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Naylor KL, Jeyakumar N, Kang Y, Dixon SN, Garg AX, Al-Jaishi A, Blake PG, Chanchlani R, Fu L, Harel Z, Ip J, Kitchlu A, Kwong JC, Nesrallah G, Oliver MJ, Stukel TA, Wald R, Weir M, Yau K. Clinical Outcomes and Healthcare Utilization in Patients Receiving Maintenance Dialysis After the Onset of the COVID-19 Pandemic in Ontario, Canada. Can J Kidney Health Dis 2025; 12:20543581251328077. [PMID: 40161414 PMCID: PMC11954382 DOI: 10.1177/20543581251328077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Accepted: 02/20/2025] [Indexed: 04/02/2025] Open
Abstract
Background The impact of the COVID-19 pandemic on clinical outcomes and healthcare utilization in patients receiving maintenance dialysis is unclear. Objective To compare the rates of clinical outcomes and healthcare utilization in patients receiving maintenance dialysis (in-center and home modalities) before and during the COVID-19 pandemic. Design Population-based, repeated cross-sectional study. Setting Linked administrative healthcare databases from Ontario, Canada. Patients Adults receiving maintenance dialysis from March 15, 2017, to March 14, 2020 (pre-COVID-19 pandemic period) and from March 15, 2020, to March 14, 2023 (COVID-19 pandemic period). Measurements Our primary outcome was all-cause mortality. Our secondary outcomes included non-COVID-19-related mortality, all-cause hospitalizations (excluding elective surgeries), emergency room visits, intensive care unit admissions, and hospital admissions with mechanical ventilation. We also examined cardiovascular-related hospitalizations, kidney-related outcomes, and ambulatory visits. Methods We used Poisson generalized estimating equations to model pre-COVID outcome trends and used these to predict post-COVID outcomes and to estimate the relative change (i.e., the ratio of the observed to the expected rate). Results In 31 900 individuals receiving maintenance dialysis during the study period, the crude incidence rate (per 1000 person-years) of all-cause mortality was 165.0 in the pre-COVID-19 period, compared to 173.2 during the first year of the pandemic and 171.7 during the first 36 months of the pandemic. After adjustment, there was a statistically significant increase in all-cause mortality in 14 out of the 36 months of the COVID-19 period compared to the pre-COVID-19 period, with 494 recorded COVID-19-related deaths. However, when examining the overall all-cause mortality across the months, the adjusted relative rate (aRR) comparing the observed to expected all-cause mortality rate was not statistically significant in the first year of the pandemic (1.08, 95% CI: 1.00, 1.16) and the first 36 months of the pandemic (1.08, 95% CI: 0.99, 1.18) compared to the pre-pandemic period. The crude incidence rate of non-COVID-19-related mortality was 165.0 in the pre-COVID-19 period, compared to 163.3 during the first year of the pandemic and 157.7 during the first 36 months. After adjustment, there was no substantial change in the rate of non-COVID-19-related deaths in the first year of the pandemic (aRR 1.01, 95% CI: 0.94, 1.09), but there was a substantial decrease in all-cause hospitalization, with an aRR of 0.92 (95% CI: 0.88, 0.97), and a substantial decrease in emergency room visits and intensive care unit admissions; findings were consistent 36 months into the pandemic. Limitations External generalizability to other jurisdictions may be limited, with each region experiencing different COVID-19 rates and implementing different mitigation strategies. Conclusions In the maintenance dialysis population, all-cause mortality was significantly higher during several months of the pandemic; however, the overall rate of all-cause mortality was not substantially higher than expected in the first 36 months of the COVID-19 pandemic. There was no substantial increase in non-COVID-19-related mortality despite a substantial decrease in acute healthcare utilization. Ongoing monitoring of the dialysis population will offer further insights into the long-term effects of the pandemic.
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Affiliation(s)
- Kyla L. Naylor
- ICES Western, London Health Sciences Centre Research Institute, London, ON, Canada
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
| | - Nivethika Jeyakumar
- ICES Western, London Health Sciences Centre Research Institute, London, ON, Canada
| | - Yuguang Kang
- ICES Western, London Health Sciences Centre Research Institute, London, ON, Canada
| | - Stephanie N. Dixon
- ICES Western, London Health Sciences Centre Research Institute, London, ON, Canada
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Amit X. Garg
- ICES Western, London Health Sciences Centre Research Institute, London, ON, Canada
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Ahmed Al-Jaishi
- ICES Western, London Health Sciences Centre Research Institute, London, ON, Canada
| | - Peter G. Blake
- Division of Nephrology, Western University, London, ON, Canada
| | - Rahul Chanchlani
- Department of Medicine, Pediatrics, McMaster University, Hamilton, ON, Canada
- ICES, ON, Canada
| | | | - Ziv Harel
- Division of Nephrology, Department of Medicine, St. Michael’s Hospital, University of Toronto, ON, Canada
| | - Jane Ip
- Ontario Renal Network, Ontario Health, Toronto, Canada
| | - Ahbijat Kitchlu
- Division of Nephrology, University Health Network, University of Toronto, ON, Canada
| | - Jeffrey C. Kwong
- ICES, ON, Canada
- Public Health Ontario, Toronto, Canada
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Gihad Nesrallah
- Department of Medicine, Humber River Regional Hospital, Toronto, ON, Canada
| | - Matthew J. Oliver
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Therese A. Stukel
- ICES, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, ON, Canada
| | - Ron Wald
- Division of Nephrology, Department of Medicine, St. Michael’s Hospital, University of Toronto, ON, Canada
- Department of Nephrology and Hypertension, Tel Aviv Medical Center, Israel
| | - Matthew Weir
- ICES Western, London Health Sciences Centre Research Institute, London, ON, Canada
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Kevin Yau
- Division of Nephrology, Department of Medicine, Toronto General Hospital, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
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Cui L, Zhang L, Li J, Li Y, Hao X, Xu Y, Li C. Correlation between ultrafiltration rate and hemoglobin level and erythropoietin response in hemodialysis patients. Ren Fail 2024; 46:2296609. [PMID: 38178573 PMCID: PMC10773628 DOI: 10.1080/0886022x.2023.2296609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/13/2023] [Indexed: 01/06/2024] Open
Abstract
This study aimed to investigate the correlation between ultrafiltration rate (UFR) and hemoglobin levels and erythropoietin (EPO) response in patients receiving maintenance hemodialysis (MHD). 225 MHD patients were divided into three groups according to the UFR: < 10 ml/h/kg, 10-13 ml/h/kg, and >13 ml/h/kg. Clinical parameters and prognosis were compared among the groups. Multiple linear correlation and regression analyses were conducted. SPSS 26.0 (IBM, Chicago, IL, USA) was used to analyze all statistics. The UFR < 10 ml/h/kg group was older than the other groups (p < 0.05). The UFR > 13 ml/h/kg group had the highest SpKt/V (p < 0.05), monthly EPO dose/weight (p < 0.001), and EPO resistance index (p < 0.001), as well as the lowest dry weight (p < 0.001), BMI (p < 0.001), hemoglobin (p < 0.001), hematocrit (p < 0.05), and red blood cell count (p < 0.05). Multiple linear regression analysis showed that sex, dry weight, UFR, calcium, phosphorus, albumin, and C-reactive protein levels were associated with hemoglobin levels. Multivariate logistic regression analysis revealed that a higher UFR was associated with lower hemoglobin levels, while male sex and higher levels of calcium and albumin were associated with higher hemoglobin levels. High UFR is associated with more severe anemia and EPO resistance in MHD. This study provides new insights into anemia management in patients undergoing hemodialysis.
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Affiliation(s)
- Li Cui
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lili Zhang
- Department of Nutrition, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jing Li
- Department of Nutrition, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuan Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaolei Hao
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Xu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chunmei Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
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Zucaro L, Longobardi C, Miele A, Villanova A, Suzumoto Y. Nanocarrier-Based Drug Delivery Systems Targeting Kidney Diseases. Kidney Blood Press Res 2024; 49:884-897. [PMID: 39406192 DOI: 10.1159/000541848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 10/04/2024] [Indexed: 11/12/2024] Open
Abstract
BACKGROUND The potential applications of nanotechnology in the medical field have become increasingly recognized in recent years. Nanocarriers have emerged as a versatile tool, offering a wide range of applications due to their unique properties. In addition to the targeted drugs delivery, nanocarriers have also proven to be extremely effective in imaging and diagnostics. Continuous advances in nanotechnology have paved the way for innovative solutions to complex challenges in human health, shaping the future of nanotechnology and its applications. SUMMARY By exploring different types of nanoparticles, this review delves into the different characteristics that can be tailored to enhance their kidney access. Although the structural complexity of the kidney may prevent nanocarriers passage, optimization of nanocarrier characteristics such as shape, size, charge, and surface modifications may overcome these barriers, allowing for targeted delivery. By harnessing the potential of nanoparticles, researchers aim to develop targeted and efficient therapies that can address various kidney-related disorders. KEY MESSAGES This review highlights the promising advancements in nanotechnology and their potential impact on improving the therapeutic outcomes for several kidney diseases.
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Affiliation(s)
- Laura Zucaro
- Biogem, Molecular Biology and Genetics Research Institute, Ariano Irpino, Italy
- Department of Mental, Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Consiglia Longobardi
- Biogem, Molecular Biology and Genetics Research Institute, Ariano Irpino, Italy
- Department of Mental, Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Miele
- Biogem, Molecular Biology and Genetics Research Institute, Ariano Irpino, Italy
- Department of Mental, Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Villanova
- Biogem, Molecular Biology and Genetics Research Institute, Ariano Irpino, Italy
- Department of Mental, Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Yoko Suzumoto
- Biogem, Molecular Biology and Genetics Research Institute, Ariano Irpino, Italy
- Institute of Biochemistry and Cell Biology, National Research Council of Italy (CNR), Naples, Italy
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Park HC, Kim DH, Cho AJ, Kim BY, Lee M, Kim GO, Kim J, Lee YK. Remaining life expectancy of Korean hemodialysis patients: how much longer can they live? Kidney Res Clin Pract 2024; 43:671-679. [PMID: 38389145 PMCID: PMC11467359 DOI: 10.23876/j.krcp.23.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/24/2023] [Accepted: 11/09/2023] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Hemodialysis (HD) patients have a higher mortality rate compared to the general population. However, no study has investigated life expectancy in Korean HD patients so far. Therefore, this study aimed to calculate the remaining life expectancy among Korean maintenance HD patients and compare it to those of the general population as well as HD patients from other countries. METHODS Baseline data were retrieved from HD quality assessment data from 2015. Among the patients over 30 years old who were alive at the beginning of 2016 (20,304 males and 14,264 females), a total of 22,078 (12,621 males and 9,457 females) were still alive at the end of 2021 while 12,490 (7,683 males and 4,807 females) were deceased during 6 years of follow-up. We used the life table method to calculate the expected remaining years of life in 2-year increments. RESULTS The remaining life expectancies for 60-year-old patients were 11.64 years for males and 14.64 years for females. The average remaining life expectancies of the HD population were only about half of the general population. Diabetic patients demonstrated shorter life expectancy compared to patients with hypertension or glomerulonephritis. The remaining life expectancy of Korean HD patients was similar to that of Japanese and was almost double that of HD patients in Western countries such as Europe and the United States. CONCLUSION The HD population shows a shorter life expectancy compared to the general population. Longitudinal analysis should be warranted to analyze the effect of advanced dialysis technology on improved survival rates among the HD population.
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Affiliation(s)
- Hayne Cho Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Do Hyoung Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
| | - AJin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Bo Yeon Kim
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Miri Lee
- Department of Quality Assessment, Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Gui Ok Kim
- Department of Quality Assessment, Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Jinseog Kim
- Department of Bigdata and Applied Statistics, Dongguk University, Gyeongju, Republic of Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
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Babroudi S, Weiner DE, Neyra JA, Drew DA. Acute Kidney Injury Receiving Dialysis and Dialysis Care after Hospital Discharge. J Am Soc Nephrol 2024; 35:962-971. [PMID: 38652567 PMCID: PMC11230726 DOI: 10.1681/asn.0000000000000383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
The number of patients with AKI receiving outpatient hemodialysis (AKI-D) is increasing. At present, on the basis of limited data, approximately one third of patients with AKI-D who receive outpatient dialysis after hospital discharge survive and regain sufficient kidney function to discontinue dialysis. Data to inform dialysis management strategies that promote kidney function recovery and processes of care among patients with AKI-D receiving outpatient dialysis are lacking. In this article, we detail current trends in the incidence, risk factors, clinical outcomes, proposed management, and health policy landscape for patients with AKI-D receiving outpatient dialysis and identify areas for further research.
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Affiliation(s)
- Seda Babroudi
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Daniel E. Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - David A. Drew
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
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Canada KE, Vogelsmeier AA, Popejoy LL, Powell K, Brandt L, Rantz M. Exploring Hospital Transfers for Long-Stay Nursing Home Residents With End-Stage Renal Disease. J Nurs Care Qual 2024; 39:232-238. [PMID: 38198671 DOI: 10.1097/ncq.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Nursing home residents with end-stage renal disease (ESRD) are an understudied, yet growing population within nursing homes. PURPOSE To describe hospital transfers for nursing home residents diagnosed with ESRD and receiving hemodialysis. METHODS Data were analyzed for residents with ESRD transferred to the hospital between October 2016 and September 2020 (n = 219). Descriptive statistics, bivariate analyses, logistic regression, and content analysis were used for analysis. RESULTS Clinical factors associated with transfers included abnormal vitals, altered mental state, and pain. Other factors included lack of care planning and advance directives, provider communication, resident/family preferences, missing/refusing dialysis, and facility resources. The odds of an observation/emergency department only visit was 2.02 times larger when transferred from the dialysis clinic. CONCLUSIONS Advance care planning and coordinated care between nursing home and dialysis clinics are needed along with proactive planning when residents miss dialysis or experience a condition change at the dialysis clinic.
