Nocturnal hemodialysis: an underutilized modality?

PURPOSE OF REVIEW: There is increasing evidence that extended-hours regimens are associated with improved outcomes for patients on maintenance hemodialysis programs. Home hemodialysis programs are a well established way for patients to benefit from extended-hours dialysis overnight; however, there are significant barriers to home hemodialysis, which means that for many this is not an option. In center, nocturnal hemodialysis is an increasingly recognized way of offering extended-hours treatment to patients unable to undertake home-based programs and is an underutilized modality for such patients to gain from the physiological benefits of extended-hours dialysis regimens. RECENT FINDINGS: Recent data suggest that nocturnal dialysis programs confer a significant survival advantage over both standard dialysis and short-daily dialysis regimens with evidence proposing that this is mediated through beneficial cardiovascular remodeling. Moreover, there is strong evidence that nocturnal dialysis regimens associate with significant improvements in quality-of-life measures and social well being. SUMMARY: Nocturnal hemodialysis is an underutilized way of offering extended-hours hemodialysis to patients in both the home and in-center environments. As the evidence base around nocturnal dialysis grows, clinicians and dialysis providers are becoming increasingly obliged to investigate implementation strategies for nocturnal dialysis services to improve patient outcomes and experience of care

Falanga: The clinical correlates of surgical outcomes as a result of foot whipping in a resource poor setting

Background: Falanga is a punishment that involves hitting the bare soles of a person's feet. The consequences of this punishment may be limb and life-threatening. Post-traumatic acute kidney injury (AKI) secondary to rhabdomyolysis is a well-documented complication. Patients often require prompt surgical intervention and renal replacement therapy (RRT). The clinical and biochemical presentation of these patients and subsequent outcomes are poorly understood. Aims: This prospective observational study describes the clinical presentation and effects of foot whipping on patient outcomes. Methodology: Prospective data were collected over a one-year period for 135 patients presenting following blunt force assault admitted to a single centre. Presenting clinical characteristics and patient outcomes were recorded and correlations between presenting clinical characteristics and surgical and clinical outcomes were assessed. Results: Of 138 patients presenting following blunt force assault 96% were male with a mean age of 28.8 ± 8.01. Thirty-six out of the 138 patients presenting following blunt force assault had received foot-whipping only (falanga group, FG). Ten of these 36 patients in the FG group required surgical intervention, with one requiring a below knee amputation, compared with only two patients who required surgical intervention in the group who experienced blunt force trauma not restricted to foot whipping (Sjambok group). Average length of stay was 4 days (range 2-38) in FG group compared with 5 (range 1-21) in SG group, with no mortalities in either group. For patients in the FG, Hb was higher at presentation compared to patients in the SG group (135.2 33.7 vs 124.2 21.3, p = 0.03) and correlated positively with the need for surgical intervention (r = 0.6, p < 0.01). In this same group, the presenting characteristics of CK (4251.3 3087.4, p = 0.1 vs 7422.6 12347.7, p = 0.1) and urine output (0.95 0.4 vs 0.7 0.4) positively correlated with RRT [CK r = 0.6, p < 0.01, UO r = 0.46, p < 0.01]. Conclusion: Patients who present following falanga frequently require surgical intervention and the related healthcare utilisation and morbidity is high. Clinical indicators of a greater systemic injury at presentation may correlate with an increased likelihood of requiring surgical intervention or RRT

Differences in native T1 and native T2 mapping between patients on hemodialysis and control subjects

PurposeMyocardial native T1 is a potential measure of myocardial fibrosis, but concerns remain over the potential influence of myocardial edema to increased native T1 signal in subjects prone to fluid overload. This study describes differences in native T2 (typically raised in states of myocardial edema) and native T1 times in patients on hemodialysis by comparing native T1 and native T2 times between subjects on hemodialysis to an asymptomatic control group. Reproducibility of these sequences was tested.MethodsSubjects were recruited prospectively and underwent 3 T-cardiac MRI with acquisition of native T1 and native T2 maps. Between group differences in native T1 and T2 maps were assessed using one-way ANOVAs. 30 subjects underwent test-retest scans within a week of their original scan to define sequence reproducibility.Results261 subjects completed the study (hemodialysis n = 124, control n = 137). Native T1 times were significantly increased in subjects on hemodialysis compared to control subjects (1259 ms ± 51 vs 1212 ms ± 37, p ConclusionsThe increased native T1 signal demonstrated in subjects on hemodialysis occurs independently of differences in native T2 and the two parameters are not orthogonal. Elevated native T1 in patients on hemodialysis may be driven by water related to myocardial fibrosis rather than edema from volume overload.</div

