Background The increasing incidence of chronic kidney disease (CKD) is straining the capacity of outpatient clinics. Remote healthcare delivery might improve CKD follow-up compared with conventional face-to-face follow-up. Patient-reported outcomes (PROs) are used to empower remote follow-up and patient engagement. The consequences of shifting from face-to-face follow-up to remote outpatient follow-up on kidney function, health resource utilisation and quality of life remain unknown.Methods We conducted a multicentre pragmatic non-inferiority trial at three outpatient clinics in the Central Denmark Region. A total of 152 incident outpatients with CKD were randomised (1:1:1) to either PRO-based, PRO-telephone follow-up or standard of care (SoC). The primary outcome was the annual change in kidney function measured by the slope of the estimated glomerular filtration rate (eGFR). The non-inferiority margin was an eGFR of 2.85 ml/min/1.73 m2/year. Mean differences were estimated using intention-to-treat (ITT), per protocol and random coefficient models.Results Mean eGFR slope differences between PRO-based and SoC were -0.97 ml/min/1.73 m2/year [95% confidence interval (CI) -3.00-1.07] and -1.06 ml/min/1.73 m2/year (95% CI -3.02-0.89) between PRO-telephone and SoC. Non-inferiority was only established in the per-protocol analysis due to CIs exceeding the margin in the ITT group. Both intervention groups had fewer outpatient visits: -4.95 (95% CI -5.82 to -4.08) for the PRO-based group and -5.21 (95% CI -5.95 to -4.46) for the PRO-telephone group. We found no significant differences in quality of life, illness perception or satisfaction.Conclusion Differences in the eGFR slope between groups were non-significant and results on non-inferiority were inconclusive. Thus, transitioning to remote PRO-based follow-up requires close monitoring of kidney function. Reducing patients' attendance in the outpatient clinic was possible without decreasing either quality of life or illness perception. ClinicalTrials.gov identifier: NCT03847766Conclusion Differences in the eGFR slope between groups were non-significant and results on non-inferiority were inconclusive. Thus, transitioning to remote PRO-based follow-up requires close monitoring of kidney function. Reducing patients' attendance in the outpatient clinic was possible without decreasing either quality of life or illness perception. ClinicalTrials.gov identifier: NCT03847766 Graphical Abstract

Acute intermittent porphyria is one of eight disorders arising from disturbances in heme biosynthesis where the precursors, 5-aminolevulinate and porphobilinogen, are elevated in plasma and urine. Attacks are characterized by severe abdominal pain, vomiting and/or obstipation, neurological manifestations, and psychological disturbances. The mainstay of treatment is hemin infusion to induce the negative feedback of heme synthesis. Hemodialysis is casuistically suggested as an alternative treatment. We present a case report of a 78-year-old male with acute intermittent porphyria and renal failure treated with peritoneal dialysis resulting in complete discontinuance of longstanding painful and disabling porphyria attacks.

Background Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI. Methods Among 1580 patients participating in the Peridialysis study, a study of causes and timing of DI, we registered features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice. Patients were followed for 12 months or until transplantation. A flexible parametric model was used to identify independent factors associated with all-cause mortality. Results First-year mortality was 19.33%. Independent factors predicting death were high age, comorbidity, clinical contraindications to PD or HD, suboptimal DI, high eGFR, low serum albumin, hyperphosphatemia, high C-reactive protein, signs of overhydration and cerebral symptoms at DI. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD. Conclusions First-year mortality in incident dialysis patients was in addition to high age and comorbidity, associated with clinical contraindications to PD or HD, clinical symptoms, hyperphosphatemia, inflammation, and suboptimal DI. In patients with a “free” choice of dialysis modality based on their personal preferences, PD and in-center HD led to broadly similar short-term outcomes.

We describe the case of a 24-year-old male patient with multiple sclerosis (MS) who was treated with Teriflunomide for eight months. However, due to MS progression, treatment was switched to Ocrelizumab. After 15 months of therapy with Ocrelizumab the patient developed edema and nephrotic-range albuminuria. Kidney biopsy showed focal segmental glomerulosclerosis (FSGS) and Ocrelizumab treatment was stopped. Teriflunomide is less likely to have caused FSGS due to a three week wash-out period and a timespan of 15 months between the last Teriflunomide dose and development of albuminuria. Treatment with Ocrelizumab has been associated with organ-specific inflammation in MS-patients, thus an association between the development of FSGS and Ocrelizumab therapy is possible, and this case suggests considering this potential association.

