Deep Dive · Two Roads: Hemodiafiltration or Medium Cutoff Dialyzers?

One subject this week, three papers, in the order a clinician needs them.The first randomized trial ever run on preparing a frail older patient for dialysis versus preparing them for a life without it. A bedside way to tell which patients are standing at that fork. And a framework for the conversation none of us were trained to have.Chapters00:00 Cold open and running order01:27 Preparing for dialysis, or not09:59 Who counts as frail15:04 The conversation21:53 CloseThe papersCaskey FJ, et al. Preparing for responsive management versus renal dialysis in older people living with kidney failure and frailty or multimorbidity in the UK (Prepare for Kidney Care). The Lancet, online November 4, 2026. https://doi.org/10.1016/S0140-6736(26)01818-0Ingwiller M, et al. Frailty as a Predictor of Mortality in Dialysis: A Multicenter Validation of the Clinical Frailty Scale. Kidney Medicine 2026;8(11):101510. https://doi.org/10.1016/j.xkme.2026.101510Samyn M-C, et al. Lived Experiences of Home-Based Conservative Kidney Management in Older Adults: A Qualitative Study. AJKD 2026;88(5):692-703.e1. https://doi.org/10.1053/j.ajkd.2026.05.012Hole B, Gelfand S. “There’s No Goal…Except That We Take Care of Them”: Meeting the Needs of People Whose Kidney Failure is Managed Conservatively. AJKD 2026;88(5):684-686. https://doi.org/10.1053/j.ajkd.2026.08.004Schell JO, et al. Applying a Better Conversations Framework to Dialysis Decision-Making for Patients with Advanced CKD. JASN 2026;37(11):2571-2573. https://doi.org/10.1681/ASN.0000001163Full show notes, including why “no winner” is not the same as “the two are equal”, are at nephspace.com.Disclosures. The Lancet trial had no industry funding (NIHR Health Technology Assessment programme). Among its authors, Simon Davies reports a Byonyks advisory board role and lectures for Vantive; Emma Murphy reports travel support from CSL Vifor; Caoimhe Rice is an employee of PPD Evidera; Joanna Coast developed the ICECAP measures. The Kidney Medicine, AJKD and JASN pieces report no funding and no relevant financial interests.Physician-led, AI-assisted. Dr. Wael Hussein chooses the papers, reviews and edits every script, and approves every episode. AI (Claude, by Anthropic) writes the first draft from the full text of each paper, and a separate AI check compares every number with the papers; Dr. Hussein then reviews and edits the draft before the AI hosts (ElevenLabs) voice it. Everything is summarized in our own words.For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. Full disclaimer: nephspace.com/disclaimerViews are the creator’s own and not those of his employer. No sponsors.

A rising hemoglobin on an SGLT2 inhibitor: bonus, or warning sign? A meta-analysis of 85 randomized trials in JAMA puts the average rise at about 0.6 g/dL and calls its clinical significance unclear, while its editorial leans toward benefit. We read it alongside a small study of patients on SGLT2 inhibitors at altitude, where the clots clustered in those whose hemoglobin rose most, and a JASN study showing that kidney transplant recipients with polycystic kidney disease clot more, which its authors think is at least partly explained by their own higher hemoglobin. Then a first for our field: Europe revoked avacopan in August, after regulators concluded that data-integrity problems made its pivotal trial's efficacy data unreliable and that its liver-injury signal weighed against it. The FDA alleges the trial's one-year result was re-scored after unblinding; the New England Journal of Medicine retracted the paper at its academic authors' request, and the company disputes the account. Also: a registry study of when to place the peritoneal dialysis catheter, where starting within 30 days carried about three times the risk of an early complication; and a practical review of how to control the rate of sodium correction on CVVH by customizing the replacement bags.Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board. The peritoneal dialysis catheter segment concerns dialysis practice; that study was funded by the Canadian Institutes of Health Research with support from the International Society for Peritoneal Dialysis North American Chapter, the Ontario Renal Network, Vantive Healthcare and Medtronic, and several of its authors report ties to dialysis companies, including Vantive Healthcare and Fresenius Medical Care. Authors of the JAMA meta-analysis and of the JASN transplant study report relationships with companies that market SGLT2 inhibitors and other kidney drugs, and the authors of the JAMA editorial report consulting relationships with anemia drug companies. In the avacopan segment, the FDA's allegations about the ADVOCATE trial are contested by