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Affiliation(s)
- Kelli E Canada
- Author Affiliations: School of Social Work, University of Missouri, Columbia (Dr Canada); Sinclair School of Nursing, University of Missouri, Columbia (Drs Vogelsmeier, Popejoy, Powell, and Rantz); and University of Missouri Center for Health Ethics, Columbia (Dr Brandt)
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Corr M, Pachchigar A, O’Neill M, Higgins R, O’Neill S, Hanko J, Masengu A. A decade of arteriovenous fistula creations in the ⩾75 years population: Equal opportunity or sub-optimal use of resources. J Vasc Access 2024; 25:1093-1099. [PMID: 36609176 PMCID: PMC11308278 DOI: 10.1177/11297298221147571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 12/09/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The optimal vascular access in the elderly remains contentious in the context of increasingly limited resources and anticipated survival on hemodialysis. Research focus has shifted to include the impact of vascular access on quality of life. This study explored clinical outcomes in individuals aged ⩾75 years who had an arteriovenous fistula (AVF) created in a single center over a 10-year period. MATERIALS AND METHODS Demographic and clinical data concerning AVFs created January 2009-December 2019 were identified from a prospective database for retrospective analysis. Outcome measures were AVF patency and failure to mature rates plus overall patient and vascular access survival. The Vascular Access Specific Quality of life measure (VASQoL) was completed in a contemporary cohort aged ⩾75 years established on HD in October 2021. RESULTS AVF outcomes were available for 272 patients (93%). The failure to mature (FTM) rate was 36% with the significant predictors of AVF FTM being the creation of a radiocephalic AVF (OR 8.13, 95% CI 8.02-8.52, p < 0.01), female gender (OR 4.84, 95% CI 4.70-5.41, p < 0.01), and a history of peripheral vascular disease (OR 5.25, 95% CI 5.22-6.00, p value = 0.02). Functional patency was associated with a median 12-month survival benefit compared to those whose fistula FTM (p < 0.01). The median patency duration for a functionally patent AVF was 3 years. Elderly patients with a fistula reported a lower quality of life in VASQoL scoring than those with central venous catheters. CONCLUSIONS In this cohort, AVF creation in individuals aged ⩾75 years AVFs was associated with comparable AVF patency rates to younger patients. AVF functional patency was associated with superior patient survival compared to those with AVF FTM. A multi-disciplinary surveillance program may help reduce AVF loss. Further work on how vascular access choice impacts quality of life in elderly patients is required.
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Affiliation(s)
- Michael Corr
- Centre of Public Health, Queen’s University, Belfast, UK
- Regional Nephrology & Transplant Unit, Belfast Health and Social Care Trust, Belfast, UK
| | | | | | - Rebecca Higgins
- Regional Nephrology & Transplant Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Stephen O’Neill
- Centre of Public Health, Queen’s University, Belfast, UK
- Regional Nephrology & Transplant Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Jennifer Hanko
- Regional Nephrology & Transplant Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Agnes Masengu
- Regional Nephrology & Transplant Unit, Belfast Health and Social Care Trust, Belfast, UK
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Bothe T, Fietz AK, Mielke N, Freitag J, Ebert N, Schaeffner E. The Lack of a Standardized Definition of Chronic Dialysis Treatment in German Statutory Health Insurance Claims Data—Effects on Estimated Incidence and Mortality. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:148-154. [PMID: 38381660 PMCID: PMC11539888 DOI: 10.3238/arztebl.m2024.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Chronic kidney failure (CKF) is often treated with dialysis, which is invasive and costly and carries major medical risks. The existing studies of patients with CKF requiring dialysis that are based on claims data from German statutory health insurance (SHI) carriers employ varying definitions of this entity, with unclear consequences for the resulting statistical estimates. METHODS We carried out a cohort study on four random samples, each consisting of 62 200 persons aged 70 or above, from among the insurees of the SHI AOK Nordost, with one sample for each of the years 2012, 2014, 2016, and 2018. The prevalence, incidence, mortality, and direct health care costs of CKF requiring dialysis were estimated and compared on the basis of four different definitions from literature and a new definition developed by the authors in reference to billing data. RESULTS The different definitions led to variation in 12-month prevalences (range: 0.33-0.61%) and 6-month incidences (0.058-0.100%). The percentage of patients with prior acute kidney injury (AKI) ranged from 27.6% to 61.8%. Among incident patients, three-month survival ranged from 70.2% to 88.1%, and six-month survival from 60.5% to 81.3%. In CKF patients without prior AKI, the survival curves differed less across definitions (80.2-91.8% at three months, 70.7-84.4% at six months). The monthly health care costs ranged from €6010 to €9606, with marked variability across definitions in the costs of inpatient and outpatient care. CONCLUSION The lack of a standardized definition of CKF requiring dialysis in German SHI claims data leads to variability in the estimated case numbers, mortality, and health care costs. These differences are most probably in part due to the variable inclusion of inpatients who received short-term dialysis after AKI.
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Affiliation(s)
- Tim Bothe
- Institute for Public Health, Charité – Universitätsmedizin Berlin, Germany
| | - Anne-Katrin Fietz
- Institute for Public Health, Charité – Universitätsmedizin Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Germany
| | - Nina Mielke
- Institute for Public Health, Charité – Universitätsmedizin Berlin, Germany
| | - Julia Freitag
- AOK Nordost – Die Gesundheitskasse, Potsdam, Germany
| | - Natalie Ebert
- *These authors share last authorship
- Institute for Public Health, Charité – Universitätsmedizin Berlin, Germany
| | - Elke Schaeffner
- *These authors share last authorship
- Institute for Public Health, Charité – Universitätsmedizin Berlin, Germany
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Gaillard F, Bachelet D, Couchoud C, Laouenan C, Peoc'h K, Simon Q, Charles N, Jourde-Chiche N, Daugas E. Lupus activity and outcomes in lupus patients undergoing maintenance dialysis. Rheumatology (Oxford) 2024; 63:780-786. [PMID: 37338593 DOI: 10.1093/rheumatology/kead293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVES Lupus activity has long been considered to decline after initiation of maintenance dialysis (MD). This assumption is based on limited historical data. We aimed to describe the natural history of lupus in patients undergoing MD. METHODS We assembled a national retrospective cohort of lupus patients who started dialysis between 2008 and 2011, included in the REIN registry with a 5-year follow-up. We analysed healthcare consumption from the National Health Data System. We evaluated the proportion of patients 'off-treatment' (i.e. receiving 0-5 mg/d of corticosteroids, without any immunosuppressive therapy) after the start of MD. We describe the cumulative incidences of non-severe and severe lupus flares, cardiovascular events, severe infections, kidney transplantation and survival. RESULTS We included 137 patients (121 females and 16 males), with a median age of 42 years. The proportion of patients 'off-treatment' at dialysis initiation was 67.7% (95% CI: 61.8, 73.8%), and increased to 76.0% (95% CI: 73.3, 78.8) at 1 year and 83.4% (95% CI: 81.0, 85.9%) at 3 years, with a lower proportion in younger patients. Lupus flares mainly occurred in the first year after MD initiation, and at 12 months 51.6% of patients had presented a non-severe lupus flare and 11.6% a severe lupus flare. In addition, 42.2% (95% CI: 32.9, 50.3%) and 23.7% (95% CI: 16.0, 30.7%) of patients at 12 months had been hospitalized for cardiovascular events or infections, respectively. CONCLUSION The proportion of lupus patients off-treatment increases after MD initiation, but non-severe and severe lupus flares continue to occur, mainly during the first year. This calls for the continued follow-up of lupus patients by lupus specialists after dialysis initiation.
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Affiliation(s)
- François Gaillard
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hôpital Edouard Herriot, Lyon, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Delphine Bachelet
- Department of Biostatistical Epidemiology and Clinical Research, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, INSERM CIC-EC 1425, Paris, France
| | - Cécile Couchoud
- REIN, Agence de la Biomédecine, Saint Denis la Plaine, Saint Denis, France
| | - Cédric Laouenan
- Department of Biostatistical Epidemiology and Clinical Research, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, INSERM CIC-EC 1425, Paris, France
| | - Katell Peoc'h
- Laboratoire d'Excellence GR-Ex, Université Paris Cité, Centre de Recherche sur l'Inflammation, INSERM UMR1149, Paris, France
- Service de Biochimie, Hôpital Bichat, DMU BIOGEM, AP-HP, Paris, France
| | - Quentin Simon
- Laboratoire d'Excellence Inflamex, Université Paris Cité; Centre de Recherche sur l'inflammation, INSERM UMR1149, CNRS EL8252, Paris, France
| | - Nicolas Charles
- Laboratoire d'Excellence Inflamex, Université Paris Cité; Centre de Recherche sur l'inflammation, INSERM UMR1149, CNRS EL8252, Paris, France
| | - Noémie Jourde-Chiche
- Aix-Marseille Univ, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, Marseille, France
| | - Eric Daugas
- Laboratoire d'Excellence Inflamex, Université Paris Cité; Centre de Recherche sur l'inflammation, INSERM UMR1149, CNRS EL8252, Paris, France
- Department of Nephrology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
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Song GH, Choi HB, Park HC, Kim DH, Lee YK, Cho AJ. Geriatric Nutritional Risk Index and First-Year Mortality in Incident Hemodialysis Patients. Nutrients 2024; 16:652. [PMID: 38474780 DOI: 10.3390/nu16050652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
OBJECTIVE The Geriatric Nutritional Risk Index is a simple nutritional screening method, and this study aimed to investigate the association between the initial Geriatric Nutritional Risk Index and all-cause mortality in incident patients in the first year after the initiation of hemodialysis. MATERIALS AND METHODS This study is a retrospective cohort study and used the Korean Renal Data System database. Patients who were eligible for Geriatric Nutritional Risk Index assessment and underwent hemodialysis from January 2016 to December 2019 were included. The primary outcome was all-cause mortality, and outcome evaluation was performed in December 2020. A Cox proportional hazard model was used to analyze the association between the Geriatric Nutritional Risk Index and mortality. RESULTS A total of 10,545 patients were included, and the mean age was 63.9 ± 3.7 years. The patients were divided into four groups by the quartile of the Geriatric Nutritional Risk Index with a mean value of 96.2 ± 8.2. During the study period, 545 (5.2%) deaths occurred. The surviving patients had higher Geriatric Nutritional Risk Index values than ones who died in the first year of hemodialysis initiation (96.6 ± 7.5 vs. 88.2 ± 9.3, p < 0.001). Quartile 1 (Geriatric Nutritional Risk Index < 91.8) showed a significantly increased risk of all-cause (Hazard Ratio: 2.56; 95% Confidence Interval: 2.13-3.09; p < 0.001) and cardiovascular mortality (Hazard Ratio: 22.29; 95% Confidence Interval: 1.71- 3.08; p < 0.001) at the first year in comparison with Quartile 4 (Geriatric Nutritional Risk Index ≥ 101.3). In areas under the receiver-operating characteristic curves of all-cause mortality, the Geriatric Nutritional Risk Index model improved predictive values, compared to the baseline model. The area with the Geriatric Nutritional Risk Index model was significantly higher than the one with a model including albumin or body mass index (p < 0.001). CONCLUSIONS These findings suggest that a low Geriatric Nutritional Risk Index (<91.8) is associated with first-year all-cause and cardiovascular mortality in patients who start hemodialysis and may be a useful and reproducible tool for assessing prognoses in this population.
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Affiliation(s)
- Gi Hyun Song
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea
- Kidney Research Institute, Hallym University, Seoul 07441, Republic of Korea
| | - Han Byul Choi
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea
- Kidney Research Institute, Hallym University, Seoul 07441, Republic of Korea
| | - Hayne Cho Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea
- Kidney Research Institute, Hallym University, Seoul 07441, Republic of Korea
| | - Do Hyoung Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea
- Kidney Research Institute, Hallym University, Seoul 07441, Republic of Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea
- Kidney Research Institute, Hallym University, Seoul 07441, Republic of Korea
| | - AJin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea
- Kidney Research Institute, Hallym University, Seoul 07441, Republic of Korea
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11
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Armstrong M, Wityk Martin TL, Zimmermann GL, Drall K, Pannu NI. Personalising haemodialysis treatment with incremental dialysis for incident patients with end-stage kidney disease: an implementation study protocol. BMJ Open 2024; 14:e075195. [PMID: 38286687 PMCID: PMC10826580 DOI: 10.1136/bmjopen-2023-075195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 12/20/2023] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Incremental dialysis is a personalised dialysis prescription based on residual kidney function that allows for the initial use of shorter duration, less frequent and less intense dialysis. It has been associated with enhanced quality of life and decreased healthcare costs when compared with conventional dialysis. While nephrologists report prescribing incremental dialysis, few dialysis programmes offer a systematic approach in offering and evaluating its use. To move evidence into practice, and in order to improve the safety and quality of providing incremental dialysis care, we have designed an implementation study. This study aims to evaluate the systematic assessment of patients starting facility-based haemodialysis for eligibility for incremental dialysis, and the prescription and monitoring of incremental dialysis treatment. METHODS AND ANALYSIS A hybrid effectiveness and implementation study design is being used to evaluate the implementation of the programme at dialysis sites in Alberta, Canada. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to capture individual-level and organisational-level impact of the project. Clinical outcomes related to kidney function will be monitored on an ongoing basis, and patient-reported outcomes and experience measures will be collected at baseline and then quarterly throughout the first year of dialysis. ETHICS AND DISSEMINATION The study was approved by the Health Research Ethics Board of the University of Alberta. The study is funded by the Strategic Clinical Networks of Alberta Health Services. The study will help answer important questions on the effectiveness of incremental dialysis, and inform the acceptability, adoption, feasibility, reach and sustainability of incremental dialysis within provision of haemodialysis care.
