Ukrainian Journal of Nephrology and Dialysis

. Patients with end-stage kidney disease, who require hemodialysis for more than three months, have little chance of terminating dialysis. The purpose of this case report is to show the effects of patient kidney care and nutrition on the termination of dialysis and patient follow-up. We present a 74-year-old end-stage kidney disease patient who underwent hemodialysis 3 times a week for 7 years. After the patient underwent a special kidney care and nutrition program called Toprak’s Kidney Care, hemodialysis was terminated by gradually reducing the dialysis sessions over 2.5 months. During the 62-month follow-up after discontinuing dialysis, the patient required no kidney replacement therapy. The glomerular filtration rates were stable at 8-10 mL/min/1.73 m2. During the follow-up period, the patient was not hospitalized and no major adverse cardiac events occurred. To date, the patient remains in good health. Toprak’s Kidney Care and nutritional support may be considered during the termination of HD in ESKD patients. The discontinuation of HD in ESKD patients who have adequate urine output may be considered, even after 7 years of HD. Consensus and clinical guidelines regarding the termination of chronic HD in ESKD patients are needed.

Approximately 840 million people are diagnosed with CKD worldwide and around 10 million people per year require kidney replacement therapy. Unfortunately, only 2.5 million of these patients have access to kidney replacement therapy [4,8]. Thus, the education of CKD patients is important. Patients may prevent or delay health problems secondary to CKD by consuming the right food and drinks. Dietary interventions and lifestyle changes can improve kidney function [7,[9][10][11]. One study showed that HD could be terminated after dietary adjustment in HD patients [9].
Based on our 17 years of nephrology experience, we have created a care program for CKD patients called Toprak's Kidney Care [7,11]. Herein, we present the case of an ESKD patient with an arteriovenous fistula who was removed from HD after 7 years by following Toprak's Kidney Care. After more than 5 years, the patient still does not require HD or kidney transplantation. Although this is only a single case, the results are promising; very long-term HD treatment may be terminated with careful and strict patient care. Furthermore, patients can maintain good health for many years after termination of HD. This is the third reported case in which a patient discontinued longterm HD due to Toprak's Kidney Care. We do not use any products, drugs or applications that may be harmful to CKD patients or whose content is unknown. Almost all of the components of Toprak's Kidney Care are also used in many other medical fields and diseases for many years [12][13][14][15][16][17][18][19][20][21][22][23]. Toprak's Kidney Care aims to improve the kidney functions, and social and psychological conditions of CKD patients. One of the most difficult things in the world is to change the life and of patients in a positive way. We are trying to do this with Toprak's Kidney Care.
The philosophy. Science, empathy, trust, patience, hope, faith, respect, and love constitute the philosophy of Toprak Kidney Care. The language, race, color, gender, religion, and country of the patient are not factors that affect our love for our patients. Patient participation in Toprak's Kidney Care is free. We do not have any sponsors. Under normal circumstances, a nephrologist's 24/7 patient support, arranging conferences, preparing training videos and doing home visits are things that require financial resources and funding. We bear all the expenses necessary for these transactions ourselves. Our biggest sponsor is the intense love and prayers of our patients. A sweet smile between the patient and his nephrologist, without any conflict of interest, is much more valuable to us than a whole world of gold.
The history. The idea to create Toprak's Kidney Care first emerged in 2006. The corresponding author of this paper has been following thousands of CKD patients for years as a single nephrologist and also conducts the education of CKD patients and their caregivers. Most of these patients are stage 5 CKD patients. Working under very intense conditions for years, having patients from many countries, cultures, and different geographies and following them as a single nephrologist gave us experience in the field of nephrology, especially in CKD patient education and care. We patiently listened to thousands of questions about lifestyle and healthy eating from our patients and recorded them all. In line with the suggestions of our patients and their caregivers, we have prepared a better patient education program each time. As a result of years of effort, we combined our experience with existing nephrology guidelines and Toprak ' countries, die before they can reach dialysis or kidney transplantation due to impossibilities [4,8]. Knowing this, we dedicate all of our energies to helping people with CKD live longer and healthier without the need for dialysis or a kidney transplant or delaying this need as much as possible. We have found that in the follow-up and treatment of thousands of our patients, classical nephrology patient education and current nephrology guidelines are insufficient at some points and cannot answer the questions of the patients. Many CKD patients did not know or misunderstood exactly how they should be fed. For these reasons, we decided to create Toprak's Kidney Care, considering that a new kidney care model is needed."

