Introduction: Fluid overload is a major determinant of morbidity and mortality in maintenance hemodialysis (MHD) patients. This exploratory study describes the integration of lung ultrasound (LUS), modified Venous Excess Ultrasound Score (mVExUS), and bioimpedance analysis (BIA) for non-invasive fluid status assessment in MHD. Additionally, this study aimed to correlate congestion with malnutrition using echographic parameters (nutritional ultrasound [NUS]) in congestive and non-congestive patients. Methods: In this single-center retrospective observational cohort study, 47 adult patients on MHD underwent pre-dialysis evaluation with LUS, mVExUS, NUS, and BIA. Patients were classified as congestive if they had an mVExUS score ≥2, LUS with ≥3 B-lines in ≥3 thoracic zones and BIA with the ratio of extracellular water to total body water ECW/TBW ≥0.39. NUS was used to assess the quadriceps rectus femoris (QRF) and preperitoneal visceral fat (PPVF), measuring Y-axis, Y-axis/height, cross-sectional muscle area rectus femoris (CS-MARF), and supramuscular fat (SMF). Demographic, biochemical, functional, and dialysis-related parameters were collected. Frailty, sarcopenia and nutritional status were evaluated. Congestive patients were reassessed after 5 weeks. Results: Eight patients (17%) met criteria for congestion. As expected by the predefined congestion criteria, patients classified as congestive showed higher mVExUS grades (p < 0.001), greater B-line burden (11.9 vs. 2.9), and higher ECW/TBW ratios (0.42 vs. 0.40; p = 0.004). After 5 weeks, congestive patients exhibited improvements in N-terminal pro-B-type natriuretic peptide (NT-proBNP), portal vein pulsatility index, and pulmonary congestion, without adverse hemodynamic events. The CS-MARF was 1.81 ± 0.11 cm2 in congestive versus 2.91 ± 0.78 cm2 in non-congestive (p = 0.0004). Conclusion: The integration of LUS, mVExUS, BIA and NUS provide a descriptive framework for multimodal assessment of fluid and nutritional status in MHD patients. These findings should be considered hypothesis-generating and require validation in prospective studies.

Background: Psychological distress is common in hemodialysis patients and is linked to worse clinical outcomes and lower quality of life. Nutritional and inflammatory disturbances may impact emotional well-being. Gender likely acts as a biological and psychosocial modifier. This study examined the link between depression, anxiety, and stress in hemodialysis patients and a broad range of biochemical markers, focusing on gender as a main factor. Methods: A cross-sectional study included 54 adults on maintenance hemodialysis at a hospital in Madrid, Spain. Emotional distress was measured using the DASS-21. Predialysis biochemical markers assessed were β₂-microglobulin, albumin, hemoglobin, hematocrit, phosphorus, potassium, iron, calcium, and vitamin D. Statistical analyses included Spearman correlations, HC3-robust regressions with Gender × Biomarker interactions, false discovery rate correction (q = 0.10), penalized regressions (ridge/LASSO), partial least squares structural equation modeling (PLS-SEM), and mixed-cluster analysis. Results: Women reported higher depression, anxiety, and stress, and had lower albumin, calcium, and vitamin D (p < 0.05). Depression was independently linked to female gender, lower calcium, and the Gender × β₂-microglobulin interaction (adjusted R² = 0.30). In PLS-SEM analysis, a latent global psychological distress measure was directly related to β₂-microglobulin and inversely related to albumin and calcium (R² = 0.47). Nutritional markers partly mediated the gender–distress link. Cluster analysis found three biopsychosocial profiles: metabolically balanced, catabolic–emotional, and resilient–compensated. Conclusions: Gender shapes the relationships among inflammation, nutrition, and psychological distress in hemodialysis. Including gender-sensitive emotional and nutritional assessments in nephrology nursing could foster more personalized and practical care. Findings highlight the value of gender-aware psycho-nutritional screening in dialysis.

