PURPOSE:Inappropriate polypharmacy is highly prevalent among patients with chronic kidney disease (CKD) and could be reduced through targeted deprescribing interventions. We aimed to evaluate the feasibility and preliminary effectiveness of a multidisciplinary team-delivered deprescribing intervention for CKD patients undergoing hemodialysis (HD). METHODS:A parallel-group pilot randomized controlled trial (RCT) was conducted among adult HD patients. Participants were randomized into either intervention or control groups. The intervention group received a structured deprescribing program using an evidence-based protocol and algorithms. Outcome measures were assessed at baseline, three, and six months. The primary outcomes were feasibility and safety, while secondary outcomes included the number of potentially inappropriate medications (PIMs), pill burden, health service utilization, medication adherence, treatment burden, and quality of life. FINDINGS:Of 75 eligible patients, 54 (72%) were recruited, and three (5.6%) withdrew. All intervention components were delivered with no serious adverse events. At six months, the control group had four times more PIMs than the intervention (RR = 4.03, 95% CI 2.78-5.84; P < 0.001). There were no significant differences over time between the groups in pill burden, treatment burden, adherence, and quality of life. Overall, 85.1% of the proposed deprescribing plans were successfully implemented, with six discontinued due to recurrent symptoms or patient preference. The most commonly deprescribed medications were proton pump inhibitors and antihypertensives. IMPLICATIONS:The multidisciplinary deprescribing intervention was feasible, safe, and demonstrated preliminary effectiveness in reducing PIMs among HD patients. These findings support progression to a definitive RCT to confirm the effectiveness. TRIAL REGISTRATION:ClinicalTrial.gov. NCT06324045. Registered on 15 March 2024.

Background Patients with kidney failure (KF) are at high risk of inappropriate polypharmacy; however, this can be mitigated through deprescribing. While several evidence-based deprescribing guidelines exist for various patient populations, their applicability and utility in KF settings remain limited.Aim This study aimed to adapt existing evidence on deprescribing in KF to develop practical deprescribing algorithms that support clinicians in implementing deprescribing interventions in KF care.Methods Available evidence about deprescribing in KF was reviewed, and local prescribing trends among KF patients were explored. Second, a panel of five experts in pharmacotherapy, medication safety, and clinical research was convened and conducted consensus development workshops to appraise the evidence and develop comprehensive deprescribing algorithms for patients with KF. The adapted algorithms were reviewed by nephrology consultants (n = 3) and clinical pharmacists (n = 2) for clinical validation. The validated algorithms were also applied in a pilot deprescribing study to assess their feasibility and utility in this setting.Results One general and 18 drug class-specific evidence-based deprescribing algorithms in KF care were developed. These provide a structured, stepwise approach to assessing medication appropriateness and guiding deprescribing decisions. Expert validation resulted in refinements of the algorithms. In the pilot testing among hemodialysis (HD) and low clearance clinics, the generic deprescribing algorithm was applied in all cases. The drug-class-specific algorithms were used in 41 deprescribing plans (55.4%) in the HD and in 5 (45.5%) in the low-clearance clinic settings.Conclusion We developed and validated a set of evidence-based deprescribing algorithms tailored to patients with KF, offering a practical and structured approach to support clinicians in deprescribing potentially inappropriate medications.

Qatar's national assisted home hemodialysis (AHHD) is an innovative care model developed to address the distinct challenges of elderly hemodialysis patients with limited mobility. This vulnerable patient population exhibits a high prevalence of central catheter utilization as dialysis vascular access, necessitating comprehensive management of associated complications, primarily dysfunction and infection. Many in this population have exhausted other options and required recombinant tissue plasminogen activator (r-TPA) to maintain good catheter function. This study assessed the efficacy and safety of utilizing the high-risk medication, r-TPA, as a tunneled catheter lock solution in a home healthcare setting. This retrospective descriptive study examines patients undergoing AHHD between January 1, 2023, and December 31, 2024. Clinical data were extracted from medical records, including demographic information, treatment specifics, and key outcomes. The primary efficacy outcomes assessed included dialysis adequacy (measured by KT/V), blood flow rate (BFR), arterial pressure average and the incidence of catheter-related bloodstream infections (CRBSI). Safety outcomes were evaluated based on the occurrence of adverse events during the study period. A total of 38 patients on r-TPA maintenance catheter lock were included in the study (24.5% of total AHHD patients), with a mean age of 74.5 years, reflecting the elderly population served by the program. In all instances, diluted r-TPA at a concentration of 1 mg/mL was administered, with the dose adjusted based on the catheter lumen size. Dwell times ranged between 24 and 72 hours, and patient follow-up ranged between 1 and 24 months with a mean of 9.13 months. The r-TPA successfully maintained adequate BFR >250 mL/min in 86.84 % of cases. Dialysis adequacy (measured by KT/V) remained within acceptable ranges in 86.84 % with a mean of 1.45. CRBSI occurred in 4 patients over the study period (0.19/1000 catheter days). No major adverse events were reported (allergic reaction or bleeding), and minor bleeding occurred in 5.2 % of cases. Overall, catheter replacement was required in 9 cases (23.6 %) (4 for CRBSI and 5 for persistent catheter malfunction). The use of r-TPA as a tunneled catheter lock solution in the AHHD program demonstrated excellent efficacy and safety. The incidence of CRBSI and serious bleeding was very low, underscoring the safety of this high-risk medication in a home healthcare setting when used properly. Despite These findings, highlight the feasibility and safety of incorporating r-TPA into AHHD programs.