Case Report
In October 2017, a 74-year-old man was admitted to our nephrology outpatient clinic from another city, hoping to recover from HD. The patient heard that if urine output was adequate, patients could be removed from HD. The patient had ESKD and underwent HD 3 days per week, 4 hours per session for 84 months in a dialysis center. The medical records revealed that the patient was diagnosed with stage 4 CKD in July 2008 and was followed up for 2 years at a university hospital nephrology division. A kidney biopsy was not performed to determine the etiology of CKD due to the small size of both kidneys. An arteriovenous fistula was placed in December 2009. HD was started in August 2010 due to pulmonary edema and a glomerular filtration rate (GFR) of 9.7 mL/min/1.73m 2 . The patient was added to the cadaveric kidney transplant list. The patient has had prediabetes for 5 years, insomnia for 6 years, and drank two alcoholic beverages a week for almost 15 years.
After undergoing HD for 7 years, the patient applied to our kidney care program. The patient met the criteria for HD reduction or discontinuation according to Toprak''s Kidney Care, as shown in Table 1. In Toprak's Kidney Care, all patients at the HD pass the selection according to Table 1 and the algorithm of Fig. 2. We do not have any pre-selection conditions or criteria. The patient's willingness and motivation to cooperate is the main reason for starting participation in the program. Also in our case, the patient and her caregiver were highly motivated to participate in Toprak's Kidney Care. To remove the patient from HD or to reduce the HD session, the patient must meet 6 major and 3 minor criteria.
The patient was evaluated according to the flow chart created for the reduction or discontinuation of HD (Fig. 2). The patient had an arteriovenous fistula with aneurysms in the right arm (Fig. 3). The patient was evaluated the day before the patient's routine HD. The patient was stable and had a urine output of 1500 mL/day. The kidney ultrasound showed bilateral small-sized kidneys with increased echogenicity ( Table 2).   A program consisting of changes in medications, lifestyle, and nutritional habits was started (Tables 3 and 4).

Lifestyle changes
Smoking  Dietary interventions and lifestyle changes can facilitate the termination or reduction of HD. We prepared 18 educational videos and 132 conferences for patients and caregivers. Nephrotoxic drug use or excessive salt intake was < 1% in our patients [7,[9][10][11]24] Providing 24/7 medical support to patients and caregivers by nephrologists using a mobile phone and social network The mobile phone number of the nephrologist is given to patients. If the patient or caregiver needs support, they can connect directly to the nephrologist Health systems have adopted eHealth to improve kidney care [25]. We could not find a publication investigating the effects of direct access to a nephrologist 24/7 on the discontinuation of HD Hospitalization of AKI patients with CKD in the nephrology division. Follow-up visits, examinations, consultations, management of comorbidities, and treatment of patients by the same nephrologist Substantial experience in HD discontinuation over 14 years and following > 7000 CKD patients without starting HD, even with a GFR < 3 mL/ min/1.73 m 2 (Unpublished information. The information of these patients can be accessed by "e-nabiz" patient data bank system of the Ministry of Health of the Republic of Turkey. Clinical studies on these patients are still ongoing).
