Data on the efficacy and safety of sacubitril/valsartan in hemodialysis patients with heart failure and preserved left ventricular ejection fraction (≥ 50%, HFpEF) or mildly reduced left ventricular ejection fraction (41%-49%, HFmrEF) were analyzed, as well as cardiac functional parameters and safety after withdrawal of sacubitril/valsartan. Ninety-eight maintenance hemodialysis patients with heart failure with preserved or mildly reduced ejection fraction were included in the present study. Patients were divided into sacubitril/valsartan and control groups according to whether they had been, or were being, treated with sacubitril/valsartan. Patients were further divided into continuation and discontinuation groups based on whether sacubitril/valsartan was discontinued at the end of follow-up. Laboratory examination results, echocardiographic parameters, and the occurrence of major adverse cardiac events were recorded and analyzed. There were 50 patients in the control group and 48 in the sacubitril/valsartan group. The median follow-up time was 14.5 months. Compared with the control group, the serum B-type natriuretic peptide levels and echocardiographic parameters in the sacubitril/valsartan group significantly decreased from baseline at 6-month follow-up (p < 0.05). In the sacubitril/valsartan group, there were 28 patients in the continuation group and 20 in the discontinuation group. The reduction in left ventricular end-diastolic diameter in the sacubitril/valsartan group reversed in the discontinuation group (by 10%) after drug withdrawal, whereas it was stable in the continuation group (change 0.66%, p = 0.030). Patients with lower left ventricular end-diastolic diameters at the end follow-up (≤ 50 mm) exhibited a lower incidence of major adverse cardiac events compared to those with higher diameters (>50 mm; p = 0.012). Sacubitril/valsartan improved cardiac function in patients on hemodialysis with heart failure and preserved or mildly reduced left ventricular ejection fraction. Long-term continuous use of sacubitril/valsartan may reduce left ventricular end-diastolic diameter and positively impact prognosis.
Gastrointestinal bleeding is very common among hemodialysis patients. This high bleeding risk is caused by uremic platelet dysfunction, vascular fragility, intradialytic hemodynamic instability, and widespread antithrombotic therapy. Small bowel lesions, especially angiodysplasias, constitute a significant but often overlooked source of recurrent or occult hemorrhage while conventional endoscopy frequently fails to identify these lesions. Investigation of small bowel lesions in hemodialysis patients and identification of bleeding risk of this vulnerable population. Narrative review. English language studies in the last 25 years using PubMed and Google Scholar databases up to November 2025. Search terms included "hemodialysis," "small bowel lesions," "angiodysplasia," and "gastrointestinal bleeding." The review incorporates different types of research including observational cohorts, randomized trials, cross-sectional studies, systematic reviews, and narrative reviews involving hemodialysis adult or end stage renal disease populations. Across the analysis of 26 studies, capsule endoscopy revealed a significantly higher prevalence of small bowel lesions in hemodialysis patients compared to controls, with angiodysplasias being the most frequent finding. Large-scale epidemiological analyses identified hemodialysis as an independent risk factor for gastrointestinal hemorrhage compared to peritoneal dialysis, providing the clinical background for the increased susceptibility of these patients to small bowel-specific lesions. Overall, patients have a higher risk of rebleeding tendency than controls and exhibited a high-risk phenotype characterized by recurrent angiodysplasia-related bleeding and elevated one-year mortality rates following the first bleeding episode. Small bowel lesions may constitute a major and underrecognized cause of gastrointestinal bleeding in hemodialysis patients. Capsule endoscopy offers the highest diagnostic yield, yet optimal treatment strategies remain undefined, and recurrent bleeding episodes are common. Thus, effective management requires early detection, individualized therapeutic planning, and careful treatment with anticoagulant and antiplatelet drugs.
