Background: Arterial stiffness, measured by pulse wave velocity (PWV), is highly predictive of mortality in dialysis patients. As such, PWV is frequently used in clinical research studies and may have a role in clinical practice if shown to be suitably reliable. Measurement of PWV using the SphygmoCor® system is known to be an observer-dependent technique. The aim of this study was to investigate the ability of 4 observers to acquire reproducible PWV and pulse wave analysis (PWA) measurements after a 6-week training period. Methods: Reproducibility of this technique was investigated using repeated measurements of the carotid-femoral PWV and PWA of the radial pulse by the 4 observers after a period of training. Both healthy volunteers and individuals with chronic kidney disease (CKD) were recruited for this study. Measurements were considered to have met quality control if 2 consecutive measurements were visually acceptable, within 1.5 m/s of each other and had a standard deviation of less than 10%. A fixed-effect analysis of variance was used to test the variation in measurements between the observers; the intraclass correlation coefficient (ICC) was used to assess the statistical agreement between the observers. Results: A total of 20 individuals volunteered for PWV and PWA measurements (13 with CKD and 7 without); the mean age was 58 years (range 24–83). The average PWV was 9.4 ± 3.6 m/s. There was no significant difference shown between the 4 observers’ measurements (p = 0.25). Further, there was good statistical agreement between the observers (ICC = 0.95). Conclusions: After a period of training it is possible for multiple observers to have reproducible measurements of PWV and PWA. Assurance of reproducibility is important when more than one individual is collecting data in a study, particularly when assessing changes over time.

Peritoneal dialysis (PD) is a well-established renal replacement therapy for end-stage renal disease patients. Nonetheless, on an annual basis, at least 10% of patients shift from PD to hemodialysis for a variety of reasons. Thus the issue of vascular access creation needs to be addressed for this small but significant group of patients. Despite the relatively consistent number of dropouts, the creation of an arteriovenous fistula prior to transfer remains suboptimal, and variable from center to center. Literature for this specific area is poor and dated. Guidelines seem to suggest vascular access creation in high-risk failure patients, but they have no detailed criteria to select patients that would likely fail PD and therefore take advantage of a backup access. There is a need to better understand and predict patients that require conversion to hemodialysis to develop a plan that focuses on wellness and maximum quality of life in the lifecycle of PD patients. This review addresses the issue of vascular access planning in adult PD patients, presents the available literature on the topic and the current guidelines and recommendations, and describes a research agenda to guide decision making in clinical practice.

Background Uremic patients on regular dialytic treatment (RDT) are often affected by a complex metabolic syndrome leading to osteodystrophy. Bone changes are primarily due to high bone turn over, often combined with a mineralization defect leading to increased bone fractures and bone deformities. Although rarely considered, the craniofacial skeleton represents one of the peculiar targets of this complex metabolic disease whose more dramatic pattern is a form of leontiasis ossea. This complication, although described, has never been evaluated in depth nor quantitatively assessed. In order to assess facial deformities in uremic conditions and to understand the possible relation with hyperparathyroidism, we undertook a quantitative evaluation of soft facial structures in a cohort of uremic patients undergoing RDT. Methods The three-dimensional coordinates of 50 soft-tissue facial landmarks were obtained by an electromagnetic digitizer in 10 male and 10 female patients with chronic renal insufficiency aged 53–81 years, and in 34 healthy individuals of the same age, ethnicity and sex. Uremic patients were enrolled according to hyperparathyroid status (PTH < 300 pg/mL and PTH > 500 pg/mL). From the landmarks, facial distances, angles and volumes were calculated according to a geometrical face model. Results Overall, the uremic patients had significantly larger facial volumes than the reference subjects. The effect was particularly evident in the facial middle third (maxilla), leading to an inversion of the mandibular-maxillary ratio. Facial dimensions were increased in all three spatial directions: width (skull base, mandible, nose), length (nose, mandible), and depth (mid face, mandible). The larger maxilla was accompanied by a tendency to more prominent lips (reduced interlabial angle). Some of the facial modifications (nose, lips, mandible) were significantly related to the clinical characteristics of the patients (age, duration of renal insufficiency and PTH levels). Conclusions This report, the first in the literature, shows that facial structures of uremic patients are enlarged in comparison with matched normal subjects and that increased bone turnover could be responsible – at least in part – for facial bone changes.

