Unplanned dialysis initiation in chronic kidney disease (CKD) patients is associated with adverse outcomes, yet reliable predictors for optimal dialysis timing remain elusive. The clinical significance of longitudinal changes in brain natriuretic peptide (BNP) levels and body weight (BW) in this context is unclear. We examined whether these parameters predict the risk of unplanned dialysis. This retrospective cohort study included 231 CKD patients initiating maintenance dialysis between 2014 and 2024 at a single Japanese university hospital. Predictors were BNP levels and BW ratios, defined as the 3-month value divided by the average of values obtained 6-12 months before dialysis initiation. The primary outcome was unplanned dialysis initiation. We assessed associations between BNP levels or BW ratio and unplanned dialysis initiation using multivariable logistic regression models. Among 231 patients included in the analysis, 137 (59%) had planned and 94 (41%) unplanned dialysis initiation. The median (interquartile range) age was 70 (61-79) years, and 67 (29%) were female. BNP levels increased toward dialysis initiation, particularly in the unplanned group, whereas BW remained largely stable in both groups. A high BNP ratio (>median) was significantly associated with an increased likelihood of unplanned dialysis initiation (odds ratio [OR], 5.64; 95% confidence interval [CI], 2.90-10.99). For the BW ratio, both weight loss (<25th percentile; OR, 3.47; 95% CI, 1.58-7.65) and weight gain (>75th percentile; OR, 2.33; 95% CI, 1.11-4.87) were associated with an increased likelihood of unplanned dialysis initiation. Retrospective, single-center design with possible residual confounding and limited generalizability; unavailability of body composition data. In patients with advanced CKD, trajectories of BNP, together with BW, were significant predictors of unplanned dialysis initiation. Close monitoring of these parameters might help identify high-risk patients and facilitate a timely dialysis transition. For people with advanced chronic kidney disease, timely dialysis initiation is important for better outcomes. However, there is still not enough evidence to determine the optimal time to start dialysis, which makes this goal difficult to achieve. Focusing on fluid overload—a common reason for dialysis—we examined the potential of 2 fluid status markers, brain natriuretic peptide (BNP) levels and body weight (BW), as predictors of unplanned dialysis initiation. Among 231 patients starting dialysis, a marked increase in pre-dialysis BNP levels was associated with a higher incidence of unplanned dialysis, whereas BW loss and gain were similarly linked to increased risk. These findings suggest that monitoring BNP levels and BW trends might help inform the timing of dialysis initiation.
Resilience is a crucial feature of the nursing workforce, particularly among those working in dialysis care. Patients with end-stage kidney disease (ESKD) or chronic kidney disease need to be able to adjust and survive despite hardship. Studies have shown that enhanced resilience is correlated with increased life satisfaction and psychological endurance in individuals undergoing hemodialysis. Resilience is an adaptive coping capacity that can strengthen the benefit of structured care on trust while buffering reliance on interpersonal support, potentially yielding opposing moderation patterns across pathways. This study investigated the psychosocial determinants that influence the satisfaction and resilience of patients in dialysis and explored global challenges, including healthcare environment, provider-patient interactions, and medical procedures in Taiwan. A cross-sectional survey was conducted with 380 stable dialysis patients who had undergone dialysis for more than 3 months without complications at a medical center in Taiwan between September and October 2022. Participants completed Brief Resilience Scale (BRS) questionnaires assessing resilience, trust, treatment satisfaction, and perceived quality of environmental conditions. The questionnaires were primarily self-administered (paper-based). The data were analyzed using partial least squares structural equation modeling (PLS-SEM) to evaluate relationships and moderating effects. Analysis with PLS-SEM was selected for its suitability to prediction-oriented modeling with interaction (moderation) effects and complex latent constructs. Resilience significantly enhanced the positive relationship between medical processes and patient trust but negatively moderated the association between nursing care and trust. High-quality environmental facilities (featuring cleanliness, comfort, privacy, adequate physical layout, and adequate equipment in the dialysis unit) and physician interactions were crucial factors that strengthened patient resilience. Moreover, patient trust strongly predicted satisfaction with dialysis care. Demographic variables, including age, gender, and dialysis modality, were not significant predictors of satisfaction. Resilience substantially influenced patient trust and satisfaction in dialysis care. The integration of resilience-focused strategies, enhancement of care environments, and facilitation of effective communication among healthcare providers are recommended as essential measures for optimizing patient outcomes in chronic dialysis settings. Negative moderation suggests that, when resilience is high, patients may rely more extensively on internal coping and less on interpersonal reassurance, thus weakening the incremental effects of nursing support on trust. The findings may inform settings with comparable dialysis care structures and frameworks of patient-experience monitoring.