Synthetic dialysis membranes, particularly those composed of polysulfone blended with polyvinylpyrrolidone, are commonly used in hemodialysis due to their efficiency. However, hypersensitivity reactions-often atypical and not fitting traditional type A and B classifications-have increasingly been reported. Symptoms include chest tightness, bronchospasm, oxygen desaturation, and hypotension, often without clear etiology. The need for safer alternatives has led to interest in newer dialyzer technologies, such as the hydrophilic helixone membrane which incorporates tocopherol to enhance biocompatibility. We conducted a multicenter, retrospective observational study in four hemodialysis units in Catalonia (Spain). Thirty-one stable patients previously diagnosed with hypersensitivity to synthetic membranes and dialyzing with cellulose triacetate were switched to hydrophilic helixone (CorAL) dialyzers. Clinical data, including symptoms before and after the switch, were extracted from medical records. The primary outcome was the occurrence of adverse reactions after the transition. Of the 31 patients (mean age 70.1 ± 13.9 years), the most common symptoms at initial reaction included cutaneous (21, 67.7%), respiratory (13, 41.9%), and cardiovascular (9, 29.0%) manifestations. After switching to hydrophilic helixone, 28 patients (90.3%) had no further hypersensitivity symptoms over a mean follow-up of 5.8 ± 4.3 months. Three patients experienced mild reactions (two with pruritus, one with hypotension) and reverted to cellulose triacetate. No significant associations were found between relapse and the type of membrane or symptom profile. The hydrophilic helixone membranes appear to be a safe and well-tolerated alternative for patients with a history of hypersensitivity to synthetic membranes. These findings suggest that hydrophilic helixone dialyzers may allow more patients to continue treatment with synthetic membranes without severe reactions, potentially improving biocompatibility and treatment flexibility in routine clinical practice. While the findings are promising, larger prospective studies are necessary to confirm the safety and long-term clinical benefits.
Loss of skeletal muscle mass in chronic kidney disease is strongly associated with reduced physical function and increased mortality. Although well recognized, the impact of volume overload, on physical function and muscle strength, remains understudied. This study aimed to assess the association between volume overload, physical function, and muscle strength in individuals on hemodialysis. Fifty-two individuals on hemodialysis were included. Muscle strength was assessed using hand dynamometry, defining dynapenia as muscle strength < 20 kg in women and < 30 kg in men. Physical function was measured using the short physical performance battery, with "low physical function" defined as a score ≤ 8.0. Bioelectrical impedance vector analysis z-score graph was plotted according to physical function and muscle strength classification as normal or reduced. Resistance and reactance data, normalized to height, were converted into z-scores and plotted on a z-score graph. The comparison of bioelectrical impedance vector analysis between groups was performed using Hotelling's T 2 test. In addition, multivariate logistic regression was used to explore the association between volume overload with muscle strength and physical function. Bioelectrical impedance vector analysis z-score graphs showed that individuals with reduced physical function were outside the 95th percentile of the major axis, indicating volume overload, while those with normal physical function had adequate hydration status (p < 0.0001). In Model 1 of the multivariate logistic regression, volume overload was associated with low physical function. In Model 2, none of the independent variables were associated with muscle strength. Individuals on hemodialysis with reduced physical function exhibited higher volume overload. Although volume overload is associated with worse physical function, no association was observed with muscle strength.
Hemodialysis, the primary treatment for chronic kidney disease, prolongs life but is frequently accompanied by physical and psychological symptoms that impair quality of life. Progressive muscle relaxation exercises offer a novel non-pharmacological approach to symptom management. This study aimed to evaluate progressive muscle relaxation exercises on dialysis-related symptoms (primary outcome) and quality of life (secondary outcome) in patients undergoing hemodialysis. A randomized controlled pre-test-post-test study was conducted between May and September 2025 in two dialysis units in eastern Türkiye. Ninety-two hemodialysis patients were randomly assigned to either an intervention group (n = 46) or a control group (n = 46). The intervention group received 24 sessions of progressive muscle relaxation exercises over 8 weeks, while the control group received routine care. Data were collected at baseline and after the intervention using the dialysis symptom index and the Short Form-36 quality-of-life scale. The groups were similar in baseline. After the intervention, the progressive muscle relaxation exercises group demonstrated a significant reduction in symptom burden, with mean dialysis symptom index scores decreasing from 29.4 ± 13.3 to 16.3 ± 6.77 (t = 7.21, p < 0.001). Short-Form-36 quality-of-life scores increased from 51.4 ± 9.83 to 65.8 ± 10.1 (t = 4.67, p < 0.001), with significant improvements in physical functioning, vitality, pain, general health, and mental well-being (p < 0.05). Progressive muscle relaxation exercises reduced dialysis-related symptoms and improved quality of life in hemodialysis patients. Given its simplicity, non-invasive nature, and low cost, it may be used as a complementary intervention in routine hemodialysis care. Further research should examine long-term effects and broader clinical applicability.
