OBJECTIVE: Insomnia is a prevalent sleep disorder among patients undergoing hemodialysis for chronic kidney disease. This study aimed to translate the sleep condition indicator (SCI), an insomnia screening tool based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), into a traditional Chinese version (SCI-TC) and evaluate the reliability and validity of this version for patients undergoing hemodialysis.
METHODS: This cross-sectional study conducted from November 2022 to June 2023 involved 200 patients on hemodialysis (mean age, 65.56 years; 61.5% men). Participants completed a series of questionnaires, with insomnia diagnosed according to DSM-5 criteria as the gold standard. A receiver operating characteristic (ROC) curve analysis was conducted to examine the sensitivity and specificity of the SCI-TC.
RESULTS: According to the DSM-5 criteria, 38% of the participants had insomnia. Cronbach\'s alpha for the SCI-TC was 0.92. The SCI-TC exhibited a good fit as a two-factor model, and its scores were significantly associated with those of the traditional Chinese versions of the Insomnia Severity Index, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, EuroQol 5-Dimensions scale, and EuroQol Visual Analogue Scale (r =  - 0.94, - 0.53, - 0.38, 0.27, and 0.30, respectively; all p < 0.05). The ROC curve analysis revealed an optimal cutoff of 16 points, with the sensitivity, specificity, and area under curve of 88.2%, 84.7%, and 0.91(95% confidence interval, 0.87-0.95), respectively.
CONCLUSIONS: The SCI-TC demonstrates robust reliability and validity in detecting insomnia among patients undergoing hemodialysis. These findings suggest that health-care providers should considering using the SCI as an easy-to-use tool for the timely detection of insomnia in this population.

BACKGROUND: The application value of myocardial work (MW) in evaluating myocardial function and predicting major adverse cardiovascular events (MACE) in maintenance hemodialysis (MHD) patients has not been fully explored.
OBJECTIVE: Comparing noninvasive MW parameters between MHD patients and healthy controls, and further determining its value in predicting MACE in MHD patients.
METHODS: A prospective single-institution study included 92 MHD patients without prior cardiovascular disease and 40 age- and sex-matched healthy controls. Conventional echocardiographic data, global longitudinal strain (GLS), and MW parameters (global work index [GWI], global constructive work [GCW], global work efficiency [GWE], global wasted work [GWW]) were derived and compared between MHD and the control. Logistic regression was used to determine the predictive value of these parameters for MACE. The receiver operating characteristic curve was utilized to compare the predictive differences of MACE between GWE and GLS.
RESULTS: Compared with healthy individuals, MHD patients had significantly reduced GWE, GLS and elevated LVMI, GWW (all p < 0.001), while there was no significant difference in left ventricular ejection fraction. Twenty eight (30%) MHD patients experienced MACE. Two nested models adding GWE and GLS, respectively, showed that age (p < 0.005), GWE (p = 0.034), and GLS (p = 0.014) were independent predictors of MACE. The AUC derived from GWE for predicting MACE was significantly higher than that derived from GLS (0.836 vs. 0.743, p = 0.039).
CONCLUSIONS: Myocardial work is a novel tool for assessing left ventricular myocardial performance in MHD patients. GWE is an independent predictor of MACE.

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by type II and type III hypersensitivity reactions that affect multiple organs, including the joints, heart, lungs, brain, skin, and kidneys. Patients with SLE can experience a range of symptoms, ranging from fever and joint pain to a distinctive butterfly facial rash. Severe complications may encompass conditions such as diffuse alveolar hemorrhage (DAH), pulmonary hypertension, and lupus nephritis, among others. Among them, DAH, a critical pulmonary complication in SLE, involves bleeding from interstitial capillaries and alveoli due to immune complex damage. This case report describes a patient who was initially misdiagnosed but later confirmed to have SLE. The patient presented with persistent symptoms, including cough, dyspnea, and fever, over two weeks and subsequently developed hematuria and hemoptysis within the last two days. The progression of symptoms led to an acute exacerbation, resulting in her admission to the emergency department. Subsequent evaluations confirmed the diagnosis of lupus nephritis and DAH. This case highlights the importance of considering SLE in the differential diagnosis of unexplained systemic symptoms and underscores the urgent need for medical intervention in DAH to substantially reduce mortality.

UNASSIGNED: Different vitamin D analogs might have advantages over calcitriol.
UNASSIGNED: To evaluate the effects of paricalcitol vs. calcitriol based vitamin D receptor activators on calcium-phosphate metabolism and pulse wave velocity in hemodialysis patients.
UNASSIGNED: Observational, cross-sectional and 1 year follow-up study.
UNASSIGNED: 181 hemodialysis patients were enrolled in this study as divided in to 5 groups based on vitamin D therapy. Baseline and 12th month data on blood biochemistry, pulse wave velocity and cumulative dose of treatments were compared in each study group as well as in overall paricalcitol vs. calcitriol-based treatment groups.
UNASSIGNED: From baseline to 12th month, significant improvement in pulse wave velocity and parathyroid hormone was shown in paricalcitol-based treatment group without a significant change in calcium, phosphate, alkaline phosphatase. A significant increase in pulse wave velocity, serum phosphate levels, calcium x phosphate product and serum alkaline phosphatase levels were noted in calcitriol-based treatment group with no significant change in serum calcium and parathyroid hormone levels.
UNASSIGNED: Our findings revealed superiority of paricalcitol than calcitriol based vitamin D receptor activator therapy in terms of serum phosphate levels, CaxP product, dose requirement for vitamin D and the control of pulse wave velocity.