Patients with end-stage renal disease (ESRD) undergoing hemodialysis are at increased risk of anxiety and depression, which may adversely affect treatment adherence and quality of life. Data on the prevalence and determinants of these conditions among Palestinian hemodialysis patients remain limited outside pandemic settings. A cross-sectional study was conducted among 435 adult hemodialysis patients consecutively recruited from four dialysis centers in the West Bank, Palestine, between December 2025 and January 2026. Data were collected using interviewer-administered questionnaires covering sociodemographic characteristics, clinical and dialysis-related factors, perceived social support, and the Hospital Anxiety and Depression Scale (HADS). Descriptive statistics were performed, followed by chi-square and Kruskal-Wallis tests. Multivariable linear regression analyses were used to identify factors independently associated with anxiety and depression scores. The median age was 55 years, with equal representation of men and women. Most participants lived in villages (60.9%), were married (67.4%), had primary or secondary education, reported low income (61.6%), and were unemployed (77.2%). The majority used arteriovenous fistulas for vascular access (66.9%), with a median dialysis duration of 36 months. Abnormal anxiety and depression were identified in 31.5% and 40.2% of participants, respectively, while borderline symptoms were present in 24.4% and 36.3%. Higher education, medium income, better perceived social support, and catheter vascular access were independently associated with lower anxiety scores. Higher depression scores were associated with longer dialysis duration, higher weekly dialysis frequency, diabetes mellitus, lower educational level, and poor social support. Age, sex, and most comorbidities were not independently associated with psychological outcomes. Anxiety and depression are highly prevalent among Palestinian hemodialysis patients. Psychosocial and sociodemographic factors-particularly education, income, and social support-appear to have a greater influence on mental health than most biomedical variables. Routine psychological screening and integrated psychosocial interventions should be incorporated into hemodialysis care.
Dialysis headache is a common complication of hemodialysis that negatively affects patients' comfort and quality of life. Due to the limitations and potential adverse effects of pharmacological treatments in patients with renal impairment, this study aimed to compare the effectiveness of acupressure and eucalyptus inhalation on headache severity in patients undergoing hemodialysis. This study was a randomized controlled clinical trial conducted on patients undergoing hemodialysis at the Salam Dialysis Center in Tehran in 2023. Participants were selected through convenience sampling and then randomly assigned to three groups: acupressure, eucalyptus inhalation, and control (11 patients in each group). The control group received routine care only. Data were analyzed using appropriate statistical tests in SPSS version 26 at a significance level of 0.05. This randomized controlled clinical trial with a pretest-posttest design was conducted in 2023 at the Salam Dialysis Center in Tehran, Iran. Thirty-three patients were selected through convenience sampling and randomly allocated into three groups (n = 11 each): acupressure, eucalyptus inhalation, and control. In the acupressure group, pressure was applied to the HeGu (LI4), Yintang, Taiyang, and GB20 points for 1 min each during the first 20 min of dialysis across three consecutive sessions. In the eucalyptus group, participants inhaled 1 mL of eucalyptus oil from a distance of 30 cm for 5 min at the beginning of dialysis. Headache severity was measured using the Numeric Rating Scale (0-10) before and after intervention. Data were analyzed using repeated-measures ANOVA and Bonferroni post hoc tests in SPSS version 26 (two-sided tests, α = 0.05). The participants consisted of 18 men (54.5%) and 15 women (45.4%), with a mean age of 55.30 ± 14.97 years. No significant differences were observed among the three groups regarding demographic and clinical characteristics (p > 0.05). No significant differences were observed among the groups at baseline (p = 1.00). After the intervention, headache severity significantly decreased in both acupressure and eucalyptus groups compared with control (p < 0.001). The time × group interaction effect was significant (F (2,30) = 33.76, p < 0.001, η² = 0.692). No significant difference was found between acupressure and eucalyptus groups (p = 1.00). Both eucalyptus inhalation and acupressure demonstrated potential effectiveness in reducing headache severity in patients undergoing hemodialysis. These simple, low-cost, and non-invasive interventions may be considered as complementary approaches in dialysis care to improve patient comfort and reduce headache-related discomfort.