The relationship between serum calcium levels at the initiation of hemodialysis and coronary artery calcium score (CACS) remains unclear. This study examined whether albumin-corrected calcium (correctedCa; Payne's formula) and ionized calcium (ionizedCa) measured at dialysis initiation are associated with CACS assessed by screening coronary computed tomography. This single-center cross-sectional study included 176 adults who initiated hemodialysis between 2015 and 2023 and underwent coronary computed tomography with CACS measurement within ±30 days. Restricted cubic spline (RCS) logistic regression was used to evaluate the associations of correctedCa and ionizedCa with CACS ≥ 400, adjusting for clinical covariates. Subgroup analyses were performed according to the median serum albumin level. For models in which nonlinearity was not significant, logistic models treating the variable as a linear term were fitted to calculate odds ratios (OR) per 1-standard deviation (SD) increase. The mean age was 70.9 years, 32.9% were women, 54.3% had diabetes, and the mean eGFR was 5.45 mL/min/1.73 m2. Higher calcium levels were associated with higher CACS. ionizedCa showed a linear association with CACS ≥ 400 (OR per 1-SD, 1.51; 95% CI, 1.08-2.11). correctedCa also showed a statistically linear association (OR per 1-SD, 1.53; 95% CI, 1.09-2.13), although the RCS curve visually plateaued at higher correctedCa levels. Subgroup analyses revealed that this convex pattern was driven by the low-albumin group. Higher calcium at hemodialysis initiation was associated with increased coronary calcification. ionizedCa tended to show a more stable linear relationship with CACS than correctedCa, as correctedCa may overestimate ionizedCa in patients with low albumin. Measurement of ionizedCa at dialysis initiation may help refine vascular calcification risk stratification as patients enter the dialysis period.
Hemodialysis water distribution systems represent a critical component of dialysis treatment, requiring meticulous design and material selection to ensure water purity and patient safety. Recent advances in biomaterial science and fluid dynamics have revolutionized our understanding of optimal system design, particularly regarding biofilm mitigation strategies. This review examines cutting-edge developments in water distribution loop design, focusing on novel approaches to flow dynamics optimization, next-generation material compatibility, and innovative disinfection protocols specifically tailored for dialysis applications. We present a comprehensive evaluation of both traditional and emerging piping materials. The analysis incorporates recent clinical data on material performance in actual dialysis centers, including polyvinylchloride (PVC), chlorinated PVC (CPVC), polyvinylidene fluoride (PVDF), cross-linked polyethylene (PEX), and stainless steel. The manuscript introduces a new paradigm for maintaining adequate flow velocities (1.5-6 feet per second [FPS]) through dynamic flow modulation technology. Furthermore, we detail groundbreaking construction techniques that reduce contamination risks and analyze the latest disinfection methods, presenting clinical evidence supporting the superiority of pulsed-thermal disinfection systems (80°C-85°C with variable pressure cycles) for biofilm prevention. The discussion challenges traditional PVC system dogma and presents a compelling case for smart material systems like nano-enhanced PEX and antimicrobial stainless steel, supported by longitudinal studies. Finally, we address the critical practical considerations of cost, operational logistics, and regulatory compliance that influence the adoption of these advanced technologies in modern dialysis installations.