Abstract BACKGROUND AND AIMS Patients in haemodialysis are a vulnerable group, thought to have a poor antibody response to vaccination. In Denmark dialysis, patients were one of the first patient groups to be vaccinated against COVID-19. By investigating the antibody response of dialysis patients, we will gain unique knowledge about the vaccine efficacy in this group. METHOD The study is a multicentre observational trial involving the dialysis departments of three Danish hospitals: The Regional Hospital Holstebro, the Regional Hospital Viborg and Aalborg University Hospital. All patients had blood samples taken before vaccination (baseline) and three blood samples every third month after vaccination to evaluate the antibody response. COVID-19 antibodies where analysed with Sandwich ELISA technique, which is a routine analysis at the Department of Clinical Microbiology in Aarhus University Hospital with a lowest limit of detection at 4.8 Bau/mL and limit of detection at 2080 Bau/mL. Antibody levels are reported as medians with interquartile range. Non-parametric comparison was performed to evaluate differences. RESULTS A total of 219 patients with chronic kidney failure in haemodialysis were included. Of the 219, 11 (5%) had positive COVID-19 PCR tests prior to baseline blood sampling. However, at baseline prior to vaccination only 6 of 219 (3%) had antibodies higher than the lowest detectable limit of 4.8. Baseline medians were 4.8 (4.8; 4.8) and 9.55 (4.81; 51.5) for all patients and for patients with positive COVID-19 test respectively. Two of the six (33%) patients with confirmed prior COVID infection and with no significant antibody levels were in immunosuppressive treatment. At first sample after vaccination, 35 of 219 (16%) patients had no detectable antibody titer. Overall titre median was 318 (41.7; 985.7). In the above, no distinction was made between those fully vaccinated and those with only 1 dose at the time of the first sample. When only regarding the antibody response of those double vaccinated at first sample, the median is 563.5 (158.5; 1130). For those with COVID-19 infection prior to vaccination, the median titre was 2080 (1900; 2080) at first sample after vaccination. Of the 219, 30 (13.7%) patients were in active immunosuppressive therapy at baseline, at first sample median in this group was lower at 86 (20; 194) (P < .05 compared to patients not on immunosuppression). In the second and third sample after vaccination, taken approximately 3 and 6 months after vaccination, the overall medians were 165(44.4; 385) and 69.4 (20;181) respectively (P < .05 versus before vaccination for both samples). For patients with prior infection, the medians were 1815 (1302; 2080) and 1590 (698.8;2080) respectively (P > .05 versus before vaccination and P < .05 versus patients without prior infections regarding both samples). The patients in immunosuppressing therapy had a median of 26 (10.3; 127.2) and 14.6 (7.8; 43) in second and third sample, respectively. Eight fully vaccinated patients had no antibody response above limit of detection, three of these (38%) were in ongoing treatment with immunosuppressive medication. No correlations were found between antibody response and comorbidity or cause of renal impairment. CONCLUSION This study shows that 211 of 219 dialysis patients have a positive antibody response to the COVID vaccines. Those infected prior to vaccination had a greater response in all the samples. Few patients had low antibody response, some of these were in immunosuppressive treatment. Patients treated with immunosuppressive therapy had a significantly lower antibody response compared to patients not in treatment with this.

BACKGROUND:In patients with end-stage kidney disease (ESKD), home dialysis offers socio-economic and health benefits compared with in-centre dialysis but is generally underutilized. We hypothesized that the pre-dialysis course and institutional factors affect the choice of dialysis modality after dialysis initiation (DI).METHODS:The Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of the choice of dialysis modality were registered.RESULTS:Among 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications [384 ( 24.2%)] or no assessment [106 (6.7%); mainly due to late referral and/or suboptimal DI] or death [26 (1.6%)]. Older age, comorbidity, late referral, suboptimal DI, acute illness and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (HD; 3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to the choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a 'home dialysis first' institutional policy.CONCLUSIONS:Given a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reduce the incidence of late referral and unplanned DI and, in acutely ill patients, by implementing an educational programme after improvement of their clinical condition.