Impact of changing medical workforce demographics in renal medicine over 7 years: Analysis of GMC national trainee survey data

Increasing numbers of doctors in training are taking career breaks, with burnout cited as a potential cause. This study analysed General Medical Council (GMC) national training survey data (renal medicine) to understand the impacts of changing workforce demographics on trainee outcomes and wellbeing. Increasing proportions of female, Black, Asian and minority ethnic (BAME), and international medical graduates are entering the workforce. Specialty exam pass rates have fallen and are lower for BAME and international medical graduates in renal medicine. Time to complete higher specialty training has increased for female trainees. Self-reported burnout rates for renal trainees were higher than other medical specialties and highest for male BAME trainees. Burnout was only partially mitigated by less-than-full-time working, but had no impact on progression, sick-leave or time out of training. It is important to recognise changes to the workforce and proactively plan to effectively support a more diverse group of trainees, to enable them to succeed and reduce differential attainment

The AFLETES study: atrial fibrillation in veteran athLETEs and the risk of stroke

ObjectivesEndurance athletes are at an increased risk of atrial fibrillation (AF) when compared with the general population. However, the risk of stroke in athletes with AF is unknown.Design and settingWe aimed to assess this risk using an international online survey.PatientsIndividuals that had competed in ≥1 competitive events and were ≥40 years old were included.InterventionsSelf-reported demographic, medical history, and training history data were collected, and a CHA2DS2-VASc was calculated.Main outcome measuresBinary logistic regression was used to assess variables associated with AF and stroke.ResultsThere were 1002 responses from participants in 41 countries across Africa, Asia, Australasia, Europe, and North and South America, and 942 were included in the final analysis. The average age was 52.4 ± 8.5 years, and 84% were male. The most common sports were cycling (n = 677, 72%), running (n = 558, 59%), and triathlon (n = 245, 26%). There were 190 (20%) individuals who reported AF and 26 individuals (3%) who reported stroke; of which, 14 (54%) had AF. Lifetime exercise dose [odds ratio (OR), 1.02, 95% confidence interval (95% CI),1.00-1.03, P = 0.02] and swimming (OR, 1.56, 95% CI, 1.02-2.39, P = 0.04) were associated with AF in multivariable analysis, independent of other risk factors. Atrial fibrillation was associated with stroke (OR, 4.18, 95% CI, 1.80-9.72, P ConclusionsThis survey provides early evidence that veteran endurance athletes who develop AF may be at an increased risk of developing stroke, even in those deemed to be at low risk by CHA2DS2-VASc score

The reproducibility of cardiac magnetic resonance imaging measures of aortic stiffness and their relationship to cardiac structure in prevalent haemodialysis patients

Background Aortic stiffness is one of the earliest signs of cardiovascular disease (CVD) in patients with chronic kidney disease and an independent predictor of mortality. It is thought to drive left ventricular (LV) remodelling, an established biomarker for mortality. The relationship between direct and indirect measures of aortic stiffness and LV remodelling is not defined in dialysis patients, nor are the reproducibility of methods used to assess aortic stiffness using cardiac magnetic resonance (CMR) imaging. Methods Using 3T CMR, we report the results of (i) the interstudy, interobserver and intra-observer reproducibility of ascending aortic distensibility (AAD), descending aortic distensibility (DAD) and aortic pulse wave velocity (aPWV) in 10 haemodialysis (HD) patients and (ii) the relationship between AAD, DAD and aPWV and LV mass index (LVMi) and LV remodelling in 70 HD patients. Results Inter- and intra-observer variability of AAD, DAD and aPWV were excellent [intraclass correlation (ICC) > 0.9 for all]. Interstudy reproducibility of AAD was excellent {ICC 0.94 [95% confidence interval (CI) 0.78–0.99]}, but poor for DAD and aPWV [ICC 0.51 (−0.13–0.85) and 0.51 (−0.31–0.89)]. AAD, DAD and aPWV associated with LVMi on univariate analysis (β = −0.244, P = 0.04; β =−0.315, P < 0.001 and β = 0.242, P = 0.04, respectively). Only systolic blood pressure, serum phosphate and a history of CVD remained independent determinants of LVMi on multivariable linear regression. Conclusions AAD is the most reproducible CMR-derived measure of aortic stiffness in HD patients. CMR-derived measures of aortic stiffness were not independent determinants of LVMi in HD patients. Whether one should target blood pressure over aortic stiffness to mitigate cardiovascular risk still needs determination

