Sudden death is one of the more frequent causes of death for hemodialysis patients, but the underlying mechanisms, contribution of arrhythmia, and associations with serum chemistries or the dialysis procedure are incompletely understood. To study this, implantable loop recorders were utilized for continuous cardiac rhythm monitoring to detect clinically significant arrhythmias including sustained ventricular tachycardia, bradycardia, asystole, or symptomatic arrhythmias in hemodialysis patients over six months. Serum chemistries were tested pre- and post-dialysis at least weekly. Dialysis procedure data were collected at every session. Associations with clinically significant arrhythmias were assessed using negative binomial regression modeling. Sixty-six patients were implanted and 1678 events were recorded in 44 patients. The majority were bradycardias (1461), with 14 episodes of asystole and only one of sustained ventricular tachycardia. Atrial fibrillation, although not defined as clinically significant arrhythmias, was detected in 41% of patients. With thrice-weekly dialysis, the rate was highest during the first dialysis session of the week and was increased during the last 12 hours of each inter-dialytic interval, particularly the long interval. Among serum and dialytic parameters, only higher pre-dialysis serum sodium and dialysate calcium over 2.5 mEq/L were independently associated with clinically significant arrhythmias. Thus, clinically significant arrhythmias are common in hemodialysis patients, and bradycardia and asystole rather than ventricular tachycardia may be key causes of sudden death in hemodialysis patients. Associations with the temporal pattern of dialysis suggest that modification of current dialysis practices could reduce the incidence of sudden death.

Patients with carotid atherosclerosis are at increased risk of both stroke and ischaemic heart disease. Low-density lipoprotein (LDL) is a heterogeneous group of particles, with small, dense particles being more atherogenic. We studied 79 patients (51 men, mean +/- SD age 62.4 +/- 11.7 years) referred for Doppler ultrasound assessment of the carotid arteries. Evidence of carotid atherosclerosis, defined as the presence of atherosclerotic plaque, stenosis or occlusion in one or more of the six carotid artery segments examined, was found in 44 patients (56%). LDL subfractions were analysed by disc polyacrylamide gel electrophoresis with prior ultracentrifugation of serum to remove chylomicrons. This method produces a LDL score; the higher the score, the greater the proportion of the more atherogenic LDL subfractions. Mean LDL score was significantly higher in diseased patients (mean +/- SD, 1.56 +/- 0.61) than the normal group (1.26 +/- 0.65) (t = 2.12, p = 0.037). There was no significant association between LDL score and severity of carotid artery stenosis. Age (adjusted odds ratio 1.09, 95% CI 1.03-1.15) and smoking history (2.09, 95% CI 1.10-3.98) predicted carotid atherosclerosis in logistic regression analysis, with LDL score achieving borderline significance (2.20, 95% CI 0.91-5.29). Small, dense LDL subfractions are associated with carotid atherosclerosis and may be a modifiable risk factor for stroke as well as ischaemic heart disease.

