Cardiovascular disease is more common in patients with chronic kidney disease (CKD), and traditional risk factors do not adequately predict those at risk for cardiovascular (CV) events. Recent evidence suggests elevated trimethylamine N-oxide (TMAO), created by gut microflora from dietary L-carnitine and choline, is associated with CV events. We investigated the relationship of TMAO levels in patients with stages 3b and 4 CKD to ischemic CV events using the CanPREDDICT cohort, a Canada-wide observational study with prospective 3-year follow-up of adjudicated CV events. Baseline samples were obtained for 2529 CKD patients. TMAO, choline, and L-carnitine levels were measured using tandem mass spectrometry. Baseline median TMAO level was high for the whole cohort (20.41 μM; interquartile range [IQR]: 12.82-32.70 μM). TMAO was independently associated with CV events (hazard ratio 1.23; 95% confidence interval: 1.06-1.42 / 1 SD lnTMAO) after adjusting for all potential CV risk factors. Those in the highest TMAO quartile had significantly higher risk of CV events (adjusted hazard ratio 1.59; 95% confidence interval: 1.04-2.43; P = 0.0351) in the analysis of recurring ischemic events. Among those with stage 3b CKD (hazard ratio 1.45; 95% confidence interval: 1.12-1.87 / 1 SD lnTMAO), independent of kidney function, TMAO levels identified those at highest risk for events. Our results suggest that TMAO may represent a new potentially modifiable CV risk factor for CKD patients. Further studies are needed to determine sources of variability and if lowering of TMAO reduces CV risk in CKD.

Results: After conversion to INHD, median values for phosphorus decreased from 5.9 to 3.7 mg/dl (P < 0.01), alkaline phosphatase level increased from 84 to 161 U/L (P < 0.01), and percentage reduction in urea increased from 74 to 89% (P < 0.01). The mean number of antihypertensive drugs prescribed declined from 2.0 to 1.5 (P < 0.05) during the course of INHD, and the mean daily dosage of phosphate binders declined from 6.2 to 4.9 at study end (P < 0.05). There was a significant reduction in erythropoietin-stimulating agent use of 1992 U/wk (P < 0.01). There was no significant change in median hemoglobin, iron saturation, corrected calcium, or parathyroid hormone levels. Overall, quality of life, sleep, intradialytic cramps, appetite, and energy level all improved significantly on INHD.Conclusions: INHD offers an effective form of HD for long-term dialysis patients who are unable to perform home HD.

We describe the St Michael's Hospital (SMH) modified buttonhole (BH) cannulation technique as a method that offers a solution for fistulae with aneurysmal dilatation due to repetitive cannulation in a restricted area. This is a prospective cohort study of 14 chronic hemodialysis (HD) patients with problematic fistulae (marked aneurysmal formation and thinning of the overlying skin, bleeding during treatment, and prolonged hemostasis post-HD) because of repetitive, localized cannulation. Each patient was followed for 12 months. The protocol was as follows: creation of tunnel tracks by 1 to 3 experienced cannulators per patient, using sharp needles. After the tunnel tracks were established and cannulation was easily achieved with dull needles, additional cannulators were incorporated with the guidance of a mentor. Bleeding from cannulation sites during dialysis ceased within 2 weeks and skin damage resolved within 6 months in all patients. Hemostasis time postdialysis decreased from 24 to 15 min. Cannulation pain scores decreased significantly. Access flows and dynamic venous pressure measurements remained unchanged. No interventions were required to maintain access patency. In 2 cases, the aneurysms became much less evident. Complications included one episode of septic arthritis and one contact dermatitis. A third patient developed acute bacterial endocarditis 9 months following completion of her follow-up. The SMH modified BH cannulation technique can salvage problematic fistulae, prevent further damage, and induce healing of the skin in the areas of repetitive cannulation. This technique can be successfully achieved by multiple cannulators in a busy full-care HD unit.

A reduced RBC lifespan continues to contribute to renal anemia despite technologic advancements and improved uremic environment.