Background: Cognitive impairment and fatigue are common in patients with advanced chronic kidney disease (CKD). However, whether these symptoms reflect kidney failure itself or factors associated with hemodialysis (HD) remains unclear. This study compared cognitive performance and fatigue between patients with CKD G5 not requiring kidney replacement therapy, referred to as CKD G5 not on dialysis (CKD G5 ND), and those receiving maintenance HD. Methods: In this cross-sectional, single-center study, 68 clinically stable patients with kidney failure were enrolled, including 27 patients with CKD G5 ND and 41 patients receiving HD. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA) and fatigue via the Fatigue Assessment Scale (FAS). Results: Global cognitive performance did not differ significantly between patients receiving HD and those with CKD G5 ND, with median MoCA scores of 24.00 and 23.00, respectively. Cognitive impairment was frequent, affecting 61.0% of HD patients and 74.1% of those with CKD G5 ND. Fatigue severity was also comparably high, with significant fatigue in 51.2% and 44.4% of individuals, respectively. No association was observed between global cognitive performance and fatigue. Exploratory analyses showed that language performance was inversely associated with total and mental fatigue after false discovery rate correction. In the adjusted logistic regression, HD status was associated with lower odds of cognitive impairment; however, this finding should be interpreted cautiously, given the cross-sectional design, small sample size, and baseline clinical differences between groups. Conclusions: Cognitive impairment and fatigue were highly prevalent both in patients with CKD G5 ND and those receiving maintenance HD, with no significant between-group differences in global cognitive performance or fatigue severity scores. These findings suggest that neuropsychological vulnerability may be present in patients with kidney failure before dialysis initiation.

Slow low-efficiency dialysis (SLED) is viewed historically a ‘hybrid’ technique of kidney replacement therapy, representing a transition between intermittent and continuous kidney replacement therapy. It can be performed with a mobile single-pass batch dialysis system or multifunctional hemodialysis machines, using reduced dialysate flow and an extended procedure duration. We summarized the technical aspects, as well as the practical advantages of SLED. Moreover, we present our experience of using SLED in selected difficult clinical conditions, such as intraoperative renal replacement therapy during liver transplantation, in sepsis, and in heart failure patients with recalcitrant volume overload. In this paper, we aimed to describe the unique advantages of SLED in terms of efficacy, safety, and, more importantly, sustainability in kidney care in the intensive care units.

Purpose:The aim of the study was to evaluate the interventions in endoAVF created with the WavelinQ 4-F EndoAVF system to clarify the role of this method in personalised vascular access strategy for end-stage renal disease patients. Material and methods:Endovascular fistula creation was performed in 16 patients. The type of additional endovascular procedures during fistula creation was evaluated. Postoperative surgical and endovascular intervention was divided into maintenance and enhanced maturation procedures. The necessity of using assisted maturation was examined by Kaplan-Meier analysis, the rate of interventions per patients per year and evaluation of the type, time, and the relationship between intraoperative and postoperative interventions. Results:Access primary patency was significantly lower than access cumulative and functional patency (p < 0.001). During endoAVF creation 73.3% patients required 16 additional endovascular procedures. After endoAVF creation 73.3% patients needed endovascular 22 procedures and 20% underwent surgical interventions. Nine (81.8%) out of 11 patients required intravascular procedures due to lack of fistula maturation - 9 (45%) angioplasties and 11 (55%) vein embolisations. The postoperative venous embolisation rate was significantly dependent on vein embolisation during endoAVF creation (p < 0.04). After endoAVF creation significantly more patients - 11 (73.3%) - required endovascular interventions compared to 3 (20%) with surgical interventions (p < 0.01). Postoperative endovascular and surgical interventions was 0.09 and 0.02 per patients per year, respectively. Conclusions:Maturation of endoAVFs required significantly more endovascular than surgical interventions. Venous embolisation combined with fistula creation reduced postoperative embolisation.