Hemodialysis professionals are particularly at risk due to the chronic nature of patient care and the intense emotional burden it entails. The aim of this study is to determine the levels of compassion fatigue and brain fog among healthcare professionals working in these units, to examine the relationship between them, and to identify their predictive factors. This study employed a descriptive and analytical design, with data collected between February 16 and June 16, 2024. Reporting followed the STROBE checklist. The study population consisted of healthcare professionals working in private and public hemodialysis centers in Turkey. A non-probability snowball sampling method was used. Data were collected using a Descriptive Information Form, the Compassion Fatigue-Short Scale, and the Brain Fog Scale. Of the participants, 82.0% were female, and 33.6% were between 36 and 45 years of age. Participants reported moderate levels of compassion fatigue (59.67 ± 21.25) and high levels of brain fog (80.01 ± 26.53). A strong positive correlation was observed between compassion fatigue and brain fog (r = 0.744, p < 0.001). Compassion fatigue levels were significantly predicted by gender, profession, and brain fog (p < 0.005). Conversely, brain fog levels were significantly predicted by the institution of employment, profession, and compassion fatigue (p < 0.005). Healthcare professionals experienced moderate levels of compassion fatigue and high levels of brain fog, both of which can impair well-being and job performance. Early recognition and management of these conditions are crucial. Nursing practice and health policy should emphasize supportive interventions such as mental health programs, resilience training, and workload management to protect staff well-being and sustain quality patient care.
Patients with kidney failure receiving dialysis are at an increased risk of cardiovascular events. Hemodiafiltration (HDF) has been shown to decrease cardiovascular mortality. Due to concerns around technical challenges and the need to achieve ultra-pure water standards, HDF is not readily available for those receiving hemodialysis at home. This study was conducted to describe the process and outcomes in implementing a home HDF program. Patients who received home HDF training between 2014 and 2024 at the Princess Alexandra Hospital, Australia were included. The primary outcome was the proportion of patients who successfully completed training for HDF at home. Outcomes related to training duration, water, and clinical outcomes including hospitalizations, transfer to facility-based hemodialysis were analyzed descriptively. In total, 42 patients (67% male, mean age 51.1 ± 12.8 years) undertook HDF therapy at home. About 39 patients commenced HDF training with a 100% training success rate, and 3 patients were supported by nursing-assisted HDF therapy at home. Median training duration was 61 days, which was longer for patients who were new to starting home dialysis (126 days), compared to those who converted from home hemodialysis to HDF (14.5 days, p < 0.05). HDF prescriptions were highly variable (mean treatment hours 15.7 ± 4.9 h/week). The median time of home HDF treatment was 17.5 months (interquartile range IQR 9.9-31). In the first 6 months after starting HDF at home, there were no hospitalizations due to dialysis-related technical issues including water-related problems. Three patients (7%) transitioned to facility-based hemodialysis. HDF at home is a safe therapy for patients who are considered to receive hemodialysis at home, offering increased flexibility and personalized prescriptions.
To investigate the effects of precannulation ice massage on pain, ecchymosis, hematoma, and patient satisfaction during arteriovenous (AV) fistula cannulation in patients receiving maintenance hemodialysis. This nonrandomized, sequential crossover study included 40 hemodialysis patients. Each participant underwent routine cannulation (control condition) followed by precannulation ice massage (intervention condition) in subsequent sessions. Pain and satisfaction were assessed using a 10-point Visual Analog Scale. Ecchymosis and hematoma were measured using transparent grid film with computerized area calculation. Data were analyzed using repeated-measures analysis of variance and Cohen's d. Ice massage significantly reduced pain during cannulation (Visual Analog Scale: 2.90 ± 1.08 vs. 6.12 ± 1.34; p < 0.001, d = 2.64), 72-h ecchymosis (2.02 ± 0.80 mm2 vs. 4.95 ± 1.41 mm2; p < 0.001, d = 2.55), and 72-h hematoma (1.57 ± 1.05 cm vs. 2.85 ± 0.83 cm; p < 0.001, d = 1.35). Patient satisfaction was significantly higher in the intervention condition (8.12 ± 0.72 vs. 5.02 ± 1.07; p < 0.001, d = 3.39). Precannulation ice massage is an effective, noninvasive intervention to reduce cannulation pain, minimize local complications, and enhance patient satisfaction. This simple and cost-effective method should be integrated into evidence-based hemodialysis care protocols. ClinicalTrials.gov identifier: NCT06332118 (prospectively registered).
