative imaging, targeted duplex ultrasound in response to clinical findings, and ultrasound-guided cannulation can improve access selection, maturation, and salvage while avoiding low-value routine surveillance. Peritoneal dialysis remains underutilized despite comparable outcomes in many cohorts and lower average per-patient costs than in-center hemodialysis. Site-of-service optimization (office-based/ASC vs. hospital) and multidisciplinary, life-plan-based access programs further reduce admissions, catheter days, and per-patient costs. CONCLUSIONS:A value-based VA strategy for ESKD should prioritize minimizing catheter exposure, tailoring AVF versus AVG use to patient risk, integrating PD where feasible, using selective imaging and monitoring, matching site of service to case complexity, and organizing multidisciplinary access teams aligned with quality and cost metrics.
A 40-year-old woman on peritoneal dialysis for 3 years presented with febrile peritonitis. Metagenomic next-generation sequencing (mNGS) confirmed Mycobacterium tuberculosis complex in ascitic fluid, leading to prompt anti-tuberculosis therapy. She initially improved but developed ultrafiltration failure 15 months later and transitioned to hemodialysis. At 18 months, she developed bowel obstruction, bloody ascites, and characteristic imaging and laparoscopic findings of encapsulating peritoneal sclerosis (EPS). Despite supportive care, she deteriorated and died 30 months after tuberculosis peritonitis diagnosis. This case highlights that mNGS enables rapid diagnosis of tuberculous peritonitis when conventional tests are inconclusive, and that tuberculosis peritonitis may serve as a potent inflammatory trigger for EPS even after peritoneal dialysis cessation. Early recognition and timely intervention may improve outcomes.
BACKGROUND:Tunneled dialysis catheters (TDCs) remain the mainstay of unplanned and urgent start hemodialysis. TDCs are implanted by interventional radiologists, surgeons, or nephrologists, and these clinicians must be familiar with the management of TDC-related complications. Postimplantation bleeding at the exit site of a TDC poses diagnostic and therapeutic challenges. METHODS:In this case report, we describe a simple bedside method for precise localization of the bleeding spot and targeted placement of a compression suture to arrest exit site bleeding from a TDC. DISCUSSION:Bleeding at the exit site may be the result of bleeding from a venotomy wound or the tunnel tract or the exit wound itself. Precise localisation of the bleeding spot is an essential first step in achieving secure hemostasis. Currently recommended measures like application of manual compression, compressive dressing, local infiltration of hemostatic agents, and suturing of the exit site are limited by their empirical nature and failure to specifically target the bleeding vessel.
Physical activity has been recommended as an effective strategy to prevent complications in patients receiving hemodialysis. Multiple guidelines for chronic kidney disease recommend at least 150 min per week of moderate-intensity physical activity. However, the prevalence of meeting recommended physical activity levels among hemodialysis patients remains unclear, and the factors influencing physical activity participation require further investigation. We systematically searched PubMed, Web of Science, MEDLINE, EMBASE, CINAHL, Scopus, PsycINFO, China National Knowledge Infrastructure, WanFang, Chinese Biomedical Literature Service System, and SPORTDiscus from inception to March 5, 2025. The Agency for Healthcare Research and Quality was used to evaluate the methodological quality of included studies. The pooled prevalence was calculated using a random-effects model. Subgroup analysis was conducted to explore sources of heterogeneity. We screened 24,566 records, reviewed 252 full texts, and included 12 studies (N = 8938). The pooled prevalence of meeting recommended physical activity was 32% (95% CI, 20%-46%). Higher prevalence was observed in studies with shorter dialysis vintage, self-administered PA instruments, smaller sample sizes, and those published before 2020. Factors underlying inactivity were multifactorial, spanning pathophysiological, psychological, and treatment-related domains. This review indicates a low prevalence of meeting recommended physical activity levels among hemodialysis patients, which is influenced by multiple factors. It is recommended that future studies further explore intervention strategies targeting physical activity on dialysis and non-dialysis days, based on factors that influence physical activity, to improve adherence.
BACKGROUND:Blood hemoglobin (Hb) levels typically increase during maintenance hemodialysis (MHD) sessions. This intradialytic Hb change (ID-HbC) may increase thrombotic risks depending on its magnitude. This study investigated the magnitude. METHODS:In 115 MHD sessions with standard hemodialysis modality, relative-ID-HbC, which was calculated from pre- and post-dialysis Hb values, was examined in relation to ultrafiltration volume normalized to dry weight (UFV/DW). RESULTS:Relative-ID-HbC ranged from -0.037 to 0.324, with a median (interquartile range) of 0.104 (0.070-0.177). A significant positive correlation was observed between relative-ID-HbC and UFV/DW (r = 0.50, p < 0.001), with a least-squares regression slope of 3.1. In about 1/3 sessions with UFV/DW > 0.05, relative-ID-HbC exceeded 0.2. CONCLUSION:More than 20% increase in Hb can occur in sessions with UFV/DW > 0.05, whereas the typical increase is around 3% per 1% increase in UFV/DW. To reduce thrombotic risks, anemia therapy raising pre-dialysis Hb > 10.5 g/dL should preferably be avoided in MHD patients who require UFV/DW > 0.05.