AbstractIntroductionCognitive impairment (CI) is common in both end‐stage kidney disease (ESKD) and alcohol‐related liver cirrhosis. The aim of this study was to assess the prevalence and patterns of CI in patients awaiting kidney and liver transplantation, and to identify its determinants.MethodsIn this cross‐sectional, prospective study, 31 consecutive patients with ESKD and 31 consecutive patients with alcohol‐related liver cirrhosis, all currently on transplant waiting lists, were screened for cognitive decline using the Addenbrooke's Cognitive Examination. Medical history, demographics, and laboratory test results were also collected.ResultsThe prevalence of CI among patients with ESKD and alcohol‐related liver cirrhosis was 26% and 90%, respectively. In both groups, memory was the most affected cognitive domain, along with verbal fluency in patients with ESKD, and visuospatial abilities in patients with alcoholic cirrhosis. The most statistically significant increase in the prevalence of CI was found in patients with lower educational attainment, in both alcohol‐related liver cirrhosis and ESKD populations as well as in older patients with alcoholic cirrhosis. Furthermore, better cognitive functioning in ESKD patients was associated with higher levels of total lymphocyte count and alanine transaminase (ALT), and in alcohol‐related liver cirrhosis patients with higher levels of ALT and aspartate transaminase. A nonsignificant trend toward lower memory domain scores was also observed with increasing ammonia levels and increasing severity of liver disease (higher Child–Pugh scores). Finally, suboptimal performance on the screening test was correlated with the severity of liver disease as assessed by the Model for End‐Stage Liver Disease Sodium (MELD‐Na), but not at the statistically significant level.ConclusionsThe prevalence of CI, especially in patients with alcohol‐related liver cirrhosis, is high and can be a significant clinical problem, negatively affecting the transplantation process. Routine screening tests in this group would contribute to the implementation of appropriate management, such as rehabilitation program or psychosocial treatments and facilitate the provision of specialized health care.

Background: Chronic kidney disease (CKD) is a risk factor for cognitive impairment (CI), and this risk is the highest in patients with end-stage kidney disease (ESKD). As a multifactorial disease, CI may be influenced by several potentially modifiable lifestyle and behavioral factors that may reduce or increase the risk of dementia. The aim of this study was to evaluate the associations between the known modifiable risk factors for dementia and the risk of CI in patients with ESKD treated with renal replacement therapy. The Charlson Comorbidity Index and the risk of CI in patients with ESKD were also assessed. Methods: In this cross-sectional study, 225 consecutive patients with ESKD treated with different modalities of renal replacement therapy were assessed for cognitive decline using the Addenbrooke’s Cognitive Examination (ACE III) test. Information was also collected on modifiable risk factors for dementia, medical history and demographics. Results: This study included 117 patients after kidney transplantation (KT) and 108 patients with ESKD undergoing peritoneal dialysis and hemodialysis. The prevalence of modifiable risk factors for dementia differed between the groups; KT patients were more likely to be physically active, residing in cities with populations of less than 500,000 inhabitants, and were less likely to suffer from depression. Furthermore, the KT group had a lower Charlson Comorbidity Index score, indicating less severe comorbidities, and a lower risk of CI (3.6 ± 1.67 vs. 5.43 ± 2.37; p = 0.001). In both the KT and dialysis groups, patients with CI were more likely to have a sedentary lifestyle (45% vs. 9%, p = 0.001 and 88% vs. 48%, p = 0.001, respectively), whereas lower educational attainment and depression had a significant negative impact on ACE III test results, but only in KT patients. Finally, cognitive function in dialysis patients was negatively affected by social isolation and living in urban areas. Conclusions: Modifiable risk factors for dementia, particularly a sedentary lifestyle, are associated with a higher risk of CI in patients treated with different renal replacement therapy modalities. As CI is an irreversible condition, it is important to identify lifestyle-related factors that may lead to dementia in order to improve or maintain cognitive function in patients with ESKD.