Background and Aim:The demand for hemodialysis (HD) among patients with end-stage kidney disease (ESKD) is rising globally. A well-functioning vascular access (VA) is crucial for effective dialysis therapy. This study aims to determine the incidence and risk factors of primary arterio-venous access (AVA) maturation failure in HD patients. Methods:This retrospective cohort study included adult HD patients who underwent AVA creation between 01/01/2021 and 31/12/2023 in Qatar. Data, including demographics, medical comorbidities, AVA type, time to maturation, and incidence of AVA failure, were obtained from a national electronic health record system. Results:Among 242 AVA creations, the primary AVA failure rate was 28%, with an incidence of 9.3 per 100 cases per year. Failure was significantly higher in older patients (p < 0.001), those with diabetes mellitus (p = 0.03), atherosclerosis (p = 0.02), and lower systolic and diastolic blood pressures (p = 0.02 and p < 0.001, respectively). Statin use was higher in patients with matured AVA (68.9% vs. 45.5%; p < 0.001). Multivariate analysis identified diabetes mellitus [OR: 3.672 (95%CI: 1.532-8.801); p = 0.004], atherosclerosis [OR: 2.348 (95%CI: 1.001-5.504); p = 0.002], and age [OR: 1.036 (95%CI: 1.010-1.064); p = 0.007] as risk factors for failure. Statin use [OR: 0.167 (95%CI: 0.080-0.347); p < 0.001] and higher systolic blood pressure [OR: 0.989 (95%CI: 0.966-1.000); p = 0.05] were protective factors. Conclusion:Primary AVA failure in hemodialysis patients in Qatar is notably high, with advanced age, diabetes, atherosclerosis, and low blood pressure increasing risk. Statin use and higher systolic blood pressure provide protective effects. These findings highlight the need for managing risk factors to improve AVA maturation success and enhance dialysis outcomes.

BACKGROUND:Chronic kidney disease (CKD) is a major global health concern that is associated with multiple complications and comorbidities, leading to polypharmacy, inappropriate prescribing, and increased risk of adverse drug events. Deprescribing has emerged as an effective strategy to mitigate these consequences. Evidence-based guidelines are essential to support appropriate deprescribing practices in this population. A variety of deprescribing tools and guidelines are now widely available, but little is known about their utility in CKD setting. This study aimed to identify and characterize published deprescribing tools and guidelines specifically designed for patients with CKD. METHODS:A comprehensive search of PubMed, EMBASE, Cochrane Library, guidelines registries, and international deprescribing networks was conducted up to December 2024. Records were included if they presented a tool or guideline for deprescribing in patients with CKD. After removing duplicates, titles and abstracts were screened, followed by full-text reviews conducted using Rayyan® AI Software. RESULTS:Of the 257 full-text records assessed, 11 met the eligibility criteria, detailing the development of 10 deprescribing tools and guidelines in CKD. These were categorized into four types: (1) comprehensive deprescribing process guidance (n = 2); (2) protocols for comprehensive deprescribing care models (n = 2); (3) drug-specific deprescribing algorithms (n = 4); and (4) screening tools for specific deprescribing steps (n = 2). The development methods of the tools varied: two tools combined literature reviews with expert consensus, four were based on literature reviews alone, three employed pre-determined systematic development frameworks, and the remaining tool was an individualized electronic decision-support tool. Several tools had undergone validation (n = 3) or pilot testing (n = 4) in various clinical settings. CONCLUSIONS:This review identified and characterized the existing tools and guidelines for deprescribing in CKD, suggesting a limited but diverse body of resources. This review highlights the need for more robust, evidence-based deprescribing tools development that is tailored to the complex needs of CKD populations.