Amgen, which markets the drug in the United States; a hearing has been requested and the matter is unresolved. The European authorization was held by CSL Vifor. The NDT editorial's conflict-of-interest statement declares none, while its acknowledgments record that its senior author's institution has received unrestricted research grants from GlaxoSmithKline, CSL Vifor and Novartis for his investigator-initiated studies, and consulting fees from AstraZeneca, Alexion, GSK, Novartis, Otsuka, Roche, Sobi and CSL Vifor for his consultancies. Full disclosures are in each paper. These disclosures were not read on air this week.Chapters00:00 Cold open and running order01:28 Hemoglobin on SGLT2 inhibitors: bonus or warning? A meta-analysis of 85 randomized trials (JAMA) with its editorial, a study of patients on SGLT2 inhibitors at altitude (Kidney360), and venous thromboembolism after kidney transplant in polycystic kidney disease (JASN)08:19 Avacopan revoked in Europe: what the FDA alleges happened to the ADVOCATE trial's one-year result, the retraction, Amgen's response, the liver injury cases, and what a European taskforce says about patients doing well on the drug (NDT editorial, with the FDA's April 2026 letter, the NEJM retraction notice and editorials in Arthritis & Rheumatology and The Lancet Rheumatology)14:54 When to place the PD catheter: in a North American registry study of about 1,500 first catheters, complications at 90 days did not differ significantly by eGFR group, but within the low-eGFR group each 1 mL/min lower carried more risk, and starting PD within 30 days of insertion carried about three times the risk (AJKD)17:44 Sodium on CVVH: a practical review of how to customize the replacement bags to control the rate of sodium correction, and why the worry about correcting too fast on CRRT is extrapolated from the general hyponatremia literature (Seminars in Dialysis)21:27 ClosePapers in this episodeYang Y, Yang C, Wang Y, et al. Sodium-Glucose Cotransporter 2 Inhibitor Use and Levels of Hemoglobin, Markers of Iron Metabolism, and Erythropoiesis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. JAMA. Published online October 24, 2026. https://doi.org/10.1001/jama.2026.19921Eckardt KU, Koury MJ. Increased Hemoglobin With Sodium-Glucose Transporter 2 Inhibitors — A Consistent Extra Benefit? JAMA. Published online October 24, 2026. https://doi.org/10.1001/jama.2026.22329Aoun M, Madero M, Fernández Yepez AK, et al. Impact of Altitude on Hemoglobin Response to Sodium-Glucose Cotransporter 2 Inhibitors in CKD: The SGaLTItude Study. Kidney360. Published online August 4, 2026. https://doi.org/10.34067/KID.0000001305Bais T, Alnaim AA, Tegzess E, et al. Risk of Venous Thromboembolism in Kidney Transplant Recipients with Autosomal Dominant Polycystic Kidney Disease. J Am Soc Nephrol. Published online October 26, 2026. https://doi.org/10.1681/ASN.0000001298Teng YKO, et al., for the ERN RITA Autoimmune Vasculitis Taskforce. Avacopan across borders: regulatory divergence and treatment dilemmas for ANCA-associated vasculitis. Nephrol Dial Transplant. Published online October 26, 2026. https://doi.org/10.1093/ndt/gfag253Dhoot A, Quinn RR, Clarke A, et al. Association of Estimated GFR at the Time of Peritoneal Dialysis Catheter Insertion With Dialysis-Related Complications. Am J Kidney Dis. Published online October 26, 2026. https://doi.org/10.1053/j.ajkd.2026.06.031Alrashidi FS. Updated Management of Sodium Disorders During Continuous Venovenous Hemofiltration. Semin Dial. Published online October 29, 2026. https://doi.org/10.1111/sdi.70053Also mentionedRubin EJ. Retraction: Jayne DRW et al. Avacopan for the Treatment of ANCA-Associated Vasculitis, N Engl J Med 2021;384:599-609. N Engl J Med. Published online June 29, 2026. https://doi.org/10.1056/NEJMe2608684US Food and Drug Administration, Center for Drug Evaluation and Research. Tavneos (avacopan): proposal to withdraw approval; notice of opportunity for a hearing. April 27, 2026. https://www.fda.gov/media/192160/downloadChapman GB, Pugh D, Dhaun N. From ADVOCATE to ADVOGATE: Is This the End of Avacopan? Arthritis Rheumatol. Published online 2026. https://doi.org/10.1002/art.70352The Lancet Rheumatology. The end for avacopan. Lancet Rheumatol. 2026;8(8):e587. https://doi.org/10.1016/S2665-9913(26)00225-0Spasovski G. Hyponatraemia — treatment standard 2024. Nephrol Dial Transplant. 2024;39(10):1583-1592. https://doi.org/10.1093/ndt/gfae162Physician-led, AI-assisted. Dr. Wael Hussein chooses the papers, reviews and edits every script, and approves every episode. AI (Claude, by Anthropic) writes the first draft from the full text of each paper, and a separate AI check compares every number with the papers; Dr. Hussein then reviews and edits the draft before the AI hosts (Ele...

