Quality of life of end-stage renal disease patients and study on the implementation of nocturnal home hemodialysis in Greece

The aim of this study was to measure the overall health-related quality of life of patients receiving hemodialysis in Greece and to assess willingness, motivation, and concerns about participating in a nocturnal home hemodialysis program. This review measured successfully the quality of life of 146 end-stage renal disease (ESRD) patients undergoing hemodialysis in 10 hemodialysis centers all over Greece and studied the factors that affect their choice to adopt a specific treatment. Physical and mental health status and health-related quality of life, measured by the Kidney Disease Quality of Life Short Form accompanied by the demographic data gathered, provide information that can help to improve ESRD patient care in Greece. A comparison with the Greek general population identifies lower physical functioning scores for the ESRD patients, while the mental functioning scores are comparable with those of the Greek general population. Moreover, it is important to notice the willingness expressed by half of the patients to participate in a potential program of nocturnal home hemodialysis.     

Pharmacologic adjuvants to epoetin in the treatment of anemia in patients on hemodialysis

Anemia is a common complication of chronic kidney disease, particularly in patients who are on dialysis. The use of recombinant human erythropoietin has led to the eradication of severe anemia in the dialysis population. Correction of anemia in these patients has been associated with better quality of life and clinical outcomes. Some hemodialysis patients have anemia that either is relatively refractory to epoetin therapy or requires very high doses of epoetin (i.e., hyporesponsiveness), despite having adequate iron stores, and are thus unable to achieve or maintain target hemoglobin levels. Several pharmacologic agents have been studied for effects on improving response to epoetin, either to counter hyporesponsiveness or simply to reduce epoetin use for purely economic reasons. This review examines the available literature regarding the efficacy of these potential pharmacologic adjuvants to epoetin in the treatment of anemia in patients on maintenance hemodialysis, with special emphasis on androgens, vitamin C (ascorbic acid), and L-carnitine. A review of published guidelines and recommendations for use of these agents in hemodialysis patients is provided.     

Quality of life in chronic hemodialysis patients in Russia

The aim of this cross-sectional study was to compare health-related quality of life (HRQOL) of Russian hemodialysis (HD) patients with the general population and international data, and to determine factors influencing HRQOL. One thousand forty-seven HD patients from 6 dialysis centers were studied (576 male, age 43.5 +/- 12.5 years, HD duration 55.0 +/- 47.2 months). Health-related quality of life was evaluated by SF-36. Self-appraisal Depression Scale (W. Zung), State-Trait Anxiety Inventory, and Level of Neurotic Asthenia Scale were used. Hemodialysis patients scored significantly lower than the general Russian population in the majority of SF-36 scales. The only exception was the Mental Health score, which was even better than the general population. The Mean physical component score (PCS) of HD patients was 36.9 +/- 9.7, and the mental component score was (MCS) 44.2 +/- 10.5. In multiple linear regression analysis, increasing age, HD duration, depression level and number of days of hospitalization in the past 6 months were significant independent predictors of low PCS along with a low level of serum albumin. Advancing age was also a predictive factor for low MCS along with increase of HD duration, depression level, trait anxiety, and level of asthenia. As far as we know, this is the first study to report on HRQOL of a large sample of Russian HD patients performed using SF-36. Compared with the general population, Russian HD patients had significantly lower scores on the majority of SF-36 scales, especially in the physical domain. The mean PCS and MCS were comparable with European data for HD patients. A number of demographic, clinical, and psychological variables affect HRQOL.     

Health-related quality of life is maintained in hemodialysis patients receiving pharmaceutical care: A 2-year randomized, controlled study