Introduction. Experience of COVID-19 in kidney transplant recipients (KTRs) with clinical presentation, management, factors influencing mortality, and antibody response is limited. Material and Methods. A retrospective data of COVID-19 in KTRs was collected and analyzed. The mortality rate, risk factors, and antibody response were primary objectives, while the clinical presentation, laboratory indicators, and pharmacological management were secondary objectives. Results. The 67 KTRs with polymerase chain reaction (PCR) confirmed COVID-19 infection reported between 1 May 2020 and 31 December 2020; 61.2% of patients were hospitalized; and 20.9% needed ventilation. The overall mortality was 26.9%, while blood group A had 50% mortality. The treatment options and used were steroids (100%), convalescent plasma (32.8%), ivermectin (58.2%), doxycycline (55.2%), remdesivir (34.3%), tocilizumab (10.4%), antibiotics (61.2%), anti-fungals (26.9%), low molecular weight heparin (45.3%), and oral anti-coagulants (26.9%). Anti-nucleosides (mycophenolate or azathioprine) were discontinued in 76.1% and calcineurin inhibitors (CNI) in 26.9%. Significant mortality ( p < 0.001 ) was observed in patients presenting with SpO2 <94 needing ICU care, ventilation, dialysis/acute kidney injury (AKI), and empirical therapies like convalescent plasma and remdesivir. The age of survivors versus nonsurvivors was not significantly different ( p = 0.02 ). The positive blood culture, low serum albumin, high TLC, high blood urea, interleukin-6, and CT severity score ≥15 were statistically significant in nonsurvivors. Overall mortality, mortality of hospitalized patients, and mortality of ventilated patients was 27%, 44%, and 100%, respectively. The median value of SARS-CoV-2 (COVID-19) IgG antibody was 68.60 (IQR, 28.5–94.25) AU/ml in more than 90% of survivors. Conclusion. KTRs with COVID-19, needing ICU care, dialysis and ventilation support had poor outcomes. Recovered patients mounted adequate antibody response.

South and Southeast Asia is the most populated, heterogeneous part of the world. The Association of Vascular Access and InTerventionAl Renal physicians (AVATAR Foundation), India, gathered trends on epidemiology and Interventional Nephrology (IN) for this region. The countries were divided as upper-middle- and higher-income countries as Group-1 and lower and lower-middle-income countries as Group-2. Forty-three percent and 70% patients in the Group 1 and 2 countries had unplanned hemodialysis (HD) initiation. Among the incident HD patients, the dominant Vascular Access (VA) was non-tunneled central catheter (non-TCC) in 70% of Group 2 and tunneled central catheter (TCC) in 32.5% in Group 1 countries. Arterio-Venous Fistula (AVF) in the incident HD patients was observed in 24.5% and 35% of patients in Group-2 and Group-1, respectively. Eight percent and 68.7% of the prevalent HD patients in Group-2 and Group-1 received HD through an AVF respectively. Nephrologists performing any IN procedure were 90% and 60% in Group-2 and Group 1, respectively. The common procedures performed by nephrologists include renal biopsy (93.3%), peritoneal dialysis (PD) catheter insertion (80%), TCC (66.7%) and non-TCC (100%). Constraints for IN include lack of time (73.3%), lack of back-up (40%), lack of training (73.3%), economic issues (33.3%), medico-legal problems (46.6%), no incentive (20%), other interests (46.6%) and institution not supportive (26%). Routine VA surveillance is performed in 12.5% and 83.3% of Group-2 and Group-1, respectively. To conclude, non-TCC and TCC are the most common vascular access in incident HD patients in Group-2 and Group-1, respectively. Lack of training, back-up support and economic constraints were main constraints for IN growth in Group-2 countries.

Aim There is paucity of data on the epidemiology of end‐stage kidney disease (ESKD) from South Asia and South‐East Asia. The objective of this study was to assess the aetiology, practice patterns and disease burden and growth of ESKD in the region comparing the economies. Methods The national nephrology societies of the region; responded to the questionnaire; based on latest registries, acceptable community‐based studies and society perceptions. The countries in the region were classified into Group 1 (High|higher‐middle‐income) and Group 2 (lower|lowermiddle income). Student t‐test, Mann‐Whitney U test and Fisher's exact test were used for comparison. Results Fifteen countries provided the data. The average incidence of ESKD was estimated at 226.7 per million population (pmp), (Group 1 vs. Group 2, 305.8 vs. 167.8 pmp) and average prevalence at 940.8 pmp (Group 1 vs. Group 2, 1306 vs. 321 pmp). Group 1 countries had a higher incidence and prevalence of ESKD. Diabetes, hypertension and chronic glomerulonephritis were most common causes. The mean age in Group 2 was lower by a decade (Group 1 vs. Group 2—59.45 vs 47.7 years). Conclusion Haemodialysis was the most common kidney replacement therapy in both groups and conservative management of ESKD was the second commonest available treatment option within Group 2. The disease burden was expected to grow >20% in 50% of Group 1 countries and 78% of Group 2 countries along with the parallel growth in haemodialysis and peritoneal dialysis.