Management of cardiovascular risk factors reduces CKD progression [4,8]. Avoiding nephrotoxic agents and maintaining fluid balance can be more successful under nephrology supervision. We have not found any publication on the role of follow-up of CKD patients by the same nephrologist on termination or reduction of HD

Spiritual care
The corresponding author is spiritual care certified. Depression/anxiety improved > 80% in patients CKD patients who had spiritual care were more likely to give a positive assessment of their care [19] Prevention of constipation Use of laxatives is < 5%. We solve this problem by walking barefoot, exercise, alkaline water, spices, honey, olive oil, probiotics, reflexology, magnesium, and keeping TSH < 5 mIU/L Constipation is an important risk factor for progression to ESKD and an indicator of gut dysbiosis. In constipation, harmful bacteria and uremic toxins increase in the intestines. If we cannot prevent constipation, we cannot reduce or stop HD [14,23]. Constipation and decreased GFR levels are common in patients with hypothyroidism. CKD is associated with a higher prevalence of primary hypothyroidism. Higher TSH levels led to higher prevalence of CKD [36]. For these reasons, we try to keep the TSH < 5 mIU/L in CKD patients." Український журнал нефрології та діалізу №2 (78) 2023 Випадки з клінічної практики Сlinical case reports Table 4 Interventions Moderate protein restriction improves hyperkalemia, hyperphosphatemia, and delays CKD progression [10]. Recent studies question the restriction of plantderived potassium and phosphorus. Phytate is a phosphorus found in legumes, nuts, seeds, and grains that passes through the digestive tract unabsorbed. Plant-based proteins have fewer uremic toxins and may slow CKD progression [39,40]. Black seed oil protects the kidneys [13]. Pumpkin is a good source of vitamins, omega-3, fiber, magnesium, zinc, and iron [15]. Nuts are rich in fiber and useful against constipation. Dietary intake of poultry, fish, eggs, or dairy products may delay the progression of CKD. However, microplastics, heavy metals, and phosphorus are found in fish. We use red meat, chicken, and plantbased proteins in patients Intermittent fasting Fasting for 14 hours without water restriction and eating for 10 hours for patients with BM ≥ 25 kg/m2 and diabetics who do not use intensive insulin Intermittent fasting improves obesity, diabetes mellitus, and hypertension, and may decrease CKD progression. In patients with polycystic kidney disease, intermittent fasting reduces cyst growth [40] Consuming probiotics 3 mL apple or jujube vinegar, 30 g sauerkraut with lemon and olive oil, 35 g yogurt/day, 150 mL ayran, and 200 mL kefir per week

Continuation of
In CKD, uremic toxins increase in the intestines and promote aerobic bacteria growth. Probiotics improve the intestines and slow the progression of CKD [14] Consuming ziziphus jujuba and other fruits and vegetables Jujube (dried 28 g/day or raw 20 g/day). Green apples (150 g in diabetics, 300 g/day in non-diabetics), lemon (25 g/ day), watermelon (150 g/wk), and green olives (30 g/day). Boiled spinach, leek, zucchini, artichoke, broccoli, cabbage, celery, purslane, and okra (2 gr/kg/day, of them). 150 g roasted pepper, 200 g eggplant, 100 g tomato, 100 g onion, 10 g garlic, 100 g cucumber per week When taken in moderate amounts, fruits and vegetables do not cause hyperkalemia or hyperphosphatemia and provide many vitamins, minerals, and antioxidants that CKD patients need [40]. Jujube prevents hypertension, diabetes, and hyperlipidemia and restores kidneys in CKD patients. Jujube meets a significant portion of the daily vitamin and mineral needs [12]. Anticoagulant users should not consume jujube Consumption of bee products 1,5 g/kg/day of flower honey in nondiabetics. Banning propolis, royal jelly, and pollen Honey protects kidneys against oxidative stress and infection in rats [42]. Propolis, royal jelly, and pollen may cause nephropathy in humans. Acute kidney injury, acute interstitial nephritis, hyperkalemia and hyponatremia have been reported after the use of these products [43] Cooking kidney-friendly foods at home We teach patients how to make foods at home. > 98% of patients stay away from ready-made foods and cook their meals We could not find a publication investigating the effects of preparing and eating kidney-friendly meals at home on kidney function and HD discontinuation Drinking alkaline water Water consumption with pH is 7.5-8.5 Reducing acid load by alkaline water may slow GFR decline and decrease metabolic acidosis in CKD [44] Banning white bread consumption Patients consumed oopsie, siyez, rye, or whole grain bread, lavash, pita, or phyllo dough instead of white bread. Cessation of white bread consumption may have a role in HD discontinuation Dieticians recommend white bread to CKD patients because of low phosphorus and potassium levels. However, white bread is high in chemicals, which are harmful to the kidneys [20]. Phosphorus and potassium levels can be controlled by proper diet Avoiding excessive salt restriction (<2 g/day). Using bitter, spice, vinegar, and lemon instead of salt 2 g/day rock salt for patients with hypertension/proteinuria and 5 g/ day for patients with salt-wasting nephropathy and hypotension. In a day, 3 mL apple/jujube vinegar, 25 g lemon, 2 g chili or isot pepper, and 4 g black pepper or 6 g sumac may be used instead of salt Lowering salt intake reducing hypertension and proteinuria. However, excessive salt restriction may cause hyponatremia and is a risk for CKD progression [45]. Anticoagulant users should not consume cinnamon, ginger, turmeric, and cloves. Black seed and fennel should not be used in pregnancy and breastfeeding [43] Український журнал нефрології та діалізу №2 (78) 2023 Ukrainian Journal of Nephrology and Dialysis, 2 (78)'2023 Випадки з клінічної практики Сlinical case reports Table 4 Interventions

and applications of Toprak's Kidney Care Clinical practice Rationales and standpoint