Patients undergoing maintenance hemodialysis frequently encounter a substantial psychosocial burden, yet conventional care frequently lacks the capacity to deliver comprehensive, sustained psychosocial support due to limitations in resources. Nurse-led peer support, which integrates professional expertise with the lived experience of peers, presents a promising complementary model; however, its consolidated efficacy in this population lacks rigorous synthesis. This systematic review and meta-analysis aimed to evaluate the effects of nurse-led peer support on self-management, psychological status, and quality of life in patients receiving maintenance hemodialysis. This review systematically searched ten databases (PubMed, Web of Science, Embase, CINAHL, Cochrane Library, Scopus, CNKI, WanFang, VIP, and SinoMed) from their inception to 20 January 2025 for randomized controlled trials and quasi-experimental studies. A meta-analysis was performed using random-effects models to pool standardized mean difference (SMD). The quality assessment and meta-analysis were conducted utilizing the Cochrane RevMan 5.4 software, with the evidence quality being evaluated employing the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. The present study is registered in PROSPERO with the registration number CRD42025639997. A total of 292 literature records were retrieved, among which 27 studies met the inclusion criteria, and 11 provided data suitable for analysis (n = 1074). The overall risk of bias was thus determined to be low to moderate. Peer support demonstrated significant benefits for self-management (SMD = 0.77, 95% CI: 0.60-0.94; I2 = 35%), quality of life (SMD = 0.91, 95% CI: 0.50-1.32; I2 = 77%), and depression (SMD = -0.87, 95% CI: -1.39-0.36; I2 = 70%). Evidence from two studies suggests that anxiety may be alleviated. The certainty of evidence was moderate for most outcomes. This systematic review and meta-analysis indicates that nurse-guided peer support improves self-management capabilities and quality of life among maintenance hemodialysis patients while alleviating depressive and anxiety symptoms. Due to the limited number of included studies and heterogeneity in intervention protocols, implementation formats, and supporter criteria, the certainty of evidence is mostly moderate. However, consistent results support the positive clinical benefits of this intervention. Therefore, integrating structured peer support into routine care systems represents an effective complementary strategy. Future research should focus on identifying key factors influencing its efficacy, developing standardized intervention protocols, and validating the effectiveness and sustainability of blended online-offline delivery models.
Patients on hemodialysis have comorbidities and malnutrition and are subject to polypharmacy, which contributes to disability and sarcopenia. These conditions increase the risk of falls and are associated with fractures, morbidities, substantial costs, nursing home admissions, hospitalization, and mortality. This prospective study evaluated the association of physical function, postural balance, frailty, fear of falling, and quality of life with the occurrence and number of falls within a 12-month interval in patients on hemodialysis. Patients were assessed for physical function (gait speed over 15 ft., timed up and go [TUG] test, 5-repetition sit-to-stand [5-STS] test, and handgrip strength), postural balance (Mini-Balance Evaluation Systems Test [Mini-BESTest]), frailty, fear of falling (Falls Efficacy Scale-International [FES-I]), and quality of life (36-Item Short Form Health Survey [SF-36]). Interviews were conducted for 12 months to monitor falls. One hundred twelve patients were included and the incidence rate was 1.62 falls/person-years. The occurrence of falls was associated with the TUG (OR: 1.24; 95% CI: 1.01-1.53) and 5-STS (OR: 1.11, 95% CI: 1.02-1.21) performance and frailty (OR: 7.22, 95% CI: 1.71-30.50). The number of falls was associated with the gait speed (OR: 0.22; 95% CI: 0.06-0.77), TUG test results (OR: 1.37; 95% CI: 1.16-1.62), handgrip strength (OR: 0.95; 95% CI: 0.91-0.99), Mini-BESTest (OR: 0.87; 95% CI: 0.78-0.96), frailty (OR: 4.43; 95% CI: 1.87-10.51), FES-I score (OR: 1.11; 95% CI: 1.06-1.17), and SF-36 scores in the physical functioning (OR: 0.98; 95% CI: 0.96-0.99), physical role (OR: 0.99; 95% CI: 0.98-0.99), and physical component summary (OR: 0.96; 95% CI: 0.92-0.99) domains. Patients undergoing hemodialysis have a higher incidence of falls. Falls are associated with physical function, postural balance, frailty, and quality of life.