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Affiliation(s)
- Marni Armstrong
- Medicine Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Gabrielle L Zimmermann
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta SPOR SUPPORT Unit, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kelsea Drall
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Neesh I Pannu
- Medicine Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
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12
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Cheng XBJ, Chan CT. Systems Innovations to Increase Home Dialysis Utilization. Clin J Am Soc Nephrol 2024; 19:108-114. [PMID: 37651291 PMCID: PMC10843223 DOI: 10.2215/cjn.0000000000000298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
Globally, there is an interest to increase home dialysis utilization. The most recent United States Renal Data System (USRDS) data report that 13.3% of incident dialysis patients in the United States are started on home dialysis, while most patients continue to initiate KRT with in-center hemodialysis. To effect meaningful change, a multifaceted innovative approach will be needed to substantially increase the use of home dialysis. Patient and provider education is the first step to enhance home dialysis knowledge awareness. Ideally, one should maximize the number of patients with CKD stage 5 transitioning to home therapies. If this is not possible, infrastructures including transitional dialysis units and community dialysis houses may help patients increase self-care efficacy and eventually transition care to home. From a policy perspective, adopting a home dialysis preference mandate and providing financial support to recuperate increased costs for patients and providers have led to higher uptake in home dialysis. Finally, respite care and planned home-to-home transitions can reduce the incidence of transitioning to in-center hemodialysis. We speculate that an ecosystem of complementary system innovations is needed to cause a sufficient change in patient and provider behavior, which will ultimately modify overall home dialysis utilization.
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Affiliation(s)
- Xin Bo Justin Cheng
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
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13
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El Shamy O. The Peritoneal Dialysis Surprise Question and Technique Survival: Are you surprised? Perit Dial Int 2024; 44:3-5. [PMID: 38192083 DOI: 10.1177/08968608231223291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Affiliation(s)
- Osama El Shamy
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
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14
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Wan M, Yu J, Liu Y, Wang Y, Qiu Y, Yi C, He W, Yang X, Guo Q, Liu D. Left ventricular strain and myocardial work in short-term peritoneal dialysis patients. Ren Fail 2023; 45:2284838. [PMID: 38017695 PMCID: PMC11001367 DOI: 10.1080/0886022x.2023.2284838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Initiation of dialysis encompasses new cardiovascular challenges on patients with end-stage renal disease (ESRD). This study used two-dimensional speckle-tracking echocardiography (2D-STE) to investigate the change of left ventricular (LV) myocardial function undergoing peritoneal dialysis (PD) within 1-3 months. METHODS A total of 56 patients with ESRD and 27 healthy controls were enrolled in this prospective study. Mean duration of PD was 44.41 ± 16.44 days. We evaluated LV myocardial function of patients with ESRD in baseline and within 1-3 months after PD by 2D-STE with global longitudinal strains (GLS) and myocardial work (MW). Based on the level of serum phosphate before PD, patients were divided into two groups: the group with normal serum phosphate or hyperphosphatemia. RESULTS Compared with healthy controls, patients with ESRD had impaired GLS (p < .001) and increased global work index (GWI) (p = .034), global constructive work (GCW) (p < .001), global wasted work (GWW) (p < .001), and lower global work efficiency (GWE) (p = .002). After PD therapy, GWI (p = .001), GCW (p < .001), and GWW (p = .023) decreased and closed to healthy subjects (p > .05) and no significant improvement was observed in GLS (p = .387). GLS of basal segments worsened in the hyperphosphatemia group (p = .005) and GWW reduced remarkably in the group with normal serum phosphate after PD treatment (p = .008). The change of left ventricular internal diameter in diastole (LVIDd) was the only parameter influenced GWI in post-dialysis patients (β = 0.324, p = .013). CONCLUSIONS Short-term PD treatment improved LV MW in ESRD patients. They benefited more when receiving treatment before the increase of serum phosphorus.
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Affiliation(s)
- Minjie Wan
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jianwen Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Yanqiu Liu
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yan Wang
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yagui Qiu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Chunyan Yi
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Wei He
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Qunying Guo
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Donghong Liu
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Hsu RK, Rubinsky AD, Shlipak MG, Johansen KL, Estrella MM, Lee BJ, Peralta CA, Hsu CY. Associations between abrupt transition, dialysis-requiring AKI, and early mortality in ESKD among U.S. veterans. BMC Nephrol 2023; 24:339. [PMID: 37964185 PMCID: PMC10647139 DOI: 10.1186/s12882-023-03387-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 11/03/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Mortality is high within the first few months of starting chronic dialysis. Pre-ESKD trajectory of kidney function has been shown to be predictive of early death after dialysis initiation. We aim to better understand how two key aspects of pre-dialysis kidney function-an abrupt transition pattern and an episode of dialysis-requiring AKI (AKI-D) leading directly to ESKD-are associated with early mortality after dialysis initiation. METHODS We extracted national data from U.S. Veterans Health Administration cross-linked with the United States Renal Data System (USRDS) to identify patients who initiated hemodialysis during 2009-2013. We defined abrupt transition as having a mean outpatient eGFR ≥ 30 ml/min/1.73m2 within 1 year prior to ESKD. AKI-D was identified using inpatient serum creatinine measurements (serum Cr increase by at least 50% from baseline) along with billing codes for inpatient receipt of dialysis for AKI within 30 days prior to the ESKD start date. We used multivariable proportional hazards models to examine the association between patterns of kidney function prior to ESKD and all-cause mortality within 90 days after ESKD. RESULTS Twenty-two thousand eight hundred fifteen patients were identified in the final analytic cohort of Veterans who initiated hemodialysis and entered the USRDS. We defined five patterns of kidney function decline. Most (68%) patients (N = 15,484) did not have abrupt transition and did not suffer an episode of AKI-D prior to ESKD (reference group). The remaining groups had abrupt transition, AKI-D, or both. Patients who had an abrupt transition with (N = 503) or without (N = 3611) AKI-D had the highest risk of early mortality after ESKD onset after adjustment for demographics and comorbidities (adjusted HR 2.10, 95% CI 1.66-2.65 for abrupt transition with AKI-D; adjusted HR 2.10, 95% CI 1.90-2.33 for abrupt transition without AKI-D). In contrast, patients who experienced AKI-D without an abrupt transition pattern (N = 2141 had only a modestly higher risk of early death (adjusted HR 1.19, 95% CI 1.01-1.40). CONCLUSIONS An abrupt decline in kidney function within 1 year prior to ESKD occurred in nearly 1 in 5 incident hemodialysis patients (18%) in this national cohort of Veterans and was strongly associated with higher early mortality after ESKD onset.
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Affiliation(s)
- Raymond K Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Anna D Rubinsky
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Michael G Shlipak
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Kirsten L Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of Nephrology, Hennepin Healthcare, Minneapolis, MN, USA
| | - Michelle M Estrella
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Benjamin J Lee
- Houston Methodist Institute for Academic Medicine, Houston, TX, USA
- Houston Kidney Consultants, Houston, TX, USA
| | - Carmen A Peralta
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Cricket Health, Inc, San Francisco, CA, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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16
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Zheng S, Parikh RV, Tan TC, Pravoverov L, Patel JK, Horiuchi KM, Go AS. CKD stage-specific utility of two equations for predicting 1-year risk of ESKD. PLoS One 2023; 18:e0293293. [PMID: 37910454 PMCID: PMC10619781 DOI: 10.1371/journal.pone.0293293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND The Kidney Failure Risk Equation (KFRE) and Kaiser Permanente Northwest (KPNW) models have been proposed to predict progression to ESKD among adults with CKD within 2 and 5 years. We evaluated the utility of these equations to predict the 1-year risk of ESKD in a contemporary, ethnically diverse CKD population. METHODS We conducted a retrospective cohort study of adult members of Kaiser Permanente Northern California (KPNC) with CKD Stages 3-5 from January 2008-September 2015. We ascertained the onset of ESKD through September 2016, and calculated stage-specific estimates of model discrimination and calibration for the KFRE and KPNW equations. RESULTS We identified 108,091 eligible adults with CKD (98,757 CKD Stage 3; 8,384 CKD Stage 4; and 950 CKD Stage 5 not yet receiving kidney replacement therapy), with mean age of 75 years, 55% women, and 37% being non-white. The overall 1-year risk of ESKD was 0.8% (95%CI: 0.8-0.9%). The KFRE displayed only moderate discrimination for CKD 3 and 5 (c = 0.76) but excellent discrimination for CKD 4 (c = 0.86), with good calibration for CKD 3-4 patients but suboptimal calibration for CKD 5. Calibration by CKD stage was similar to KFRE for the KPNW equation but displayed worse calibration across CKD stages for 1-year ESKD prediction. CONCLUSIONS In a large, ethnically diverse, community-based CKD 3-5 population, both the KFRE and KPNW equation were suboptimal in accurately predicting the 1-year risk of ESKD within CKD stage 3 and 5, but more accurate for stage 4. Our findings suggest these equations can be used in1-year prediction for CKD 4 patients, but also highlight the need for more personalized, stage-specific equations that predicted various short- and long-term adverse outcomes to better inform overall decision-making.
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Affiliation(s)
- Sijie Zheng
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California, United States of America
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Rishi V. Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Thida C. Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Leonid Pravoverov
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California, United States of America
| | - Jignesh K. Patel
- Department of Nephrology, Kaiser Permanente Sacramento Medical Center, Sacramento, California, United States of America
| | - Kate M. Horiuchi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, United States of America
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California, United States of America
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
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17
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Kolbrink B, Schüssel K, von Samson-Himmelstjerna FA, Esser G, Floege J, Kunzendorf U, Schulte K. Patient-focused outcomes after initiation of dialysis for ESRD: mortality, hospitalization and functional impairment. Nephrol Dial Transplant 2023; 38:2528-2536. [PMID: 37202223 PMCID: PMC10615626 DOI: 10.1093/ndt/gfad099] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Outcome data regarding clinically relevant endpoints after starting dialysis for end-stage renal disease (ESRD) are sparse, and early events after starting dialysis are particularly underestimated. The aim of this study was to describe patient-focused outcomes in ESRD patients starting from first dialysis. METHODS The data basis for this retrospective observational study were anonymized healthcare data from Germany's largest statutory health insurer. We identified ESRD patients who initiated dialysis in 2017. Deaths, hospitalizations and occurrence of functional impairment within 4 years after starting dialysis were recorded starting from first treatment. Hazard ratios in dialysis patients compared with an age- and sex-matched reference population without dialysis were generated, stratified by age. RESULTS The dialysis cohort included 10 328 ESRD patients who started dialysis in 2017. First dialysis was performed in-hospital for 7324 patients (70.9%), and 865 of these died during the same hospitalization. One-year mortality for ESRD patients initiating dialysis was 33.8%. Functional impairment occurred in 27.1% of patients, while 82.8% of patients required hospitalization within 1 year. Hazard ratios of dialysis patients compared with the reference population for mortality, functional impairment and hospitalization at 1-year were 8.6, 4.3 and 6.2. Dialysis patients <50 years were disproportionately affected, with >40-fold increased risk of adverse events compared with their peers. CONCLUSIONS The emergence of morbidity and mortality after starting dialysis for ESRD is significant, especially in younger patients. Patients have a right to be informed about the prognosis associated with their condition.
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Affiliation(s)
- Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Christian-Albrechts-University, Kiel, Germany
| | | | | | - Grit Esser
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Christian-Albrechts-University, Kiel, Germany
| | - Jürgen Floege
- Division of Nephrology and Immunology, Rheinisch Westfälische Technische Hochschule University of Aachen, Aachen, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Christian-Albrechts-University, Kiel, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Christian-Albrechts-University, Kiel, Germany
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18
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Zhang F, Shi T, Feng X, Shi Y, Zhang G, Liu Y, Fu P. Visit-to-visit HbA1c variability is associated with poor prognosis in peritoneal dialysis patients with type 2 diabetes mellitus. BMC Nephrol 2023; 24:288. [PMID: 37775768 PMCID: PMC10542698 DOI: 10.1186/s12882-023-03348-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/23/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND The prognosis of diabetic peritoneal dialysis patients is poor. HbA1c serves as a crucial indicator for monitoring blood glucose control in patients with diabetes. Nevertheless, the relationship between visit-to-visit HbA1c variability and prognosis in peritoneal dialysis with diabetes remains unclear. METHODS All participants were categorized into 3 groups based on the HbA1c variability score (HVS), which is the frequency of 0.5% (5.5 mmol/mol) alter in visit-to-visit HbA1c values. Then, the hazard ratio to HVS with all-cause mortality was analyzed using the Cox hazard model, followed by the Fine-Gray competing risk model for major adverse cardiovascular events. Subgroup and sensitivity analysis were conducted to ascertain the robustness of the findings. RESULTS Eight hundred twenty patients with type 2 diabetes were finally enrolled in this study from 2,855 participants with a mean age of 56.9 ± 14.6 years and a median follow-up time of 44 months [IQR: 27-70], death occurred in 496 (60.2%) individuals. Compared with the lowest category (HVS < 1/3) after being adjusted by potential confounding factors, the hazard ratio for all-cause mortality was 4.59 (3.74-5.64) and the sub-distribution hazard ratio for major adverse cardiovascular events was 1.91 (1.46-2.51) of the highest category (HVS ≥ 2/3). Subgroup interaction and sensitivity analysis, including the adjustment for variables such as time-weighted average HbA1c, HbA1c measurement times and expansion, confirmed the reliability of the results. CONCLUSION The HVS is related to the risk of poor prognosis in peritoneal dialysis with type 2 diabetes mellitus, independently of clinical multiple variables, and is a novel indicator with clinical guidance.
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Affiliation(s)
- Fengping Zhang
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
- Department of Nephrology, Jiujiang NO.1 People's Hospital, Jiujiang, China
| | - Taotao Shi
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
- Department of Nephrology, Jiujiang NO.1 People's Hospital, Jiujiang, China
| | - Xiaoran Feng
- Department of Nephrology, Jiujiang NO.1 People's Hospital, Jiujiang, China
| | - Yunying Shi
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
| | - Guilin Zhang
- Department of Nephrology, The NO.1 Affiliatedffiliated Hospital of Nanchang University, Nanchang, China
| | - Yu Liu
- Department of Nephrology, Pingxiang People's Hospital, Pingxiang, China
| | - Ping Fu
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.