It was ASN Kidney Week, and IgA nephropathy took center stage: four phase 3 trials in the New England Journal of Medicine and an FDA accelerated approval for ravulizumab. Two drugs first approved on proteinuria, sibeprenlimab and atacicept, reported their two-year results, and kidney function barely declined. We explain why the trials arrived all at once, how the proteinuria stand-in earned its place, and where stand-ins have misled us before. Then the access center: a randomized trial in people 70 and older in which catheters needed the fewest procedures, and a bioengineered vessel for women (both conference abstracts so far). Also: empagliflozin in polycystic kidney disease, where kidneys grew faster on the drug in a small pilot; whether the PUSH stone trial tested water or coaching; how few hemodialysis guidelines say what to do with residual kidney function; a patient's view of incremental PD; and the new HHS Kidney Care National Plan, which names the ties between dialysis chains and nephrologists.Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board. The HHS plan segment discusses the dialysis market and the responses of dialysis companies, including Fresenius Medical Care, and the residual kidney function and incremental PD segments concern dialysis prescription, including home dialysis. Industry funding of the studies discussed: VISIONARY (Otsuka), ORIGIN 3 and PIONEER (Vera Therapeutics), I CAN (Alexion, AstraZeneca Rare Disease), RAINIER (Vertex), the iptacopan extension (Novartis), IMAgINATION (sefaxersen, Roche and Ionis) and the tissue-engineered vessel trial (Humacyte, with Humacyte authors). The empagliflozin trial in ADPKD was funded by the NIDDK and the PKD Foundation, among other non-industry sources. These disclosures were not read on air this week.Chapters00:00 Cold open and running order01:56 IgA nephropathy: the year the endpoint changed. Sibeprenlimab (VISIONARY) and atacicept (ORIGIN 3) report two-year kidney function results in NEJM, ravulizumab gets FDA accelerated approval on proteinuria, why proteinuria earned its place as a stand-in, and where stand-ins have failed before07:43 Vascular access: what to do on Monday. A randomized trial of fistula, graft or catheter in people 70 and older, a bioengineered vessel versus a fistula in women (both conference abstracts), and a registry study of catheters and mortality (JASN)10:20 Empagliflozin in ADPKD: a randomized, placebo-controlled pilot of an SGLT2 inhibitor in polycystic kidney disease (JASN), 50 patients, that was safe, but kidney volume grew faster on the drug12:35 Stones and water: a Kidney International commentary on the PUSH trial (The Lancet) asks whether it tested water or the coaching14:10 Residual kidney function: a scoping review (Hemodialysis International) finds that few hemodialysis guidelines say how to measure it or use it16:15 Incremental PD: a patient's voice. Jan van Cruchten's essay in CJASN's Patient Voice series on a dose as low as possible and as high as necessary17:37 The HHS Kidney Care National Plan: prevention, transplant and the dialysis market, including the financial ties between dialysis chains and nephrologists, and the responses from DaVita, Fresenius Medical Care and Kidney Care Partners21:04 ClosePapers in this episodeRizk DV, Barratt J, Suzuki Y, et al., for the VISIONARY Trial Investigators Group. Sibeprenlimab in IgA Nephropathy — Final Phase 3 Trial Analysis. N Engl J Med. Published online October 22, 2026. https://doi.org/10.1056/NEJMoa2609127Barratt J, Brenner RM, Barbour SJ, et al., for the ORIGIN Phase 3 Trial Investigators. Atacicept in IgA Nephropathy — Phase 3 Trial Final Efficacy Analysis. N Engl J Med. Published online October 22, 2026. https://doi.org/10.1056/NEJMoa2610103Barratt J, Farag YMK, Rice K, et al., for the I CAN Trial Group. Ravulizumab in IgA Nephropathy — Interim Analysis of a Phase 3 Trial. N Engl J Med. Published online October 23, 2026. https://doi.org/10.1056/NEJMoa2607544Heggen B, et al., for the OASIS Study Group. Arteriovenous Fistulas, Grafts, or Central Venous Catheters as Vascular Access for Older Adults Starting Hemodialysis: A Randomized Controlled Trial. ASN Kidney Week 2026, abstract TH-OR112 (conference abstract), October 22, 2026. https://www.asn-online.org/education/kidneyweek/2026/program-abstract.aspx?controlId=4593007Hussain MA, Roy-Chaudhury P, Bou-Ghannam S, Niklason LE, Parikh SJ. Randomized Controlled Trial of an Acellular Tissue Engineered Vessel vs. Arteriovenous Fistula for Hemodialysis Access in Female Patients with ESKD: A Phase 3 CLN-PRO-V012 Interim Analysis. ASN Kidney Week 2026, abstract TH-OR113 (conference abstract), October 22, 2026. https://www.asn-online.org/education/kidneyweek/2026/program-abstract.aspx?controlId=4593585Roetker NS, Wetmore JB, Liu J, Gilbertson DT, Johansen KL. Trends in Mortality of Patients with Central Venous Catheters versus Arteriovenous Accesses for Hemodialysis. J Am Soc Nephrol. Published online October 22, 2026. https://doi.org/10.1681/ASN.0000001293Seliger SL, Gitomer B, You Z, et al. Empagliflozin Therapy in Autosomal Dominant Polycystic Kidney Disease: A Feasibility Randomized Controlled Trial. J Am Soc Nephrol. Published online October 24, 2026. https://doi.org/10.1681/ASN.0000001271Letavernier E, Drüeke TB. Kidney stone disease: to drink or not to drink—that is the question. Kidney Int. 2026;110:1078-1080. https://doi.org/10.1016/j.kint.2026.07.025Hiba SI, Woldemichael J, Awad AS, Abdel-Rahman E, Warfel OR, Gautam SC, Murea M. Clinical Practice Guidelines on the Integration of Residual Kidney Function in Hemodialysis Prescription: A Global Scoping Review. Hemodial Int. 2026. https://doi.org/10.1111/hdi.70123van Cruchten J. A Kidney Patient's Perspective on Incremental Peritoneal Dialysis and Shared Decision-Making. Clin J Am Soc Nephrol. Published online October 16, 2026. https://doi.org/10.2215/CJN.0000001259U.S. Department of Health and Human Services. Kidney Care National Plan. 2026 (released October 20, 2026). https://aspe.hhs.gov/reports/kidney-care-national-planAlso mentionedBarratt J, Zhang H, Han SH, et al., for the RAINIER AIS-D08 Trial Group. Interim Analysis of a Phase 3 Trial of Povetacicept in IgA Nephropathy. N Engl J Med. Published online October 23, 2026. https://doi.org/10.1056/NEJMoa2608682Rovin BH, et al. Iptacopan in IgA nephropathy, long-term extension (up to 48 months). Kidney Int. 2026, journal pre-proof (open access). https://www.kidney-international.org/article/S0085-2538(26)00826-4/fulltextASN Kidney Week 2026 late-breaking abstracts (conference abstracts): atacicept in the PIONEER study (SA-OR079, Lafayette RA, et al., October 24, 2026) and the IMAg...