Arterial pulse wave features (PWFs) reflect hemodynamic changes during hemodialysis and, while their use is not currently recommended by clinical practice guidelines, many PWFs are associated with patient outcomes beyond classical blood pressure measurements. Pre-dialysis fluid overload (FO), intradialytic relative blood volume (RBV), and cumulative ultrafiltration volume (cUFV) may influence PWFs, but these relationships remain incompletely characterized. We aimed to explore associations between FO, RBV, cUFV, and PWFs during hemodialysis. We analyzed 79 hemodialysis sessions in 24 patients over five weeks. Each session included pre-dialysis bioimpedance spectroscopy, cuff-based pulse wave measurements every 15 minutes, and continuous RBV/cUFV monitoring. Associations between RBV or cUFV and 28 PWFs (including blood pressure measures, parameters of cardiac function, and various arterial wave features derived from pulse wave analysis) were assessed using confounder-adjusted generalized estimating equations. Repeated-measures correlation analysis evaluated within-patient associations between pre-dialysis FO and both initial PWF levels (median from the first 45 minutes) and their intradialytic changes (late minus early 45-minute median). We analyzed 817 pulse wave measurements from 24 patients (21 men; median age 66 years). RBV was associated with 18/28 PWFs (64%), whereas cUFV was associated with 10/28 (36%), with distinct patterns: associations with RBV were observed mainly for the cardiac function parameters (stroke volume, cardiac output, heart rate) and arterial wave components (forward/backward wave amplitudes, wave intensity peaks, reflection coefficient), while associations with cUFV were observed mainly for diastolic blood pressure, peripheral resistance, and reservoir pressure. Significant early-to-late intradialytic changes in PWFs included a decrease in stroke volume, reflection coefficient and cardiac output, as well as an increase in pulse pressure amplification and reflected intensity peak. Among initial PWF levels, only the excess pressure integral correlated with pre-dialysis FO; however, FO correlated positively with intradialytic changes in systolic and mean blood pressure, pulse wave velocity, and reservoir pressure, indicating attenuated decreases in these parameters when baseline fluid excess was higher. In the studied cohort, RBV and cUFV showed distinct association profiles with PWFs during hemodialysis. These relationships warrant consideration in studies assessing or intervening on PWFs in dialysis patients.
Heart failure and atherosclerotic comorbidities are common among patients receiving maintenance hemodialysis, yet therapeutic options remain limited. We aimed to clarify the long-term prognostic impact of reduced left ventricular ejection fraction (LVEF) and coronary heart disease (CHD) and explore potential determinants of cardiac recovery in this population. We retrospectively analyzed 310 hemodialysis patients who underwent coronary angiography for suspected CHD. Patients were stratified by baseline LVEF (< 40% vs. ≥ 40%) and the presence of CHD. Five-year mortality was compared between the groups, and associations with coronary intervention were examined. In a subset with follow-up echocardiography, changes in LVEF were analyzed in relation to medication use, coronary intervention, and relative post-dialysis body weight reduction. Patients with reduced LVEF had worse survival than those with normal LVEF (log-rank p = 0.001). Moreover, patients with reduced LVEF and concomitant CHD exhibited the poorest prognosis (log‑rank p = 0.001). Neither PCI nor medical therapy was associated with improvement in LVEF. In contrast, greater post-dialysis body weight reduction independently predicted attenuated recovery of cardiac function (HR 0.89; 95% CI 0.81-0.98; p = 0.018), with continuous analyses confirming an inverse relationship between ultrafiltration intensity and ΔLVEF. In hemodialysis patients with reduced LVEF, the coexistence of CHD requiring intervention identifies a high-risk phenotype, while cardiac recovery appears more strongly influenced by dialysis-related physiology than by conventional therapies. These findings highlight the need for personalized care strategies that integrate ischemic risk assessment with individualized dialysis management.