Abstract Background and Aims Home dialysis with peritoneal dialysis (PD) or home hemodialysis (HD) has medical and socioeconomic benefits but home dialysis is generally underutilized. While many factors determine choice of initial dialysis modality, starting patients on home dialysis requires timely planning, educational activities and an active program to promote home dialysis. Here we investigated factors including patient suitability, pre-dialysis preparations and institutional factors determining choice of dialysis modality among patients initiating dialysis. Method Choice of dialysis modality was investigated in 1588 consecutive patients (age 63.8 ±15.3 years. 35.8% female; diabetic nephropathy 24.4%) participating in the Peridialysis study, a multinational multi-centre prospective study of causes and timing of planned and unplanned dialysis initiation (DI) over a 3-year period in 15 Nordic and Baltic nephrology departments. All dialysis modalities were available and free of charge to patients. All centres offered pre-dialysis education programs to patients with timely referral. Clinical and biochemical data during the pre-dialytic period, centre data, and reasons for DI and choice of dialysis modality were registered. Results: 516 (32.4%) patients were not offered home dialysis because they were judged to be unsuitable (384; 24%): PD was contraindicated in 338 (21.2%) patients - for physical (142; 8.9%), mental (80, 5.0%) or abdominal (116; 7.3%) reasons and HD was contraindicated in 46 (2.9%) patients. In addition, 106 (6.7%) were not offered home dialysis for various reasons; and deaths before modality choice occurred in 26 (1.6%) patients. Factors associated with unsuitability were high age, comorbidity, late referral (risk ratio, RR, 1.9), inflammation (C-reactive protein >50 mg/L (RR 2.6) and rapid loss of renal function (RR 2.0). Patients who were not assessed for home dialysis comprised mainly patients with late referral (RR 5.8) and/or unplanned DI (RR 9.6). Of the remaining 1072 (67.6%) patients, who had a free choice of modality, 700 (65.3%) chose home dialysis, either PD (661; 61.7%) or home HD ( 39 3.6%) while 372 (34.7%) patients chose centre HD. Factors associated with choice of centre dialysis were late referral (RR 1.8), suboptimal DI (RR 2.0), symptomatic uraemia (RR 1.6) and p-urea >30 mM (2.6). Somatic differences between patients choosing home dialysis and centre dialysis were minor. Independent institutional factors reducing information about home dialysis were treatment at a university hospital (RR 4.3) and absence of an active preference for home dialysis, “home dialysis first” policy (RR 3.0). Conclusion The results of the Peridialysis study indicate that the incidence of home dialysis could be increased by a “home dialysis first” department policy and by efforts to reduce the incidence of late referrals and unplanned DI. Acutely ill patients and patients with unplanned DI may be candidates for home dialysis if assessment of home dialysis suitability and dialysis educational program are performed after their clinical condition has improved. Given a free choice, most patients (65%) choose home dialysis.

BACKGROUND:Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care. METHODS:In the 'Peridialysis' study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI. RESULTS:SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI. CONCLUSIONS:SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.

Abstract Background and Aims Home dialysis with peritoneal dialysis (PD) or home hemodialysis (HD) has medical and socioeconomic benefits but home dialysis is generally underutilized. While many factors determine choice of initial dialysis modality, starting patients on home dialysis requires timely planning, educational activities and an active program to promote home dialysis. Here we investigated factors including patient suitability, pre-dialysis preparations and institutional factors determining choice of dialysis modality among patients initiating dialysis. Method Choice of dialysis modality was investigated in 1588 consecutive patients (age 63.8 ±15.3 years. 35.8% female; diabetic nephropathy 24.4%) participating in the Peridialysis study, a multinational multi-centre prospective study of causes and timing of planned and unplanned dialysis initiation (DI) over a 3-year period in 15 Nordic and Baltic nephrology departments. All dialysis modalities were available and free of charge to patients. All centres offered pre-dialysis education programs to patients with timely referral. Clinical and biochemical data during the pre-dialytic period, centre data, and reasons for DI and choice of dialysis modality were registered. Results: 516 (32.4%) patients were not offered home dialysis because they were judged to be unsuitable (384; 24%): PD was contraindicated in 338 (21.2%) patients - for physical (142; 8.9%), mental (80, 5.0%) or abdominal (116; 7.3%) reasons and HD was contraindicated in 46 (2.9%) patients. In addition, 106 (6.7%) were not offered home dialysis for various reasons; and deaths before modality choice occurred in 26 (1.6%) patients. Factors associated with unsuitability were high age, comorbidity, late referral (risk ratio, RR, 1.9), inflammation (C-reactive protein >50 mg/L (RR 2.6) and rapid loss of renal function (RR 2.0). Patients who were not assessed for home dialysis comprised mainly patients with late referral (RR 5.8) and/or unplanned DI (RR 9.6). Of the remaining 1072 (67.6%) patients, who had a free choice of modality, 700 (65.3%) chose home dialysis, either PD (661; 61.7%) or home HD ( 39 3.6%) while 372 (34.7%) patients chose centre HD. Factors associated with choice of centre dialysis were late referral (RR 1.8), suboptimal DI (RR 2.0), symptomatic uraemia (RR 1.6) and p-urea >30 mM (2.6). Somatic differences between patients choosing home dialysis and centre dialysis were minor. Independent institutional factors reducing information about home dialysis were treatment at a university hospital (RR 4.3) and absence of an active preference for home dialysis, “home dialysis first” policy (RR 3.0). Conclusion The results of the Peridialysis study indicate that the incidence of home dialysis could be increased by a “home dialysis first” department policy and by efforts to reduce the incidence of late referrals and unplanned DI. Acutely ill patients and patients with unplanned DI may be candidates for home dialysis if assessment of home dialysis suitability and dialysis educational program are performed after their clinical condition has improved. Given a free choice, most patients (65%) choose home dialysis.