End-stage renal disease and initiation of hemodialysis (HD) adversely affect health-related quality of life (HRQOL). There are currently no data evaluating the effect of pharmaceutical care (PC) on HRQOL in HD patients. HD patients were randomized to receive PC; one-on-one, in-depth medication reviews conducted by a clinical pharmacist or Standard of Care (SOC); and brief medication reviews conducted by dialysis nurses. The renal quality of life profile (RQLP) was administered at baseline and then at 1 and 2 years after study initiation. The RQLP is a 43-item questionnaire that has 5 dimensions: Eating/Drinking, Physical Activities, Leisure Time, Psychosocial Activities, and Impact of Treatment, where increasing scores reflect worsening of HRQOL. A total of 107 patients were enrolled (SOC: n=46; PC: n=61). Besides gender, there were no differences in the demographics or the baseline total RQLP scores. The mean±SD total RQLP scores at Year 1 were significantly worse in SOC compared with PC (88±31 vs. 71±34, respectively; P=0.03). Significant worsening of Eating and Drinking (5.9±3.3 vs. 4.4±3.1, respectively; P=0.04), Physical Activities (37±13.6 vs. 30±16.3, respectively; P=0.04), and Leisure Time scores (8.3±3.4 vs. 5.9±3.6, respectively; P=0.03) was also observed in the SOC group. After 2 years, only the SOC patients had worsening of Leisure Time (7.5±3.0 vs. 5.2±3.9, respectively; P=0.04). No other parameters were different between the groups after 2 years. These data indicate that patients who have clinical care provided by pharmacists do not have worsened HRQOL after 1 year and are able to maintain HRQOL for an additional year.     

Factors affecting anemia management in hemodialysis patients: a single-center experience

The difficulty maintaining hemoglobin (Hgb) within the targets recommended by KDOQI is widely recognized. While factors responsible for erythropoietin resistance have been widely studied, factors responsible for the marked fluctuations and the inability to maintain Hgb within the target range have only begun to be investigated. This study was a cross-sectional review of anemia management in hemodialysis patients. The purpose was to evaluate factors responsible for Hgb decreases of 0.5 or 1.0 g/dL and to determine the primary factors responsible for Hgb decreases below 11 g/dL. Hgb values and clinical events were extracted from patient management databases between January 1, 2005 and November 30, 2006. Isolated events were defined as events that occurred at least 30 days after any previous event and had Hgb measurements within 2 weeks before and after the event. Increasing hospital length of stay and surgical access intervention were the most common events that resulted in a decrease in Hgb. The most common factor present in patients with Hgb decreases below 11 g/dL was the withholding of recombinant human erythropoietin (rHuEPO) within the preceding 2 months. This was the only explanation for the decrease in Hgb to <11 g/dL in 38.5% of such events. The ability to maintain dialysis patients' Hgb in the target range is complicated by intervening acute events that require hospitalization or surgical access interventions. The withholding of rHuEPO appears to be a major factor in Hgb decreases below 11 g/dL.     

Nutritional education for management of osteodystrophy: Impact on serum phosphorus,quality of life,and malnutrition

Introduction Osteodystrophy management includes dietary phosphorus restriction, which may limit protein intake, exacerbate malnutrition‐inflammation syndrome and mortality among hemodialysis patients. Methods A multicenter randomized controlled trial was conducted in Lebanon, to test the hypothesis that intensive nutrition education focused on phosphorus‐to‐protein balance will improve patient outcomes. Six hemodialysis units were randomly assigned to the trained hospital dietitian (THD) protocol (210 patients). Six others (184 patients) were divided equally according to the patients’ dialysis shifts and assigned to Dedicated Dietitian (DD) and Control protocols. Patients in the THD group received nutrition education from hospital dietitians who were trained by the study team on renal dietetics, but had limited time for hemodialysis patients. Patients in the DD group received individualized nutritional education on dietary phosphorus and protein management for 6 months (2‐hour/patient/month) from study renal dietitians. Patients in the control group continued receiving routine care from hospital dietitians who had limited time for these patients and were blinded to the study. Serum phosphorus (mmol/L), malnutrition‐inflammation score (MIS), health‐related quality of life (HRQOL) index and length of hospital stay (LOS) were assessed at T0 (baseline), T1 (postintervention) and T2 (post6 month follow up). Findings Only the DD protocol significantly improved serum phosphorus (T0:1.78 ± 0.5, T1:1.63 ± 0.46, T2:1.69 ± 0.53), 3 domains of the HRQOL and maintained MIS at T1, but this protective effect resolved at T2. The LOS significantly dropped for all groups. Discussion The presence of competent renal dietitians fully dedicated to hemodialysis units was superior over the other protocols in temporarily improving patient outcomes.     

