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Background: Haemodialysis access patterns differ internationally. This can not only be explained by differences in patient cohorts. What is considered the right access for the right patient is debated and it is unclear which patient-related factors affect the choice of access. The aim of the study was to investigate how patient-specific factors as body size and comorbidities influenced the choice of haemodialysis access in a real-life setting.

Methods: Retrospective cohort study including all patients receiving a haemodialysis access in Sweden between 2013 and 2022. Data from the Swedish Renal Registry (SNR) and the National Patient Register (NPR) was used. Data regarding age, sex, cause of kidney failure, previous kidney replacement therapy, height and weight (after dialysis), were collected from SNR. Data on comorbidities were extracted both from SNR and the NPR. AV-accesses were grouped into four categories depending on location of artery. Changes in arteriovenous access creation over time and patient-related factors affecting the choice of first access were analysed.

Results: Of 10,170 patients, 9706 with 17,709 accesses were included. The creation of upper-arm fistulas (p = 0.042) and arteriovenous grafts (p = 0.007) increased. Small body size, female sex, diabetes mellitus, vintage, previous haemodialysis treatment (all p < 0.001), age (p = 0.002) and peripheral arterial disease (p = 0.031) led to more central venous catheters. Small body size, female sex, peripheral arterial disease, vintage, previous haemodialysis treatment (all p < 0.001) and diabetes mellitus (p = 0.023) decreased the probability for selecting a forearm fistula. Upper-arm fistulas were preferred over arteriovenous grafts for those with small body size (p < 0.001 for body surface area), female sex (p = 0.003) and previous haemodialysis (p < 0.001).

Conclusions: The use of upper-arm fistulas and arteriovenous grafts is increasing, while forearm arteriovenous fistulas remain the primary access modality. Patient-related factors influencing the choice of access seemed to be related to vessel size and quality, rather than age and cardiovascular comorbidities.

Background: By entering collecting duct principal cells via the epithelial sodium channel (ENaC), lithium is capable of inducing vasopressin insensitivity, resulting in excessive urine production, nephrogenic diabetes insipidus (NDI) and potential for other long-term forms of renal dysfunction. ENaC inhibitors (ENaC-I) such as amiloride have been shown in animal models to minimise this adverse effect, and while ENaC-I are often considered an effective strategy, the literature on ENaC-I for lithium-related polyuria has not yet been synthesised despite the importance of this topic. This review aimed to identify all published evidence for adjunctive use of an ENaC-I for lithium-related polyuria to estimate its effectiveness while also exploring potential moderators of effectiveness.

Method: The systematic search covered databases MEDLINE, EMBASE and PsycINFO complemented by handsearches, aiming to identify all studies of ENaC-I interventions in lithium-treated patients with pre- and post-ENaC-I polyuria as outcomes.

Results: 10 studies totalling 25 participants were eligible for inclusion and were synthesised narratively. Amiloride was the ENaC-I used in 24/25 participants, and triamterene in the other. 8/10 publications were single case reports, 4 of which presented substantial confounding issues. Clear improvements to polyuria were demonstrated in most papers, including the two larger studies.

Conclusions: Although it appears very likely that ENaC inhibitors help ameliorate polyuria in lithium-treated patients, the quantity and quality of evidence is low. Heterogeneity in patient characteristics, intervention characteristics and study designs limit conclusions regarding the contribution of factors likely to influence ENaC-I effectiveness for lithium-induced polyuria. Besides, adverse effects require further exploration.

Background: Long-term lithium treatment decreases kidney function. However, it remains unclear whether stopping lithium improves kidney function.

Objectives: To study kidney function in patients who stopped and subsequently restarted lithium treatment.

Methods: Mirror-image design using data from the LiSIE retrospective cohort study. The mirror was set to when lithium was stopped with a 5-year pre- and post-mirror period. Adult patients with bipolar, schizoaffective disorder or unipolar depression, who had lithium ≥4.5 years in the pre-mirror period, were included. Creatinine measurements were available from 1997 to 2017. The main outcome was the difference in mean annual change of the estimated glomerular filtration rate (eGFR) adjusted for sex, hypertension and diabetes mellitus.

Results: A total of 168 participants (94 women, 74 men) were included. Mean annual eGFR change was −1.58 (−1.87 to −1.28) mL/min/1.73 m²/year before and −0.023 (−0.49 to +0.44) mL/min/1.73 m²/year after lithium discontinuation (p < 0.0001 for difference). The improvement was 0.77 (0.35–1.20) mL/min/173 m²/year in participants with eGFR >60 mL/min/1.73 m², and 3.03 (2.15–3.92) mL/min/1.73 m²/year for participants with eGFR <30 mL/min/1.73 m². The effect was persistent over the 5-year post-mirror study period. For participants restarting lithium, the mean annual eGFR change was −1.71 (−2.26 to −1.16) mL/min/1.73 m²/year, a setback compared to their lithium-free post-mirror period (p < 0.0001). We did not see any difference compared to the pre-mirror period (p = 0.51).