Determination of the correct fluid volume and dry weight Some HD patients appear to have very low dry weight. We reexamined the dry weights and volume status in all patients who might discontinue or reduce HD Inaccurate measurement of ideal dry weight, unnecessary ultrafiltration, unnecessary diuretics, and fluid restriction may reduce kidney perfusion. After correcting, urine quamtity can increase and the possibility of HD reduction and discontinuing increases [7,11,24,46] Obesity and malnutrition We do not follow strict diet. In patients who have no appetite or BMI < 18,5 kg/m 2 , the possibility of stopping HD is very low. Most of our patients have a BMI > 20 kg/m² Both obesity and malnutrition are associated with progression to ESKD. Malnutrition is more dangerous than obesity [47]. Restrictive eating may lead to malnutrition, inflammation, and atherosclerosis. Being slightly overweight gives much better results in CKD Allopurinol for hyperuricemia, bicarbonate for mild metabolic acidosis, multiple vitamins to support B12, B6, B1, and folic acid levels, and erythropoietin for anemia were administered. High salt and alcohol intake were terminated. The patient was drinking 750-1000 mL of water and 500 mL of other liquids a day. We allowed an intake of 1.5 liters of water and 500 mL of other liquids per day because there was no hypervolemia. The patient and the patient's caregiver attended our education conference. The patient did not undergo HD on the second day due to the clinical and laboratory findings. The patient felt much better on the second day. The urine output was adequate, the blood pressure was in the normal range, and no hypervolemia was detected. The serum creatinine levels increased from 3.1 mg/dL to 4.2 mg/dL. The electrolyte levels were in the normal range. We reduced the weekly HD to two on the second day. After 42 days, we reduced HD to once a week. After 73 days, we found no uremic symptoms such as nausea, vomiting, fatigue, weight loss, pruritus, or changes in mental status, severe acidosis, uncontrolled hypertension, hyponatremia, hyperphosphatemia, hyperkalemia, or fluid overload. Urine output was sufficient. GFR levels stabilized at an average of 8-10 ml/min/1.73 m 2 ( Table 2). There was no indication for HD. Depression and anxiety improved. Based on these findings, HD was terminated. Thus, the 88-month HD of the patient ended.
At the time of this report, the patient has been followed for 62 months and remains HD-free. At each outpatient clinic appointment, patient compliance with our recommendations for eating, drinking, lifestyle, and medication was reviewed with a standard questionnaire. Our patient largely complied with the exact serving sizes we suggested during the follow-up period. During the 62-month follow-up, the patient was not hospitalized, and no major adverse cardiac events occurred. The patient continues to come for examination every 3 months.
Discussion. In elderly HD patients, the remaining life expectancy is approximately 3 years [4]. If the patient described above had not applied to us, he would most likely be on HD for the remainder of his life or had an unnecessary kidney transplant. The discontinuation of HD for this patient may have been facilitated by restricting the high salt diet, reducing daily protein intake, increasing exercise, increasing fluid intake, and providing alternative treatments to the patient; these changes in diet and exercise resulted in increased kidney perfusion, decreased oxidative stress, and decreased proteinuria (see Table 4).
Our patient had HD-dependent ESKD according to medical records, laboratory analyses, and kidney ultrasound findings. The patient received pre-dialysis care for 2 years in a nephrology clinic and ESKD was diagnosed. In addition, an AV fistula was created during the pre-dialysis care and the patient was on the cadaveric kidney transplant list. According to the patient's medical record, a kidney biopsy was not performed and the cause of ESKD was unknown. We could not find a kidney biopsy. Therefore, we cannot say anything clearly about the relationship between the termination of HD and the histological type of kidney damage. Has our patient been mistakenly diagnosed with ESKD and undergone unnecessary HD for over 7 years? Such a possibility is impossible for a nephrologist. The initiation of HD was corrected for a patient with pulmonary edema and a GFR value of 9.7 mL/ min/1.73 m 2 . The IDEAL study which was published in August 2010 showed that with careful clinical management, HD may be delayed until either the GFR <7.0 ml/min or more traditional clinical indicators for the initiation of HD are present. Our patient was started on HD in August 2010, when deferral HD was not in practice as the results of the IDEAL study were just published [48]. However, we could not determine if the initiation of the HD program was too early for the present case. Many patients with CKD develop AKI, are diagnosed with ESKD, and become HD-dependent [2,4,7]. If this situation is not noticed and the patient continues HD, kidney function will further decrease with HD and the patient will be sentenced to HD for life. In our patient, daily fluid intake was restricted and fluid was removed by ultrafiltration in each HD session. Unnecessary ultrafiltration and fluid restriction in the HD period can lead to prerenal azotemia, which further disrupts kidney perfusion [5,7]. Our patient had preserved diuresis and no hypervolemia. After increasing the patient's oral fluid intake and terminating ultrafiltration and HD, a slight increase in urine quantity was observed in our patient. A 1500 ml urine output per day is very unusual for a patient on HD for 7 years. However, although rare, residual kidney function may be preserved for years in some patients. Reninangiotensin-aldosterone system blockade, incremental HD, use of biocompatible membranes and ultrapure dialysate, blood pressure control, diuretic usage, diet, and HD modality influence the preservation of residual kidney function in HD patients [49].