BACKGROUND:Pulmonary congestion (PC) is frequent in Hemodialysis (HD) patients and is associated with deleterious prognosis. Lung ultrasound (LUS) accurately quantifies PC; however, many methods exist to evaluate PC using LUS. Here, we validate a simplified LUS-guided protocol for managing PC in HD patients and explore its impact on blood pressure control. METHODS:We enrolled 100 HD patients from 6 dialysis units in 3 countries in a multi-center randomized controlled trial. All patients had LUS after their mid-week session on days 1, 15, 30, 45, and 60. LUS was performed using the 8-zone method to obtain a global B-line score (BLS). Doctors and nurses performed LUS at the bedside. Dry weight was adjusted according to the standard of care in the control group, while it was reduced by 500 g if BLS was above five on day 1 and by 500 g further on Day 15 if BLS was still above 5 in the active group. Blood pressure home monitoring (BPHM) was obtained weekly. RESULTS:The mean BLS on day 1 (13 ± 9) decreased to (8 ± 5) on day 60 (P < 0.001) in the active group. In contrast, the control group showed no significant changes in B-line score on day 60 compared to baseline. HBPM on day 60 was similar to the baseline in both groups. Applying this protocol did not increase the intra-dialytic hypotension frequency. CONCLUSIONS:This simplified LUS-guided protocol for managing PC was effective and safe in HD patients and could be considered for inclusion in standard care practices. Nurses and advanced caregivers may perform LUS in HD units. LUS-guided management may have a positive impact on blood pressure control.

The determination of an appropriate sample size is pivotal in medical research, not only for achieving statistical adequacy but also for ensuring ethical integrity and resource efficiency. This editorial elucidates the complexities involved in defining the lower and upper limits of sample size across various research paradigms. The lower limit is essential for maintaining sufficient statistical power and precision, which depend on several factors, including the study's objectives, inherent population variability, and the desired accuracy of results. An insufficient sample size poses a risk of significant Type II errors and produces wide confidence intervals, thereby undermining the reliability and applicability of the research findings. Conversely, the upper limit encounters practical constraints related to resource allocation and ethical considerations, where the principle of diminishing returns becomes evident as sample sizes increase beyond a certain threshold. This scenario leads to minimal gains in precision at the cost of potential participant risk and resource overutilization. The editorial advocates for a methodical approach to sample size calculation, utilizing statistical tools such as sample size formulas, and G*Power and adopting innovative methodologies, including adaptive trial designs and Bayesian statistics. These strategies facilitate dynamic adjustments based on interim results and prior knowledge, respectively, promoting optimal resource utilization while preserving robust statistical power. Ultimately, the careful calibration of sample size enhances the validity and ethical integrity of medical research, thereby bolstering its contribution to scientific knowledge.

ABSTRACT Background and Aims The neutrophil‐to‐lymphocyte ratio (NLR) is a cost‐effective indicator of inflammation, which may impact decisions regarding therapy for patients undergoing continuous renal replacement therapy (CRRT), even with ongoing clinical arguments. This study aimed to examine the correlation between NLR and the prognosis of critically ill patients undergoing CRRT, specifically about mortality and morbidity. Additionally, the study sought to assess NLR's potential as a prognostic indicator for CRRT initiation. Methods Data were retrospectively analyzed from 175 critically ill patients who received CRRT. Clinical factors and biochemical markers were compared between survivors and non‐survivors at admission, before CRRT, and at 24 and 72 h post‐CRRT initiation. Results Elevated NLR levels were significantly associated with increased in‐hospital mortality. Neutrophil counts showed statistical significance across all measurement points, while NLR and lymphocyte counts were significant only on the third day of CRRT (p 0.001 and 0.011, respectively). Non‐survivors had higher NLR values than survivors and experienced shorter hospital stays (median 22 vs. 44 days for survivors, p < 0.001). Patients with higher baseline NLR values also had more complications. Conclusions The NLR shows potential as a prognostic predictor for mortality in CRRT patients. Its integration into clinical practice could enhance patient care and treatment timing, and further studies should validate its clinical utility.

Introduction:Inappropriate polypharmacy is prevalent among patients with chronic kidney disease (CKD), and can be mitigated by deprescribing. We aim to evaluate the clinical and economic impact of a multidisciplinary deprescribing programme in Qatar's healthcare system. Methods:This randomised controlled trial will be conducted at ambulatory dialysis centres, with an internal pilot to assess the feasibility of recruitment, intervention implementation, and safety measures. Patients will be randomised to usual care or an intervention group where a clinical pharmacist, in collaboration with a multidisciplinary healthcare team, will deliver a structured deprescribing intervention, including periodic monitoring over six months. Outcomes will be measured at baseline, three, and six months. The primary outcome is the proportion of patients with at least one potentially inappropriate medication (PIM). Secondary outcomes include pill burden, treatment burden, hospitalisations, emergency department visits, quality of life, and adherence. A cost-benefit analysis will also be performed. A total of 250 patients provides 90% power to detect a 50% reduction in PIM prevalence (α = 0.05). The statistical analysis will be based on the intention-to-treat principle, using mixed-effects models to account for repeated measures. Discussion:Findings will provide novel evidence on deprescribing in CKD, informing future clinical and policy interventions. Trial Registration:ClinicalTrial.gov. NCT06324045. Registered on 15 March 2024.