BACKGROUND: Individuals with chronic kidney disease (CKD) often experience reduced muscle strength and diminished health-related quality of life (HRQoL), and engaging in regular exercise may improve them. The aim of this study was to assess the effect of intradialytic exercise using non-immersive virtual reality (VR) on body composition of patients with CKD on hemodialysis (HD).
METHODS: This was a substudy in a clinical trial of intradialytic exercise intervention using a non-immersive VR game in which the patient interacted by moving the lower limbs. Body composition was determined by BCM Fresenius multifrequency stereoscopic bioimpedance. Body mass index (BMI), fat tissue index (FTI), lean tissue index (LTI), extracellular/intracellular water (EIW), and phase angle (PA) were recorded in 52 patients, 24 in the control group (CG) and 28 in the exercise group (EG).
RESULTS: Statistically significant differences were observed between both groups. The LTI increased in the EG while it decreased in the CG. The FTI and the EIW decreased in the EG compared to the increase observed in the CG.
CONCLUSIONS: Intradialytic exercise using non-immersive VR was associated with an increase in LTI and a decrease in FTI of CKD patients on HD.

Background/Objectives: Levels of circulating soluble thrombomodulin (sTM), an anticoagulant factor, are associated with the severity and progression of arteriosclerotic diseases. However, the role of elevated sTM levels remains to be clarified in patients on dialysis. As the calcification propensity time T50 is a novel marker of arterial calcification, we aimed to determine the association between sTM and T50 in patients on hemodialysis (HD). Methods: This cross-sectional study included 49 adult patients on maintenance HD. Correlation analysis was performed to test the association between T50 and patient characteristics. Linear regression was used to evaluate the association between T50 and sTM. Results: Partial correlation analysis showed a strong association between T50 and glycated albumin, phosphorous, and sTM levels (partial correlation coefficient: r [partial] = -0.359, p = 0.023; r [partial] = -0.579, p < 0.001; and r [partial] = 0.346, p = 0.029, respectively). Multivariate linear regression analysis revealed that only sTM level was significantly and positively associated with T50 (β = 0.288; t = 2.27; p = 0.029; 95% confidence interval, 0.082-1.403). Conclusions: sTM is independently and positively associated with the propensity time for calcification, suggesting that sTM could be a good marker of arterial calcification progression in patients on HD.

Background: Tunneled central venous catheters are commonly used for dialysis in patients without a functional permanent vascular access. In an emergent setting, a non-tunneled, temporary central venous catheter is often placed for immediate dialysis. The most critical step in the catheter insertion is venipuncture, which is often a major cause for longer intervention times and procedure-related adverse events. To avoid this critical step when placing a more permanent tunneled catheter, an exchange over a previously placed temporary one can be considered. In this paper, we present a modified switching approach with a separate access site. Methods: In this retrospective analysis of a prospective database, we examined whether this modified technique is non-inferior to a de novo application. Therefore, we included all 396 patients who received their first tunneled dialysis catheter at our site from March 2018 to March 2023. Out of these, 143 patients received the modified approach and 253 the standard de novo ultrasound-guided puncture and insertion. Then, the outcomes of the two groups, including adverse events and infections, were compared by nonparametric tests and multivariable logistic regression. Results: In both groups, the implantations were 100% successful. Catheter explantation due to infection according to CDC criteria was necessary in 18 cases, with no difference between the groups (5.0% vs. 4.4% p = 0.80). The infection rate per 100 days was 0.113 vs. 0.106 in the control group, with a comparable spectrum of bacteria. A total of 12 catheters (3 vs. 9) had to be removed due to a periinterventional complication. An early-onset infection was the reason in two cases (1.3%) in the study group and five in the control group (1.9%). A total misplacement of the catheter occurred in two cases only in the control group. After adjustment for potential confounders via multivariable logistic regression there was not a significant difference in the complication rate (adjusted odds ratio, aOR = 0.53, 95% CI = 0.14-2.03, p = 0.351) but an estimated decreased risk overall based on the average treatment effect of -1.7% in favor of the study group. Conclusions: The present study shows that a catheter exchange leads to no more infections than a de novo placement; hence, it is a feasible method. Moreover, misplacements and control chest X-rays to exclude pneumothorax after venipuncture were completely avoided by exchanging. This approach yields a much lower infection rate than previous reports: 1.3% compared to 2.7% in all existing aggregated studies. The presented approach seems to be superior to existing switching methods. Overall, an exchange can also help to preserve veins for future access, since the same jugular vein is used.