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Laham G, Pujol GS, Guzman J, Boccia N, Abib A, Diaz CH. Early start hemodialysis with a catheter may be associated with greater mortality: A propensity score analysis. Semin Dial 2023; 36:294-302. [PMID: 37088891 DOI: 10.1111/sdi.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/30/2022] [Accepted: 04/10/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Deciding when and how to initiate hemodialysis (HD) is still controversial. An early start (ES) seems to show a lack of benefit. "Lead time bias" and comorbidities have been associated with different outcomes in ES groups. On the other hand, it is well accepted that the impact the type of vascular access (VA) has on patient survival. Our aim was to evaluate survival with early start (ES) versus late start (LS) on HD, taking into account the vascular access (VA) used. METHODS Between 01/1995 and 06/2018, 503 incidental patients initiated HD at our Dialysis Unit. eGFR was estimated by the CKD-EPI equation. Diabetes mellitus (DM), coronary disease (CD), and peripheral vascular disease (PVD) were considered comorbid conditions. According to eGFR and VA, patients were divided into four groups: G1: ES (eGFR > 7 mL/min) with catheter (ES + C), G2: ES with fistula or graft (F/G) (ES + F/G), G3: LS (eGFR< 7 mL/min) with catheter (LS + C), and G4: LS with F/G (LS + F/G). The cut-off value to define ES or LS was based on median eGFR for these 503 patients. We compared patient's survival rates by Kaplan-Meier and log-rank test. The four groups were compared before and after matching with propensity scores (PS). Cox analysis was performed to determine the impact of predictors of mortality. RESULTS Median eGFR was 7 (5.3-9.5) mL/min/1.73 m2 , median follow-up time was 30.9 (13-50) months, 52.1% had F/G access at entry, and 46.9% died during the observation period. Among the four groups, the ES + C were significantly older, and there were more diabetics and comorbid conditions, while phosphatemia, iPTH, albumin, and hemoglobin were significantly higher in the LS groups. Before propensity score (PS) matching, the ES + C group had a poor survival rate (p < 0.0001), while LS + F/G access had the best survival. After PS, a total of 180 patients were selected in the same four groups and ES + C kept showing a statistically significant poorer survival. Multivariate analysis revealed that ES + C was an independent predictor of mortality. CONCLUSION In this retrospective study, ES + C on HD was associated with a higher mortality rate than LS. This association persisted after PS matching.
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Affiliation(s)
- Gustavo Laham
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Gervasio Soler Pujol
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Jenny Guzman
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Natalia Boccia
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Anabel Abib
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Carlos H Diaz
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
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20
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Lim JH, Kim JH, Jeon Y, Kim YS, Kang SW, Yang CW, Kim NH, Jung HY, Choi JY, Park SH, Kim CD, Kim YL, Cho JH. The benefit of planned dialysis to early survival on hemodialysis versus peritoneal dialysis: a nationwide prospective multicenter study in Korea. Sci Rep 2023; 13:6049. [PMID: 37055558 PMCID: PMC10102303 DOI: 10.1038/s41598-023-33216-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/09/2023] [Indexed: 04/15/2023] Open
Abstract
Optimal preparation is recommended for patients with advanced chronic kidney disease to minimize complications during dialysis initiation. This study evaluated the effects of planned dialysis initiation on survival in patients undergoing incident hemodialysis and peritoneal dialysis. Patients newly diagnosed with end-stage kidney disease who started dialysis were enrolled in a multicenter prospective cohort study in Korea. Planned dialysis was defined as dialysis therapy initiated with permanent access and maintenance of the initial dialysis modality. A total of 2892 patients were followed up for a mean duration of 71.9 ± 36.7 months and 1280 (44.3%) patients initiated planned dialysis. The planned dialysis group showed lower mortality than the unplanned dialysis group during the 1st and 2nd years after dialysis initiation (1st year: adjusted hazard ratio [aHR] 0.51; 95% confidence interval [CI] 0.37-0.72; P < 0.001; 2nd year: aHR 0.71; 95% CI 0.52-0.98, P = 0.037). However, 2 years after dialysis initiation, mortality did not differ between the groups. Planned dialysis showed a better early survival rate in hemodialysis patients, but not in peritoneal dialysis patients. Particularly, infection-related mortality was reduced only in patients undergoing hemodialysis with planned dialysis initiation. Planned dialysis has survival benefits over unplanned dialysis in the first 2 years after dialysis initiation, especially in patients undergoing hemodialysis. It improved infection-related mortality during the early dialysis period.
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Affiliation(s)
- Jeong-Hoon Lim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Ji Hye Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Yena Jeon
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Yon Su Kim
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Shin-Wook Kang
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Chul Woo Yang
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Nam-Ho Kim
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Hee-Yeon Jung
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Sun-Hee Park
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Chan-Duck Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Yong-Lim Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea.
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea.
| | - Jang-Hee Cho
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea.
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea.
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21
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Little DJ, Arnold M, Hedman K, Sun P, Haque SA, James G. Rates of adverse clinical events in patients with chronic kidney disease: analysis of electronic health records from the UK clinical practice research datalink linked to hospital data. BMC Nephrol 2023; 24:91. [PMID: 37020294 PMCID: PMC10077632 DOI: 10.1186/s12882-023-03119-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/17/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Further understanding of adverse clinical event rates in patients with chronic kidney disease (CKD) is required for improved quality of care. This study described baseline characteristics, adverse clinical event rates, and mortality risk in patients with CKD, accounting for CKD stage and dialysis status. METHODS This retrospective, noninterventional cohort study included data from adults (aged ≥ 18 years) with two consecutive estimated glomerular filtration rates of < 60 ml/min/1.73 m2, recorded ≥ 3 months apart, from the UK Clinical Practice Research Datalink of electronic health records obtained between January 1, 2004, and December 31, 2017. Select adverse clinical events, associated with CKD and difficult to quantify in randomized trials, were assessed; defined by Read codes and International Classification of Diseases, Tenth Revision codes. Clinical event rates were assessed by dialysis status (dialysis-dependent [DD], incident dialysis-dependent [IDD], or non-dialysis-dependent [NDD]), dialysis modality (hemodialysis [HD] or peritoneal dialysis [PD]), baseline NDD-CKD stage (3a-5), and observation period. RESULTS Overall, 310,953 patients with CKD were included. Comorbidities were more common in patients receiving dialysis than in NDD-CKD, and increased with advancing CKD stage. Rates of adverse clinical events, particularly hyperkalemia and infection/sepsis, also increased with advancing CKD stage and were higher in patients on HD versus PD. Mortality risk during follow-up (1-5-year range) was lowest in patients with stage 3a NDD-CKD (2.0-18.5%) and highest in patients with IDD-CKD (26.3-58.4%). CONCLUSIONS These findings highlight the need to monitor patients with CKD for comorbidities and complications, as well as signs or symptoms of clinical adverse events.
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Affiliation(s)
- Dustin J Little
- Late Cardiovascular, Renal, Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, 20876, USA.
| | - Matthew Arnold
- Real World Data Science, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Katarina Hedman
- Biometrics CVRM, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Ping Sun
- Real World Data Science, Oncology Business Unit, AstraZeneca, Cambridge, UK
| | - Syed Asif Haque
- Global Patient Safety BioPharma, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, MD, USA
| | - Glen James
- Cardiovascular, Renal, Metabolism Epidemiology, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
- Present Address: Integrated Evidence Generation & Business Innovation, Bayer PLC, Reading, UK
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22
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Betiru EA, Mamo E, Jara Boneya D, Adem A, Abebaw D. Survival Analysis and Its Predictors Among Hemodialysis Patients at Saint Paul Hospital Millennium Medical College and Myungsung Christian Medical Center in Addis Ababa, Ethiopia, 2021. Int J Nephrol Renovasc Dis 2023; 16:59-71. [PMID: 36875008 PMCID: PMC9983441 DOI: 10.2147/ijnrd.s401022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Background Diabetes mellitus and hypertension are the most prominent conditions causing chronic kidney disease and eventually end-stage renal disease. Renal replacement therapy, particularly hemodialysis (HD), is the mainstay of treatment. The aim of this study is to assess the overall survival status of HD patients and potential survival predictors at Saint Paul hospital millennium medical college (SPHMMC) and Myungsung Christian Medical Center (MCM) in Addis Ababa, Ethiopia. Methods A retrospective cohort study was conducted on HD patients at SPHMMC and MCM general hospital from January 1, 2013 to December 30, 2020. Kaplan Meier, Log-rank, and Cox proportional regression models were used for the analysis. Estimated risks were reported as hazard ratios with 95% confidence intervals and P<0.05 was considered as having a significant association. Results A total of 128 patients were included in the study. Median survival time was 65 months. The predominant co-morbid condition was found to be diabetes mellitus with hypertension (42%). The total risk time for these patients was 143,617 person years. The overall incidence rate of death was 2.9 per 10,000 person years (95% CI=2.2-4). Patients who developed blood stream infection were 2.98-times more likely to die than those without infection. Those using an arteriovenous fistula were 66% less likely to die than those using a central venous catheter. Additionally, patients treated in a government-owned facility were 79% less likely to die. Conclusion The study identified that the median survival time of 65 months was comparable with developed nations. Significant predictors of death were found to be blood stream infection and type of vascular access. Government-owned treatment facilities showed better patient survival.
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Affiliation(s)
- Eyob Assefa Betiru
- General Public Health Department, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
| | - Ephrem Mamo
- Public Health Departments, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
| | - Dube Jara Boneya
- Departments of Public Health College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Abebawork Adem
- Departments of Public Health College of Health Sciences, Gambi Medical College, Addis Ababa, Ethiopia
| | - Dessie Abebaw
- Public Health Department of Reproductive Health's, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
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23
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Yang K, Shang Y, Yang N, Pan S, Jin J, He Q. Application of nanoparticles in the diagnosis and treatment of chronic kidney disease. Front Med (Lausanne) 2023; 10:1132355. [PMID: 37138743 PMCID: PMC10149997 DOI: 10.3389/fmed.2023.1132355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/22/2023] [Indexed: 05/05/2023] Open
Abstract
With the development of nanotechnology, nanoparticles have been used in various industries. In medicine, nanoparticles have been used in the diagnosis and treatment of diseases. The kidney is an important organ for waste excretion and maintaining the balance of the internal environment; it filters various metabolic wastes. Kidney dysfunction may result in the accumulation of excess water and various toxins in the body without being discharged, leading to complications and life-threatening conditions. Based on their physical and chemical properties, nanoparticles can enter cells and cross biological barriers to reach the kidneys and therefore, can be used in the diagnosis and treatment of chronic kidney disease (CKD). In the first search, we used the English terms "Renal Insufficiency, Chronic" [Mesh] as the subject word and terms such as "Chronic Renal Insufficiencies," "Chronic Renal Insufficiency," "Chronic Kidney Diseases," "Kidney Disease, Chronic," "Renal Disease, Chronic" as free words. In the second search, we used "Nanoparticles" [Mesh] as the subject word and "Nanocrystalline Materials," "Materials, Nanocrystalline," "Nanocrystals," and others as free words. The relevant literature was searched and read. Moreover, we analyzed and summarized the application and mechanism of nanoparticles in the diagnosis of CKD, application of nanoparticles in the diagnosis and treatment of renal fibrosis and vascular calcification (VC), and their clinical application in patients undergoing dialysis. Specifically, we found that nanoparticles can detect CKD in the early stages in a variety of ways, such as via breath sensors that detect gases and biosensors that detect urine and can be used as a contrast agent to avoid kidney damage. In addition, nanoparticles can be used to treat and reverse renal fibrosis, as well as detect and treat VC in patients with early CKD. Simultaneously, nanoparticles can improve safety and convenience for patients undergoing dialysis. Finally, we summarize the current advantages and limitations of nanoparticles applied to CKD as well as their future prospects.
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Affiliation(s)
- Kaibi Yang
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yiwei Shang
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Nan Yang
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Shujun Pan
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Juan Jin
- Department of Nephrology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang, China
- *Correspondence: Juan Jin,
| | - Qiang He
- Department of Nephrology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang, China
- Qiang He,
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24
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Lee TW, Bae W, Choi J, Bae E, Jang HN, Chang SH, Park DJ. The neutrophil-to-lymphocyte ratio may indicate when to start hemodialysis. Ren Fail 2022; 44:1401-1408. [PMID: 35969022 PMCID: PMC9397444 DOI: 10.1080/0886022x.2022.2110894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We evaluated whether the neutrophil-to-lymphocyte ratio (NLR) could aid dialysis decision-making in combination with the clinical presentation and biochemical findings. We retrospectively evaluated the medical records of 279 patients who commenced chronic maintenance hemodialysis. We compared the laboratory findings at 6 months before dialysis to those at dialysis initiation. NLR cutoffs and risk factors for each of six uremic symptoms were determined. Mean age was 60.7 years and mean estimated glomerular filtration rate (eGFR) was 5.7 ± 2.5 mL/min/1.73 m2 at the time of hemodialysis and 7.7 ± 3.8 mL/min/1.73 m2 6 months earlier (p < 0.001). The mean NLR increased significantly from 2.5 ± 1.0 to 4.9 ± 2.8 (p < 0.001). The NLR was positively correlated with the C-reactive protein level (r = 0.202, p = 0.009) and negatively correlated with those of albumin (r = −0.192, p = 0.001) and total CO2 (r = −0.134, p = 0.023). The NLR cutoffs for neurological and gastrointestinal symptoms as determined using receiver operator curve analysis were 2.4 (area under the curve [AUC] 0.976; 95% confidence interval [CI] 0.960–0.993; sensitivity 92.2%; specificity 94.7%) and 3.6 (AUC 0.671; 95% CI 0.588–0.755; sensitivity 68.1%; specificity 63.5%), respectively. On multiple linear regression analysis of neurological symptoms, the NLR was a significant predictor (β = −0.218, p = 0.017), as was age (β = 0.314, p = 0.037). In conclusion, the NLR may serve as a supplementary marker predicting uremic symptoms and a need for hemodialysis in stage 5 CKD patients.