Anticancer therapy for patients with gastric cancer on hemodialysis is challenging owing to varying pharmacokinetics and a lack of clinical trial data. This study aimed to evaluate the efficacy and safety of the capecitabine plus oxaliplatin (CapeOX) regimen in a 73-year-old male Japanese patient with stage IV gastric cancer (human epidermal growth factor receptor 2 negative) undergoing hemodialysis. The selected chemotherapy regimen was approximately 50% dose of CapeOX (capecitabine 1500 mg/day on days 1-14 and oxaliplatin 100 mg/day 2-h infusion on day 1) every 3 weeks. Data on plasma drug concentrations, metabolic enzyme genetic polymorphisms, and clinical outcomes were analyzed. Anticancer therapy initially controlled the tumor; however, disease progression and cumulative peripheral neuropathy led to discontinuation after 17 cycles (approximately 12 months of treatment). Oxaliplatin exhibited a rebound increase after each dialysis session (dialyzer clearance [CLdial]: median, 44.12 [interquartile range {IQR}: 24.89 - 70.08] mL/min; hemodialysis removal rate: median, 35.98% [IQR: 19.63 - 54.45]. α-fluoro-β-alanine, the final metabolite of capecitabine, accumulated substantially, although approximately half of them was removed by hemodialysis (CLdial: median, 61.32 [IQR: 24.89 - 70.08] mL/min; hemodialysis removal rate: median, 47.98% [IQR: 44.74 - 50.29]). The UPB1 intronic variant and a DPYD missense mutation (1627 A > G) were detected. The DPYD variant likely influenced 5-fluorouracil metabolism, as its area under the concentration-time curve from 0 to 12 h was comparable to the standard dosage. These findings suggest that appropriate dose reduction and genetic screening might be considered part of chemotherapy guidance to improve safety and effectiveness for patients with advanced gastric cancer undergoing hemodialysis.
Background/Objectives: Protein-bound uremic toxins (PBUTs), particularly p-cresyl sulfate (PCS) and indoxyl sulfate (IS), are associated with cardiovascular toxicity and increased mortality. Conventional hemodialysis (HD) removes PBUTs poorly, and the efficacy of medium cut-off (MCO) dialyzer membranes remains uncertain. Furthermore, PBUT production is influenced by gut microbial metabolism and can be modified through diet. We hypothesized that MCO dialysis would provide superior clearance of PCS and IS compared with online hemodiafiltration (OL-HDF), and that combining MCO dialysis with increased dietary fiber and short-chain fatty acid (SCFA) intake would further reduce PBUT levels. Methods: In this prospective randomized trial, 62 maintenance HD patients underwent a 2-week wash-in period with high-flux HD (HF-HD) and were then randomized to MCO-HD (EXP) or OL-HDF (CON). After a 4-week intervention with the assigned dialysis modality, both groups continued with the same dialysis treatment and received an 8-week dietary intervention consisting of 19 g/day fiber and 1 g/day sodium propionate. The study concluded with a 4-week wash-out period on HF-HD. Primary outcomes were total serum PCS and IS levels measured at four timepoints. Results: Fifty-two patients completed the study. No significant changes in PCS or IS were observed after the dialysis-only intervention. PCS levels remained stable throughout the study. When the aligned dialysis regimen was combined with the dietary intervention, IS levels were significantly lower in the CON than in the EXP group (31.5 ± 10.3 vs. 42.0 ± 15.8 µmol/L; p = 0.006), with a partial rebound after wash-out in the CON group (39.6 ± 20.9 µmol/L; p = 0.003). Conclusions: While MCO-HD and OL-HDF had a similar effect on serum PCS and IS concentrations, only OL-HDF combined with the dietary intervention significantly reduced IS levels.
Poor sleep quality is common in patients receiving maintenance hemodialysis (MHD) and may worsen symptom burden and outcomes. This study evaluated Pittsburgh sleep quality index (PSQI)-defined poor sleep quality and its associated factors in a single-center MHD cohort. This single-center cross-sectional study included 143 patients receiving MHD at the Fifth People's Hospital of Jinan from June to December 2024. Sleep quality was assessed using the PSQI. Patients were categorized as having good sleep quality (PSQI < 5) or poor sleep quality (PSQI ≥ 5). Demographic, clinical, dialysis-related, and laboratory variables were collected, including dialysis vintage, residual urine volume, weekly dialysis frequency, and dialysis adequacy assessed by standard weekly Kt/V (stdKt/V). An exploratory subgroup analysis was also performed in patients with diabetes mellitus. Of the 143 patients, 76 (53.1%) had poor sleep quality. Significant between-group differences were observed for age, diabetes mellitus, restless legs syndrome (RLS), and dialysis adequacy (all P < .05). In univariable logistic regression, older age (odds ratio [OR] 1.044, 95% CI: 1.013-1.076, P = .005), diabetes mellitus (OR 3.041, 95% CI: 1.518-6.096, P = .002), RLS (OR 3.717, 95% CI: 1.647-8.392, P = .002), and stdKt/V < 2.1 (OR 2.562, 95% CI: 1.218-5.389, P = .013) were associated with poor sleep quality. In multivariable model 1, older age (per 1-year increase; OR 1.041, 95% CI: 1.005-1.079, P = .027), diabetes mellitus (OR 2.625, 95% CI: 1.194-5.772, P = .016), and stdKt/V < 2.1 (OR 2.875, 95% CI: 1.264-6.542, P = .012) remained independently associated with poor sleep quality, whereas female sex was not significant (OR 1.801, 95% CI: 0.775-4.185, P = .171). In model 2, diabetes mellitus (OR 2.609, 95% CI: 1.184-5.749, P = .017), stdKt/V < 2.1 (OR 2.346, 95% CI: 1.039-5.296, P = .040), and RLS (OR 3.002, 95% CI: 1.175-7.668, P = .022) remained significant. In an exploratory subgroup analysis of patients with diabetes mellitus, calcium-phosphorus product > 55 mg2/dL2 was associated with poor sleep quality. Poor sleep quality was common in this MHD cohort and was associated with older age, diabetes mellitus, RLS, and lower dialysis adequacy. In patients with diabetes mellitus, the calcium-phosphorus product finding should be interpreted as exploratory.