For years, most of us thought it didn't matter whether critically ill patients started on intermittent hemodialysis or continuous therapy. In the ICRAKI trial, starting on intermittent hemodialysis was linked to more deaths, and the trial stopped early. We explain why the size of that gap is uncertain, but its direction is harm, and why the trial couldn't show that intermittent was no worse. A JAMA study follows last week's fluids-or-pressors thread: resuscitation was only about one liter in six of ICU fluid, with maintenance and the fluid that comes in with drugs making up most of the rest. Then the dialysis unit: how hard it is to deprescribe gabapentin and other risky medications, pedaling on the dialysis bike, and what a new fistula asks of the heart.Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board. The exercise segment discusses a study of an exercise program implemented in Portuguese dialysis units with support from NephroCare, the clinic network of Fresenius Medical Care; two authors are affiliated with NephroCare, and outcome data came from Fresenius's clinical database. The segment also mentions hemodiafiltration, which Fresenius sells. Dr. Hussein also wrote the Healio Perspective on the deprescribing study discussed in this episode.Chapters00:00 Cold open and running order01:27 Intermittent or continuous dialysis in the ICU: the ICRAKI trial (NEJM) set out to show intermittent hemodialysis was no worse, couldn't show that, and was stopped early after more deaths with intermittent hemodialysis as the first therapy; Dr. Paul Palevsky's editorial asks whether we're asking the right question08:00 Where ICU fluid comes from: after last week's fluids-or-pressors trial, PRoFLUID (JAMA) finds resuscitation was only about one liter in six; maintenance and the fluid that comes in with drugs and line flushes made up most of the rest10:38 Deprescribing on dialysis: the IMPROVED feasibility study (Kidney360) on stopping gabapentin and other potentially inappropriate medications in older adults on hemodialysis, and why fitting it into the workflow is the hard part14:59 Exercise on the dialysis bike: in a Portuguese cohort (Kidney Medicine), pedaling about 90 minutes a week or more during dialysis was linked to fewer deaths and fewer hospital days; an association worth testing in proper trials19:24 The fistula and the heart: a small Sydney study (Kidney Medicine) on cardiac output and NT-proBNP as a new fistula matures21:09 ClosePapers in this episodeGaudry S, Boubaya M, Louis G, et al., for the ICRAKI Trial Group. Intermittent or Continuous Renal-Replacement Therapy in Acute Kidney Injury. N Engl J Med. Published online October 14, 2026. https://doi.org/10.1056/NEJMoa2608397Palevsky PM. Continuous or Intermittent Renal-Replacement Therapy — What Is the Question? N Engl J Med. Published online October 14, 2026 (editorial). https://doi.org/10.1056/NEJMe2612910Blok SG, de Grooth HJ, Pisani L, et al., for the PRoFLUID Investigators. Fluid Therapy in Mechanically Ventilated Critically Ill Adult Patients. JAMA. Published online October 14, 2026. https://doi.org/10.1001/jama.2026.21291Hall R, Rutledge J, Alvarado H, et al. Intervention to Manage and Prevent Overuse of Potentially Inappropriate Medications in Dialysis (IMPROVED): A Feasibility Study. Kidney360. Published ahead of print 2026. https://doi.org/10.34067/KID.0000001285Manley HJ, Li NC, Born S, et al. Medication Burden and Regimen Complexity among Dialysis Patients from 2003 to 2024. Clin J Am Soc Nephrol. 2026;21(9):1575-1583. https://doi.org/10.2215/CJN.0000001114Martins PM, Leal DV, Ferreira AA, Wilund KR, Viana JL. Association of Intradialytic Exercise With Mortality and Hospitalization: A Cohort Study. Kidney Med. Published online October 9, 2026 (article in press). https://doi.org/10.1016/j.xkme.2026.101570Shah NA, Thomas R, Thomas SD, et al. The Proof is in the Peptide: Baseline NT-proBNP and Cardiac Output Responses at AVF Maturation in Hemodialysis Patients. Kidney Med. Published online October 13, 2026 (article in press). https://doi.org/10.1016/j.xkme.2026.101580Also mentionedHealio, October 14, 2026: Deprescribing for older adults on hemodialysis feasible; but challenges remain, with a Perspective by Dr. Wael Hussein. https://www.healio.com/news/nephrology/20261014/deprescribing-for-older-adults-on-hemodialysis-feasible-but-challenges-remainPhysician-led, AI-assisted. Dr. Wael Hussein chooses the papers, reviews and edits every script, and approves every episode. AI (Claude, by Anthropic) writes the first draft from the full text of each paper, and a separate AI check compares every number with the papers; Dr. Hussein then reviews and edits the draft before the AI hosts (ElevenLabs) voice it. Everything is summarized in our own words.For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. Full disclaimer: nephspace.com/disclaimer. Views are the creator's own and not those of his employer. No sponsors.nephspace.com · [email protected]