INTRODUCTION AND AIMS:Aliskiren as an add-on therapy to losartan further reduced proteinuria among patients with diabetic nephropathy, yet the ALTITUDE study designed to investigate the potential renal protection benefits using this combination was prematurely terminated due to increased adverse events in the aliskiren arm.The potential long-term efficacy of aliskiren in non-diabetic chronic kidney disease (CKD) is unknown.METHODS: This open-label, prospective, randomized, controlled trial investigated the renoprotective potential and safety of aliskiren added to an angiotensin II receptor blocker in non-diabetic CKD stages 3-4 patients in a University teaching hospital in Hong Kong.Eligible patients receiving an ARB at the maximal dose were randomly assigned aliskiren or conventional treatment to achieve BP under 130/80 mmHg.The coprimary outcomes were doubling of baseline serum creatinine (sCr) or a 40% reduction in estimated glomerular filtration rate (eGFR); and incident end-stage renal disease (ESRD).Secondary endpoints included cardiovascular events, hyperkalemia and death.RESULTS: 76 patients were randomized: 37 to aliskiren (27 male, mean age 55.0611.1 y), and 39 to control (27 male, mean age 55.069.4 y).There was no difference in baseline demographics, sCr (194661 vs. 215665 lmol/l, P¼0.15), eGFR (31.969.0 vs. 27.769.0ml/min/1.73m 2 , P¼0.05), and urine protein-to-creatinine ratio for treatment vs. control subjects.After a follow-up of 144 weeks, four patients in intervention group and seven patients in control group reached the composite endpoint of doubling of sCr or ESRD (10.8% vs. 18.0%,P¼0.377).The number of cardiovascular events was 4 (10.8%) vs. 1 (2.6 %), P¼0.147.Hyperkalemia was encountered in 7 (18.9%) vs. 2 (5.1%) patients (P¼0.063).There was no difference in the rate of eGFR change or proteinuria between the 2 groups.CONCLUSIONS: Aliskiren conferred no additional renoprotective benefit nor increased adverse events except for more hyperkalemia in non-diabetic CKD patients.

The aim of this study was to document the differences between two Roche creatinine measurement methods, the CREP2 test on the cobas c702 and the CREA PLUS test on the Modular P. Samples with creatinine isotope dilution mass spectrometry (IDMS) values were analyzed on both instruments. Method comparison using the remaining plasma samples was performed twice, using two different lot numbers of reagents and two different lot numbers of calibrators on both instruments. Medians and percentiles of the plasma creatinine values produced on the Modular P and cobas c702 from 2012 to 2017 were compared. The recovery of samples with IDMS creatinine values (SRM 967a level 1, SRM 967a level 2, serum X and five serum pools from Roche) was 101.7%-110.2% on the cobas c702 and 98.9%-102.6% on the Modular P. Comparison of the two methods showed that the slope was close to 1.0 using linear, Deming and Passing Bablok regressions, but all equations showed a negative intercept, indicating that the cobas c702 overestimates plasma creatinine in relation to the Modular P by 4-6 mu mol/L. The median value for routine plasma creatinine lies between 74 and 77 mu mol/L for the Modular P and 81 mu mol/L for the cobas c702. After the cobas c702 was factorized in September 2016, the median plasma creatinine value decreased to 75 mu mol/L. In conclusion, the CREP2 method on the cobas c702 overestimates creatinine by 4-6mol/L, which has a significant influence on the estimated glomerular filtration rate (eGFR) in children.