Inappropriate polypharmacy is an evident problem among patients with chronic kidney disease (CKD). These can be averted by deprescribing. We aimed to evaluate the feasibility, sustainability, and preliminary efficacy of a multidisciplinary team-delivered deprescribing intervention for patients on hemodialysis (HD) in Qatar. This study is a pilot randomized controlled trial (RCT). Adults receiving chronic HD at Qatar's largest ambulatory dialysis center who communicate in English or Arabic are included. Participants are randomized into the control or intervention groups. Intervention patients receive a structured deprescribing intervention using a developed evidence-based guideline. Outcome measures are collected at baseline and six months for all study participants. The primary outcomes included recruitment and retention rates, adherence to intervention components, and serious adverse events (SAE). The secondary outcomes included the number of potentially inappropriate medications (PIMs), pill burden, and self-reported adherence assessed by the Adherence to Refills and Medications Scale (ARMS). Of the 75 eligible patients, 55 (73.3%) were recruited (C: n = 29, I: n = 26), with an average age of 54 ± 15 years. Of these, 3 (5.4%) dropped out before the 6 months of data collection. All of the intervention components were delivered to the intervention group. These included medication review, deprescribing plans, specialty team consultations, patient education, plan implementation, monitoring, and documentation. There were no reported SAEs. At baseline, participants in the intervention and control groups had a mean ± SD weekly pill burden of 17.6 ± 6.6 and 15.8 ± 4.4, respectively. The mean ± SD number of potentially inappropriate medications (PIMs) was 1.9 ± 1.5 in the intervention group and 2.1 ± 1.3 in the control group. Over six months, the intervention group experienced a significant reduction in PIMs compared to the control group, with a mean difference of 0.84 (95% CI: 0.284 to 1.339, p < 0.0005). However, there were no significant changes in pill burden or adherence scores between the two groups at the end of the study period. A total of 74 deprescribing plans were proposed for the 26 patients in the intervention group. Of these, 53 plans were successfully implemented, while 9 were rejected by physicians, 6 were refused by patients, and 6 were discontinued due to recurrent symptoms or patient preference. The most commonly deprescribed medications included proton pump inhibitors (PPIs), antihypertensive agents, antihyperglycemic agents, and diuretics. The multidisciplinary deprescribing intervention was feasible and effective for HD patients with no safety issues. The structured deprescribing intervention is promising to improve the patient's health outcomes.

The number of elderly dialysis patients in Qatar is rising, with 58% over the age of 60. Many face mobility challenges, often needing ambulance transport for treatment. To address this, the assisted home hemodialysis (AHHD) program was introduced, providing at-home dialysis to improve their quality of life. We highlight the challenges faced during its implementation and the solutions adopted. We documented all challenges encountered during the implementation of the AHHD program from its inception in June 2021 through December 2024. Additionally, we recorded the solutions applied to overcome these obstacles to ensure the program's success and sustainability. After 3.5 years of implementing the AHHD program, 169 patients were enrolled. Throughout the program's initiation and maintenance, we encountered several challenges, with the most significant being: (i) Patient or Family Anxiety About Home Dialysis: This challenge was more pronounced among patients with prior dialysis experience, with only 50% of them agreeing to join AHHD compared to over 90% of newly initiated dialysis patients. Extended patient and family training sessions, coupled with in-depth discussions, proved effective in addressing these concerns. (ii) Central Venous Catheters (CVC) Management: 69% of patients were on dialysis via CVCs, with nearly one-third requiring tissue plasminogen activator (TPA) as a maintenance catheter lock. Despite major safety concerns regarding TPA use in home settings, the issue was successfully managed with proper training to staff and patients, we had no bleeding episodes or hypersensitivity. (iii) Staff Training and Experience: The lack of experience among nurses and physicians posed a significant challenge, as home dialysis demands a unique combination of medical expertise and social adaptability. This issue was resolved by providing 6-8 weeks of specialized training before integrating staff into the AHHD program. (iv) Emergency Preparedness: To handle medical or technical emergencies, a small dialysis center was established as a backup facility, ensuring seamless patient care when needed. (v) Catheter-Related Infections: Concerns were mitigated by adhering to infection control protocols training and adherence. As a result, infection rates were reduced to be reported in only 3 cases, highlighting the efficacy of the protocol. Despite the frequent challenges encountered during the establishment of the AHHD program, these obstacles were manageable when weighed against the significant benefits.