Three reflexes worth rethinking. In septic shock in the emergency department, stopping the fluid and starting the vasopressor early showed no difference in days alive and out of the hospital compared with the classic fluids-first approach, with about half the extra fluid. In a blinded ICU trial, sodium bicarbonate for metabolic acidosis in shock fixed the blood gas but did not significantly lower death, dialysis or lasting kidney damage. And a review of 13 interview studies asks why so few patients start peritoneal dialysis. Each with what's new, the caveats and what it means on Monday.Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board; Fresenius sells peritoneal dialysis equipment. The PD segment includes our take on US payment for staff-assisted home dialysis and a bill in Congress. One author of an ASN Kidney News viewpoint discussed in the bicarbonate segment, Dr. Lenar Yessayan, reports a seat on a Fresenius Medical Care medical advisory board (the authors' own disclosure).Chapters00:00 Cold open and running order01:12 Fluids or pressors in septic shock: in the ARISE FLUIDS trial (NEJM), stopping the fluid and starting the vasopressor early showed no difference in days alive and out of the hospital, with about half the extra fluid07:02 Bicarbonate at 2 a.m.: the blinded SODa-BIC trial (NEJM), its editorial and two ASN Kidney News viewpoints. A better blood gas, but no significant difference in death, dialysis or lasting kidney damage12:24 Why PD remains underused: an AJKD review of 13 qualitative studies finds fear, clinicians, one-session education, urgent starts and missing home support decide before the patient does17:15 ClosePapers in this episodeThe ARISE FLUIDS Investigators and the ANZICS Clinical Trials Group and ACEM Clinical Trials Network. Vasopressors or Fluids in Early Septic Shock. N Engl J Med 2026;395:1387-1398. https://doi.org/10.1056/NEJMoa2516225The SODa-BIC Investigators and the ANZICS Clinical Trials Group. Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock. N Engl J Med 2026;395:1062-1074. https://doi.org/10.1056/NEJMoa2600526Ostermann M, Cook DJ. Sodium Bicarbonate in Critical Illness — A New Chapter for the Book. N Engl J Med 2026;395 (editorial). https://doi.org/10.1056/NEJMe2610218Sette L. A Better Blood Gas but Not a Better Outcome: Rethinking Bicarbonate in the ICU. Kidney News 2026;18(10/11):59. https://doi.org/10.62716/kn.004282026Teixeira JP, Yessayan L, Tolwani A. Intravenous Bicarbonate for Metabolic Acidosis in the ICU: Improving Outcomes or Just Fixing Numbers? Kidney News 2026;18(10/11):60-61. https://doi.org/10.62716/kn.004552026Shankar R, et al. Barriers to and Facilitators of the Adoption of Peritoneal Dialysis: A Systematic Review of Qualitative Studies. Am J Kidney Dis 2026 (articles in press). https://doi.org/10.1053/j.ajkd.2026.07.013Also mentionedH.R. 8875, Improving Home Dialysis Act of 2026 (119th Congress), mentioned in the PD segment. https://www.congress.gov/bill/119th-congress/house-bill/8875Physician-led, AI-assisted. Dr. Wael Hussein chooses the papers, reviews and edits every script, and approves every episode. AI (Claude, by Anthropic) writes the first draft from the full text of each paper, and a separate AI check compares every number with the papers; Dr. Hussein then reviews and edits the draft before the AI hosts (ElevenLabs) voice it. Everything is summarized in our own words.For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. Full disclaimer: nephspace.com/disclaimer. Views are the creator's own and not those of his employer. No sponsors.nephspace.com · [email protected]

A 60-page referral, nine years of creatinine, and an AI summary waiting on two desks: the attending's and the first-year fellow's. A Kidney360 perspective says to hand drafting, summarizing and paperwork to AI first, because a clinician checks the draft. A CJASN perspective says that same drafting is how fellows learn judgment, and warns of "never-skilling". We look at what the evidence actually shows: an ambient-scribe trial in which the better of two tools saved about 20 seconds per note, trainees who accepted roughly three of every four wrong AI answers, and endoscopists who detected fewer adenomas on their own after AI arrived in their units. Then a Fight Night verdict.The takeaway: AI can take the paperwork off a nephrologist's desk, but the safety net is still a human who knows enough to catch its mistakes, so fellows need to build that skill before they hand anything over.Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board. Several of the dialysis AI tools discussed come from Fresenius. He also directs quality improvement and research for nephrology fellows.Chapters00:00 Cold open, welcome and disclosure01:22 The attending's desk: hand AI the paperwork first? The ambient-scribe trial and the dialysis AI tools07:27 The fellow's desk: never-skilling, a hallucination-spotting test, colonoscopy deskilling, and AI practice patients12:36 Who checks the checker: the ASN statement, authors' ties, and a pre-visit medication-reconciliation idea15:10 Fight Night verdict and the Monday-morning changePapers discussedAiumtrakul N, Thongprayoon C, Cheungpasitporn W. Artificial Intelligence in Nephrology Practice: Practical Pathways to Improve Efficiency. Kidney360 2026 (ahead of print, open access). https://journals.lww.com/kidney360/fulltext/10.34067/kid.0000001424~artificial-intelligence-in-nephrology-practice-practicalFong JMN, Wang AYM. Equipping Nephrology Fellows with the Knowledge, Skills, and Attitudes for the Artificial Intelligence Era. CJASN 2026 (ahead of print). https://doi.org/10.2215/CJN.0000001239Lukac PJ, et al. Ambient AI Scribes in Clinical Practice: A Randomized Trial. NEJM AI 2025;2(12). https://doi.org/10.1056/AIoa2501000Zhou