The primary objective was to evaluate the impact of the Community-Hospital-Family Interactive Management (CHFIM) Model on social isolation in elderly patients undergoing maintenance hemodialysis. Secondary objectives included assessing its effects on social support, loneliness, depression, and family function. A total of 160 elderly maintenance hemodialysis patients from the Blood Purification Center of Taixing People's Hospital between July 2023 and March 2024 were selected as the study subjects. Using a controlled trial design, the patients were divided into a control group (n = 80) and an intervention group (n = 80). The control group received routine care, while the intervention group received Community-Hospital-Family Interactive Management. The social network level, social support level, loneliness, and depression levels of the two groups were compared. After the intervention, the intervention group showed significant improvements in social network level (primary outcome) and social support, along with significant reductions in loneliness and depression (secondary outcomes) compared to the control group (p < 0.05). The CHFIM Model effectively reduces social isolation in elderly maintenance hemodialysis patients, promoting their physical and mental health. Chinese Clinical Trial Registry, ChiCTR2500107611.
Hemodiafiltration has demonstrated improved outcomes in end-stage kidney disease, particularly with higher convection volumes than conventional hemodialysis. However, data on multiethnic Asian populations remain limited. This study evaluated the feasibility of achieving relatively high targeted convection volumes in hemodiafiltration in patients with end-stage kidney disease in Singapore. This retrospective cohort analysis included 1404 patients undergoing hemodiafiltration between 2019 and 2023 at Fresenius Kidney Care clinics in Singapore using data obtained from the EuCliD database. Patients aged ≥ 18 years and on hemodiafiltration for > 3 months were included. Multivariate regression models were used to assess the factors associated with the attainment of convection volume. Over 291,000 hemodiafiltration sessions were analyzed. The mean convection volumes achieved were 21.8 L in post-dilution and 40.8 L in pre-dilution mode. Higher blood flow rates and treatment durations were significantly associated with relatively high targeted convection volume (p < 0.001). The distribution of convection volume was similar among Chinese, Indian, and Malay patients. Ethnicity, age, and vascular access were not significant predictors. Approximately 29% of the variation in achieved convection volume was attributable to center-related factors. Relatively high targeted convection volume in hemodiafiltration was consistently achieved across a multiethnic cohort in Singapore. These findings support the feasibility of delivering high-volume hemodiafiltration to diverse real-world settings.
This study aimed to evaluate the effects of three different music-based interventions on anxiety and fatigue levels in patients undergoing hemodialysis, compared to a concurrent control group receiving standard care. This randomized controlled trial involved 64 patients receiving maintenance hemodialysis. They were randomly assigned to four equal groups (n = 16 each): live music, live ney sound therapy (using a traditional reed flute known for its soothing, breath-like tones), a music-repeating robotic parrot therapy (an interactive robotic parrot that repeats music or sounds provided by the patient), or a control group (no intervention). The experimental groups received 30-min sessions 3 days per week for 2 months. The "Beck Anxiety Scale" and "Fatigue Severity Scale" were used to measure anxiety and fatigue, respectively. Assessments were performed before the intervention, immediately after the 2-month intervention period, and at 2 months after the end of the intervention period. Before the intervention, there were no significant differences in anxiety or fatigue scores across the four groups (p > 0.05). After the interventions, all three groups exposed to music therapy showed significant reductions in both anxiety and fatigue scores compared to the control group (p < 0.001). All three therapies were effective in managing anxiety and fatigue symptoms in hemodialysis patients. Among them, music-repeating robotic parrot therapy demonstrated the most superior and longest-lasting effects in reducing both anxiety and fatigue levels. ClinicalTrials.gov identifier: NCT07238374.
