Background/Aims: As numbers of maintenance hemodialysis patients are growing, debilitating conditions of muscle wasting and atrophy are becoming some of the greatest concerns in end-stage renal disease patients. Exercise training has various potential benefits in terms of prevention of a sustained decline in functional status. This study aimed to evaluate the physical, psychological, laboratory, and dialysis-related effects of intradialytic exercise. Methods: We enrolled 22 patients from a hemodialysis center for a 6-month nonrandomized prospective trial. Combination of aerobic exercise with bicycle ergometer and anaerobic exercise with elastic bands was conducted during hemodialysis. Data including physical fitness test results, dialysis-related measurements, and biochemical laboratory results were collected at baseline, 3, and 6 months. Depression and quality of life were assessed using Beck Depression Inventory and Short Form-36 health survey. Results: After exercise completion, there were significant improvements in back muscle power, forward and backward trunk flexibility, vertical jump, elbow flexion, sit to stand test, and 6-minute walk test (p < 0.05). No significant changes were observed in dry weight, blood pressure, Kt/V, and biochemical variables, except for intradialytic hypotension (p < 0.05). For depression, Beck Depression Inventory showed statistically significant enhancement (p < 0.05). Scores of Short Form-36 health survey did not show significant increase in each domain, except for bodily pain (p < 0.05). Conclusions: Combined aerobic and anaerobic exercise training during dialysis was found to be effective on physical health status, intradialytic hypotension, and depression in terms of mental health. Therefore, the findings of the current study may provide an appropriate guidance for encouraging exercise by nephrologists.

Significance Statement: Steroid resistance, relapse, and side effects are common issues in use of high-dose steroids as first-line treatment for adult minimal change nephrotic syndrome. Tacrolimus is used as a steroid-sparing immunosuppressant to reduce adverse effects of long-term or repeated steroid treatment, but no large-scale randomized study has compared combined tacrolimus and low-dose steroid with high-dose steroid in treating minimal change nephrotic syndrome in adults. In this open-label randomized trial, the authors found that treatment with tacrolimus plus low-dose steroid was noninferior to high-dose steroid for complete remission at 8 weeks, and that treatment with a maintenance dose of tacrolimus during steroid tapering reduced the relapse rate, with no clinically-relevant safety differences. This indicates that tacrolimus is an effective alternative to high-dose steroids in this disease, although investigation into long-term safety is warranted. Background: Tacrolimus is used as a steroid-sparing immunosuppressant in adults with minimal change nephrotic syndrome. However, combined treatment with tacrolimus and low-dose steroid has not been compared with high-dose steroid for induction of clinical remission in a large-scale randomized study. Methods: In this 24-week open-label noninferiority study, we randomized 144 adults with minimal change nephrotic syndrome to receive 0.05 mg/kg twice-daily tacrolimus plus once-daily 0.5 mg/kg prednisolone, or once-daily 1 mg/kg prednisolone alone, for up to 8 weeks or until achieving complete remission. Two weeks after complete remission, we tapered the steroid to a maintenance dose of 5–7.5 mg/d in both groups until 24 weeks after study drug initiation. The primary end point was complete remission within 8 weeks (urine protein: creatinine ratio 3.0 g/g) after complete remission to within 24 weeks of study drug initiation. Results: Complete remission within 8 weeks occurred in 53 of 67 patients (79.1%) receiving tacrolimus and low-dose steroid and 53 of 69 patients (76.8%) receiving high-dose steroid; this difference demonstrated noninferiority, with an upper confidence limit below the predefined threshold (20%) in both intent-to-treat (11.6%) and per-protocol (17.0%) analyses. Groups did not significantly differ in time until remission. Significantly fewer patients relapsed on maintenance tacrolimus (3–8 ng/ml) plus tapered steroid versus tapered steroid alone (5.7% versus 22.6%, respectively; P=0.01). There were no clinically relevant safety differences. Conclusions: Combined tacrolimus and low-dose steroid was noninferior to high-dose steroid for complete remission induction in adults with minimal change nephrotic syndrome. Relapse rates were significantly lower with maintenance tacrolimus and steroid compared with steroid alone. No clinically-relevant differences in safety findings were observed.

The present study, entitled Trial on Education And Clinical outcomes for Home PD patients (TEACH), investigated the effect of frequent retraining at home on the outcomes of peritoneal dialysis (PD). TEACH is a multicentre, open-label, randomised, controlled trial with parallel arms. Patients starting PD were randomized into either the conventional retraining group (CG) or the frequent retraining group (FG). Patients in the FG were given more frequent home visits for retraining. The primary endpoint was exit site infection (ESI). Secondary endpoints were peritonitis, any PD-related infections, hospitalization, technique failure, and patient survival. A generalised estimating equations (GEE) approach was employed for the adjusted effect of training level on the outcomes. Cox regression was employed for peritonitis and other secondary outcomes. The subjects were randomised to either the FG (n = 51) or the CG (n = 53). Although the time of initial training did not differ between the 2 groups, the total time of training was longer and the frequency of training visits was higher in the FG. In the GEE model, the p-values for interactions between groups and time were significant for both ESI and any PD-related infections, suggesting that the event rates of the two groups significantly changed over time. The event rates for the FG decreased over time, and the event rates for the CG increased after month 12. In the older subgroup (age ≥ 60), frequent retraining had a significant effect in the risk reduction of the first episode of peritonitis (adjusted HR 0.01 [0.001–0.35], p = 0.01). Frequent retraining at home reduced the risk of PD-related infections.