Aim of the studyThe study aimed to assess the prevalence of executive function impairment among patients with chronic kidney disease (CKD) undergoing dialysis, with no subjective cognitive problems and with normal global cognition on the Mini-Mental State Examination (MMSE). We also investigated the relationship between cardiovascular risk factors and cognitive test results.Rationale for the studyPatients with CKD, including those undergoing renal replacement therapy, are at a higher risk of developing cognitive impairment (CI) than the general population. Recent research has shown CI to be a growing problem among CKD patients worldwide. Yet, it remains underdiagnosed, even though it may significantly influence the lives of patients.Materials and methodsIn this cross-sectional, prospective study, 58 dialysis patients with no cognitive decline on the MMSE screening were assessed for executive function impairment using the Executive Clock-Drawing Task (CLOX). Moreover, past medical history, demographic data, and laboratory test results were collected.ResultsThe mean patient age was 59.47 +/- 14.98 years, and the mean duration of dialysis was 45.93 +/- 48.49 months. The prevalence of executive function impairment amounted to 8.6%. Moreover, remarkably similar pattern of clock drawing was observed, with numbers written outside the clock face in the CLOX1 test.ConclusionsExecutive dysfunctions in dialysis patients may manifest itself before the onset of global cognitive impairment. There appear to be a deficit in the spatial domain as well. Better education may play a protective role.

BackgroundThe risk of morbidity and mortality in the group of people qualified for kidney transplantation is high. Although currently, the qualification for kidney transplantation is very extensive and detailed, the final examination and assessment at the transplant center is crucial for the success of the transplantation.Case reportA 50-year-old woman with end-stage kidney disease was admitted to the Department of General, Vascular, and Transplant Surgery on July 21, 2023, for kidney transplantation. A month earlier, she had undergone surgery to create an arteriovenous fistula on the left forearm. The regional anesthesia was performed. Apart from temporary pain and cough, the postoperative course was uncomplicated. Upon admission to the Department, the patient was in good general condition, and only a dry cough was noted during the physical examination. Chest X-ray revealed pneumothorax on the left side with partial lung atelectasis. The patient was temporarily disqualified from kidney transplantation and the pneumothorax was cured. She is currently on the active list waiting for a kidney transplant.ConclusionsThe analysis of the above case emphasizes the importance of a physical examination and final qualification at the transplant center. Detailed examination and evaluation at the above center can improve patients' quality of life and survival.

Introduction: Hemodialysis patients are at higher risk of developing cognitive impairment, but the pattern of affected cognitive domains is still undetermined. Little is also known about the symptoms of depression and anxiety in hemodialysis patients. Methods: In this cross-sectional study, we included 74 consecutive adult patients undergoing hemodialysis. Cognitive functions were assessed using the Addenbrooke Cognitive Test III. In addition, all patients were screened for symptoms of depression and anxiety using the Hospital Anxiety and Depression Scale. Results: The mean age of hemodialysis patients was 65.69 ± 14 years. Among the patients, there were 27% and 31% of patients with mild cognitive impairment and suspected dementia, respectively. In the group of patients with suspected dementia, all cognitive functions had significantly lower values compared to these functions in incognitively unimpaired and mild cognitive impairment patients. The most impaired domain was verbal fluency, which reflects impairments in executive function. Depression and anxiety symptoms were observed in 28% and 22% of patients, respectively. Patients with anxiety symptoms had higher levels of endogenous creatinine, parathyroid hormone, and hemoglobin, as well as decreased creatinine clearance, being younger and less educated. No factors contributing to the occurrence of depressive symptoms were found. Conclusion: Cognitive dysfunction is a significant problem in hemodialysis patients. Our study showed that the prevalence of cognitive impairment and depression and anxiety symptoms in hemodialysis patients was high. The domain of executive functions was most affected. Furthermore, creatinine, parathyroid hormone, hemoglobin levels, creatinine clearance, and education affected the anxiety scale score.