A Brief History of Daily Hemodialysis

Daily hemodialysis has been in uninterrupted practice since its introduction in California in 1967. Early trials were stopped for technical, logistical, and economical problems, but a rapidly increasing number of centers now perform it on close to 200 patients, either as long nightly or short daytime hemodialysis. Increasing the frequency of dialysis appears much more important in improving patient well-being than increasing the Kt/V dose, and patients quickly experience much more vigor, energy, and improved quality of life when starting daily hemodialysis. Blood pressure improves, and medications can often be discontinued. Similarly, the need for erythropoietin decreases, and nutrition and dry body mass increase. While the cost of dialysis increases, the total cost for a patient decreases as medications and hospitalizations decrease. Technical innovation will solve the logistical problems by letting a machine do the labor necessary to begin and end a dialysis session. Access problems have decreased for native fistula, and the other access types have not been studied enough.     

Quality of life development during initial hemodialysis therapy and association with loss of residual renal function

Introduction: Health related quality of life (HRQOL) is markedly reduced in hemodialysis patients compared to the general population. We investigated the course of self‐reported HRQOL over time and the association with selected factors, focusing on changes in glomerular filtration rate (GFR). Methods: Eighty‐two newly started hemodialysis patients from the SAFIR cohort filled out the Kidney Disease Quality of Life Short Form Version 1.3 (KDQOL‐SF^TM) questionnaire at baseline, 6 and 12 months. The SAFIR study was a randomized, placebo‐controlled, double‐blind intervention study, examining the effects of the angiotensin II receptor blocker irbesartan. HRQOL was a secondary outcome measure. Main inclusion criteria: Dialysis vintage <1 year, left ventricular ejection fraction >30% and urinary output >300 mL/day. GFR was measured with mean creatinine and urea clearance from 24‐hour urine collections at baseline, 6 and 12 months. Findings: Irbesartan treatment did not affect HRQOL. Patients were pooled into one group for further analyses. Decline in GFR correlated significantly with decreasing HRQOL over time. HRQOL was stable over time, with a slight nonsignificant tendency toward improved HRQOL. The largest HRQOL‐differences (positive values equal improved HRQOL) observed during the 12 month study period were (mean[95% confidence interval]): Burden of kidney disease:6.4[?2.2;15.0], Role limitations‐physical:12.7[?2.1;27.5], and Role limitations‐emotional:9.7[?5.2;24.6]. Comorbidity, especially diabetes, hospital admissions, female gender, and age were strongly associated with lower HRQOL in cross sectional analysis. Discussion: Preservation of residual renal function seems to be important for HRQOL. In newly started HD patients, HRQOL showed little change after 12 months. HRQOL was negatively affected by comorbidity, especially diabetes, hospital admissions, female gender, and age.     

Multi-factor scale consolidation when theory is weak

As a practical matter, Spirituality and Quality of Life in the health sciences are usually measured separately. Theoretical foundations for this distinction, however, are not strong. In this research, an empirical investigation was conducted into their joint calibration with a Rasch model. Functional Assessment of Cancer Therapy-General (28 items), a cancer health-related quality of life measure (HRQOL), and Functional Assessment of Chronic Illness - Spiritual Well-Being (12 items), a measure of religious and existential well-being (Spirituality), were co-calibrated with a Rasch model implemented with WINSTEPS software for ratings from 545 breast cancer patients. The results show a hierarchical integration of QOL and Spirituality items on a common variable, and both patient separation (2.66) and reliability (.88) improve after co-calibration. Principal Component Analysis of co-calibrated item residuals did not show major threats to dimensionality, and joint calibration explains item variance comparable to separate calibrations (51.9%). Although patient measures (logits) based on separate and co-calibration are within two standard errors, ethnic and racial group values shift after co-calibration.     

Hemodialysis in the Elderly

Background:  Health-related quality of life (HRQOL) is an important outcome of medical treatment effectiveness.
Objectives:  Thirty-six item short-Form (SF-36) first has been used in hemodialysis (HD) patients in Taiwan.
Method:  HRQOL was measured by using SF-36 in 497 HD patients in 5 hospitals.
Results:  Male sex, age less than 50 years, higher education level (EL), marriage, employed status (EPS), less comorbid medical condition (CMC), and non-diabetic patients were all predicted a better physical component scale (PCS). Age less than 50 years, BMI greater than 18.5, HEL, EPS, and NDP were all predicted a higher mental component scale (MCS). Scales contributing to a summary measure of physical health, the PCS score, was significantly lower in women (35 ± 12.3) than in men (37.9 ± 12.3). There is no difference in MCS score between women and men. In multivariate analysis, age, CMC, diabetes, serum creatinine (SCr), and erythropoietin responsiveness were significant independent predictors of PCS. Diabetes, EL, SCr, and erythropoietic responsiveness were significant independent predictors of MCS. All of the individual scales, PCS and MCS scores were lower in the Taiwan HD patients than values for the US general population. Each of the individual scales and MCS scores were substantially lower in Taiwan HD group than in the US HD cohort. But the bodily pain of PCS was significantly higher in Taiwan HD group in spite of mean PCS scores for Taiwan HD group and US HD study participants were nearly equal at 36.3 and 36.1, respectively.
Conclusion:  Physical and mental aspects of quality of life are substantially reduced among Taiwan HD patients, but higher bodily pain tolerance. A number of demographic and clinical characteristics significantly impact on HRQOL in Taiwan HD patients. To our knowledge, this is the first time we demonstrate the HRQOL by using SF-36 in Chinese HD patients.     