Stigma is a significant psychosocial challenge among patients receiving maintenance hemodialysis (HD). Evidence from conflict-affected, resource-limited settings is scarce, particularly regarding anticipated stigma, perceived social support, and site-level differences in dialysis care. To assess the prevalence of anticipated stigma and its association with perceived social support and clinical factors among maintenance HD patients in Syria. This multicenter cross-sectional study was conducted from June 30 to December 4, 2025, among 507 adult patients receiving maintenance hemodialysis across five Syrian governorates. Data were collected using interviewer-administered questionnaires. Perceived social support measured by the Multidimensional Scale of Perceived Social Support (MSPSS), and clinical and dialysis-related characteristics, including blood transfusion history, erythropoietin therapy, chronic pruritus, perceived dialysis-related financial burden, and hemodialysis hospital/governorate. The primary outcome was anticipated stigma, defined operationally as a Chronic Illness Anticipated Stigma Scale (CIASS) total score > 24. Secondary measures included CIASS and Multidimensional Scale of Perceived Social Support (MSPSS) total and domain scores. Analyses included Spearman correlations, nonparametric group comparisons, hierarchical block-wise binary logistic regression, and a sensitivity analysis treating CIASS total score as a continuous variable. The mean age was 48.3 years (SD 14.9), and 57.0% of participants were male. Anticipated stigma was identified in 39.6% of patients, with a median CIASS score of 24 (IQR 19-28). Median MSPSS score was 67 (IQR 58-73), and 66.9% of participants reported high perceived social support. CIASS and MSPSS scores were inversely correlated (rₛ = -0.170, p < 0.001). In the fully adjusted hierarchical model, blood transfusion history was independently associated with higher odds of anticipated stigma (OR 2.09, 95% CI 1.27-3.45), while higher MSPSS score was associated with lower odds (OR 0.965, 95% CI 0.949-0.983). Hemodialysis hospital/governorate remained significantly associated with anticipated stigma in the final model (p < 0.001). Sensitivity analysis using CIASS as a continuous outcome showed consistent direction of associations. Anticipated stigma was common among maintenance HD patients in this conflict-affected setting. Higher perceived social support was consistently associated with lower anticipated stigma, whereas blood transfusion history was associated with higher stigma. These findings should be interpreted as associative and exploratory rather than predictive, and do not represent a clinical screening or prediction tool. Future research should address psychological and institutional determinants to better explain stigma mechanisms in this population.
Chronic kidney disease (CKD) in children poses unique challenges, especially in resource-poor developing countries, with limited facilities for renal replacement therapy (RRT). We present three cases of children with end-stage renal disease from Sri Lanka in whom traditional access has been exhausted secondary to sepsis and thrombosis. Three patients were not candidates for peritoneal dialysis, and several attempts for tunnelled and non-tunnelled catheters limited the ability to continue RRT until the donor work-up for transplantation was completed. Therefore, surgical placement of a vascular catheter (vascath) to enter the inferior vena cava (IVC) directly was performed under general anaesthesia. Patient 1, a nine-year-old boy, successfully maintained dialysis through the IVC catheter until transplantation. Patient 2, a fourteen-year-old boy with extensive thrombosis, underwent successful cannulation with good outcomes at 4 months' follow-up. Patient 3, a twelve-year-old girl post-nephrectomy, initially dialysed successfully but later died due to cardiac failure unrelated to the access site. This procedure provided effective haemodialysis access, mitigating severe volume overload and hyperkalaemia. They also tolerated subsequent dialysis sessions well. This case series highlights the critical role of unconventional dialysis access methods in resource-constrained settings, where advanced interventional radiology options may be unavailable. While IVC cannulation for haemodialysis is more commonly described in adults, these are the first reported cases of vascath insertion into the IVC in paediatric patients. Additionally, these findings underscore the importance of innovative strategies to manage paediatric CKD in low-resource settings, pending definitive renal transplantation.