Late arteriovenous fistula (AV fistula) occlusion is a major cause of morbidity in hemodialysis patients. The Systemic Immune-Inflammation Index (SII), Neutrophil-to-Lymphocyte Ratio (NLR), and Geriatric Nutritional Risk Index (GNRI) have emerged as candidate prognostic biomarkers. This study aimed to compare their predictive accuracy, evaluate their independent prognostic value, and develop a combined risk score. This retrospective cohort study included 750 hemodialysis patients undergoing primary AV fistula creation. Baseline Systemic Immune-Inflammation Index, Neutrophil-to-Lymphocyte Ratio, and Geriatric Nutritional Risk Index were collected preoperatively. The primary outcome was late AV fistula occlusion (> 90 days). Predictive performance was assessed using ROC analysis and Cox proportional hazards regression. Over a median follow-up of 48 months, 38.0% of patients developed late AV fistula occlusion. Systemic Immune-Inflammation Index demonstrated the highest predictive accuracy (AUC: 0.79), significantly outperforming Geriatric Nutritional Risk Index (p < 0.001). In multivariate analysis, Systemic Immune-Inflammation Index > 850 (Hazard ratios 3.15, 95% CI: 2.28-4.35), Neutrophil-to-Lymphocyte Ratio > 4.5 (Hazard ratios 2.78, 95% CI: 2.02-3.82), and Geriatric Nutritional Risk Index < 92 (Hazard ratios 1.92, 95% CI: 1.41-2.62) were independent predictors. A combined risk score integrating these biomarkers achieved superior discrimination (AUC: 0.83). Baseline vascular diameters were not independently associated with occlusion risk in this cohort. The synergistic interaction between inflammation and malnutrition identifies a distinct high-risk phenotype. The combined risk score is a readily implementable tool that may support personalized surveillance strategies to improve long-term AV fistula outcomes in hemodialysis patients.
Central venous stenosis and occlusion are recognized complications in hemodialysis patients and commonly present with ipsilateral arm, neck, or facial swelling. Unilateral breast edema is an uncommon manifestation that may mimic primary breast disorders and delay diagnosis. A 58-year-old woman with end-stage kidney disease receiving maintenance hemodialysis through a left-arm arteriovenous fistula presented with progressive unilateral left breast swelling accompanied by ipsilateral arm edema and facial congestion. Clinical evaluation excluded infection, malignancy, and lymphedema. Duplex ultrasonography suggested a central venous abnormality, and venography demonstrated complete occlusion of the left brachiocephalic vein with extensive collateral venous circulation. Endovascular treatment was performed with balloon angioplasty followed by self-expanding stent implantation because of significant elastic recoil. Post-procedural venography confirmed restoration of venous flow. The patient experienced rapid improvement in breast, arm, and facial swelling, with near-complete resolution at 1-month follow-up while maintaining functional dialysis access. Central venous obstruction should be considered in the differential diagnosis of unilateral breast swelling in hemodialysis patients. Prompt recognition and endovascular intervention can provide effective symptom relief, prevent unnecessary diagnostic procedures, and preserve vascular access.