Background and Objectives: Nutritional status is essential for outcomes in hemodialysis (HD) patients. Incremental HD (iHD) may help preserve residual renal function, but its effect on nutrition and body composition is unclear. Nutritional ultrasound (NUS) offers a non-invasive way to assess muscle and fat, complementing methods like BIA. This study compared nutritional status using morphofunctional assessment in patients on iHD versus conventional HD (cHD). Material and Methods: This single-center observational cross-sectional study included 74 stable adult HD patients (>3 months). Patients were stratified into iHD (n = 13; 1–2 sessions/week) and cHD (n = 61; 3 sessions/week). Evaluations included clinical and biochemical parameters, BIA, handgrip strength, nutritional scores and NUS assessed mass muscle of anterior quadriceps rectus femoris (QRF), supramuscular fat (SMF), subcutaneous adipose tissue (SAT), and preperitoneal visceral fat (PPVF). Results: Patients on iHD exhibited a more favorable nutritional and inflammatory profile, with a lower risk of malnutrition and a reduced prevalence of protein-energy wasting (PEW) syndrome. Although BIA failed to clearly differentiate between groups, NUS identified better preservation of SMF in iHD patients (8.3 ± 2.5 vs. 6.6 ± 2 mm; p = 0.009), as well as higher preperitoneal visceral fat thickness (1.9 ± 4.9 vs. 0.6 ± 0.3 cm; p = 0.04). There was also a trend toward greater muscle thickness in the iHD group, such as the Y-axis (9.5 ± 2 vs. 8.5 ± 2.3 mm; p = 0.17) and cross-sectional area muscle of rectus femoris (CS-MARF in cm²) (2.9 ± 0.6 vs. 2.6 ± 0.8 mm; p = 0.1) of anterior QRF, although without reaching statistical significance. Conclusions: These results highlight the value of NUS as a sensitive method for assessing nutritional status in HD patients, particularly within individualized strategies such as iHD, where it may provide key complementary information not captured by conventional methods.

Background: Valproic acid (VPA) poisoning has a dynamic clinical course and may require extracorporeal toxin removal (ECTR) in severe cases. Intermittent hemodialysis is the preferred ECTR technique; however, clinical experience with expanded hemodialysis (HDx) using medium cut-off (MCO) membranes in acute VPA intoxication is scarce. We describe a case of severe VPA poisoning managed with intermittent HDx and outline the clinical rationale and kinetic response. Case Report: A 54-year-old woman presented to the emergency department after accidental presumably ingesting approximately 4 g of VPA, with depressed consciousness (Glasgow Coma Scale 7) and metabolic acidosis (pH 7.10, HCO₃⁻ 13 mmol/L, PCO₂ 50 mmHg, lactate 2.8 mmol/L, ionized calcium 0.8 mmol/L, elevated anion gap). Initial plasma VPA was 262.99 µg/mL, ammonia was 14 µmol/L, and cranial computed tomography showed no acute abnormalities. ECTR was initiated in the intensive care unit as intermittent HDx using an MCO dialyzer for 4 h. Serial VPA concentrations were obtained before treatment, at 2 h, and at the end of the session to guide real-time prescription adjustment, with an increase in blood flow from 200 to 230 mL/min. Results: VPA decreased from 262.99 µg/mL pre-HD to 141.48 µg/mL at 2 h (46.2% reduction) and 97.81 µg/mL at 4 h (62.8% reduction), with clear improvement in the level of consciousness. A mild post-dialysis rebound was observed (100.07 µg/mL at 14 h). The patient recovered without additional ECTR and was discharged with normalized VPA levels on follow-up. Conclusions: In this patient, intermittent HDx with an MCO membrane was feasible, well tolerated, and associated with rapid VPA clearance and neurological recovery. Serial drug monitoring enabled bedside optimization of the dialysis prescription and post-treatment evaluation. A single HDx session was sufficient, and VPA therapy was safely reintroduced under close monitoring.