Dialysis-related amyloidosis (DRA) is a clinically significant complication of long-term hemodialysis, primarily affecting the bones and joints. Involvement of oral cavity is uncommon, and almost all reported cases are localized to the tongue. Here, we report a rare case of DRA presenting as a large tumor originating from the maxillary gingiva in a hemodialysis patient. We also review previously reported cases of oral DRA. A 77-year-old Japanese woman with diabetic kidney disease had been receiving maintenance hemodialysis for 11 years. She was referred to our hospital for evaluation of a large tumor extending from the maxillary gingiva to the palate. Although she had been completely edentulous in the maxilla for years, she did not wear dentures. A biopsy specimen from the tumor revealed diffuse subepithelial deposition of eosinophilic, amorphous material, which was positive for direct fast scarlet stain and exhibited apple-green birefringence under polarized light. Immunohistochemistry confirmed the presence of β2-microglobulin, leading to the diagnosis of DRA. The tumor was surgically resected, and no recurrence was noted during follow-up. Our case and literature review suggest that chronic mechanical stimulation in the oral cavity may contribute to the development of oral DRA. These findings highlight the importance of regular oral examinations and the elimination of mechanical irritation in patients receiving maintenance hemodialysis.
This study aimed to develop a structured retraining program for peritoneal dialysis nurses using the ADDIE model, emphasizing clinical nursing expert orientation and job competency to facilitate their transition toward expert-level practice. From May 1, 2023, to September 30, 2025, the research team followed the five stages of the ADDIE model to assess training needs, learner characteristics, and available resources for retraining peritoneal dialysis specialist nurses. Based on these findings, training modules, content, formats, and assessment strategies were systematically designed, and a preliminary training framework was developed. Twenty-two experts in peritoneal dialysis participated in two rounds of Delphi consultations to refine and finalize the program. The finalized retraining program was subsequently implemented and evaluated among 36 nurses who had obtained the Zhejiang Province Peritoneal Dialysis Nursing Specialist Certificate. The final retraining program comprised 11 modules and 38 topics, including 28 theoretical and 10 practical sessions. Nurses reported high satisfaction scores: 4.74 (4.61, 5.00) during the formative evaluation and 5.00 (4.00, 5.00) during the summative evaluation. By September 2025, 88.89% of participants had progressed to the level of clinical experts. Following the retraining program, nurses demonstrated significant improvements in theoretical examination scores (mean 89.31 ± 6.21, P < 0.001), and the number of independent clinics increased from 13 to 33. Academic productivity and professional engagement, including scientific publications, consultations, lectures, and leadership activities, also increased significantly (P < 0.001). At the peritoneal dialysis center, rates of peritonitis and catheter-related infections declined significantly (all P < 0.001). Further, achievement rates for serum albumin, hemoglobin, serum phosphorus, Kt/V, Ccr, and TOT targets improved significantly (all P < 0.001). The retraining and utilization program for peritoneal dialysis specialist nurses developed in this study is systematic, reliable, and innovative. By emphasizing both practical competencies and professional development, the program aligns closely with clinical demands while enhancing nurses' intrinsic motivation. Participants' feedback indicated strong acceptance and positive evaluation of the retraining program.