68% vs. 69% for acute )), and 38% for those not requiring ) as compared to ESRD patients).The cumulative 5-year mortality after ICU admission with 95 % CI appears in figure 2. 90-day ESRD survivors were younger, less severely ill and needed less vasopressor treatment than 90-day ESRD non-survivors.CONCLUSIONS: Acute RRT patients had a higher crude short-term mortality than patients with preexisting ESRD but did not have a significantly different mortality after adjustment for confounders.This could have been due to a lack of power, but it may be speculated that this reflected acute RRT patients being more severely ill.The short-term mortality of patients with preexisting ESRD was comparable to that of patients not receiving RRT when adjusted for confounders, although the crude mortality was considerably higher.The severity of acute illness and the burden of comorbidities seem more important than the lack of kidney function in itself in evaluating the patient for the possible benefit of being admitted to the ICU.

OBJECTIVE:Patients on maintenance hemodialysis (HD) are unable to compensate for an enlarged mineral load with increased excretion of calcium and phosphate in the urine. Hence, excess calcium and phosphate must be neutralized by other mechanisms to avoid toxicity. The present study examined the acute handling of a mineral load in HD patients as compared with healthy subjects.DESIGN:Controlled intervention study.SUBJECTS:Twelve HD patients and 12 matched healthy subjects.INTERVENTION:After a weight-adjusted standardized meal, blood samples were collected for the following 9 hours for ionized calcium, phosphate, parathyroid hormone (PTH), and fibroblast growth factor-23 (FGF23). The fractional excretion of calcium and phosphate was measured in controls. The patients were not allowed to take phosphate binders 24 hours before the experiment, and the study was performed on a non-HD day.RESULTS:In healthy subjects, plasma calcium and phosphate did not change significantly from baseline, whereas HD patients demonstrated a decrease in plasma phosphate from 60 to 120 minutes by maximum 10% ([6; 13%], mean [95% confidence interval], P < .001) below baseline. PTH increased in both HD patients and controls and peaked 300 minutes after the meal 11% ([4; 19%], P < .004) above baseline in both groups. No changes in FGF23 were observed in HD patients, whereas FGF23 steadily decreased in controls, reaching nadir values at the end of the study 16% ([10; 21%], P < .001) below baseline. Control subjects demonstrated an immediate postprandial increase in the fractional excretion of both calcium and phosphate CONCLUSIONS: In HD patients, the mineral load paradoxically induced a decrease in plasma phosphate, whereas ionized calcium remained unchanged although PTH increased. These findings suggest that excess calcium and phosphate may be disposed of by mineral deposition, which may include soft tissue and vascular calcification.

IntroductionThe aim of this study was to establish reference intervals for plasma cystatin C and creatinine in adults using the Gentians cystatin C method traceable to the international calibrator standard ERM‐DA471/IFCC and a creatinine method traceable to the IDMS (Isotope Dilution Mass Spectrometry) creatinine reference method.MethodsBlood samples were collected from 304 healthy blood donors (152 men and 152 women between 17 and 66 years old) with 30‐31 men and 30‐31 women in each ten‐year interval. Plasma cystatin C was analyzed using the Gentian Cystatin C assay on a Roche cobas c702 analyzer, and plasma creatinine was analyzed using the CREA Plus assay on the Roche Modular P analyzer.ResultsThe nonparametric reference intervals for plasma cystatin C were 0.58‐1.00 mg/L in women (median 0.78 mg/L, range 0.56‐1.06 mg/L) and 0.62‐1.04 mg/L in men (median 0.79 mg/L, range 0.61‐1.07 mg/L). The Mann‐Whitney U test revealed no gender‐related difference in plasma cystatin C (P = .21). A common reference interval in women and men was calculated to be 0.61‐1.01 mg/L (median 0.79 mg/L, range 0.56‐1.07 mg/L). The nonparametric reference interval for plasma creatinine was 52‐89 μmol/L in women (median 69 μmol/L, range 52‐92 μmol/L) and 61‐108 μmol/L in men (median 86 μmol/L, range 56‐118 μmol/L). The Mann‐Whitney U test revealed a gender‐related difference in plasma creatinine (P < .0001).ConclusionIn conclusion, we have established reference intervals for plasma cystatin C and creatinine in adults using methods traceable to international standards.