In this group of incident PD patients, we demonstrate a lower prevalence of vascular calcification than in hemodialysis patients, a correlation of calcification with PWV, and an important finding that PWV can change in either direction over a short period of time, which are associated with modifiable risk factors.

In the last 10 years, it has been well documented that mineral metabolism abnormalities in dialysis patients are associated with an enhanced risk of morbidity and mortality for cardiovascular disease. Extraskeletal calcifications represent one of the major risk factors involved in the pathogenesis of cardiovascular disease in this population. In fact, secondary hyperparathyroidism and hyperphosphatemia associate with increased cardiovascular mortality in uremic patients for two reasons: first for the passive deposition of calcium and phosphate in soft tissues; second for the active role of inorganic phosphate on direct induction of extraskeletal mineralization of the tunica media in the vasculature of these patients. In peritoneal dialysis patients, many unbalances of calcium and phosphate metabolism are present. In particular, recent cohort studies indicate that most patients do not reach targets indicated by clinical practice guidelines. Further efforts to control hyperphosphatemia are essential, in order to reduce the impact of secondary hyperparathyroidism both on bone and cardiovascular system.

Dietary management of hyperphosphatemia and hyperparathyroidism have long been important elements in the clinical management of CKD stage 4 and 5 for the prevention of mineral bone disease. The rationale for phosphate lowering has been further justified, given the accumulating data to support the association of phosphate with vascular damage, in this population who are at high risk of cardiovascular (CV) death. Phosphate is a novel CV risk factor in both CKD and in the general population, and a growing body of literature suggests that high normal serum phosphate may be a risk factor for progression of CKD. Few studies have examined hard outcomes after phosphate lowering. Nonetheless, given the balance of data both in cell, animal and human studies, the use of phosphate lowering strategies at earlier stages of CKD, perhaps even prior to serum phosphate level rising, may well be justified. This review will discuss the complications associated with higher serum phosphate, the potential benefits of early phosphate intervention, practical considerations of low phosphate diets and novel strategies for evaluating these strategies in clinical practice.

Background/Aims: Novel biomarkers may help explain the pathobiology of vascular disease in chronic kidney disease, and thus set the stage for identification of therapeutic targets, potential reversibility, and improved outcomes in this population. Methods: 124 subjects with GFR <60 ml/min or on renal replacement therapy underwent measurement of inflammatory, vascular and cardiac biomarkers as well as aortic pulse wave velocity (PWV) testing. A subset of patients (n = 60) had repeat PWV measured at 6 months. Results: Thirty-four percent of the patients were diabetic, and 50% had a history of cardiovascular disease or congestive heart failure. Median PWV was 9.8 (IQR 8.3–12.7) m/s. No significant correlations between the measured biomarkers and baseline PWV was observed. An increase in PWV (>1.5 m/s) over 6 months was observed in those subjects with diabetes, a higher brain natriuretic peptide level, lower cholesterol and lower phosphate level. Age (HR 1.086, p = 0.0028), fetuin (0.024, p = 0.0448), and interleukin-10 (top tertile HR 4.720, p = 0.0359) were associated with mortality. Conclusions: In this cohort of patients with chronic kidney disease and diabetes and/or heart disease, we were unable to demonstrate that select biomarkers can inform processes leading to vascular disease. Biomarkers do appear to have utility in predicting future events in this population.

We described a new method for catheter exchange, which allows the easy insertion of a new catheter and the creation of a new and safer subcutaneous tunnel. In addition, we demonstrated that in cases of complete catheter removal, it is possible to reinsert a catheter in the same vein through a guidewire, even when reinsertion was attempted up to 1 day later.