With recent advances in systemic chemotherapy for pancreatic cancer, a subset of patients with initially unresectable disease, particularly those who respond favorably to treatment, can now undergo conversion surgery (CS) and achieve prolonged survival. However, in patients undergoing hemodialysis (HD), optimal chemotherapy dosing and dialysis scheduling have not been established, raising concerns about increased chemotherapy-related toxicity and uncertain antitumor efficacy. Here, we report a case in which chemotherapy was successfully administered to a HD patient with unresectable locally advanced pancreatic cancer. A 48-year-old male on maintenance HD was diagnosed with pancreatic head cancer, pathologically confirmed as acinar cell carcinoma (ACC). The tumor showed a 270° involvement of the superior mesenteric vein and a 200° contact with the superior mesenteric artery. The patient received 19 cycles of modified FOLFIRINOX (mFFX) with a uniform 40% dose reduction under an adjusted dialysis schedule. The primary tumor decreased in size, achieving a partial response according to Response Evaluation Criteria In Solid Tumors (RECIST). Subsequently, the patient underwent pancreaticoduodenectomy with portal vein resection. Pathological examination revealed a pathological complete response. No adjuvant chemotherapy was administered, and no recurrence has been observed during 3 years of postoperative follow-up. We successfully administered prolonged mFFX in a dialysis patient with unresectable pancreatic head ACC, enabling CS with curative intent. This case suggests that carefully dose-adjusted mFFX with appropriate dialysis scheduling can be a feasible and effective treatment option for selected HD patients with unresectable pancreatic cancer.
Patients with end-stage renal disease who are dialysis-dependent are living longer, leading to an increased incidence of long-term dialysis complications, including those related to spondyloarthropathy requiring fusions. Here, we investigated the outcomes and complications associated with spinal fusion in patients undergoing dialysis. We performed 3 separate searches involving the lumbar, thoracic, and cervical spine using MEDLINE PubMed and Boolean operators. Fourteen articles met the inclusion criteria. Although outcomes for lumbar and cervical spinal fusion in dialysis patients were comparable, complication and mortality rates were higher, likely due to the overall increased morbidity attributed to end-stage renal disease.
Biopharmaceutical manufacturing has been using ultrafiltration (UF) and diafiltration (DF) for buffer exchange, desalting, and formulation of biologics. The legacy UF/DF is commonly a two-step batch process that is challenging to integrate into end-to-end continuous biomanufacturing. Here, we introduce asymmetric dialysis, a novel one-step continuous process that combines UF and DF. It works by utilizing asymmetric flow between the inlet and outlet of the retentate and complementary flow of the dialysate solution, achieving product concentration, buffer exchange, and salt removal using a commercially available hollow fiber device. Asymmetric dialysis can achieve product concentrations of 105 (3.8×), 200 (10×), and 64 g/L (9.4×) starting from feed concentrations of 30, 20, and 7 g/L, respectively, with modest pressures of 6-7 psi. The interplay between feed and exchange buffer flow rates was exploited to make the process sustainable by reducing buffer consumption by 75% (25 L/kg mAb) compared to conventional batch UF/DF (100 L/kg, mAb). We successfully processed 7 kg of mAb at 20 g/L feed using 5-day asymmetric dialysis with a daily productivity of 0.8 kg/m2/day to product concentration of 200 g/L. These results demonstrate the potential of asymmetric dialysis, a simple, sustainable, and low-cost bioprocessing technology for continuous bioprocessing.
This pilot trial aimed to evaluate the feasibility of a nurse-led multicomponent intervention (Targeting Intake and Pills, TIPs) using serial phosphorus metrics for patients undergoing hemodialysis treatment, and to estimate variability to inform a future definitive trial. This was a pilot randomized controlled trial. This 3-month trial, conducted in Shanghai, China, enrolled maintenance hemodialysis patients with persistent hyperphosphatemia (>1.78 mmol/L [5.5 mg/dL] over two consecutive quarters) who were receiving phosphate binder therapy. The intervention included dietary phosphate management, facilitation of binder adherence, and physician referral for dialysis adequacy optimization. Outcomes assessed included feasibility (recruitment and retention rates), serum phosphorus levels (using area-under-the-curve [AUC] and rolling averages), dietary consumption, and pruritus symptoms. Of 192 participants screened, 58 (30.21%) were eligible, and 30 (51.72%) were randomized (n = 15 per group). Participant retention was 86.67% (26/30). At follow-up, 88% of scheduled quarterly serum phosphorus measurements were completed. For the secondary, exploratory clinical outcomes, the estimated between-group difference in AUC was -0.33 (95% CI: -1.24 to 0.58), with a residual standard deviation of 1.21. For pruritus, the adjusted between-group difference was -1.53 (95% CI: -4.00 to 0.94). Dietary outcomes showed substantial variability, with residual standard deviations of 144.00 mg/day for phosphate intake, 12.67 g/day for protein intake, and 299.56 kcal/day for energy intake. This pilot study demonstrated the feasibility of recruitment and data collection in hemodialysis patients. The estimates of outcome variability and the influence of baseline values provide critical information for designing a fully powered randomized controlled trial. The nurse-led TIPs intervention appears feasible and acceptable for use in routine nephrology care settings. However, its comparative clinical effectiveness remains to be established in a larger definitive trial. The trial was registered with the Chinese Clinical Trial Registry (ChiCTR) on 2020/04/03 (clinical trial registration number: ChiCTR2000031509).