In‐center hemodialysis attendance: Patient perceptions of risks,barriers, and recommendations

Missed hemodialysis treatments lead to increased morbidity and mortality in the end‐stage renal disease population. Little is known about why patients have difficulty attending their scheduled in‐center dialysis treatments. Semistructured interviews with 15 adherent and 15 nonadherent hemodialysis patients were conducted to determine patients' attitudes about dialysis, health beliefs and risk perception regarding missed treatments, barriers and facilitators to hemodialysis attendance, and recommendations to improve the system to facilitate dialysis attendance. Average time on dialysis was 2.5 years for the nonadherent group and 7.3 years in the adherent group. In both groups, patients felt that dialysis is life‐saving and a necessity. A substantial number of patients in both groups understood that missing hemodialysis treatments is dangerous and several patients could clearly communicate the risk of skipping. The most common barriers to hemodialysis were inadequate or unreliable transportation (mentioned in both groups) and a lack of motivation to get to dialysis or that dialysis is not a priority (typically mentioned by the nonadherent group). Facilitators to hemodialysis attendance included explanations from the health care team regarding the risk of skipping and relationships with other dialysis patients. Patient recommendations to improve dialysis attendance included continued education about the risk of poor attendance and more accessible transportation. Patients did not feel that home dialysis would improve adherence. Hemodialysis patients must adhere to a complex and burdensome regimen. Through the elucidation of barriers and facilitators to hemodialysis attendance and through specific patient recommendations, at least three interventions may be further investigated to improve hemodialysis attendance: Improvement of the transportation system, education and supportive encouragement from the health care team, and peer support mentorship.     

Patient experiences and preferences on short daily and nocturnal home hemodialysis

Quotidian/intensive hemodialysis (short daily and nocturnal) has variable effects on health‐related quality of life (HRQOL) as measured by standard HRQOL tools. We sought to understand the perceived benefits and limitations of quotidian dialysis by interviewing patients who had switched from conventional to home quotidian dialysis. We used a qualitative, phenomenological approach to explore the perceived benefits of quotidian dialysis from 10 patients using either short daily or nocturnal hemodialysis at a tertiary health care center in London, Canada. The patients varied in gender, age, employment status, home support, physical capacity, primary cause of kidney disease, previous forms of renal replacement therapy, and level of education. Four major themes emerged: (1) improvement in physical and mental well‐being including better blood pressure and concentration, (2) increased control over patient's own life including time availability, choosing when to dialyze, and dialyzing at home, (3) decreased perception of being sick including returning to regular employment and avoiding sicker patients who must have in‐center dialysis, and (4) identification of the competencies and supports required for quotidian dialysis including ability to provide self‐care, supportive family, and medical support. Our findings suggest when patients' willingness and physical ability to use quotidian dialysis are coupled with education and support systems to assist patients' and families' self‐directed care, patients qualitatively perceive benefits of both increased physical and mental health, both measures of health‐related quality of life.     

Comparison of survival between short-daily hemodialysis and conventional hemodialysis using the standardized mortality ratio

More frequent hemodialysis (5 or more times weekly, both short during the day and long overnight) has been shown to improve patient well-being, reduce symptoms during and between treatments, and have beneficial effects on clinical outcomes. Because of the relatively small patient sample sizes, there are little or no data on mortality from any single study at this time. This study compares survival in 117 U.S. patients treated by short-daily hemodialysis in 2003 and 2004, with patients reported in the 2003 data from the United States Renal Data System (USRDS). Expected mortality was calculated from the USRDS and compared with observed actual mortality. The standardized mortality ratio (SMR) was used to adjust for differences in patient age, sex, race, and cause of renal failure. The SMR for the short-daily hemodialysis patients was 0.39, statistically significantly better (p < 0.005) than data from the overall U.S. population of hemodialysis patients and indicating that daily hemodialysis patients had a 61% better survival. Patients treated by short-daily hemodialysis have a better survival rate than comparable populations treated by conventional hemodialysis.     