Resource efficient aortic distensibility calculation by end to end spatiotemporal learning of aortic lumen from multicentre multivendor multidisease CMR images

Aortic distensibility (AD) is important for the prognosis of multiple cardiovascular diseases. We propose a novel resource-efficient deep learning (DL) model, inspired by the bi-directional ConvLSTM U-Net with densely connected convolutions, to perform end-to-end hierarchical learning of the aorta from cine cardiovascular MRI towards streamlining AD quantification. Unlike current DL aortic segmentation approaches, our pipeline: (i) performs simultaneous spatio-temporal learning of the video input, (ii) combines the feature maps from the encoder and decoder using non-linear functions, and (iii) takes into account the high class imbalance. By using multi-centre multi-vendor data from a highly heterogeneous patient cohort, we demonstrate that the proposed method outperforms the state-of-the-art method in terms of accuracy and at the same time it consumes ∼ 3.9 times less fuel and generates ∼ 2.8 less carbon emissions. Our model could provide a valuable tool for exploring genome-wide associations of the AD with the cognitive performance in large-scale biomedical databases. By making energy usage and carbon emissions explicit, the presented work aligns with efforts to keep DL’s energy requirements and carbon cost in check. The improved resource efficiency of our pipeline might open up the more systematic DL-powered evaluation of the MRI-derived aortic stiffness

Circulating sphingolipids and relationship to cardiac remodelling before and following a low-energy diet in asymptomatic Type 2 Diabetes

Background: Heart failure with preserved ejection fraction (HFpEF) is a heterogenous multi-system syndrome with limited efficacious treatment options. The prevalence of Type 2 diabetes (T2D) continues to rise and predisposes patients to HFpEF, and HFpEF remains one of the biggest challenges in cardiovascular medicine today. Novel therapeutic targets are required to meet this important clinical need. Deep phenotyping studies including -OMIC analyses can provide important pathogenic information to aid the identification of such targets. The aims of this study were to determine; 1) the impact of a low-energy diet on plasma sphingolipid/ceramide profiles in people with T2D compared to healthy controls and, 2) if the change in sphingolipid/ceramide profile is associated with reverse cardiovascular remodelling. Methods: Post-hoc analysis of a randomised controlled trial (NCT02590822) including adults with T2D with no cardiovascular disease who completed a 12-week low-energy (∼810 kcal/day) meal-replacement plan (MRP) and matched healthy controls (HC). Echocardiography, cardiac MRI and a fasting blood for lipidomics were undertaken pre/post-intervention. Candidate biomarkers were identified from case–control comparison (fold change > 1.5 and statistical significance p < 0.05) and their response to the MRP reported. Association between change in biomarkers and change indices of cardiac remodelling were explored. Results: Twenty-four people with T2D (15 males, age 51.1 ± 5.7 years), and 25 HC (15 male, 48.3 ± 6.6 years) were included. Subjects with T2D had increased left ventricular (LV) mass:volume ratio (0.84 ± 0.13 vs. 0.70 ± 0.08, p < 0.001), increased systolic function but impaired diastolic function compared to HC. Twelve long-chain polyunsaturated sphingolipids, including four ceramides, were downregulated in subjects with T2D at baseline. Three sphingomyelin species and all ceramides were inversely associated with LV mass:volume. There was a significant increase in all species and shift towards HC following the MRP, however, none of these changes were associated with reverse cardiac remodelling. Conclusion: The lack of association between change in sphingolipids/ceramides and reverse cardiac remodelling following the MRP casts doubt on a causative role of sphingolipids/ceramides in the progression of heart failure in T2D. Trial registration: NCT02590822