Conclusions: Stopping lithium slowed down mean eGFR decline. This effect was more pronounced in participants with lower eGFR at the time of lithium discontinuation. In participants who restarted lithium, the annual decline of eGFR reverted to pre-lithium discontinuation levels.

Background: Despite the therapeutic benefits, non-adherence to lithium is common. One recent study showed that most patients discontinue lithium due to adverse effects. Little is known about individuals starting and discontinuing lithium repeatedly.

Objectives: We aimed to determine reasons for discontinuing and restarting lithium multiple times in patients with bipolar or schizoaffective disorder.

Design: Retrospective cohort study based on psychiatric case records of the SLaM Biomedical Research Centre Case Register (SLaM BRC case register).

Method: Anonymised clinical data were extracted via the Clinical Record Interactive Search (CRIS) application. Patients with at least three events of lithium discontinuation between 2012 and 2022 were included.

Results: Of 2888 eligible patients, 123 patients had discontinued lithium on at least three occasions. Psychiatric reasons, such as suspected lack of insight, feeling subjectively well or disagreeing with diagnosis, were the most common reasons for lithium discontinuations. They accounted for 77.2% of cases in the first event of discontinuation, 73.2% in the second and 72.3% in the third event. Adverse physical effects accounted for 19.5% of cases in the first event of discontinuation, 25.2% in the second and 26.0% in the third event. Relapse into the underlying affective disorder accounted for 83.7% each of reinstatements in the first and second events and 82.1% in the third event.

Discussion: In our sample, lithium was discontinued due to adverse effects in only a minority of patients. In most cases, the reasons for lithium discontinuation were considered psychiatric. Lithium was mainly restarted due to relapse. This warrants a better understanding of the reasons for repeatedly discontinuing lithium and the best way to promote lithium adherence to prevent a perpetual cycle of remitting when on lithium and relapsing when off lithium.

Apheresis is used for the treatment of many different diseases, especially when conventional therapy lacks efficacy. There are however some diseases in which apheresis is accepted as first line therapy. The aim of this analysis was to investigate the use of apheresis for the treatment of neurological diseases and the changes over two decades in the World Apheresis Association registry. During the period 2003–2023, a total of 23,699 apheresis procedures in 2963 patients with a neurological disease were performed. Data were collected during different periods by 44 centers, out of which 22 centers had been registering continuously over the latest 10 years. An increase in the proportion of neurological diseases developed over the period (p < 0.001) while the overall apheresis procedures remained stable (p = 0.46). Most procedures were due to myasthenia gravis (MG; n = 11,049 (31 % of patients), Guillain-Barré Syndrome (GBS; n = 3247 (30 %), multiple sclerosis (MS; n = 2665 (18 %)), chronic inflammatory demyelinating polyradiculoneuropathy (CIDP; n = 2367 (3 %)), and neuromyelitis optica (NMO; n = 650 (2 %)). A change in the proportion of these diseases was noted over time. Adverse events (AEs) differed significantly between the diseases. Patients with GBS had most moderate and severe AEs. Hypotension was the most common severe AE. The panorama of different neurological diseases may cause different AEs based on the variation in neurological response to the apheresis procedure and replacement fluid. It is important to expand this knowledge among those who are prescribing and those performing the apheresis procedures.

The WAA registry has been active since 2002. It allows bed side registration of safety and efficacy data. The data each center enters is accessible for its own use but also used for merged analysis. Most types of procedures are represented. Treatments of many severe diseases as well as the collection of autologous and donor cells for therapeutic use especially in oncologic diseases are recorded. Previous reports have shown a successive reduction in adverse events (AE) over the years. The aim of the present report is to update data of the risk for AE during the years from 2013 to Oct 2024. Contributions of 44 centers from 20 countries were analysed. Over these years, more than 169,000 apheresis procedures have been registered in more than 26,000 patients. During the study period the mean incidence of AE, merged for all types of procedures, was 1.6 /100 procedures for mild, 2.0/100 for moderate and 0.20/100 for severe AE, and reduced since 2013. Since 2002, death due to apheresis could not be excluded in one patient. There was an increased risk of hypotension during apheresis in patients with neurological diagnoses (ICD-10 chapter G) versus those with diseases of the musculoskeletal or connective tissue (ICD-10 chapter M) and vice versa for urticaria and tingling. In conclusion, the present data show the risk for various degrees of AE in apheresis procedures. Many patients suffer from severe illness and apheresis is often offered as a rescue therapy. Although the risk of death due to the apheresis procedure is extremely rare the concomitant severe disease itself poses a risk for severe events.