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Affiliation(s)
- Tae Won Lee
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Wooram Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jungyoon Choi
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Eunjin Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea.,Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, South Korea.,Institute of Health Science, Gyeongsang National University, Jinju, South Korea
| | - Ha Nee Jang
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Se-Ho Chang
- Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, South Korea.,Institute of Health Science, Gyeongsang National University, Jinju, South Korea.,Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Dong Jun Park
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea.,Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, South Korea.,Institute of Health Science, Gyeongsang National University, Jinju, South Korea
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25
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Rankin S, Han L, Scherzer R, Tenney S, Keating M, Genberg K, Rahn M, Wilkins K, Shlipak M, Estrella M. A Machine Learning Model for Predicting Mortality within 90 Days of Dialysis Initiation. KIDNEY360 2022; 3:1556-1565. [PMID: 36245665 PMCID: PMC9528387 DOI: 10.34067/kid.0007012021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 07/15/2022] [Indexed: 11/27/2022]
Abstract
Background The first 90 days after dialysis initiation are associated with high morbidity and mortality in end-stage kidney disease (ESKD) patients. A machine learning-based tool for predicting mortality could inform patient-clinician shared decision making on whether to initiate dialysis or pursue medical management. We used the eXtreme Gradient Boosting (XGBoost) algorithm to predict mortality in the first 90 days after dialysis initiation in a nationally representative population from the United States Renal Data System. Methods A cohort of adults initiating dialysis between 2008-2017 were studied for outcome of death within 90 days of dialysis initiation. The study dataset included 188 candidate predictors prognostic of early mortality that were known on or before the first day of dialysis and was partitioned into training (70%) and testing (30%) subsets. XGBoost modeling used a complete-case set and a dataset obtained from multiple imputation. Model performance was evaluated by c-statistics overall and stratified by subgroups of age, sex, race, and dialysis modality. Results The analysis included 1,150,195 patients with ESKD, of whom 86,083 (8%) died in the first 90 days after dialysis initiation. The XGBoost models discriminated mortality risk in the nonimputed (c=0.826, 95% CI, 0.823 to 0.828) and imputed (c=0.827, 95% CI, 0.823 to 0.827) models and performed well across nearly every subgroup (race, age, sex, and dialysis modality) evaluated (c>0.75). Across predicted risk thresholds of 10%-50%, higher risk thresholds showed declining sensitivity (0.69-0.04) with improving specificity (0.79-0.99); similarly, positive likelihood ratio was highest at the 40% threshold, whereas the negative likelihood ratio was lowest at the 10% threshold. After calibration using isotonic regression, the model accurately estimated the probability of mortality across all ranges of predicted risk. Conclusions The XGBoost-based model developed in this study discriminated risk of early mortality after dialysis initiation with excellent calibration and performed well across key subgroups.
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Affiliation(s)
| | - Lucy Han
- Booz Allen Hamilton, McLean, Virginia
| | - Rebecca Scherzer
- Kidney Health Research Collaborative (KHRC), University of California San Francisco (UCSF), San Francisco, California
| | | | | | | | - Matthew Rahn
- Office of the National Coordinator for Health Information Technology (ONC), Washington, DC
| | - Kenneth Wilkins
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, Maryland
| | - Michael Shlipak
- Kidney Health Research Collaborative (KHRC), University of California San Francisco (UCSF), San Francisco, California
| | - Michelle Estrella
- Kidney Health Research Collaborative (KHRC), University of California San Francisco (UCSF), San Francisco, California
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26
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Park H, Desai R, Liu X, Smith SM, Hincapie-Castillo J, Henry L, Goodin A, Gopal S, Pepine CJ, Mohandas R. Medicare Bundled Payment Policy on Anemia Care, Major Adverse Cardiovascular Events, and Mortality among Adults Undergoing Hemodialysis. Clin J Am Soc Nephrol 2022; 17:851-860. [PMID: 35589388 PMCID: PMC9269657 DOI: 10.2215/cjn.14361121] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/21/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In 2011, the Centers for Medicare & Medicaid Services implemented bundling of all services for patients receiving dialysis, including erythropoietin-stimulating agents use, and the Food and Drug Administration recommended conservative erythropoietin-stimulating agent dosing. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study investigated anemia care and clinical outcomes before and after the Centers for Medicare & Medicaid Services bundled payment and the revised Food and Drug Administration-recommended erythropoietin-stimulating agent labeling for Medicare-insured adults receiving hemodialysis using data from the United States Renal Data System from January 1, 2006 to December 31, 2016. Clinical outcomes included major adverse cardiovascular event (stroke, acute myocardial infarction, and all-cause mortality), cardiovascular mortality, and heart failure. Measurements were compared between prepolicy (2006-2010) and postpolicy (2012-2016) implementation using interrupted time series and Cox proportional hazards regression models. RESULTS Of 481,564 patients, erythropoietin-stimulating agent use immediately decreased by 84.8 per 1000 persons (P<0.001), with a significant decrease in the slope of the trend line (both P=0.001). Blood transfusion use rapidly increased by 8.34 per 1000 persons in April 2012 and then gradually decreased (both P=0.001). The percentage of patients with hemoglobin >11 g/dl decreased from 68% in January 2006 to 28% in December 2016, whereas those with hemoglobin <9 g/dl increased from 5% to 9%. Overall major adverse cardiovascular event (adjusted hazard ratio, 0.95; 95% confidence interval, 0.94 to 0.96), stroke (adjusted hazard ratio, 0.83; 95% confidence interval, 0.80 to 0.86), all-cause mortality (adjusted hazard ratio, 0.87; 95% confidence interval, 0.86 to 0.89), cardiovascular mortality (adjusted hazard ratio, 0.81; 95% confidence interval, 0.79 to 0.83), and heart failure (adjusted hazard ratio, 0.86; 95% confidence interval, 0.84 to 0.88) risks were lower. Acute myocardial infarction risk (adjusted hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.06) was higher after policies changed. CONCLUSIONS The Medicare reimbursement policy and Food and Drug Administration-recommended erythropoietin-stimulating agent dosing changes were associated with lower erythropoietin-stimulating agent use and lower hemoglobin levels. These changes in anemia care were associated with lower risks of major adverse cardiovascular event, stroke, mortality, and heart failure but higher risk of acute myocardial infarction among adults receiving hemodialysis.
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Affiliation(s)
- Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida .,Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Raj Desai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Xinyue Liu
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Steven M Smith
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida.,Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Juan Hincapie-Castillo
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Linda Henry
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida.,Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Amie Goodin
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida.,Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Saraswathi Gopal
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Carl J Pepine
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Raj Mohandas
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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27
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Maguire IC, Browne LD, Dawood M, Leahy F, Ryan MC, White E, O’Sullivan A, O’Sullivan L, Stack AG. Differential Impact of Central Venous Catheters versus Arteriovenous Fistulae on Quality of Life among Irish Haemodialysis Patients. KIDNEY360 2022; 3:1065-1072. [PMID: 35845328 PMCID: PMC9255886 DOI: 10.34067/kid.0006622021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 03/01/2022] [Indexed: 01/10/2023]
Abstract
Background Arteriovenous fistulae (AVF) have superior clinical outcomes compared with central venous catheters (CVC) among patients undergoing hemodialysis (HD). Yet, there is increasing recognition that health-related quality of life (HRQoL) may be more important to patients than survival and that differences may exist between AVF and CVCs in this regard. This study compared HRQoL between AVF and CVC in an Irish cohort. Methods We conducted a cross-sectional survey among prevalent patients undergoing hemodialysis (N=119) dialyzing with either an AVF or CVC at a regional program. The Short Form 36 (SF-36) and a validated Vascular Access Questionnaire (SF-VAQ) compared QoL between AVF and CVC in domains of physical functioning, social functioning, and dialysis complications. Multivariable logistic regression compared differences between groups for outcomes of physical functioning, social functioning, and dialysis complications expressed as adjusted odds ratios and 95% CI. Results Mean age was 66.6 years; 52% were using an AVF and 48% had a CVC. Patients dialyzing with an AVF were more satisfied with their access when asked directly (6.2 versus 5.0; P<0.01). Physical functioning scores for bleeding, swelling, and bruising were significantly higher for AVF than CVC (P=0.001, P=0.001, and P<0.001, respectively). In contrast, patients with a CVC reported greater difficulties in bathing and showering than those using an AVF (4.4 versus 2.0; P<0.001), whereas patients with an AVF expressed greater concerns with physical appearances. Compared with AVF, CVC users were less likely to report difficulties in physical functioning (OR=0.35; 95% CI, 0.12 to 0.94; P=0.04) but more likely to report dialysis complications (OR=1.94; 95% CI, 0.69 to 5.87; P=0.22). Conclusions Vascular access contributes to HRQoL in hemodialysis. CVCs are associated with fewer difficulties from bleeding and bruising but greater negative effect on social activities, including bathing and showering. Overall, patients with a CVC had lower dissatisfaction scores than patients with an AVF when all three domains were added. Innovation in vascular access design and engineering may confer benefits and improve patient comfort on HD.
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Affiliation(s)
| | - Leonard D. Browne
- School of Medicine, University of Limerick, Limerick, Ireland,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Mina Dawood
- Department of Nephrology, University Hospital Limerick, Limerick, Ireland
| | - Fiona Leahy
- Clinical Research Support Unit, University of Limerick, Limerick, Ireland
| | - Maria C Ryan
- Clinical Research Support Unit, University of Limerick, Limerick, Ireland
| | - Eoin White
- Health Research Institute, University of Limerick, Limerick, Ireland,School of Design, University of Limerick, Limerick, Ireland
| | - Aidan O’Sullivan
- Health Research Institute, University of Limerick, Limerick, Ireland,School of Design, University of Limerick, Limerick, Ireland,Rapid Innovation Unit - School of Design and Confirm Smart Manufacturing Center, University of Limerick, Limerick, Ireland
| | - Leonard O’Sullivan
- Health Research Institute, University of Limerick, Limerick, Ireland,School of Design, University of Limerick, Limerick, Ireland,Rapid Innovation Unit - School of Design and Confirm Smart Manufacturing Center, University of Limerick, Limerick, Ireland
| | - Austin G. Stack
- School of Medicine, University of Limerick, Limerick, Ireland,Health Research Institute, University of Limerick, Limerick, Ireland,Department of Nephrology, University Hospital Limerick, Limerick, Ireland
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Paulus A, Baernholdt M, Kear T, Jones T, Thacker L. Factors Associated With Hospital Readmissions Among U.S. Dialysis Facilities. J Healthc Qual 2022; 44:59-68. [PMID: 34191751 DOI: 10.1097/jhq.0000000000000300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The Centers for Medicare and Medicaid uses the standardized readmission ratio (SRR) to evaluate 30-day readmissions among dialysis providers in the U.S. Readmissions among dialysis recipients remains 37%. This study investigates associations among dialysis facilities and patient characteristics with facility's performance on the SRR. METHODS Descriptive, longitudinal, approach using multivariate regression analysis on data retrieved from the Dialysis Facility Report to evaluate the associations between facility-level (staffing, profit status, chain membership, clinic size, care, length of care, vascular access type, glomerular filtration rate (GFR), creatinine, hemoglobin, use of erythropoietin-stimulating agent, albumin, and primary dialysis modality) with the SRR. RESULTS Factors associated with a high SRR included nurse ratios, facility average GFR, and Northeast geographic location. Factors associated with a low SRR included patient care technician ratio, length of predialysis nephrology care, initiation of dialysis with an arteriovenous fistula, average hemoglobin, and Western geographic location. CONCLUSIONS This study defines the influence predialysis nephrology care has on dialysis facilities SRRs. Access to care, adequate preparation for dialysis, and transitional support affect facilities' performance; however, without an appropriate staffing model, dialysis facilities may continue to struggle to reduce readmissions.