Intermittent hemodialysis (HD) in high-bleeding-risk patients presents a challenge as circuit anticoagulation using heparin is contraindicated in such cases. Recently, the use of calcium-free citrate-containing dialysate with calcium supplementation emerged as a viable alternative to heparin-circuit anticoagulation. This is a retrospective, monocentric study to evaluate dialysis efficacy using calcium-free citrate-containing dialysate with calcium reinjection into the venous line in hemodialysis patients at risk of bleeding. A total of 53 patients were analyzed: 52 had a temporary contraindication to systemic anticoagulation (active bleeding or surgical intervention), and 1 chronic HD patient had prolonged bleeding time due to inoperable arteriovenous fistula stenosis. Only 7 out of 79 dialysis sessions performed were prematurely terminated (vascular access dysfunction). The median dialysis time was 240 min (range: 150-300). The chronic dialysis patient had 108 sessions with no premature termination. Frequent monitoring of ionized calcium was performed throughout the dialysis sessions: levels remained stable at T0 and T + 60 min (1.08 ± 0.08 mmol/L) and slightly increased at the end of the dialysis session (1.19 ± 0.13 mmol/L), remaining within normal limits. Target postfilter ionized calcium <0.4 mmol/L was achieved in all sessions (0.31 ± 0.07 mmol/L). There were no cases of symptomatic hypo-/hypercalcemia and no need for calcium infusion rate adjustment throughout the sessions. Hemodialysis with calcium-free citrate-containing dialysate and calcium reinjection into the venous line is efficient and safe in HD patients with contraindications to systemic anticoagulation.

Background and Objectives: Endocan, secreted from the activated endothelium, is a key player in inflammation, endothelial dysfunction, proliferation of vascular smooth muscle cells, and angiogenesis. We aimed to investigate the link between endocan and aortic stiffness in maintenance hemodialysis (HD) patients. Materials and Methods: After recruiting HD patients from a medical center, their baseline characteristics, blood sample, and anthropometry were assessed and recorded. The serum endocan level was determined using an enzyme immunoassay kit, and carotid-femoral pulse wave velocity (cfPWV) measurement was used to evaluate aortic stiffness. Results: A total of 122 HD patients were enrolled. Aortic stiffness was diagnosed in 53 patients (43.4%), who were found to be older (p = 0.007) and have a higher prevalence of diabetes (p < 0.001) and hypertension (p = 0.030), higher systolic blood pressure (p = 0.011), and higher endocan levels (p < 0.001), when compared with their counterparts. On the multivariate logistic regression model, the development of aortic stiffness in patients on chronic HD was found to be associated with endocan [odds ratio (OR): 1.566, 95% confidence interval (CI): 1.224-2.002, p < 0.001], age (OR: 1.040, 95% CI: 1.001-1.080, p = 0.045), and diabetes (OR: 4.067, 95% CI: 1.532-10.798, p = 0.005), after proper adjustment for confounders (adopting diabetes, hypertension, age, systolic blood pressure, and endocan). The area under the receiver operating characteristic curve was 0.713 (95% CI: 0.620-0.806, p < 0.001) for predicting aortic stiffness by the serum endocan level, at an optimal cutoff value of 2.68 ng/mL (64.15% sensitivity, 69.57% specificity). Upon multivariate linear regression analysis, logarithmically transformed endocan was proven as an independent predictor of cfPWV (β = 0.405, adjusted R2 change = 0.152; p < 0.001). Conclusions: The serum endocan level positively correlated with cfPWV and was an independent predictor of aortic stiffness in chronic HD patients.

Protein-energy wasting and inflammation are major risk factors for complications in hemodialysis patients. As these risk factors are triggered by a pro-inflammatory state, oxidative stress and hemodynamic dysfunction, which overlap in hemodialyzed subjects, we aimed to assess the efficacy of a cost-effective and straightforward screening tool, the Prognostic Inflammatory and Nutritional Index (PINI), in regularly screening maintenance hemodialysis (MHD) patients, to detect early signs of inflammation and malnutrition. A 12-month follow-up was carried out on a cohort of 102 adult patients undergoing maintenance dialysis, during which the Prognostic Inflammatory and Nutritional Index (PINI) was calculated using the formula alpha1-Acid Glycoprotein (AGP) × C-reactive protein (CRP)/albumin (ALB) × transthyretin (TTR). A PINI score < 1 was considered normal. The patients were stratified based on their PINI score: 66 patients (64.70%) had a normal score, below 1, while 36 patients (35.30%) had a PINI score ≥ 1. Despite the absence of clinical evidence of inflammation at enrollment, the latter group exhibited higher levels of CRP. During the follow-up period, all patients with a PINI score ≥ 1 experienced at least one acute event, compared to only 6% of patients with a normal PINI score, which presented COVID-19 infection as an acute event. The evaluation of the PINI can effectively identify the silent malnutrition-inflammation syndrome and predict the risk of acute events. This straightforward test appears to be a rapid tool that is independent of the examiner\'s experience and subjectivity, thereby potentially reducing hospitalization costs.