When pure is not so pure: Chloramine‐related hemolytic anemia in home hemodialysis patients

Worldwide, chloramines are used as the preferred disinfectant for city water supplies. Although they have distinct advantages compared with chlorine and are deemed harmless to the general population, hemodialysis (HD) patients are at risk from chloramine‐induced hemolytic anemia. In recent years, this has been highlighted in regional dialysis units but not as frequently in the home HD group. We report on 2 home HD patients who succumbed to severe oxidative hemolysis due to high mains water chloramine concentrations. Both patients were extensively investigated for other cause of anemia before a definitive diagnosis was reached. Delays in diagnosing this uncommon condition can be costly in terms of significant morbidity and excessive usage of recombinant erythropoietin and blood transfusion. Prevention primarily involves enforcing strict water quality control and establishing regular communication with water supply boards and home HD patients. Double (inline) carbon filters should be installed in patient's homes as an effective means for removing high incoming chloramine concentrations.     

Blood loss during vascular access cannulation: quantification using the weighed gauze and drape method

Anemia is an important complication of chronic renal disease, with a significant impact on the morbidity, quality of life, and mortality in this group of patients. Inadequate erythropoietin production, reduced life span of erythrocytes in uremic serum, bone marrow suppression by uremic toxins, chronic inflammation, and contaminants in the water treatment unit are recognized etiological causes of anemia in chronic kidney disease patients. Little attention has been paid to possible contributions of small but continual loss of blood during vascular access cannulation for hemodialysis in these patients. The aim of this study is to quantify the volume of blood loss during femoral vein cannulation in patients on hemodialysis. The average volume of blood loss during femoral cannulation was evaluated using a simple and inexpensive procedure of deriving volume of blood lost, from the weights of soaked gauze and drape during the access cannulation procedure. The mean blood loss per procedure during femoral cannulation was 36.52 mL+/-2.70 SD, with a range of 6.47 to 100.20 mL. The calculated average weekly loss in patients on thrice-weekly dialysis schedule is 109.56 mL of blood, with a monthly loss of 438.24 mL. Cumulative blood loss during femoral vein cannulation appears to be significant. Its contribution in the sustenance of anemia in hemodialysis patients deserves further evaluation.     

Does a history of peritoneal dialysis result in an impaired gastrointestinal life quality?

Peritoneal dialysis (PD) invariably induces sclerotic changes in the peritoneal membrane. The impact of these changes on the well-being of PD patients has not been studied sufficiently. In a matched-pair analysis, the gastrointestinal life quality of patients with a history of PD was compared with end-stage renal disease patients who never performed PD, using a standardized questionnaire (gastrointestinal life-quality index [GLQI]). We identified all patients in our dialysis unit who underwent PD between 1989 and 2001 and who were alive in October 2001 (PD patients; n=53). Patients who were treated by hemodialysis (HD patients) were recruited as pairs. Hemodialysis and PD patients did not differ in gastrointestinal life quality (GLQI: HD 106.0+/-16.4 points; PD 104.0+/-16.7 points; p=0.70). Gastrointestinal life quality was neither correlated with the number of peritonitis episodes, nor with the duration of PD treatment. Peritoneal dialysis treatment is not associated with a long-term impairment of gastrointestinal life quality.     

A king-size dialysis bed: a couple on hemodialysis for more than 30 years

Dialysis patients exhibit a higher morbidity and mortality rate than those in the general population of comparable age. Survival on dialysis has become significantly longer and is mainly related to comorbid factors. Patients are usually the main research subjects, but caregivers play a pivotal role in patients' well-being. Here we describe the remarkable case of wife and husband both on hemodialysis for 32 years.     