We follow current guidelines in the care of CKD patients [10]. Based on our 17 years of nephrology experience, we have also added alternative therapies, resulting in the emergence of Toprak's Kidney Care (Fig. 1) [7,11]. Nephrologists are currently not adequately informed about complementary and alternative medicine consumption by their patients. Because many products are at risk of either accumulating or causing interactions with medication. There are very few publications in the medical literature on alternative methods that can be applied to patients with ESKD or advanced CKD [50][51][52][53].
Toprak's Kidney Care is a newly defined care model for CKD patients, which may facilitate the termination of HD in some patients [7,11,24]. The care model includes nutritional care of the patient, and spiritual care of patients and their caregivers; depression and anxiety in both the patient and the caregiver are treated without medication. Jujube fruits may prevent kidney damage and control dyslipidemia and diabetes [12]. Therefore, jujube tea, jujube fruit, or jujube vinegar is included in Toprak's Kidney Care for CKD patients, as in the presented case. Black seed oil may improve kidney function in patients with CKD [13]. Regular consumption of probiotics may slow the progression of CKD [14]. Pumpkin seeds are a good source of vitamins and minerals needed in ESKD patients [15]. Therefore, black seed oil, probiotics, and pumpkin seeds were included in the treatment program for the present case.
Walking barefoot, which may improve kidney blood flow, is also a part of our care program [16]. Sweat treatment facilitates the excretion of potassium, sodium, urea, toxins, and excess fluids, especially in CKD patients, and was included in our treatment program [17]. Vitamin D supplementation may benefit CKD patients [10]. Vitamin D can be synthesized by the human body through the action of sunlight. Our patient had vitamin D deficiency despite taking vitamin D supplements; thus vitamin D levels were increased by sunbathing, correct nutrition, and vitamin D supplements. Shorter sleep duration and poor sleep are associated with an increased risk of CKD development [18]. The components of our care program such as siesta, walking barefoot, sweat therapy, sunbathing, spiritual care, and probiotics, may all have positive effects on sleep quality and quality of life [14,[16][17][18][19]. Our patient's insomnia decreased after beginning therapy; his sleep duration increased from 5 to 8 hours.
Few studies in the literature support these alternative therapies; thus, we cannot recommend them for all CKD patients. Our ongoing large-scale studies will clarify the benefits of alternative therapies such as the use of specific probiotics, the use of ziziphus jujuba, barefoot walking, intermittent fasting, siesta, sweat therapy, and spiritual care. The duration of exercise was increased and dietary habits changed in our patient. High salt intake was terminated and replaced with kidney-friendly spices, like bitter and lemon. Alcohol intake was also terminated. Our patient had prediabetes. White bread contains high amounts of gluten and has a high glycemic index [20]. Therefore, white bread was eliminated from the patient's diet and was replaced with siyez, rye, or whole grain bread. The high phosphorus and potassium levels were adjusted via diet changes and were in the normal range during the 62 months followup period ( Table 2).