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Murea M, Flythe JE, Anjay R, Emaad ARM, Gupta N, Kovach C, Vachharajani TJ, Kalantar-Zadeh K, Casino FG, Basile C. Kidney dysfunction requiring dialysis is a heterogeneous syndrome: we should treat it like one. Curr Opin Nephrol Hypertens 2022; 31:92-99. [PMID: 34846314 DOI: 10.1097/mnh.0000000000000754] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Advanced kidney failure requiring dialysis, commonly labeled end-stage kidney disease or chronic kidney disease stage 5D, is a heterogeneous syndrome -a key reason that may explain why: treating advanced kidney dysfunction is challenging and many clinical trials involving patients on dialysis have failed, thus far. Treatment with dialytic techniques - of which maintenance thrice-weekly hemodialysis is most commonly used - is broadly named kidney 'replacement' therapy, a term that casts the perception of a priori abandonment of intrinsic kidney function and subsumes patients into a single, homogeneous group. RECENT FINDINGS Patients with advanced kidney failure necessitating dialytic therapy may have ongoing endogenous kidney function, and differ in their clinical manifestations and needs. Different terminology, for example, kidney dysfunction requiring dialysis (KDRD) with stages of progressive severity could better capture the range of phenotypes of patients who require kidney 'assistance' therapy. SUMMARY Classifying patients with KDRD based on objective, quantitative levels of endogenous kidney function, as well as patient-reported symptoms and quality of life, would facilitate hemodialysis prescriptions tailored to level of kidney dysfunction, clinical needs, and personal priorities. Such classification would encourage clinicians to move toward personalized, physiological, and adaptive approach to hemodialysis therapy.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Rastogi Anjay
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Abdel-Rahman M Emaad
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Nupur Gupta
- Indiana University Health, Indianapolis, Indiana
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Tushar J Vachharajani
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti
- Dialysis Centre SM2, Policoro, Italy
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Anand S, Ziolkowski SL, Bootwala A, Li J, Pham N, Cobb J, Lobelo F. Group-Based Exercise in CKD Stage 3b to 4: A Randomized Clinical Trial. Kidney Med 2021; 3:951-961.e1. [PMID: 34939004 PMCID: PMC8664706 DOI: 10.1016/j.xkme.2021.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale & Objective We aimed to test interventions to improve physical activity in persons with advanced chronic kidney disease not yet receiving dialysis. Study Design Randomized controlled trial with parallel-group design. Setting & Participants We embedded a pragmatic referral to exercise programming in high-volume kidney clinics servicing diverse populations in San Jose, CA, and Atlanta, GA. We recruited 56 participants with estimated glomerular filtration rates < 45 mL/min/1.73 m2. Interventions We randomly assigned participants to a mobile health (mHealth) group—wearable activity trackers and fitness professional counseling, or an Exercise is Medicine intervention framework (EIM) group—mHealth components plus twice-weekly small-group directed exercise sessions customized to persons with kidney disease. We performed assessments at baseline, 8 weeks at the end of active intervention, and 16 weeks after passive follow-up and used multilevel mixed models to assess between-group differences. Outcomes Activity tracker total daily step count. Results Of 56 participants, 86% belonged to a racial/ethnic minority group; randomly assigned groups were well balanced on baseline step count. In intention-to-treat analyses, the EIM and mHealth groups both experienced declines in daily step counts, but there was an attenuated reduction in light intensity physical activity (standard error 0.2 [5.8] vs −8.5 [5.4] min/d; P = 0.08) in the EIM compared with the mHealth group at 8 weeks. In as-treated analyses, total daily step count, distance covered, and light and moderate-vigorous activity minutes per day improved in the EIM group and declined in the mHealth group at 8 weeks (standard error +335 [506] vs −884 [340] steps per day; P = 0.05; P < 0.05 for secondary measures), but group differences faded at 16 weeks. There were no differences in quality-of-life and mental health measures during the study. Limitations Small sample size, limited duration of study, assessment of intermediate outcomes (steps per day). Conclusions A clinic-integrated referral to small-group exercise sessions is feasible, safe, and moderately effective in improving physical activity in an underserved population with high comorbid conditions. Funding Normon S Coplon Applied Pragmatic Clinical Research program. Trial Registration NCT03311763
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Affiliation(s)
- Shuchi Anand
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, CA
| | - Susan L Ziolkowski
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, CA
| | - Ahad Bootwala
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jianheng Li
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Nhat Pham
- Division of Nephrology, Santa Clara Valley Medical Center, San Jose, CA
| | - Jason Cobb
- Renal Division, Emory University School of Medicine, Atlanta, GA
| | - Felipe Lobelo
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
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Meng L, Yang L, Zhu X, Sun Z, Zhang X, Li X, Cheng S, Guo S, Zhuang X, Zou H, Luo P, Cui W. Risk factors for early death in urgent-start peritoneal dialysis patients: A multicenter retrospective cohort study. Ther Apher Dial 2021; 26:999-1006. [PMID: 34921510 DOI: 10.1111/1744-9987.13781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/06/2021] [Accepted: 12/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Assess risk factors for early death in patients who underwent urgent-start peritoneal dialysis (USPD). METHODS Patients who initiated USPD in five peritoneal dialysis centers from 2013 to 2019 were screened in this multicenter retrospective cohort study. Risk factors for all-cause mortality within 3 months were explored. RESULTS A total of 1265 USPD patients with 43 early deaths were included. Cox regression analyses showed that age older than 60 years (hazard ratio [HR], 3.054; 95% CI [1.597, 5.842]; p = 0.001), albumin less than 30 g/L (HR, 2.234; 95%CI [1.207, 4.136]; p = 0.011), blood glucose greater than 7 mmol/L (HR, 2.766; 95%CI [1.477, 5.180]; p = 0.001), higher estimated glomerular filtration rate (eGFR; HR, 1.121; 95%CI [1.071, 1.172]; p = 0.000), and poor stages of heart failure (class IV compared with class 0-I; HR, 5.165; 95%CI [2.544, 10.486]; p = 0.000) were independent predicting factors for early death. CONCLUSIONS Risk factors for early death were older age, hypoproteinemia, hyperglycemia, higher eGFR, and severe heart failure.
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Affiliation(s)
- Lingfei Meng
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Liming Yang
- Department of Nephrology, The First Hospital of Jilin University-the Eastern Division, China
| | - Xueyan Zhu
- Department of Nephrology, Jilin Central Hospital, Jilin, China
| | - Zhanshan Sun
- Department of Nephrology, Xing'an League People's Hospital, China
| | - Xiaoxuan Zhang
- Department of Nephrology, Jilin FAW General Hospital, China
| | - Xinyang Li
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Siyu Cheng
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Shizheng Guo
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Xiaohua Zhuang
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Hongbin Zou
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Ping Luo
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Wenpeng Cui
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
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Dahiya A, Bello A, Thompson S, Schick-Makaroff K, Pannu N. Knowledge and Practice of Incremental Hemodialysis: A Survey of Canadian Nephrologists. Can J Kidney Health Dis 2021; 8:20543581211065255. [PMID: 34950483 PMCID: PMC8689607 DOI: 10.1177/20543581211065255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/27/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Incremental hemodialysis, a strategy to individualize dialysis prescription based on residual kidney function, may be associated with enhanced quality of life and decreased health care costs compared with conventional hemodialysis. OBJECTIVE We surveyed practicing Canadian nephrologists to assess knowledge, perceptions, and practice pattern on the use of incremental hemodialysis. DESIGN/SETTING We distributed a cross-sectional, web-based survey. We asked about incremental hemodialysis prescribing practices, including frequency of prescription, clinical factors used to determine suitability for treatment, and barriers to implementation. The survey was conducted from September 21 to October 30, 2020. PARTICIPANTS We distributed the survey to practicing Canadian nephrologists identified from a private membership list of the Canadian Society of Nephrology (CSN), as well as to nephrologists named on a publicly available national list of practicing Canadian nephrologists created from provincial College of Physician registries. These were samples of convenience. METHODS We conducted descriptive analysis of categorical data including frequencies for nominal variables and measures of central tendency (mean) and dispersion (standard deviation) for ordinal variables. We used chi-square analysis to identify association between participant and practice characteristics and their opinions and attitudes toward incremental dialysis. We used simple thematic analysis on free-text responses on questions regarding the prescription of incremental hemodialysis, focusing on age and baseline management of cardiac and noncardiac comorbidities. RESULTS The response rate was 35% (243/691). Most (138/211, 65%) of the participants prescribed incremental hemodialysis using an individualized approach at the nephrologist's discretion. Most participants (200/203, 98%) did not report any policy for implementation. Residual urine output was identified as the most important factor for eligibility (112/172, 65%), followed by electrolyte stability (76/172, 44%) and patient goals of care (69/117, 40%). Most participants agreed that dialysis prescriptions should take residual kidney function into consideration; however, 74% of the participants disagreed with a statement that there was strong evidence supporting incremental hemodialysis. Barriers identified included patient safety, patient acceptance of dose escalation, and logistics of scheduling. Despite these barriers, 82% of participants felt that that incremental hemodialysis is feasible with their current resources and 78% agreed that with specific criteria, it is a safe option. LIMITATIONS The generalizability of our study is limited by its response rate of 35%; however, this is comparable with typical response rates seen in electronic surveys. Most participants practice in an academic setting, which may have introduced bias to the results. CONCLUSIONS Despite the perception of limited evidence and a lack of guidance on implementation, incremental hemodialysis is frequently practiced by Canadian nephrologists. Barriers to implementation were identified, highlighting the need for research to guide practice.
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Affiliation(s)
- Anita Dahiya
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Aminu Bello
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Stephanie Thompson
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | | | - Neesh Pannu
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
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Hole BD, Casula A, Caskey FJ. Quality assuring early dialysis care: evaluating rates of death and recovery within 90 days of first dialysis using the UK Renal Registry. Clin Kidney J 2021; 15:1612-1621. [PMID: 37056423 PMCID: PMC10087010 DOI: 10.1093/ckj/sfab238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Indexed: 11/15/2022] Open
Abstract
ABSTRACT
Background
Kidney disease registries typically report populations incident to kidney replacement therapy (KRT) after excluding reversible disease. Registry-based audit and quality assurance is thus based on populations depleted of those with the highest early mortality. It is now mandatory for UK kidney units to report all recipients of dialysis, both acute and chronic. This work presents 90-day survival and recovery outcomes for all reported adults.
Methods
Seventy adult centres reporting to the UK Renal Registry were included. Those assessed as underreporting death and recovery were excluded. Survival was evaluated using a Kaplan–Meier estimator. Cox regression was used to describe hazard ratios (HRs) for age, sex and acute/chronic dialysis coding on day 1. Analysis of all-cause 90-day mortality with recovery as a competing risk is presented.
Results
Twenty-four centres were assessed as underreporting, with rates of death/recovery below the 99.7th centile. Of 5784 dialysis starters in the remaining 46 centres, 2163 (37.4%) were coded as receiving acute dialysis on day 1. Ninety days after starting, 3860 (66.7%) of all starters were receiving KRT, 1157 (20.0%) were alive having stopped, 716 (12.4%) were dead and 51 (0.9%) were lost to follow-up. Mortality was higher among those coded as receiving acute dialysis on day 1 (HR 4.88, P < 0.001). The sub-HR for recovery among those coded as receiving acute compared with chronic dialysis was 56.14 (P < 0.001).
Conclusions
Death and recovery rates are substantially higher than reported in conventional incident populations. This work highlights a vulnerable subgroup of patients largely overlooked by most national quality assurance systems.
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Affiliation(s)
- Barnaby D Hole
- Population Health, University of Bristol, Bristol, UK
- UK Renal Registry, UK Renal Association, Bristol, UK
| | - Anna Casula
- UK Renal Registry, UK Renal Association, Bristol, UK
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Ayoub K, Fry E, Marji M, Masri A, Hesselson A, Ellison K. Implantable cardioverter-defibrillators with end stage renal disease: Nationwide inpatient sample database results. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:124-131. [PMID: 34806769 DOI: 10.1111/pace.14411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/01/2021] [Accepted: 11/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND When compared to patients with normal renal function, patients with chronic kidney disease develop higher in-hospital complications post implantable cardioverter-defibrillator (ICD) therapy. However, real world data on in-hospital complications post ICD therapy in patients with end stage renal disease (ESRD) is limited. In this study, we aim to explore the procedure-related complications of ICD therapy in patients with ESRD. METHODS Using the nationwide inpatient sample (NIS) database, we conducted a retrospective analysis on ESRD patients who underwent inpatient ICD placement from 2010 to 2016. Using 1:2 propensity score matching, we compared ESRD patients to those with normal renal function. Outcomes of interest were postoperative hemorrhage and hematoma formation, blood transfusion, pericardial complications, mechanical complications requiring lead revision, vascular injury, in-hospital mortality, and length of stay. RESULTS Our sample included 40,075 cases with subsequent propensity score matching between ESRD and normal renal function. Comparatively, patients with ESRD had higher odds of postoperative hemorrhage (Odds ratio [OR] = 1.67, 95% confidence interval [CI] 1.4-1.99, p = < .0001), blood transfusion (OR, 3.88; CI 3.29-4.56; p = < .0001), mechanical complications requiring lead revision (OR, 1.24; CI 1.01-1.51; p = .035), vascular injury (OR, 2.02; CI 1.27-3.24; p = .0027), in-hospital mortality (OR, 4.56; CI 3.08-6.76; p = < .0001), and longer hospitalization (11 vs. 7 days, p = < .0001), but without significant difference in pericardial complications (OR, 1.9; CI 0.92-1.54; p = < .18). CONCLUSION In this large contemporary cohort, patients with ESRD undergoing inpatient ICD therapy are at higher risk of developing postprocedural complications including hemorrhage and hematoma, blood transfusion, mechanical complications requiring lead revision, and in hospital mortality, without increased risk of pericardial complications.
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Affiliation(s)
- Karam Ayoub
- Department of Electrophysiology, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Ethan Fry
- Department of Electrophysiology, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Meera Marji
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Ahmad Masri
- Department of Electrophysiology, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA.,Department of Cardiology, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Aaron Hesselson
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Kristin Ellison
- Department of Electrophysiology, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, USA
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Prouvot J, Pambrun E, Antoine V, Couchoud C, Vigneau C, Roche S, Francois M, Mariat C, Babici D, Prelipcean C, Moranne O. Low performance of prognostic tools for predicting death before dialysis in older patients with advanced CKD. J Nephrol 2021; 35:993-1004. [PMID: 34787796 DOI: 10.1007/s40620-021-01180-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/06/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Chronic kidney disease (CKD) is a disease which is spreading worldwide, especially among older patients. Several prognostic scores have been developed to predict death in older CKD patients, but they have not been validated. We aimed to evaluate the existing risk scores for predicting death before dialysis start, identified via an in-depth review, in a cohort of elderly patients with advanced CKD. METHODS We performed a review to identify scores predicting death, developed in and applicable to CKD patients. Each score was evaluated with an absolute risk calculation from the patients' baseline characteristics. We used a French prospective multicentre cohort of elderly patients (> 75 years) with advanced CKD [estimated glomerular filtration rate (eGFR) < 20 mL/min/1.73 m2], recruited from nephrological centres, with a 5-year follow-up. The outcome considered was death before initiating dialysis. Discrimination [area under curve (AUC)], calibration and Brier score were calculated for each score at its time frame. RESULTS Our review found 6 equations predicting death before dialysis in CKD patients. Four of these (GOLDFARB, BANSAL, GRAMS 2 and 4 years) were evaluated. The validation cohort (Parcours de Soins des Personnes Âgées Parcours de Soins des Personnes Âgées, PSPA) included 573 patients, with a median age of 82 years and a median eGFR of 13 mL/min/1.73 m2. At the end of follow-up, 287 (50%) patients had started dialysis and 238 (41%) patients had died before dialysis. The four equations evaluated showed average discrimination (AUC 0.61-0.70) and, concerning calibration, a global overestimation of the risk of death. DISCUSSION The available scores predicting death before dialysis showed low performance among older patients with advanced CKD in a French multicentre cohort, indicating the need to upgrade them or develop new scores for this population.