L carnitine in hemodialysis patients

Carnitine, 3-hydroxy-4-trimethylaminobutyrate, a small, water soluble molecule that is essential for mitochondrial fatty acid oxidation, is significantly reduced in hemodialysis patients. Uremia-induced carnitine deficiency, which is magnified by dialysis, is associated with symptoms or clinical problems such as anemia hyporesponsive to erythropoietin, cardiovascular diseases, and muscle weakness. This review examines studies dealing with the different clinical aspects of chronic renal failure patients in which carnitine deficiency may play a role and has also examined the studies, which have evaluated the effect of carnitine deficiency treatment. The reports reviewed in this study, including those more recent from our laboratory, have provided data suggesting that chronic renal failure and particularly hemodialysis patients can benefit from carnitine treatment in particular for renal anemia, insulin sensitivity, and protein catabolism. On the other hand, the heterogeneous clinical response to carnitine therapy in dialysis patients, reported by other studies, and the lack of large-scale randomized trials are the rationale for the reluctance regarding a widespread use of carnitine supplements in dialysis patients. Well-designed randomized clinical trials are therefore required to fully address the potentially important carnitine treatment in dialysis patients.     

Statin use is associated with lower inflammation and erythropoietin responsiveness index in hemodialysis patients

Patients with end-stage renal disease are prone to inflammation and inflammation is related to erythropoietin-stimulating agent hyporesponsiveness and mortality in this population. Statins have been demonstrated to reduce cardiovascular mortality in selected populations of end-stage renal disease patients. These drugs have pleiotrophic effects such as anti-inflammation. In this retrospective analysis, we determined whether the use of statins improves inflammation and inflammation-related anemia in a cohort of hemodialysis patients. Data were analyzed from Fresenius Medical Care Dialysis Clinics in Turkey between 2005 and 2007. Seventy prevalent hemodialysis patients who were on statins at the start of the study and have been on statins during follow-up (statin users) and 1293 patients who were not on statin at the start of the study and had never been prescribed any lipid-modifying drugs during follow-up (statin nonusers) were included in the study. High-sensitive C-reactive protein levels were significantly decreased in statin users (1.50±1.49 vs. 1.33±1.11 mg/L, P=0.05) compared with nonusers (1.93±3.22 vs. 2.05±2.77 mg/L). Hemoglobin levels and the rate of erythropoietin-stimulating agent users were similar. However, the prescribed erythropoietin-stimulating agent dose (31.6±27.5 vs. 47.3±45.2 U/kg/week, P<0.05) and the erythropoietin response index (2.90±2.73 vs. 4.51±4.48 U/kg/week/Hb, P=0.001) were lower in statin users compared with statin nonusers. On stepwise multiple regression analysis, gender, high-sensitive C-reactive protein, duration of hemodialysis, serum ferritin, and statin use were independent determinants of the erythropoietin responsiveness index. Our results suggest that statin treatment leads to lower inflammation and improves hematopoiesis in hemodialysis patients.     

Neutrophil and monocyte activation in chronic kidney disease patients under hemodialysis and its relationship with resistance to recombinant human erythropoietin and to the hemodialysis procedure

The aim of the present work was to further clarify leukocyte activation due to hemodialysis (HD) procedures and to investigate its relationship with recombinant human erythropoietin resistance. Therefore, we studied the expression of CXCR1 and CD11b on neutrophils, as well as the monocyte expression of CD11b, HLA‐DR, and CD14. We studied 34 chronic kidney disease (CKD) patients under HD and recombinant human erythropoietin treatment (26 responders and 8 nonresponders to recombinant human erythropoietin therapy). All CKD patients' blood samples were collected before and immediately after the HD procedure. Eighteen healthy individuals (blood donors) were also studied as a control group. Hematological data, neutrophil (CD11b and CXCR1), and monocyte (CD11b, HLA‐DR, and CD14) cell surface markers were measured in all patients (before and after the HD procedure) and controls. When compared with the controls, CKD patients presented a significant decrease in CXCR1 neutrophil expression, and in CD14 monocyte expression, accompanied by a significant increase in HLA‐DR monocyte expression. When comparing the 2 groups of patients, we found that nonresponders showed an additional decrease in CXCR1 neutrophil expression. After the HD procedure, a statistically significant increase in CD14 and CD11b monocyte surface markers and a decrease in CXCR1 neutrophil expression and in HLA‐DR monocyte expression was found. These data further strengthen our previous studies, showing that neutrophils and monocytes are activated in CKD patients, particularly in nonresponder patients. Moreover, this activation is due, at least in part, to the HD procedure, although we should not exclude that it can also be due to the enhanced inflammatory process observed in nonresponder patients.