Under normal conditions, long-term HD in ESKD patients is only terminated by kidney transplantation [8]. However, KFR occurs in approximately 8% of patients with ESKD receiving long-term HD [1-3, 5-7]. HD duration before withdrawal from HD was less than one year in most cases and only 45% survived of patients survived for one year after HD was discontinued [1, 3, 5, 6]. In one study, the median time to KFR and HD discontinuation was 8.3 months [54]. In a Swedish study, the longest period before the cessation of HD was 5.7 years [6]. Very few cases describe discontinuation of HD secondary to KFR in ESKD patients after 7 years. Letachowicz et al. reported that 97 months was the longest period of HD before cessation of HD due KFR [5]. Our case is one of the longest dialysis periods before withdrawal from HD reported in the literature. Although complete KFR was not detected, our patient has been living without HD for over 5 years. KFR rates are low in patients with permanent vascular access for HD of more than one year [1, 3, 5, 6]; therefore, the successful discontinuation of dialysis was unexpected in our patient, who had an arteriovenous fistula.
Very limited data is available on the cessation of HD in ESKD patients due to patient care or lifestyle changes. One study showed that a low protein diet led to the cessation of HD in three CKD patients [9]. We recently reported that a 71-year-old patient with ESKD was removed from HD due to Toprak's Kidney Care after 6 months of HD; the patient did not need HD for the following 9 years [11]. In another case, we reported that a 77-year-old man who had undergone HD 3 times weekly for 75 months, after which HD sessions were gradually decreased and terminated within 21 months while undergoing Toprak's Kidney Care. The patient went without HD for 10 months. Then, HD was started once weekly for 46 months. Following this period, he underwent HD 3 times weekly [24]. Thus, this is the third case report demonstrating that long-term HD can be terminated using Toprak's Kidney Care. Of note, we did not terminate HD because of a progressive decrease in urea and creatinine levels or an inability to tolerate HD. However, in most of the reported KFR cases, a progressive decrease in serum urea and creatinine or an inability to tolerate HD was observed [1-3, 5, 6, 9]. Despite low GFR levels, our kidney care program was implemented and HD sessions were gradually decreased over 2.5 months before the complete discontinuation of HD. After discontinuation of HD, the GFR values were stabilized at approximately 8-10 mL/min/1.73 m 2 , the daily amount of urine was preserved and slightly increased over time, HD was not needed, and the patient continued to lead a healthy life.
Stopping dialysis is extremely risky in ESKD patients [4,7,8]. If any complications develop after stopping HD or reducing the HD sessions, we could be accused of endangering the patient's life. In this case, we ended the HD by taking all these risks. Guidelines for termination or reduction in HD sessions should be formulated to reduce the risks to both patients and the medical staff. If we want to achieve successful results with Toprak Kidney Care, first of all, the nephrologist following the patient, the patient, patient caregivers, dialysis center employees, nurses and all doctors who deal with the patient's accompanying diseases should work in coordination and cooperation.
The main limitation of this study is that it is a single case report; we cannot conclude that all HD patients can discontinue HD with Toprak's Kidney Care. This is an important and rare presentation and the treatment approaches we used may not be beneficial to every patient. We cannot yet determine which component(s) of Toprak's Kidney Care facilitated the discontinuation of HD in this patient. To answer this question, randomized controlled studies with more patients are needed. The histology underlying the kidney disease in this patient was unknown. However, the lack of ESKD etiology does not decrease the value of the case. Importantly, HD was successfully terminated in this patient with ESKD; the patient did not require HD for over 5 years after termination, even though the patient was on HD for 7 years. We should have to calculate creatinine clearance values in 24-hour urine and residual renal clearance of urea to assess residual kidney function and assess the need for ongoing HD.
Conclusions. Toprak's Kidney Care and nutritional support may be considered during the termination of HD in ESKD patients. The discontinuation of HD in ESKD patients who have adequate urine output may be considered, even after 7 years of HD. Consensus and clinical guidelines regarding the termination of chronic HD in ESKD patients are needed.
Conflicts of Interest. The authors declare that they have no conflicts of interest.
Data Availability. The data used to support the findings of this study are included in the article. The data supporting the findings of this study are also publicly available in the electronic health system (E-nabiz) of the patient.
Fundings. This research has no funding to report.
Ethical Approval. The study was conducted ethically following the World Medical Association Declaration of Helsinki.

Consent.
The patient has given their written informed consent to publish their case (including publication of images). Approval was also obtained from the patient and his caregiver for the termination of hemodialysis treatment.
Author Contributions. Data collection and writing OT, and EAB; the conception and design of the study, or acquisition of data, or analysis and interpretation of data OT, EAB, and DEA; concept and critical review OT; final approval of the version to be submitted OT, EAB, and DEA. All authors have read and agreed to the submitted version of the manuscript.