Background. The association between economic status and kidney disease is incompletely explored even in countries with higher economy (HE); the situation is complex in lower economies (LE) of South Asia and Southeast Asia (SA and SEA). Methods. Fifteen countries of SA and SEA categorized as HE and LE, represented by the representatives of the national nephrology societies, participated in this questionnaire and interview-based assessment of the impact of economic status on renal care. Results. Average incidence and prevalence of end-stage kidney disease (ESKD) per million population (pmp) are 1.8 times and 3.3 times higher in HE. Hemodialysis is the main renal replacement therapy (RRT) (HE-68%, LE-63%). Funding of dialysis in HE is mainly by state (65%) or insurance bodies (30%); out of pocket expenses (OOPE) are high in LE (41%). Highest cost for hemodialysis is in Brunei and Singapore, and lowest in Myanmar and Nepal. Median number of dialysis machines/1000 ESKD population is 110 in HE and 53 in LE. Average number of machines/dialysis units in HE is 2.7 times higher than LE. The HE countries have 9 times more dialysis centers pmp (median HE-17, LE-02) and 16 times more nephrologist density (median HE-14.8 ppm, LE-0.94 ppm). Dialysis sessions >2/week is frequently followed in HE (84%) and <2/week in LE (64%). “On-demand” hemodialysis (<2 sessions/week) is prevalent in LE. Hemodialysis dropout rates at one year are lower in HE (12.3%; LE 53.4%), death being the major cause (HE-93.6%; LE-43.8%); renal transplants constitute 4% (Brunei) to 39% (Hong Kong) of the RRT in HE. ESKD burden is expected to increase >10% in all the HE countries except Taiwan, 10%–20% in the majority of LE countries. Conclusion. Economic disparity in SA and SEA is reflected by poor dialysis infrastructure and penetration, inadequate manpower, higher OOPE, higher dialysis dropout rates, and lesser renal transplantations in LE countries. Utility of RRT can be improved by state funding and better insurance coverage.

Background: Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region. Methods: The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups. Results: Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI -US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization. Conclusion: Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

Data comparing the clinical spectrum of COVID-19 in kidney transplant recipients (KTRs) during the first and second waves of the pandemic in India is limited. Our single-center retrospective study compared the clinical profile, mortality, and associated risk factors in KTRs with COVID-19 during the 1st wave (1st February 2020 to 31st January 2021) and the second wave (1st March-31st August 2021). 156 KTRs with PCR confirmed SARS-CoV-2 infection treated at a tertiary care hospital in New Delhi during the 1st and the second waves were analyzed. The demographics and baseline transplant characteristics of the patients diagnosed during both waves were comparable. Patients in the second wave reported less frequent hospitalization, though the intensive care unit (ICU) and ventilator requirements were similar. Strategies to modify immunosuppressants such as discontinuation of antinucleoside drugs with or without change in calcineurin inhibitors and the use of steroids were similar during both waves. Overall patient mortality was 27.5%. The demographics and baseline characteristics of survivors and nonsurvivors were comparable. A higher percentage of nonsurvivors presented with breathing difficulty, low SpO2, and altered sensorium. Both wave risk factors for mortality included older age, severe disease, ICU/ventilator requirements, acute kidney injury (AKI) needing dialysis, Chest Computerized Tomographic (CT) scan abnormalities, and higher levels of inflammatory markers particularly D-dimer and interleukin-6 levels. Conclusions. KTRs in both COVID-19 waves had similar demographics and baseline characteristics, while fewer patients during the second wave required hospitalization. The D-dimer and IL-6 levels are directly correlated with mortality.