The NightLife study — the clinical and cost-effectiveness of thrice-weekly, extended, in-centre nocturnal haemodialysis versus daytime haemodialysis using a mixed methods approach: study protocol for a randomised controlled trial

Background In-centre nocturnal haemodialysis (INHD) offers extended-hours haemodialysis, 6 to 8 h thrice-weekly overnight, with the support of dialysis specialist nurses. There is increasing observational data demonstrating potential benefits of INHD on health-related quality of life (HRQoL). There is a lack of randomised controlled trial (RCT) data to confirm these benefits and assess safety. Methods The NightLife study is a pragmatic, two-arm, multicentre RCT comparing the impact of 6 months INHD to conventional haemodialysis (thrice-weekly daytime in-centre haemodialysis, 3.5–5 h per session). The primary outcome is the total score from the Kidney Disease Quality of Life tool at 6 months. Secondary outcomes include sleep and cognitive function, measures of safety, adherence to dialysis and impact on clinical parameters. There is an embedded Process Evaluation to assess implementation, health economic modelling and a QuinteT Recruitment Intervention to understand factors that influence recruitment and retention. Adults (≥ 18 years old) who have been established on haemodialysis for > 3 months are eligible to participate. Discussion There are 68,000 adults in the UK that need kidney replacement therapy (KRT), with in-centre haemodialysis the treatment modality for over a third of cases. HRQoL is an independent predictor of hospitalisation and mortality in individuals on maintenance dialysis. Haemodialysis is associated with poor HRQoL in comparison to the general population. INHD has the potential to improve HRQoL. Vigorous RCT evidence of effectiveness is lacking. The NightLife study is an essential step in the understanding of dialysis therapies and will guide patient-centred decisions regarding KRT in the future.</p

Association of ambulatory blood pressure with coronary microvascular and cardiac dysfunction in asymptomatic type 2 diabetes

Background: Type 2 diabetes (T2D) and hypertension commonly coexist and are associated with subclinical myocardial structural and functional changes. We sought to determine the association between blood pressure (BP) and left ventricular (LV) remodeling, systolic/diastolic function, and coronary microvascular function, among individuals with T2D without prevalent cardiovascular disease. Methods: Participants with T2D and age-, sex-, and ethnicity-matched controls underwent comprehensive cardiovascular phenotyping including fasting bloods, transthoracic echocardiography, cardiovascular magnetic resonance imaging with quantitative adenosine stress/rest perfusion, and office and 24-h ambulatory BP monitoring. Multivariable linear regression was performed to determine independent associations between BP and imaging markers of remodeling and function in T2D. Results: Individuals with T2D (n = 205, mean age 63 ± 7 years) and controls (n = 40, mean age 61 ± 8 years) were recruited. Mean 24-h systolic BP, but not office BP, was significantly greater among those with T2D compared to controls (128.8 ± 11.7 vs 123.0 ± 13.1 mmHg, p = 0.006). Those with T2D had concentric LV remodeling (mass/volume 0.91 ± 0.15 vs 0.82 ± 0.11 g/mL, p < 0.001), decreased myocardial perfusion reserve (2.82 ± 0.83 vs 3.18 ± 0.82, p = 0.020), systolic dysfunction (global longitudinal strain 16.0 ± 2.3 vs 17.2 ± 2.1%, p = 0.004) and diastolic dysfunction (E/e’ 9.30 ± 2.43 vs 8.47 ± 1.53, p = 0.044) compared to controls. In multivariable regression models adjusted for 14 clinical variables, mean 24-h systolic BP was independently associated with concentric LV remodeling (β = 0.165, p = 0.031), diastolic dysfunction (β = 0.273, p < 0.001) and myocardial perfusion reserve (β = − 0.218, p = 0.016). Mean 24-h diastolic BP was associated with LV concentric remodeling (β = 0.201, p = 0.016). Conclusion: 24-h ambulatory systolic BP, but not office BP, is independently associated with cardiac remodeling, coronary microvascular dysfunction, and diastolic dysfunction among asymptomatic individuals with T2D. (Clinical trial registration. URL: https://clinicaltrials.gov/ct2/show/NCT03132129 Unique identifier: NCT03132129)