After stenosis of arteriovenous vascular access in hemodialysis patients, platelets play a crucial role in subsequent thrombus formation, leading to access failure. In a previous study, the mean platelet volume (MPV)/platelet count ratio, but not MPV alone, was shown to be an independent predictor of 4-year mortality after myocardial infarction. However, little is known about the potential influence of MPV/platelet count ratio on vascular access patency in hemodialysis patients. A total of 143 patients undergoing routine hemodialysis were recruited between January 2013 and February 2016. Vascular access failure (VAF) was defined as thrombosis or a decrease of greater than 50% of normal vessel diameter, requiring either surgical revision or percutaneous transluminal angioplasty. Cox proportional hazards model analysis ascertained that the change of MPV/platelet count ratio between baseline and 3 months [Δ(MPV/platelet count ratio)_3mo-baseline] had prognostic value for VAF. Additionally, the changes of MPV/platelet count ratio over time were compared in patients with and without VAF by using linear mixed model analysis. Of the 143 patients, 38 (26.6%) were diagnosed with VAF. During a median follow-up of 26.9 months (interquartile range 13.0–36.0 months), Δ(MPV/platelet count ratio)_3mo-baseline significantly increased in patients with VAF compared to that in patients without VAF [11.6 (6.3–19.0) vs. 0.8 (-1.8–4.0), P< 0.001]. In multivariate analysis, Δ(MPV/platelet ratio count)_3mo-baseline was an independent predictor of VAF, after adjusting for age, sex, diabetes, hypertension, coronary artery disease, cerebrovascular disease, vascular access type, the presence of previous VAF, and antiplatelet drug use (hazard ratio, 1.15; 95% confidence interval, 1.10–1.21; P< 0.001). Moreover, a liner mixed model revealed that there was a significant increase of MPV/platelet count ratio over time in patients with VAF compared to those without VAF (P< 0.001). An increase in MPV/platelet count ratio over time was an independent risk factor for VAF. Therefore, continuous monitoring of the MPV/platelet count ratio may be useful to screen the risk of VAF in patients undergoing routine hemodialysis.

Background: Although higher body mass index (BMI) is associated with better survival in patients undergoing dialysis, BMI is not an adequate obesity indicator. We hypothesized that the fat-to-lean (F/L) mass ratio could be a suitable marker of nutritional status and evaluated its prognostic impact on long-term outcomes in patients undergoing hemodialysis (HD). Methods: In total, 131 patients undergoing HD were recruited and monitored prospectively for up to 5 years. Body composition was analyzed, and other nutritional and inflammatory parameters were measured. Results: The mean age of the cohort was 60.7 ± 13.6 years, and 65 patients were diabetic. Age, sex, diabetes, comorbidity, and inflammation were associated significantly with the F/L mass ratio. During the follow-up period, 21 patients experienced cardiac events and 22 patients died. Patients with higher F/L mass ratios had significantly higher risks of all-cause death (hazard ratio [HR] 3.61, 95% CI 1.07–12.13; p = 0.038) and cardiac events (HR 3.54, 95% CI 1.05-11.94; p = 0.041) than those with lower F/L mass ratios. Conclusions: The F/L mass ratio was a useful surrogate marker of nutritional and inflammatory status, and an independent predictor of cardiac events and all-cause mortality, in patients undergoing HD.

Vascular calcification is associated with structural and functional abnormality of the heart and blood vessels. We investigated the relationship between intradialytic hypotension (IDH) and vascular calcification in hemodialysis (HD) patients, and their impacts on cardiovascular events (CVEs). We enrolled 191 maintenance HD patients who underwent plain abdomen radiography for abdominal aortic calcification score (AACS). A nadir systolic blood pressure (BP) < 90 mm Hg or the requirement of bolus fluid administration was required to quantify the hypotension diagnosis. IDH was defined as > 2 hypotension episodes during 10 HD treatments. Among the 191 patients, IDH occurred in 32. AACS was higher in the IDH group compared with the no-IDH group (8.4 ± 6.0 vs. 4.9 ± 5.2, respectively; P = 0.001). High AACS was an independent risk factor after adjustment for age, diabetes mellitus, ultrafiltration, diastolic BP, and calcium level (odds ratio (OR) = 1.09, 95% CI = 1.01–1.18; P = 0.03). Patients with both IDH and AACS ≧ 4 had the highest cumulative CVE rate (27.9%, P = 0.008) compared with 11.2%, 12.5%, and 6% for those with AACS ≧ 4 only, with IDH only, and neither, respectively. In multivariate analysis, the presence of both IDH and AACS ≧ 4 was a significant predictor of CVE (hazard ratio (HR) = 2.84, 95% CI = 1.04–7.74, P = 0.04). IDH is associated with abdominal aortic calcification and is an independent risk factor for IDH. Both IDH and high AACS were significant predictors of CVE.