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Affiliation(s)
- Julien Prouvot
- IDESP, INSERM Université de Montpellier, Montpellier, France
- Service Néphrologie-Dialyses-Aphérèses, Hôpital Universitaire de Nîmes, CHU Caremeau, Place du Pr Debré, 30000, Nimes, France
| | - Emilie Pambrun
- Service Néphrologie-Dialyses-Aphérèses, Hôpital Universitaire de Nîmes, CHU Caremeau, Place du Pr Debré, 30000, Nimes, France
| | - Valery Antoine
- IDESP, INSERM Université de Montpellier, Montpellier, France
- Service de Gériatrie, Hôpital Universitaire de Nîmes, Nimes, France
| | - Cecile Couchoud
- Registre REIN, Agence de la Biomedecine, Saint-Denis La Plaine, France
- CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, Villeurbanne, France
| | - Cecile Vigneau
- CHU Pontchaillou, Service de Néphrologie-Dialyse-Transplantation, Université Rennes 1, IRSET, Rennes, France
| | - Sophie Roche
- Service de Nephrologie‑Dialyse, CH Macon, Macon, France
| | - Maud Francois
- Service de Néphrologie-Dialyse-Transplantation, CHU Tours, Tours, France
| | - Christophe Mariat
- Service de Néphrologie, Hôpital Nord, Centre Hospitalier Universitaire de Saint-Étienne, 42055, Saint-Étienne Cedex 02, France
| | - Daniela Babici
- Service Néphrologie-Dialyse, GHR MSA, Hôpital Emile Muller, Mulhouse, France
| | - Camelia Prelipcean
- Service Néphrologie-Dialyses-Aphérèses, Hôpital Universitaire de Nîmes, CHU Caremeau, Place du Pr Debré, 30000, Nimes, France
| | - Olivier Moranne
- IDESP, INSERM Université de Montpellier, Montpellier, France.
- Service Néphrologie-Dialyses-Aphérèses, Hôpital Universitaire de Nîmes, CHU Caremeau, Place du Pr Debré, 30000, Nimes, France.
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Zhu Y, Zhang D, Hu X, Liu H, Xu Y, Hou H, Peng Y, Lu Y, Liu X, Lu F. A longitudinal study of cardiac structure and function using echocardiography in patients undergoing peritoneal dialysis. BMC Nephrol 2021; 22:342. [PMID: 34656084 PMCID: PMC8520263 DOI: 10.1186/s12882-021-02535-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/20/2021] [Indexed: 11/12/2022] Open
Abstract
Background Peritoneal dialysis (PD) can be associated with abnormal cardiac structure and function and increased mortality risk. Therefore, in this study, we analyzed the cardiac structure and function dynamic changes using echocardiography during the first 2 years of PD therapy. We also assessed its associations with all-cause mortality risk after 2 years of follow-up. Methods End-stage renal disease (ESRD) patients that have started PD from 2011 to 2017, and had echocardiography at baseline and years 1 and 2, were included in this study. Echocardiographic parameters were compared between baseline and year 2. Multivariable Cox models were used to estimate the association between echocardiographic parameters changes and all-cause mortality risk. Results We finally enrolled 72 PD patients in this study. The mean right ventricular diameter (RVD) increased from baseline (18.31 mm) to year 1 (18.75 mm) and year 2 (19.65 mm). We also observed a significant decrease in cardiac output (CO) between baseline and year 2. Additionally, a slight decrease trend in ejection fraction (EF) was observed. Finally, every 1 % increase in RVD was associated with a 68.2 % higher mortality risk after dialysis (HR, 1.682; 95 % CI, 1.017–2.783). Conclusions Our results demonstrated a susceptibility for deteriorated right cardiac structure and function during the first 2 years of PD treatment. Also, higher all-cause mortality risk was observed after 2 years of PD. Altogether, these results highlighted the need for additional focus on regular echocardiographic examinations during long-term PD management. Trial registration The PD-CRISC cohort, registered with the Chinese Clinical Trial Registry (ChiCTR1900023565).
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Affiliation(s)
- Yunyun Zhu
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, 510405, Guangzhou, China.,Department of Nephrology, Tongde Hospital of Zhejiang Province, No.234 Gucui Road, Zhejiang Province, Hangzhou, China
| | - Difei Zhang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, 510405, Guangzhou, China.,Department of Nephrology, The Second Affiliated Hospital of Guangzhou, University of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China.,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China
| | - Xiaoxuan Hu
- Department of Nephrology, The Second Affiliated Hospital of Guangzhou, University of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China.,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China
| | - Hui Liu
- Department of Nephrology, The Second Affiliated Hospital of Guangzhou, University of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China.,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China
| | - Yuan Xu
- Department of Nephrology, The Second Affiliated Hospital of Guangzhou, University of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China.,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China
| | - Haijing Hou
- Department of Nephrology, The Second Affiliated Hospital of Guangzhou, University of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China.,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China
| | - Yu Peng
- Department of Nephrology, The Second Affiliated Hospital of Guangzhou, University of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China.,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China
| | - Ying Lu
- Department of Nephrology, Tongde Hospital of Zhejiang Province, No.234 Gucui Road, Zhejiang Province, Hangzhou, China
| | - Xusheng Liu
- Department of Nephrology, The Second Affiliated Hospital of Guangzhou, University of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China. .,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China.
| | - Fuhua Lu
- Department of Nephrology, The Second Affiliated Hospital of Guangzhou, University of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China. .,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, No.111 Dade Road, 510120, Guangzhou, China.
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Drozdz M, Frazão J, Silva F, Das P, Kleophas W, Al Badr W, Brzosko S, Jacobson SH. Improvements in six aspects of quality of care of incident hemodialysis patients - a real-world experience. BMC Nephrol 2021; 22:333. [PMID: 34620096 PMCID: PMC8499463 DOI: 10.1186/s12882-021-02529-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background The transition from chronic kidney disease stage 5 to initiation of hemodialysis has gained increased attention in recent years as this period is one of high risk for patients with an annual mortality rate exceeding 20%. Morbidity and mortality in incident hemodialysis patients are partially attributed to failure to attain guideline-based targets. This study focuses on improvements in six aspects of quality of dialysis care (adequacy, anemia, nutrition, chronic kidney disease-mineral bone disorder (CKD-MBD), blood pressure and vascular access) aligning with KDIGO guidelines, during the first 6 months of hemodialysis. Methods We analyzed patient demographics, practice patterns and laboratory data in all 3 462 patients (mean age 65.9 years, 41% females) on hemodialysis (incident <90 days on hemodialysis, n=603, prevalent ≥90 days on hemodialysis, mean 55 months, n=2 859) from all 56 DaVita centers in Poland (51 centers) and Portugal (5 centers). 80% of patients had hemodialysis and 20% hemodiafiltration. Statistical analyses included unpaired and paired Students t-test, Chi-2 analyses, McNemar test and logistic regression analysis. Results Incident patients had lower Kt/V (1.4 vs 1.7, p<0.001), lower serum albumin (37 vs 40 g/l, p=0.001), lower Hb (9.9 vs 11.0 g/dl, p<0.001), lower TSAT (26 vs 31%, p<0.001), lower iPTH (372 vs 496 pg/ml, p<0.001), more often a central venous catheter (68 vs 26%, p<0.001), less often an AV fistula (34 vs 70 %, p<0.001) compared with all prevalent patients. Significantly more prevalent patients achieved international treatment targets. Improvements in quality of care was also analyzed in a subgroup of 258 incident patients who were followed prospectively for 6 months. We observed significant improvements in Kt/V (p<0.001), albumin (p<0.001), Hb (p<0.001) transferrin saturation (TSAT, p<0.001), iPTH (p=0.005) and an increased use of AV fistula (p<0.001). Furthermore, logistic regression analyses identified treatment time and TSAT as major factors influencing the attainment of adequacy and anemia treatment targets. Conclusion This large real-world European multicenter analysis of representative incident hemodialysis patients indicates that the use of medical protocols and medical targets assures significant improvements in quality of care, which may correspond to better outcomes. A selection bias of survivors with less comorbidities in prevalent patients may have influenced the results.
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Affiliation(s)
| | - João Frazão
- DaVita Portugal, Lisbon, Portugal.,Department of Nephrology, São João Hospital Center, Porto, Portugal.,School of Medicine, University of Porto, Porto, Portugal
| | | | - Partha Das
- DaVita International, London, UK.,King's College Hospital NHS Foundation Trust, London, UK
| | - Werner Kleophas
- DaVita Germany, Düsseldorf, Germany.,Clinic for Nephrology, Heinrich-Heine University, Düsseldorf, Germany
| | - Wisam Al Badr
- DaVita Kingdom of Saudi Arabia, Riyadh, Saudi Arabia
| | - Szymon Brzosko
- 1st Department of Nephrology and Transplantation, Medical University of Bialystok, Białystok, Poland.,DaVita Poland, Wroclaw, Poland
| | - Stefan H Jacobson
- Department of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden.
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Hazara AM, Bhandari S. Age, Gender and Diabetes as Risk Factors for Early Mortality in Dialysis Patients: A Systematic Review. Clin Med Res 2021; 19:54-63. [PMID: 33582647 PMCID: PMC8231690 DOI: 10.3121/cmr.2020.1541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 10/11/2020] [Accepted: 12/11/2020] [Indexed: 02/07/2023]
Abstract
Objective: To study the impact of age, gender, and presence of diabetes (any type) on the risk of early deaths (180-day mortality) in patients starting long-term hemodialysis (HD) therapy.Design: Systematic review of the literature.Setting: Out-patient (non-hospitalized), community-based HD therapy world-wide.Participants: Patients with advanced chronic kidney disease (CKD) starting long-term HD treatment for end-stage renal disease (ESRD).Methods: Medline and EMBASE were searched for studies published between 1/1/1985 and 12/31/2017. Observational studies involving adult subjects commencing HD were included. Data extracted included population characteristics and settings. In addition, patient or treatment related factors studied with reference to their relationship with the risk of early mortality were documented. The Quality in Prognosis Studies tool was used to assess risk of bias in individual studies. Findings were summarized, and a narrative account was drawn.Results: Included were 26 studies (combined population 1,098,769; representing 287,085 person-years of observation for early mortality). There were 17 cohort and 9 case-control studies. Risk of bias was low in 13 and high in a further 13 studies. Patients who died in the early period were older than those who survived. Mortality rates increased with advancing age. Female gender was associated with slightly increased early mortality rates in larger and higher quality studies. The available data showed conflicting results in relation to the association of diabetes and risk of early mortality.Conclusions: This systematic review evaluated the impact of key demographic and co-morbid factors on risk of early mortality in patients starting maintenance HD. The information could help in delivering more tailored prognostic information and planning of future interventions.
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Affiliation(s)
- Adil M Hazara
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
- Hull York Medical School, Hull, United Kingdom
| | - Sunil Bhandari
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
- Hull York Medical School, Hull, United Kingdom
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Chan K, Moe SM, Saran R, Libby P. The cardiovascular-dialysis nexus: the transition to dialysis is a treacherous time for the heart. Eur Heart J 2021; 42:1244-1253. [PMID: 33458768 PMCID: PMC8014523 DOI: 10.1093/eurheartj/ehaa1049] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 08/13/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) patients require dialysis to manage the progressive complications of uraemia. Yet, many physicians and patients do not recognize that dialysis initiation, although often necessary, subjects patients to substantial risk for cardiovascular (CV) death. While most recognize CV mortality risk approximately doubles with CKD the new data presented here show that this risk spikes to >20 times higher than the US population average at the initiation of chronic renal replacement therapy, and this elevated CV risk continues through the first 4 months of dialysis. Moreover, this peak reflects how dialysis itself changes the pathophysiology of CV disease and transforms its presentation, progression, and prognosis. This article reviews how dialysis initiation modifies the interpretation of circulating biomarkers, alters the accuracy of CV imaging, and worsens prognosis. We advocate a multidisciplinary approach and outline the issues practitioners should consider to optimize CV care for this unique and vulnerable population during a perilous passage.
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Affiliation(s)
- Kevin Chan
- National Institute of Diabetes and Digestive and Kidney Disease, Division of Kidney, Urology, and Hematology, 6707 Democracy Blvd, Bethesda, MD 20892-5458, USA
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, 950 W. Walnut Street R2-202, Indianapolis, IN 46202, USA
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr # 31, Ann Arbor, MI 48109, USA
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 77 Ave. Louis Pasteur, NRB-741-G, Boston, MA 02115, USA
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Hundemer GL, Sood MM, Canney M. β-blockers in hemodialysis: simple questions, complicated answers. Clin Kidney J 2021; 14:731-734. [PMID: 33779640 PMCID: PMC7986367 DOI: 10.1093/ckj/sfaa249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Indexed: 12/15/2022] Open
Abstract
In this issue of the Clinical Kidney Journal, Wu et al. present the results of a nationwide population-based study using Taiwanese administrative data to compare safety and efficacy outcomes with initiation of bisoprolol versus carvedilol among patients receiving maintenance hemodialysis for >90 days. The primary outcomes were all-cause mortality and major adverse cardiovascular events over 2 years of follow-up. The study found that bisoprolol was associated with a lower risk for both major adverse cardiovascular events and all-cause mortality compared with carvedilol. While the bulk of the existing evidence favors a cardioprotective and survival benefit with β-blockers as a medication class among dialysis patients, there is wide heterogeneity among specific β-blockers in regard to pharmacologic properties and dialyzability. While acknowledging the constraints of observational data, these findings may serve to inform clinicians about the preferred β-blocker agent for dialysis patients to help mitigate cardiovascular risk and improve long-term survival for this high-risk population.