Dent's disease is characterized by manifestations of proximal tubule dysfunction including hypercalciuria, kidney stones, proteinuria, rickets and progressively declining kidney function. The diagnosis is based on the presence of low-molecular-weight proteinuria, hypercalciuria and at least one of the following: nephrocalcinosis, kidney stones, haematuria, hypophosphataemia or renal insufficiency. Dent's disease is a hereditary condition that is caused by variants in the CLCN5 gene or the OCRL1 gene and affects only males. Herein, we report on two brothers who were found to have a previously reported disease-causing variant in the CLCN5 gene. One sibling had nephrocalcinosis, proteinuria and hypercalciuria, whereas the other sibling was asymptomatic and had normal laboratory findings.

Introduction The incidence of unplanned dialysis initiation (DI) with consequent increased comorbidity, mortality and reduced modality choice remains high, but the optimal timing of dialysis initiation (DI) remains controversial, and there is a lack of studies of specific reasons for DI. We investigated why and when physicians prescribe dialysis and hypothesized that physician motivation for DI is an independent factor which may have clinical consequences. Methods In the Peridialysis study, an ongoing multicenter prospective study assessing the causes and timing of DI and consequences of unplanned dialysis, physicians in 11 hospitals were asked to describe their primary, secondary and further reasons for prescribing DI. The stated reasons for DI were analyzed in relation to clinical and biochemical data at DI, and characteristics of physicians. Results In 446 patients (median age 67 years; 38% females; diabetes 25.6%), DI was prescribed by 84 doctors who stated 23 different primary reasons for DI. The primary indication was clinical in 63% and biochemical in 37%; 23% started for life-threatening conditions. Reduced renal function accounted for only 19% of primary reasons for DI but was a primary or contributing reason in 69%. The eGFR at DI was 7.2 ±3.4 ml/min/1.73 m2, but varied according to comorbidity and cause of DI. Patients with cachexia, anorexia and pulmonary stasis (34% with heart failure) had the highest eGFR (8.2–9.8 ml/min/1.73 m2), and those with edema, “low GFR”, and acidosis, the lowest (4.6–6.1 ml/min/1.73 m2). Patients with multiple comorbidity including diabetes started at a high eGFR (8.7 ml/min/1.73 m2). Physician experience played a role in dialysis prescription. Non-specialists were more likely to prescribe dialysis for life-threatening conditions, while older and more experienced physicians were more likely to start dialysis for clinical reasons, and at a lower eGFR. Female doctors started dialysis at a higher eGFR than males (8.0 vs. 7.1 ml/min/1.73 m2). Conclusions DI was prescribed mainly based on clinical reasons in accordance with current recommendations while low renal function accounted for only 19% of primary reasons for DI. There are considerable differences in physicians´ stated motivations for DI, related to their age, clinical experience and interpretation of biochemical variables. These differences may be an independent factor in the clinical treatment of patients, with consequences for the risk of unplanned DI.

OBJECTIVE:To investigate the response of serum fibroblast growth factor 21 (FGF21) to a meal and to insulin infusion in haemodialysis (HD) patients.DESIGN AND PATIENTS:Meal study: in a crossover design, 12 nondiabetic HD patients were randomly assigned to: (1) a non-HD day with one meal served, (2) a HD day with one meal served during HD and (3) a HD day with two meals served during and after HD, respectively. Twelve healthy controls participated in an experiment identical to the non-HD day. Insulin infusion study: in a crossover design, 11 nondiabetic HD patients were randomly assigned to receive a 4-h HD session with either: (1) no infusion, (2) glucose infusion or (3) glucose-insulin infusion. A meal was served 2 h before HD start.RESULTS:Meal study: serum FGF21 was 23-fold higher in HD patients than controls (P < 0·001). Postprandial FGF21 decreased on all four study days (P < 0·006), but the relative reductions from baseline were significantly greater in controls (P < 0·008). Postprandial changes in FGF21 were inversely related with triglycerides (P = 0·042) and positively related with insulin-like growth factor binding protein-1 (IGFBP-1) (P < 0·001). Serum FGF21 was only associated with changes in adiponectin (P = 0·001) and free fatty acids (P = 0·04) in the healthy controls. Insulin infusion study: as compared with no infusion, glucose and glucose-insulin infusion prevented the postprandial decrease in FGF21 and resulted in higher FGF21 concentrations by up to 25% (P = 0·003).CONCLUSIONS:Serum FGF21 was highly elevated in HD patients but the response of serum FGF21 to meal intake and insulin infusion seemed to be intact. Our results indicate that FGF21 may play an important role in short-term metabolic homoeostasis.