The traditional treatment for venous air embolism has been mainly conservative, with very few reports advocating the use of manual aspiration. The objective of this report is to describe a novel procedure that employed a practical combination of positional maneuvers and direct catheter-based aspiration for air embolism encountered during tunneled hemodialysis catheter insertion. A retrospective review of three cases of venous air embolism encountered during a 3-year period (September 2022-July 2025) was conducted, in which the patient repositioning combined with manual aspiration of intravascular air was employed. Venous air embolism characteristically occurred during removal of the dilator-guidewire assembly from the vascular sheath during the procedure, especially in long-term tunneled catheters, owing to the larger caliber of the peel-apart sheath. The embolized air has the potential to lodge in the right ventricular outflow tract, thereby reducing pulmonary venous return and cardiac output. Immediate patient repositioning combined with rapid central venous catheter insertion and targeted manual aspiration of intravascular air achieved prompt clinical stabilization in all three cases. Venous air embolism is a rare but life-threatening complication of image-guided central venous catheter insertions. For symptomatic air embolism involving the right ventricular outflow tract, prompt catheter insertion, proper positioning, and manual aspiration of air through the inserted catheter, in conjunction with oxygen supplementation, may assist in managing this acute condition promptly.
Over 20% of patients undergoing hemodialysis are unable to tolerate the discomfort associated with vascular needle insertion, and nearly half (47%) report a fear of these needles, often identifying this step as the most distressing aspect of their treatment. Currently, no universally accepted method exists to alleviate this pain effectively. The objective of the present investigation was to assess and contrast the analgesic efficacy of the Valsalva maneuver and rhythmic breathing techniques in hemodialysis patients undergoing vascular access cannulation. Ninety participants undergoing hemodialysis at Semnan University's Kosar Hospital were randomly divided into three study arms (rhythmic breathing, Valsalva maneuver, control) in this clinical trial, using convenience sampling for enrollment. The rhythmic breathing intervention group performed controlled, rhythmic respiration cycles (lasting 1 min every 5 min) during the 20 min preceding vascular access needle insertion. Patients assigned to the Valsalva group executed the technique for 16-20 s just prior to vascular access needle placement. Participants in the control arm received routine clinical care and no supplementary interventions. Numerical pain rating scale measurements were obtained two minutes following needle insertion to quantify pain levels. Significantly lower pain scores were observed in both Valsalva maneuver (3.06 ± 2.39) and rhythmic breathing (3.03 ± 2.48) groups relative to controls (6.20 ± 1.49; p < 0.001). Subsequent analysis showed that both the Valsalva maneuver and rhythmic breathing groups experienced a markedly higher reduction in pain levels compared to the control group (p < 0.001). However, the two interventions demonstrated comparable effectiveness, with no observable statistical difference between them (p = 0.99). The findings suggest that the Valsalva maneuver is equally effective as rhythmic breathing in minimizing pain during arteriovenous fistula (AV fistula) cannulation, and both methods can be recommended as non-pharmacological pain relief strategies in hemodialysis patients. Iranian Registry of Clinical Trials, Trial No: IRCT20120109008665N16. Registered 14 March 2024.
Needle phobia is a significant barrier to home HD adoption, affecting 20%-60% of adults andchildren. This comprehensive review explores the complexities of needle phobiain dialysis patients, examining its origins, mechanisms, and impact through patient experiences and coping strategies. The necessity of cannulation in home HD patients with an AV access can deter patients from adopting self-care, yet mastering self-cannulation can effectively help overcome needle phobia. Factors contributing to needle phobia include genetic predisposition, traumatic experiences, andchronic pain. The physiological response involves a diphasic reaction, with initial sympathetic activation followed by a parasympathetic surge, potentially leading to vasovagal syncope. A holistic approach to managing needle-related distress, addressing physiological pain, fear, and lack of control is proposed. This includes both pharmacological and non-pharmacological methods, such as desensitization therapy, topical anesthetics, distraction techniques, and cognitive-behavioral interventions. Systematic screening for needle phobia, education and targeted interventions can empower patientsand improve outcomes. Only then can we foster a culture of compassion, empathy, and personalized support, thereby transforming dialysis care and improving patient experiences.