Background: Hemodialysis is one of the most resources consuming medical intervention. Due to its concept, the proper amount of dialysis fluid passed through dialyzer is crucial to obtain the expected outcomes. The most frequent source of dialysis fluid is production from liquid concentrate (delivered in containers or plastic bags) in dialysis machine. Alternatively, concentrates for dialysis may be produced in dialysis center by dilution in mixing devices dry or semidry premixed compounds connected with system of central dialysis fluid delivery system. Dialysate consumption depends on various factors like type of hemodialysis machine, session duration, prescribed flow, etc. Summary: Modern hemodialysis machines are equipped with the modules which automatically reduce flow rate of dialysis fluid to the patient blood flow and minimize dialysate consumption during preparation and after reinfusion. Smart using of available options offered by manufacturers allows to save additional portion of acid concentrate and water. The weight of concentrates to be delivered to the dialysis center is the major factor influencing the cost (financial and environmental) of transportation from the manufacturer to the final consumer. The crisis on the energy carriers market and extremely high fuel prices made the transportation cost one of the significant costs of the treatment, which must be bear by supplier and finally influence on the price of goods. Key Messages: The careful choice of the concentrate delivery system can improve cost-effectiveness of dialysis. Such solutions implemented in dialysis unit helps make significant savings and decrease the impact on natural environment by carbon footprint reduction.

Purpose: Over the last few years, transplant centers have started to use various intraoperative renal replacement therapy (ioRRT) modalities during liver transplantation (LT) in patients with pre-existing renal impairment. Here, we present a study on the safety and clinical outcomes of intraoperative hemodialysis (ioHD) performed using a mobile dialysis system during LT. Patients and methods: We retrospectively analyzed 102 adult patients undergoing LT with ioHD; pre-existing renal failure and/or intraoperative metabolic derangement were ioHD treatment indications. Results: Our study cohort consisted of three groups: LT with preoperative serum creatinine (sCr) < 2 mg/dL (Group 1:n = 22), LT with preoperative sCr >2 mg/dL (Group 2:n = 73), and simultaneous liver-kidney transplantation (Group 3:n = 7). Among the procedures, 30% were re-transplantations. The mean calculated Model for End-stage Liver Disease score in Group 2 was 39.2, and 67% of patients were hospitalized in the intensive care unit. Patients in Group 1 were less acutely ill but developed severe intraoperative derangements and, therefore, underwent urgent ioHD intraoperatively. However, it was delayed when compared to Group 2. All groups achieved post-reperfusion potassium levels <4 mmol/L and a decrease in central venous pressure. No serious procedural complications occurred. Post-reperfusion syndrome occurred in 12.7% of patients. Elevated mortality was likely due to the high illness severity in the cohort. Conclusions: Performing ioHD with a mobile dialysis system during LT was safe and effective, while being easier to perform than continuous techniques. Its effect on intra-and postoperative outcomes should be addressed in a study with a control group.

BACKGROUND:It is widely accepted that patients with chronic kidney disease (CKD) should play an active role in the selection of renal replacement therapy (RRT) option. However, patients' knowledge about CKD and treatment options is limited. The implementation of structured education program and shared decision-making may result in a better preparation to RRT, more balanced choice of dialysis modalities and better access to kidney transplantation (TX).OBJECTIVES:The aim of this long-term study was to assess the impact of formalized Predialysis Education Program (fPEP) on knowlege on RRT options, as well as on selected and definitive therapy.MATERIAL AND METHODS:The study included 435 patients (53% men, mean age 60 years) with CKD stage 4 and 5, participating in fPEP at our center. The program included at least 3 visits, during which balanced information about all RRT options was presented and self-care and informed decision-making were encouraged. The knowledge about RRT options before and after fPEP attendance, and selected and definitive RRT options were assessed.RESULTS:Ninety-two percent of patients received prior nephrology care. After fPEP completion, in most patients, the knowledge about CKD and RRT options and selected preferred modality improved - 40% of participants chose hemodialysis (HD), 32% peritoneal dialysis (PD) and 18% TX. During the observation period, 4% of patients died before commencement of dialysis, 2.7% received preemptive kidney transplant, 8.6% were placed on transplant waiting list, and 94% started dialysis (30% PD and 70% HD). Among those who chose PD, 69% started PD and 24% started HD; the leading causes of the discrepancy between choosing and receiving PD was the deterioration in clinical condition (50%) and change of decision (32%).CONCLUSIONS:The fPEP increases CKD patients' knowledge on RRT methods. The implementation of a decision-making process based on fPEP leads to a satisfying distribution between modalities, with a good concordance between chosen and definitive modality.