J, et al. General practice trainees' ability to tell AI hallucinations from correct answers. BMC Med Educ 2025;25:406. https://doi.org/10.1186/s12909-025-06916-2Garbelli M, et al. Usage of the Anemia Control Model Is Associated with Reduced Hospitalization Risk in Hemodialysis. Biomedicines 2024;12:2219. https://doi.org/10.3390/biomedicines12102219Chaudhuri, et al. Machine-learning-directed interventions for hemodialysis patients at imminent risk of hospitalization. NEJM Catalyst 2026;7(3) (abstract only). https://doi.org/10.1056/CAT.25.0212Budzyń K, et al. Endoscopist deskilling risk after exposure to artificial intelligence in colonoscopy: a multicentre, observational study. Lancet Gastroenterol Hepatol 2025;10:896-903 (abstract only). https://doi.org/10.1016/S2468-1253(25)00133-5Ke Y, et al. AI-induced never-skilling in medical education. Nat Med 2026;32:1997-2006 (abstract only). https://doi.org/10.1038/s41591-026-04438-yTangri N, et al. Responsible Use of Artificial Intelligence to Improve Kidney Care (ASN statement). JASN 2026;37:881-890. https://doi.org/10.1681/ASN.0000000929Lavigne E, et al. AI-Standardized Clinical Examination Training on OSCE Performance. NEJM AI 2025;2(8) (abstract only). https://doi.org/10.1056/AIoa2500066Physician-led, AI-assisted. Dr. Wael Hussein chooses the papers, reviews and edits every script, and approves every episode. AI (Claude, by Anthropic) writes the first draft from the full text of each paper, and a separate AI check compares every number with the papers; Dr. Hussein then reviews and edits the draft before the AI hosts (ElevenLabs) voice it. Everything is summarized in our own words; read the original before changing practice.For education and information only, not medical advice. Please talk to your own physician or care team about your health. Full disclaimer: nephspace.com/disclaimer. Views are the creator's own and not those of his employer. No sponsors.nephspace.com · [email protected]

A new lipid guideline makes reduced kidney function a reason for a statin; in 2024, before it arrived, most patients for whom kidney function is now the reason had no statin prescription. An editorial asks whether GLP-1 drugs belong in dialysis units before the trials are done. A review says dialysis adequacy should be measured by what it does for the heart, troponin turns out to be a moving target during a session, and an AI reads photos of fistulas. Five picks from the week of September 25, 2026, each with the background, what's new, the caveats and what it means on Monday.Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board. Two papers in this episode have Fresenius ties: a review with coauthors affiliated with Fresenius Medical Care that rates hemodiafiltration (Fresenius makes hemodiafiltration equipment), and an AI tool from the Renal Research Institute, which authors' disclosure forms describe as a wholly owned Fresenius subsidiary. Dr. Csaba Kovesdy, author of the GLP-1 editorial, is Dr. Hussein's department chief.Chapters00:00 Cold open and running order01:37 Statins in CKD: under the 2026 ACC/AHA guideline, an eGFR of 15 to 60 is a statin indication, but statin prescriptions were lower at more advanced CKD stages (CJASN research letter, 2024 data)06:18 GLP-1 drugs on dialysis: Dr. Kovesdy's CJASN editorial on a real-world study, its design limits, and the risks of malnutrition, muscle loss and hypoglycemia10:17 Beyond Kt/V: an NDT review weighs dialysis strategies by their cardiovascular evidence, from hemodiafiltration to potassium and sodium tailoring15:21 Troponin during dialysis: a systematic review finds troponin I can rise or fall during a single session in patients without symptoms19:21 Fistula aneurysms and AI: a photo classifier flagged 25 of 26 advanced aneurysms in a first test against in-person exams23:16 ClosePapers in this episodeKim M, et al. Lipid-Lowering Therapy in Individuals with CKD. CJASN 2026 (ahead of print, research letter). https://doi.org/10.2215/CJN.0000001218Kovesdy CP. Glucagon-Like Peptide-1 Receptor Agonists in Dialysis: The Evidence Grows, but Trials Must Follow. CJASN 2026 (ahead of print, editorial). https://doi.org/10.2215/CJN.0000001256The editorial discusses Karpinski S, et al. Glucagon-Like Peptide-1 Receptor Agonist Use and Risks of Hospitalization and Mortality in Patients with End-Stage Kidney Disease. CJASN 2026. https://doi.org/10.2215/CJN.0000001208 (figures in this episode are as the editorial reports them).Zoccali C, et al. Beyond Kt/V: Redefining Dialysis Adequacy as Targeted Cardiovascular Risk Reduction. Nephrol Dial Transplant 2026 (advance article). https://doi.org/10.1093/ndt/gfag223Jørgensen JF, et al. The Intradialytic Changes in Cardiac Troponin I — A Systematic Review. Semin Dial 2026 (open access). https://doi.org/10.1111/sdi.70049Dong Z, et al. Cloud-Based AI Application for Classifying Arteriovenous Hemodialysis Vascular Access Aneurysms. CJASN 2026 (ahead of print, open access). https://doi.org/10.2215/CJN.0000001231Physician-led, AI-assisted. Dr. Wael Hussein chooses the papers, reviews and edits every script, and approves every episode. AI (Claude, by Anthropic) writes the first draft from the full text of each paper, and a separate AI check compares every number with the papers; Dr. Hussein then reviews and edits the draft before the AI hosts (ElevenLabs) voice it. Everything is summarized in our own words.For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. Full disclaimer: nephspace.com/disclaimer. Views are the creator's own and not those of his employer. No sponsors.nephspace.com · [email protected]

