Background. Patients on kidney replacement therapy comprise a vulnerable population and may be at increased risk of death from coronavirus disease 2019 (COVID-19). Currently, only limited data are available on outcomes in this patient population. Methods. We set up the ERACODA (European Renal Association COVID-19 Database) database, which is specifically designed to prospectively collect detailed data on kidney transplant and dialysis patients with COVID-19. For this analysis, patients were included who presented between 1 February and 1 May 2020 and had complete information available on the primary outcome parameter, 28-day mortality. Results. Of the 1073 patients enrolled, 305 (28%) were kidney transplant and 768 (72%) dialysis patients with a mean age of 60 ± 13 and 67 ± 14 years, respectively. The 28-day probability of death was 21.3% [95% confidence interval (95% CI) 14.3–30.2%] in kidney transplant and 25.0% (95% CI 20.2–30.0%) in dialysis patients. Mortality was primarily associated with advanced age in kidney transplant patients, and with age and frailty in dialysis patients. After adjusting for sex, age and frailty, in-hospital mortality did not significantly differ between transplant and dialysis patients [hazard ratio (HR) 0.81, 95% CI 0.59–1.10, P = 0.18]. In the subset of dialysis patients who were a candidate for transplantation (n = 148), 8 patients died within 28 days, as compared with 7 deaths in 23 patients who underwent a kidney transplantation <1 year before presentation (HR adjusted for sex, age and frailty 0.20, 95% CI 0.07–0.56, P < 0.01). Conclusions. The 28-day case-fatality rate is high in patients on kidney replacement therapy with COVID-19 and is primarily driven by the risk factors age and frailty. Furthermore, in the first year after kidney transplantation, patients may be at increased risk of COVID-19-related mortality as compared with dialysis patients on the waiting list for transplantation. This information is important in guiding clinical decision-making, and for informing the public and healthcare authorities on the COVID-19-related mortality risk in kidney transplant and dialysis patients.

Normotension can be achieved independently of the duration and dose (Kt/V urea) of HD, if the control of post-dialysis ECV is adequate. However, this is more difficult to achieve with short than with more prolonged HD during which the ultrafiltration rate is lower, BV changes are smaller and intradialysis symptoms less frequent. The results in the subgroup of patients with high ECVn at Tassin suggest that normotension may also be achieved in patients with fluid overload provided that the dialysis time is long enough to ensure more efficient removal of one or more vasoactive factors that cause or contribute to hypertension.

Background COVID-19 has exposed hemodialysis patients and kidney transplant recipients to an unprecedented life-threatening infectious disease raising concerns about kidney replacement therapy (KRT) strategy during the pandemic. The present study investigated the association of type of KRT with COVID-19 severity adjusting for differences in individual characteristics. Methods Data on kidney transplant recipients and hemodialysis patients diagnosed with COVID-19 between February 1st and December 1st 2020 were retrieved from ERACODA. Cox regression models adjusted for age, sex, frailty and comorbidities were used to estimate hazard ratios (HR) for 28-day mortality risk in all patients and in the subsets who were tested because of symptoms Results In total, 1,670 patients (496 functional kidney transplant and 1,174 hemodialysis) were included. 16.9% of kidney transplant and 23.9% of hemodialysis patients died within 28 days of presentation. The unadjusted 28-day mortality risk was 33% lower in kidney transplant recipients compared with hemodialysis patients (HR: 0.67, 95%CI: 0.52-0.85). In a fully adjusted model, the risk was 78% higher in kidney transplant recipients (HR: 1.78, 95%CI: 1.22-2.61) compared with hemodialysis patients. This association was similar in patients tested because of symptoms (fully adjusted model HR: 2.00, 95%CI: 1.31-3.06). This risk was dramatically increased during the first post-transplant year. Results were similar for other endpoints (e.g. hospitalization, ICU admission, mortality beyond 28 days) and across subgroups. Conclusions Kidney transplant recipients had a greater risk of a more severe course of COVID-19 compared with hemodialysis patients; they therefore require specific infection mitigation strategies.