Noninfectious risk factors in peritoneal dialysis (PD) are often overlooked, yet they significantly worsen patient outcomes. This review highlights nine key risk factors: advanced age and psychosocial vulnerability, malnutrition and sarcopenia, glucose and lipid metabolism disorders, hypoalbuminemia, chronic microinflammation, gut dysbiosis, kidney anemia, chronic kidney disease-mineral and bone disorder, and volume overload with elevated intra-abdominal pressure. These factors interact to increase the risks of death, decline of residual kidney function, peritoneal fibrosis and cardiovascular events. We outline practical, evidence-based protective strategies that integrate nutritional and physical rehabilitation, biocompatible dialysis regimens, individualized fluid and dialysis prescription, targeted pharmacotherapy, psychosocial support, and regular monitoring of integrated inflammatory and nutritional biomarkers. The goal is to help clinicians improve long-term outcomes and quality of life for PD patients.
This study aimed to evaluate the efficacy of a virtual reality (VR)-based bicycle exercise in psychological distress (depression and anxiety) and selected biochemical parameters among patients receiving maintenance hemodialysis (MHD). A total of 70 patients from the dialysis station at Changzhou Medical District of the No. 904th Hospital were randomly allocated into study group(VR-based bicycle exercise, n = 35) and control group(routine nursing care, n = 35). The depression and anxiety levels were assessed by Self-rating Depression Scale (SDS), and Self-rating Anxiety Scale (SAS) respectively. Physiological indicators, including serum creatinine (Scr) and blood urea nitrogen (BUN) levels, were also analyzed. Following the intervention, the study group exhibited significant reductions in SDS and SAS scores (both P < 0.05). The levels of Scr and BUN in peripheral blood were also observed to be significantly decreased in study group (P < 0.05). Correlation analysis revealed a significant positive correlation between SAS/SDS scores with both Scr and BUN levels (P < 0.05 or P < 0.01). Furthermore, regression models identified SAS scores as significant predictors of Scr and BUN levels, accounting for 27.8% and 31.9% of their variance, respectively (P < 0.05 or P < 0.01). VR-based bicycle exercise can improve psychological well-being, and was associated with beneficial changes in pre-dialysis serum biomarkers (Scr and BUN) in MHD patients. This integrated intervention represents a promising non-pharmacological strategy to complement standard care in MHD patients.
Cardiovascular disease is the leading cause of mortality in patients with chronic kidney disease (CKD), particularly among those undergoing maintenance hemodialysis (MHD). High-altitude exposure may further aggravate cardiovascular stress through chronic hypoxia. However, longitudinal data in multi-ethnic high-altitude dialysis populations remain limited. To evaluate changes in cardiac function in CKD stage 5/end-stage renal disease patients receiving MHD at high altitude and to compare findings between Yi and non-Yi ethnic groups. This retrospective study included 161 patients (103 Yi, 58 non-Yi) undergoing MHD in Ninglang Yi Autonomous County (mean altitude >2800 m). Clinical characteristics, laboratory parameters-including homocysteine (HCY)-and echocardiographic indices were assessed at baseline, 3 months, and 12 months. Longitudinal trends and ethnic differences were analyzed. In the overall cohort, pulmonary artery systolic pressure (PASP) increased significantly over time (P=0.049), while the E/A ratio declined, indicating progressive diastolic impairment. Left ventricular ejection fraction (LVEF) remained stable At 12 months, Yi patients had higher HCY levels (P=0.034), lower albumin (P=0.010) and apolipoprotein A levels (P=0.044), and a higher incidence of aortic regurgitation (AR) (P=0.012). Baseline E/A ratio was higher in Yi patients (P=0.032). CKD patients undergoing MHD at high altitude exhibit dynamic changes in cardiac function, predominantly involving pulmonary pressure and diastolic parameters. Ethnic differences in selected biochemical and echocardiographic indices suggest the need for tailored cardiovascular monitoring in high-altitude multi-ethnic dialysis populations.