To assess macular and optic nerve head characteristics in patients after kidney transplantation using noninvasive optical coherence tomography (OCT) imaging.The study had a prospective character and was performed during period from November 2019 to November 2020 at the University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina, and included 59 patients with renal graft who underwent OCT. The obtained OCT images, pathologic changes on the fundus, including macula and optic nerve, were analyzed by reviewing nonparametric measures such as scanning laser ophthalmoscope, B-scan, 3D display, as well as parametric measurements such as central macular thickness, optic nerve head excavation, and retinal nerve thickness fiber (RNFL).There is a statistically significant difference in RNFL values (P = 0.031) and cup to disc (P = 0.002) ratio in relation to duration of graft. The highest average values of RNFL was in patients with creatinine clearance <30 mL/min, while average cup to disc ratio was lowest in patients with creatinine clearance >60 mL/min.Optic nerve head edema was bilateral in 9 and unilateral in 5 patients. Fundus examination also revealed changes on posterior segment, including retinal detachment (1 patient), bilateral macular edema (9 patients), unilateral macular edema (3 patients), central serous chorioretinopathy (2 patients), and macular pseudo hole (3 patients).Different retinal pathology is present in high incidence in patients secondary to renal transplant. Immunosuppressive therapy, older age, and comorbidities are the usual causes of these changes.

BackgroundThe ability of extrarenal tissues to convert 25(OH)D (calcidiol) into 1,25(OH)2D (calcitriol) and dependence of the conversion on substrate levels provide the rationale for supplementing vitamin D in dialysis patients who usually have severe depletion of both: 25(OH)D and 1,25(OH)2D. The primary aim of the study was to compare effects of small doses of cholecalciferol (12,000 IU/week) with frequently used in Europe, small doses of alfacalcidol (1.5 μg/week) or placebo, given for 12 weeks, on serum 1,25(OH)2D in hemodialysis patients with 25(OH)D deficiency. Secondary outcomes were changes in serum calcium, phosphate, 25(OH)D, parathyroid hormone (PTH), fibroblast growth factor 23 (FGF23) and sclerostin during the treatment.MethodsThis was a prospective, randomized, partly double-blind (cholecalciferol vs. placebo) study. Out of 522 patients dialyzed in 5 centers in the Mazovian Province, 93 gave informed consent and met the inclusion criteria: any vitamin D metabolites and calcimimetics naïve; no history of liver or intestinal disease; serum 25(OH)D <20 ng/ml, iPTH <1,000 –>110 pg/ml, calcium <10.2, and phosphate <6.8 mg/dl. The subjects were stratified by serum iPTH, then randomized into 3 groups according to the treatment.ResultsTo our knowledge, this is the first study comparing head-to-head these drugs in the hemodialysis population. There were no significant differences between the groups at baseline. 81 patients completed the study. Cholecalciferol normalized serum 25(OH)D, with a mean rise from 12.9 ± 6.7 to 31.3 ± 10.1 ng/ml (p < 0.0001). This was accompanied by a marked increase of 1,25(OH)2D from 13.8 ± 9.3 to 25.1 ± 14.2 pmol/l (p < 0.0001). A rise in serum 1,25(OH)2D was also observed in alfacalcidol treated patients, however much smaller (from 13.5 ± 10.1 to 18.5 ± 11.0 pmol/l; p = 0.02). Neither cholecalciferol nor alfacalcidol treatment resulted in significant changes in serum PTH and the remaining parameters.ConclusionsIn most patients, treatment with cholecalciferol in a 12,000 IU/week dose permits safe correction of 25(OH)D deficiency and is more effective than 1.5 μg/week dose of alfacalcidol in rising serum 1,25(OH)2D. This, together with a lack of influence on circulating iPTH the usefulness of such small alfacalcidol doses in hemodialysis patients is debatable.