Background: At the beginning of the COVID-19 pandemic, concerns arose about a possible rise in alcohol consumption. Early surveys, however, more commonly pointed towards a decrease of alcohol use. But studies based on self-reports may underestimate alcohol use. They also depend on the population sampled. Because of border closures and gastronomy restrictions, countries with centralised alcohol sales provided a unique opportunity to study total domestic consumption during the pandemic without influence of private import or reliance on self-reports.

Aims: We examined the correlation between alcohol sales and national COVID-19 restrictions in three such countries, Finland, Norway and Sweden.

Method: We conducted this study as a mirror image study, comparing alcohol sales during the first 2 years of the COVID-19 pandemic with the two preceding years. We explored hours of daylight/season as potential confounders.

Results: We found no relevant change in alcohol sales during the pandemic years for Finland or Sweden. For Norway, there was a level-change in sales, which could be explained by decreased imports. Sales followed a seasonal pattern. In all three countries, the initial pandemic increase in alcohol sales coincided with an underlying annually recurring seasonal variation.

Conclusions: The COVID-19 pandemic had less of an impact on alcohol consumption in the three Nordic countries than could intuitively be expected. The increase of alcohol sales at the beginning of the COVID-19 pandemic coincided with a seasonal rise following a pre-pandemic pattern. Therefore, caution should be exercised with drawing conclusions from data with a short time perspective to avoid attribution bias.

Metformin is a biguanide antidiabetic and a first-line therapy for type-2 diabetes mellitus. It is highly effective, cheap, and easily available since taken in tablet form. Metformin-associated lactic acidosis (MALA) is a serious adverse event with high mortality. It is currently treated with bicarbonate and haemodialysis. The mechanism by which metformin can precipitate lactic acidosis remains subject to debate. Lactic acidosis has also been reported in thiamine (vitamin B1) deficiency. Thiamine deficiency results in a switch from aerobic to anaerobic metabolism with accumulation of lactate. MALA and thiamine-associated lactic acidosis are usually considered separate entities. Both, thiamine and metformin are competitive substrates of the organ cation and thiamine transporters. This way, metformin could cause thiamine deficiency in liver cells. We hypothesize that MALA may be treatable with thiamine. High-dose intravenous thiamine treatment is used routinely for the treatment of Wernicke's encephalopathy and is regarded as safe. Thiamine has been reported to have improved MALA in four cases, who had been refractory to haemodialysis. Thiamine is widely available, easy to administer, and cheap. Thiamine could already be given while waiting for dialysis. Above all, thiamine could prove life-saving in the treatment of MALA in clinical settings in which dialysis is not available.

Introduction: Although hemodialysis is lifesaving in patients with kidney failure extensive interdialytic weight gain (IDWG) between dialyses worsens the prognosis. We recently showed a strong correlation between IDWG and predialytic values of cardiac markers. The aim of the present study was to evaluate if the cardiac markers N-terminal pro-B-type natriuretic peptide (proBNP) and troponin T were influenced by IDWG and speed of fluid removal (ultrafiltration-rate).

Methods: Twenty hemodialysis patients performed in total 60 hemodialysis (three each). Predialytic values of proBNP and troponin T and changes from predialysis to 180 min hemodialysis (180–0 min) were compared with the IDWG calculated in percent of body weight. The ultrafiltration-rate was adjusted (UF-rateadj) to IDWG: (100 × weight gain between dialysis [kg])/(estimated body dry weight [kg] × length of hemodialysis session [hours]).

Results: UF-rateadj correlated (Spearman) with (1) predialytic values of IDWG (r = 0.983, p < 0.001), proBNP (r = 0.443, p < 0.001), and troponin T (r = 0.296, p = 0.025); and (2) differences in proBNP180–0min (r = 0.572, p < 0.001) and troponin T180–0min (r = 0.400, p = 0.002). UF-ratesadj above a breakpoint of 0.60 caused more release of proBNP180–0min (p = 0.027). Remaining variables in multiple regression analysis with ProBNP180–0min as dependent factor were predialytic proBNP (p < 0.001) and the ultrafiltration-rate (p < 0.001).

Conclusion: Higher UF-rateadj during dialysis was correlated to increased levels of cardiac markers. Data support a UF-rateadj lower than 0.6 to limit such increase. Further studies may confirm if limited fluid intake and a lower UF-rateadj should be recommended to prevent cardiac injury during dialysis.