I want to keep up with nephrology. But the new papers sit behind logins and scattered across sites, so I end up doomscrolling instead. NephSpace brings the week's kidney research and news together, out loud: one weekly episode on what's new, plus deep dives in between, made for the couch, the run and the drive to work.Let's transform scroll time into learning time. Knowledge, transformed: easy to reach, hard to stop.Follow on Apple Podcasts: https://podcasts.apple.com/us/podcast/nephspace/id6818364609Spotify: https://open.spotify.com/show/13ehzk9U414PYpIZK3c4yvPhysician-led, AI-assisted. Dr. Wael Hussein chooses the papers and reviews and edits every script; the hosts are AI voices (ElevenLabs). Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board; each episode's notes carry its own disclosures. For education and information only, not medical advice. Please talk to your own physician or care team about your health. Full disclaimer: nephspace.com/disclaimer. Views are the creator's own and not those of his employer.nephspace.com · [email protected]

Two dialysis patients, same city, same week. One gets a new machine that filters and replaces more than 20 liters every session. The other gets the same old machine with a new filter. Both are told it's the future. Hemodiafiltration has a survival trial but needs new machines. Medium cutoff dialyzers drop into today's machines but have no survival evidence against standard dialysis. A detective story with a Fight Night verdict, including who makes, sells and funds each road.The takeaway: Both roads clear more middle molecules, but only hemodiafiltration has shown that people live longer, and only in patients who can get the dose.Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board. Fresenius makes and sells the 5008X hemodiafiltration machine discussed in this episode. The episode names the industry ties of the review authors and of everyone quoted.Chapters00:00 Cold open and disclosure01:11 The mystery: what middle molecules are, and why clearing them might matter02:47 Road one, change the treatment: CONVINCE, its quality-of-life and cost papers, and the JASN review08:36 Road two, change the filter: Theranova, ELISIO-HX and the medium cutoff evidence11:47 The showdown: MOTheR, the head-to-head trial15:13 Follow the money: who makes, sells and funds each road16:49 Fight Night verdict and the Monday-morning changePapers discussedBlankestijn PJ, et al. Hemodiafiltration: Clinical Practice of Today and a Look into the Future. JASN 2026 (ahead of print). https://doi.org/10.1681/ASN.0000001282Healio | Nephrology, September 24, 2026. Q&A with DaVita's chief medical officer on medium cutoff dialyzers. https://www.healio.com/news/nephrology/20260924/qa-recent-fda-approval-prompts-expansion-of-medium-cutoff-dialyzersBlankestijn PJ, et al. Effect of Hemodiafiltration or Hemodialysis on Mortality in Kidney Failure (CONVINCE). N Engl J Med 2023;389:700-709. https://doi.org/10.1056/NEJMoa2304820Rose M, et al. CONVINCE quality-of-life results. Kidney Int 2024;106:961-971. https://doi.org/10.1016/j.kint.2024.07.014Schouten AEM, et al. CONVINCE cost-utility analysis. Kidney Int 2025;107:728-739. https://doi.org/10.1016/j.kint.2024.12.018Vernooij RWM, et al. Haemodiafiltration versus haemodialysis for kidney failure: an individual patient data meta-analysis of randomised controlled trials. Lancet 2024;404:1742-1749 (abstract only). https://doi.org/10.1016/S0140-6736(24)01859-2Kandi M, et al. Clinical Outcomes With Medium Cut-Off Versus High-Flux Hemodialysis Membranes: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2022;9. https://doi.org/10.1177/20543581211067087MOTheR trial (Theranova expanded hemodialysis vs online hemodiafiltration), presented at the ERA Congress, June 2026, not yet peer-reviewed. Healio, June 18, 2026. https://www.healio.com/news/nephrology/20260618/expanded-hemodialysis-noninferior-to-online-hemodiafiltrationNational Kidney Foundation. Medium Cut-Off Dialyzers for Expanded Hemodialysis: A Clinical Update. https://www.kidney.org/professionals/medium-cut-dialyzers-expanded-hemodialysisCompany and provider statements cited (promotional sources, labeled as such on air)Vantive, June 8, 2026 (MOTheR and CONCORDIA). https://www.globenewswire.com/news-release/2026/06/08/3308370/0/en/vantive-highlights-late-breaking-high-clinical-impact-data-at-era-indicating-hdx-therapy-is-a-practical-alternative-to-online-hemodiafiltration.htmlFresenius Medical Care, June 2026, "High-Volume Hemodiafiltration Remains the Benchmark for Survival Evidence in Dialysis". https://freseniusmedicalcare.com/en/media/insights/blog/high-volume-hemodiafiltration-remains-the-benchmark-for-survival/DaVita newsroom, August 5, 2026. https://newsroom.davita.com/davita-scales-expanded-hd-to-target-middle-molecules/U.S. Renal Care, July 30, 2026. https://www.prnewswire.com/news-releases/us-renal-care-drives-innovation-in-dialysis-with-increased-availability-of-medium-cut-off-dialyzers-to-support-expanded-hemodialysis-302839595.htmlHealio perspective, February 24, 2026, "Middle molecule moment" (Chan and