The estimation of representative blood pressure (BP) levels is difficult in haemodialysis (HD) patients as it is not known whether pre- or postdialytic blood pressure are predictive for the average interdialytic BP. Furthermore, the day-night BP rhythm can be disturbed in HD patients. Therefore, in this study, BP was measured during the interdialytic period using non-invasive ambulatory BP measurements in four hypotensive, six normotensive, and 12 hypertensive HD patients. It was assessed whether pre- or postdialytic BP was representative for the average interdialytic BP. Furthermore, the nocturnal BP reduction was compared between HD patients, seven normotensive controls and eight treated subjects with essential hypertension. Postdialytic BP was superior to predialytic BP in predicting the average BP during the interdialytic period. BP did not differ significantly between day 1 and day 2 of the interdialytic period but increased rapidly in the hours before dialysis. Weight gain (corrected for actual body-weight) did not correlate significantly with the increment in systolic BP (r = 0.21; P = 0.2) or diastolic BP (r = -0.02; P = 0.5) during the interdialytic period. The nocturnal decline in systolic BP was significantly attenuated (P less than 0.001) in hypertensive HD patients compared with normotensive controls. The nocturnal reduction in diastolic BP was significantly less in hypotensive (P less than 0.001) and normotensive (P less than 0.001) HD patients compared with normotensive controls and in hypertensive HD patients compared with normotensive (P less than 0.001) and hypertensive (P less than 0.001) controls.(ABSTRACT TRUNCATED AT 250 WORDS)

No changes in cardiovascular parameters were observed during pre-dilution on-line HF compared with low-flux HD. Treatment with on-line HF resulted in marked changes in the uraemic toxicity profile, an improvement in physical well-being and a small improvement in nutritional state.

In dialysis patients blood pressure can be well controlled with long dialysis (3 times a week for 8 h) in contrast to a more common short dialysis regime (3 times a week for 4 h). We studied whether the good blood pressure control in patients on long dialysis as compared to patients on short dialysis was associated with a decrease in extracellular fluid volume. Two-day interdialytic ambulatory blood pressure monitoring was performed in 26 non-diabetic patients on long dialysis, in 22 patients on short dialysis, matched for the years they were on dialysis treatment, and during 24 h in 19 healthy volunteers. After full equilibration, 24 h after dialysis, echography of the inferior caval vein was performed to determine fluid state. Cardiac dimensions and stroke index were measured by echocardiography. A blood sample was drawn for the determination of electrolytes and vasoactive hormones. 73% of the patients on short dialysis were using antihypertensive medication in contrast to none of the patients on long dialysis. However, blood pressure was significantly lower in patients on long dialysis (115 ± 21/67 ± 11 mm Hg) when compared to patients on short dialysis (143 ± 26/81 ± 16 mm Hg). Indexed caval vein diameter, left ventricular diameter index, and atrial natriuretic peptide were not significantly different in patients on long dialysis compared to patients on short dialysis. Also the cardiac index was comparable in patients on long and short dialysis. However, the total peripheral resistance index was significantly lower in patients on long dialysis compared to the patients on short dialysis and normal controls. The left ventricular mass index was increased in both patients on long and short dialysis compared to controls. We conclude that patients on long dialysis have adequate blood pressure control that seems mainly to be caused by a low total peripheral resistance. These data also suggest that factors other than a lower fluid state contribute to the good blood pressure control in patients on long dialysis.

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Although as yet no major breakthroughs have occurred to improve long-term survival of haemodialysis patients with impaired cardiovascular function, it is possible to reduce morbidity by intra-dialytic hypotension in these patients by the use of relatively simple manoeuvres. In our experience, this can be achieved using the following approach (Table 1). First, the decline in plasma volume can be reduced by adequate estimation of the optimal dry weight by objective methods, such as echography of the inferior caval vein or bioimpedance measurements. Furthermore, the ultrafiltration rate during haemodialysis should be moderate and should be limited to a maximum value, which has to be defined empirically for each individual patient. Especially in patients with excess inter-dialytic weight gain, isolated ultrafiltration should be used when the required amount of fluid cannot be removed during haemodialysis. The use of low-sodium dialysate should be avoided. Probably it is best to use a physiological sodium concentration of the dialysate because a greater sodium concentration may result in increased thirst and intra-dialytic weight gain. Sodium profiling should be based on further studies concerning plasma volume changes during haemodialysis in different patient groups. Because of the deleterious impact of acetate on vascular reactivity, it should never be used in patients prone to hypotensive periods. Vascular reactivity can also be impaired by the use of vasoactive medication prior to haemodialysis treatment. Therefore, in patients prone to hypotensive periods, vasoactive medication should be withheld the morning before haemodialysis, if possible. Also, one should be very cautious with the use of low-calcium dialysate in patients with frequent hypotensive periods, and ideally it should be avoided. If the use of these manoeuvres fails to control intra-dialytic hypotension, one should consider the use of cold dialysate. Switching to haemofiltration or to continuous treatment modes such as CAPD are other options. Future studies should address haemodynamics during other treatment modes, such as haemodiafiltration or acetate-free biofiltration.