BACKGROUND:Kidney transplant is the preferred therapy for end-stage kidney disease; however, it has been associated with some serious complications, including malignancy, which became the second leading cause of death among kidney allograft recipients. The aim of this study was to assess the prevalence of malignancy in hemodialyzed patients and in kidney transplant recipients.METHODS:A cross-sectional study was conducted in 114 prevalent hemodialyzed patients, including 7 on the waiting list and 350 kidney allograft recipients. Hemodialyzed patients and kidney allograft recipients did not differ in regard to sex, dialysis vintage, and cause of end-stage renal failure, but were significantly older.RESULTS:Among wait-listed patients, only 1 had a history of malignancy (gastric cancer stage G1). Among kidney allograft recipients, in 70 patients, malignancy developed (in total 20% of the studied population). The leading malignancy was skin cancer (18 cases), followed by post-transplant lymphoproliferative disorder (PTLD) in 10 cases, lung cancer (small cell and non-small cell lung cancer; 4 cases), renal cell carcinoma (3 cases), brain cancer (glioma; 3 cases), colorectal cancer (3 cases), Kaposi sarcoma (2 cases), Merkel carcinoma (2 cases), metastatic disease of unknown origin (2 cases), and other 23 malignancies were in a single patient (including 1 leukemia and 1 multiple myeloma). Twenty-six deaths were recorded in kidney allograft recipients with malignancy, mainly in PTLD, Kaposi sarcoma, Merkel carcinoma, sarcoma, glioma, and melanoma.CONCLUSIONS:Despite the lower prevalence of malignancy on hemodialyzed population, cancer screening in both potential transplant recipients and kidney allograft recipients is a prerequisite, because nowadays there is a scarcity of data in this area. It may be due to previous immunosuppression, long-term dialysis vintage, immunocompromised status, and immunosuppressive therapy after transplant, in particular in high-risk patients.

Introduction: Novel coronavirus disease (COVID-19) is a newly discovered contagious disease caused by SARS-CoV-2 virus, primarily manifesting as an acute respiratory illness with pneumonia, but can affect multiple organs such as kidney, heart, digestive tract, blood and nervous system. Patients with end-stage kidney disease undergoing dialysis or kidney transplant recipients are particularly vulnerable to severe COVID-19 due to the older age and high frequency of comorbidity, such as diabetes and hypertension, in this population. Reported mortality is higher than usual annual mortality and is associated with older age and number of comorbidities. Despite two years of pandemia data are still limited in relation to three modalities of renal replacement therapy in Poland. Methods: Retrospectively collected data in single university hospital on hemodialysis, peritoneal dialysis and kidney transplant recipients engrafted during pandemia. We viewed epidemiologic and clinical data of patients with laboratory-confirmed COVID-19 and assess mortality in 2019, and 2020 and 2021. Results: Unadjusted mortality in dialyzed patients (number of deaths divided by number of patients) in 2019 was 19%, while unadjusted (after exclusion of COVID-related deaths) mortality in 2020 was 21%, in 2021 mortality was 25%. The prevalence of cardiovascular deaths in 2019 and 2020 and 2021 was almost identical (41 vs 41 vs 42%). In kidney transplant recipients mortality in 2019 was 3%, in 2020 was 3% (COVID-19 related) and in 2021 was 7% (all COVID19 related). Mortality of COVID-19 positive dialyzed patients contributed to the 24% of all recorded deaths. Conclusions: Patients receiving maintenance hemodialysis were susceptible to COVID-19 and that hemodialysis centers were high- risk settings during the epidemic. However, changes in the HD schemes due to necessity to isolate COVID-19 positive patients, shortened dialyses did not change significantly of the cardiovascular mortality in dialyzed population. COVID-19 is a huge challenge and danger for dialyzed population. Kidney transplant recipients despite immunosuppression were less vulnerable.