Sonti). https://www.healio.com/news/nephrology/20260224/middle-molecule-moment-hemodiafiltration-and-expanded-hemodialysis-transform-us-dialysisAlso cited by name: Baxter's August 2020 Theranova authorization announcement, Nipro's July and August 2026 ELISIO-HX releases, and Fresenius's 2025 and 2026 releases on the 5008X rollout.Physician-led, AI-assisted. Dr. Wael Hussein chooses the papers, reviews and edits every script, and approves every episode. AI (Claude, by Anthropic) writes the first draft from the full text of each paper, and a separate AI check compares every number with the papers; Dr. Hussein then reviews and edits the draft before the AI hosts (ElevenLabs) voice it. Everything is summarized in our own words; read the original before changing practice.For education and information only, not medical advice. Please talk to your own physician or care team about your health. Full disclaimer: nephspace.com/disclaimer. Views are the creator's own and not those of his employer. No sponsors.nephspace.com · [email protected]

Two ways to clear more middle molecules arrive in US dialysis units at once. A urine dipstick can show whether patients are taking their SGLT2 inhibitor. Two papers disagree about who should let AI write the notes. Nine picks from the week of September 21, 2026, each with the story, the numbers and a take.Disclosure: Dr. Hussein serves on the Fresenius Medical Care US Home Medical Advisory Board. Fresenius sells hemodiafiltration machines, which are discussed in this episode.Chapters00:00 Cold open and running order01:10 Hemodiafiltration: a JASN review makes the case for high-volume HDF as the global default, and how to prescribe it05:06 Medium cutoff dialyzers: Nipro's ELISIO-HX is cleared in the US and DaVita is scaling it up. What the interview shows, and what it doesn't08:13 Obinutuzumab: FDA approval for preventing relapse in frequently relapsing or steroid-dependent childhood-onset nephrotic syndrome, from age 2 into adulthood11:08 Nephrology and CKM syndrome: an AJKD perspective on shifting the specialty from organ failure to prevention13:59 Atherosclerosis in CKD: a CJASN review of mechanisms, risk prediction and the treatment menu17:54 GLP-1 receptor agonists in CKD: a case-based CJASN "How I Treat" piece21:03 The dipstick adherence check: glucosuria on routine urinalysis as a marker that patients are taking their SGLT2 inhibitor24:31 AI in practice: where AI can take paperwork off the nephrologist's desk27:44 Fellows and AI: training for the AI era without "never-skilling"30:24 ClosePapers and news in this episodeBlankestijn PJ, et al. Hemodiafiltration: Clinical Practice of Today and a Look into the Future. JASN 2026 (ahead of print). https://doi.org/10.1681/ASN.0000001282Healio | Nephrology, September 24, 2026. Q&A with DaVita's chief medical officer: recent FDA approval prompts expansion of medium cutoff dialyzers. https://www.healio.com/news/nephrology/20260924/qa-recent-fda-approval-prompts-expansion-of-medium-cutoff-dialyzersHealio | Nephrology, September 25, 2026. FDA approves obinutuzumab (Gazyva) for idiopathic nephrotic syndrome. Background in this segment also came from FDA-approval coverage in Contemporary Pediatrics and HCPLive and from Genentech's trial release, not only from the Healio report. https://www.healio.com/news/nephrology/20260925/fda-approves-gazyva-for-idiopathic-nephrotic-syndrome-in-pediatric-patientsSridhar VS, Levin A. AJKD perspective on the nephrologist's role in cardiovascular-kidney-metabolic syndrome. AJKD 2026 (ahead of print). https://www.ajkd.org/article/S0272-6386(26)01125-X/fulltextCorrea S, Cuningham JW, Mc Causland FR. Atherosclerotic Cardiovascular Disease in CKD: Contemporary Insights into Pathogenesis, Diagnosis, and Management. CJASN 2026 (ahead of print). https://doi.org/10.2215/CJN.0000001199Cheung DS. GLP-1 Receptor Agonists in CKD: A Case-Based Discussion of Translating Evidence into Practice. CJASN 2026 (ahead of print). https://doi.org/10.2215/CJN.0000001252Li Z, et al. Glucosuria as a Marker of Adherence to Sodium-Glucose Cotransporter 2 Inhibitors and Clinical Outcomes in Real-World Practice. JASN 2026 (ahead of print). https://doi.org/10.1681/ASN.0000001252Aiumtrakul N, Thongprayoon C, Cheungpasitporn W. Artificial Intelligence in Nephrology Practice: Practical Pathways to Improve Efficiency. Kidney360 2026 (ahead of print, open access). https://journals.lww.com/kidney360/fulltext/10.34067/kid.0000001424~artificial-intelligence-in-nephrology-practice-practicalFong JMN, Wang AYM. Equipping Nephrology Fellows with the Knowledge, Skills, and Attitudes for the Artificial Intelligence Era. CJASN 2026 (ahead of print). https://doi.org/10.2215/CJN.0000001239Physician-led, AI-assisted. Dr. Wael Hussein chooses the papers, reviews and edits every script, and approves every episode. AI (Claude, by Anthropic) writes the first draft from the full text of each paper, and a separate AI check compares every number with the papers; Dr. Hussein then reviews and edits the draft before the AI hosts (ElevenLabs) voice it. Everything is summarized in our own words; read the original before changing practice.For education and information only, not medical advice. Please talk to your own physician or care team about your health. Full disclaimer: nephspace.com/disclaimer. Views are the creator's own and not those of his employer. No sponsors.nephspace.com · [email protected]