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Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Manish M Sood
- Department of Medicine, Division of Nephrology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
| | - Mark Canney
- Department of Medicine, Division of Nephrology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
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Habbous S, Barnieh L, Klarenbach S, Manns B, Sarma S, Begen MA, Litchfield K, Lentine KL, Singh S, Garg AX. Evaluating multiple living kidney donor candidates simultaneously is more cost-effective than sequentially. Kidney Int 2020; 98:1578-1588. [DOI: 10.1016/j.kint.2020.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/13/2020] [Accepted: 06/04/2020] [Indexed: 01/11/2023]
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Hsu CY, Parikh RV, Pravoverov LN, Zheng S, Glidden DV, Tan TC, Go AS. Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease. JAMA Intern Med 2020; 180:1647-1654. [PMID: 33044519 PMCID: PMC7551228 DOI: 10.1001/jamainternmed.2020.5009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE In the last 2 decades, there have been notable changes in the level of estimated glomerular filtration rate (eGFR) at which patients initiate long-term dialysis in the US and around the world. How changes over time in the likelihood of dialysis initiation at any given eGFR level in at-risk patients are associated with the population burden of end-stage kidney disease (ESKD) has not been not well defined. OBJECTIVE To examine temporal trends in long-term dialysis initiation by level of eGFR and to quantify how these patterns are associated with the number of patients with ESKD. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study analyzing data obtained from a large, integrated health care delivery system in Northern California from 2001 to 2018 in successive 3-year intervals. Included individuals, ranging in number from as few as 983 122 (2001-2003) to as many as 1 844 317 (2016-2018), were adult members with 1 or more outpatient serum creatinine levels determined in the prior year. MAIN OUTCOMES AND MEASURES One-year risk of initiating long-term dialysis stratified by eGFR levels. Multivariable logistic regression was performed to assess temporal trends in each 3-year cohort with adjustment for age, sex, race, and diabetes status. The potential change in dialysis initiation in the final cohort (2016-2018) was estimated using the relative difference between the standardized risks in the initial cohort (2001-2003) and the final cohort. RESULTS In the initial 3-year cohort, the mean (SD) age was 55.4 (16.3) years, 55.0% were women, and the prevalence of diabetes was 14.9%. These characteristics, as well as the distribution of index eGFR, were stable across the study period. The likelihood of receiving dialysis at eGFR levels of 10 to 24 mL/min/1.73 m2 generally increased over time. For example, the 1-year odds of initiating dialysis increased for every 3-year interval by 5.2% (adjusted odds ratio, 1.052; 95% CI, 1.004-1.102) among adults with an index eGFR of 20 to 24 mL/min/1.73 m2, by 6.6% (adjusted odds ratio, 1.066; 95% CI, 1.007-1.130) among adults with an eGFR of 16 to 17 mL/min/1.73 m2, and by 5.3% (adjusted odds ratio, 1.053; 95% CI, 1.008-1.100) among adults with an eGFR of 10 to 13 mL/min/1.73 m2, adjusting for age, sex, race, and diabetes. The incidence of new cases of ESKD was estimated to have potentially been 16% (95% CI, 13%-18%) lower if there were no changes in system-level practice patterns or other factors besides timing of initiating long-term dialysis from the initial 3-year interval (2001-2003) to the final interval (2016-2018) assessed in this study. CONCLUSIONS AND RELEVANCE The present results underscore the importance the timing of initiating long-term dialysis has on the size of the population of individuals with ESKD.
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Affiliation(s)
- Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Research, Kaiser Permanente Northern California, Oakland
| | - Rishi V Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Leonid N Pravoverov
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Sijie Zheng
- Division of Research, Kaiser Permanente Northern California, Oakland.,Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California.,Division of Medical Education, Department of Medicine, University of California, San Francisco, San Francisco
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Alan S Go
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Research, Kaiser Permanente Northern California, Oakland.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco.,Department of Medicine, Stanford University, Stanford, California.,Department of Health Research and Policy, Stanford University, Stanford, California
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Mukhopadhyay P, Woodside KJ, Schaubel DE, Repeck K, McCullough K, Shahinian VB, Pisoni RL, Saran R. Survival Among Incident Peritoneal Dialysis Versus Hemodialysis Patients Who Initiate With an Arteriovenous Fistula. Kidney Med 2020; 2:732-741.e1. [PMID: 33319197 PMCID: PMC7729241 DOI: 10.1016/j.xkme.2020.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Rationale & Objective Comparisons of outcomes between in-center hemodialysis (HD) and peritoneal dialysis (PD) are confounded by selection bias because PD patients are typically younger and healthier and may have received longer predialysis care. We compared first-year survival between what we hypothesized were clinically equivalent groups; namely, patients who initiate maintenance HD using an arteriovenous fistula (AVF) and those selecting PD as their initial modality. Study Design Observational, registry-based, retrospective cohort study. Setting & Participants US Renal Data System data for 5 annual cohorts (2010-2014; n = 130,324) of incident HD with an AVF and incident PD patients. Exposures and Predictors Exposure was more than 1 day receiving PD or more than 1 day receiving HD with an AVF. Time at risk for both cohorts was determined for 12 consecutive 30-day segments, censoring for transplantation, loss to follow-up, or end of time. Predictors included patient-level characteristics obtained from Centers for Medicare & Medicaid Services 2728 Form and other data sources. Outcomes Patient survival. Analytical Approach Unadjusted and multivariable risk-adjusted HRs for death of HD versus PD patients, averaged over 2010 to 2014, were calculated. Results The HD cohort's average unadjusted mortality rate was consistently higher than for the PD cohort. The HR of HD versus PD was 1.25 (95% CI, 1.20-1.30) in the unadjusted model and 0.84 (95% CI, 0.80-0.87) in the adjusted model. However, multivariable risk-adjusted analyses showed the HR of HD versus PD for the first 90 days was 1.06 (95% CI, 0.98-1.14), decreasing to 0.74 (95% CI, 0.68-0.80) in the 270- to 360-day period. Limitations Residual confounding due to selection bias inherent in dialysis modality choice and the observational study design. Form 2728 provides baseline data at dialysis incidence alone, but not over time. Conclusions US patients receiving HD with an AVF appear to have a survival advantage over PD patients after 90 days of dialysis initiation after accounting for patient characteristics. These findings have implications in the choice of initial dialysis modality and vascular access for patients.
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Affiliation(s)
| | | | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | | | | | - Vahakn B Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI.,Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
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Lockridge R, Weinhandl E, Kraus M, Schreiber M, Spry L, Tailor P, Carver M, Glickman J, Miller B. A Systematic Approach To Promoting Home Hemodialysis during End Stage Kidney Disease. KIDNEY360 2020; 1:993-1001. [PMID: 35369547 PMCID: PMC8815594 DOI: 10.34067/kid.0003132020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/07/2020] [Indexed: 06/14/2023]
Abstract
Home dialysis has garnered much attention since the advent of the Advancing American Kidney Health initiative. For many patients and nephrologists, home dialysis and peritoneal dialysis are synonymous. However, home hemodialysis (HHD) should not be forgotten. Since 2004, HHD has grown more rapidly than other dialytic modalities. The cardinal feature of HHD is customizability of treatment intensity, which can be titrated to address the vexing problems of volume and pressure loading during interdialytic gaps and ultrafiltration intensity during each hemodialysis session. Growing HHD utilization requires commitment to introducing patients to the modality throughout the course of ESKD. In this article, we describe a set of strategies for introducing HHD concepts and equipment. First, patients initiating dialysis may attend a transitional care unit, which offers an educational program about all dialytic modalities during 3-5 weeks of in-facility hemodialysis, possibly using HHD equipment. Second, prevalent patients on hemodialysis may participate in "trial-run" programs, which allow patients to experience increased treatment frequency and HHD equipment for several weeks, but without the overt commitment of initiating HHD training. In both models, perceived barriers to HHD-including fear of equipment, anxiety about self-cannulation, catheter dependence, and the absence of a care partner-can be addressed in a supportive setting. Third, patients on peritoneal dialysis who are nearing a transition to hemodialysis may be encouraged to consider a home-to-home transition (i.e., from peritoneal dialysis to HHD). Taken together, these strategies represent a systematic approach to growing HHD utilization in multiple phenotypes of patients on dialysis. With the feature of facilitating intensive hemodialysis, HHD can be a key not only to satiating demand for home dialysis, but also to improving the health of patients on dialysis.
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Affiliation(s)
- Robert Lockridge
- Lynchburg Nephrology Physicians, PLLC, Lynchburg, Virginia
- University of Virginia Medical Center, Charlottesville, Virginia
| | - Eric Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Michael Kraus
- Fresenius Medical Care North America, Waltham, Massachusetts
| | | | - Leslie Spry
- Lincoln Nephrology and Hypertension, PC, Lincoln, Nebraska
| | | | - Michelle Carver
- Fresenius Medical Care North America, Waltham, Massachusetts
| | - Joel Glickman
- Division of Renal Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brent Miller
- Division of Nephrology, Department of Medicine, School of Medicine, Indiana University, Bloomington, Indiana
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Garcia-Montemayor V, Martin-Malo A, Barbieri C, Bellocchio F, Soriano S, Pendon-Ruiz de Mier V, Molina IR, Aljama P, Rodriguez M. Predicting mortality in hemodialysis patients using machine learning analysis. Clin Kidney J 2020; 14:1388-1395. [PMID: 34221370 PMCID: PMC8247746 DOI: 10.1093/ckj/sfaa126] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/10/2020] [Indexed: 12/18/2022] Open
Abstract
Background Besides the classic logistic regression analysis, non-parametric methods based on machine learning techniques such as random forest are presently used to generate predictive models. The aim of this study was to evaluate random forest mortality prediction models in haemodialysis patients. Methods Data were acquired from incident haemodialysis patients between 1995 and 2015. Prediction of mortality at 6 months, 1 year and 2 years of haemodialysis was calculated using random forest and the accuracy was compared with logistic regression. Baseline data were constructed with the information obtained during the initial period of regular haemodialysis. Aiming to increase accuracy concerning baseline information of each patient, the period of time used to collect data was set at 30, 60 and 90 days after the first haemodialysis session. Results There were 1571 incident haemodialysis patients included. The mean age was 62.3 years and the average Charlson comorbidity index was 5.99. The mortality prediction models obtained by random forest appear to be adequate in terms of accuracy [area under the curve (AUC) 0.68–0.73] and superior to logistic regression models (ΔAUC 0.007–0.046). Results indicate that both random forest and logistic regression develop mortality prediction models using different variables. Conclusions Random forest is an adequate method, and superior to logistic regression, to generate mortality prediction models in haemodialysis patients.
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Affiliation(s)
| | - Alejandro Martin-Malo
- Department of Nephrology, Reina Sofia University Hospital, Cordoba, Spain.,Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Spain.,RETICs-REDinREN (National Institute of Health Carlos III), Madrid, Spain
| | - Carlo Barbieri
- Fresenius Medical Care Italia, Vaiano Cremasco, Cremona, Italy
| | | | - Sagrario Soriano
- Department of Nephrology, Reina Sofia University Hospital, Cordoba, Spain
| | - Victoria Pendon-Ruiz de Mier
- Department of Nephrology, Reina Sofia University Hospital, Cordoba, Spain.,Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Spain
| | - Ignacio R Molina
- Department of Nephrology, Reina Sofia University Hospital, Cordoba, Spain
| | - Pedro Aljama
- Department of Nephrology, Reina Sofia University Hospital, Cordoba, Spain.,Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Spain
| | - Mariano Rodriguez
- Department of Nephrology, Reina Sofia University Hospital, Cordoba, Spain.,Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Spain.,RETICs-REDinREN (National Institute of Health Carlos III), Madrid, Spain
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Abstract
The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization. Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care.
The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care. The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease. Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life. Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis. Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators). Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.
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Can incremental haemodialysis reduce early mortality rates in patients starting maintenance haemodialysis? Curr Opin Nephrol Hypertens 2020; 28:641-647. [PMID: 31369421 DOI: 10.1097/mnh.0000000000000537] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Early mortality rates after the start of maintenance haemodialysis therapy are high. Compared with three-times weekly haemodialysis, incremental haemodialysis is associated with better preservation of residual renal function (RRF) and at least equivalent mid-term to long-term survival. However, there is paucity of data in relation to its use as a means of helping patients through the transitional period, when they first become dialysis dependent. RECENT FINDINGS Studies of incremental haemodialysis have overlooked early mortality as an outcome measure. This is primarily due to their retrospective design which makes it difficult to link early deaths to the frequency of haemodialysis. New data confirm previous observations associating incremental haemodialysis with favourable outcomes. They also raise the possibility that in selected groups and for short periods, the pursuit of set clearance targets during the early days of dialysis may not necessarily bring additional short-term gains. SUMMARY We argue that, while simpler ways of estimating RRF are being explored, future trials must consider implementing incremental haemodialysis focusing on practical aspects of care in the transitional period; safety monitoring in such regimes should be undertaken using conventional methods. Such an approach is likely to benefit a larger subset of haemodialysis population.
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Silver SA, Bota SE, McArthur E, Clemens KK, Harel Z, Naylor KL, Sood MM, Garg AX, Wald R. Association of Primary Care Involvement with Death or Hospitalizations for Patients Starting Dialysis. Clin J Am Soc Nephrol 2020; 15:521-529. [PMID: 32139363 PMCID: PMC7133142 DOI: 10.2215/cjn.10890919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES It is uncertain whether primary care physician continuity of care associates with a lower risk of death and hospitalization among patients transitioning to maintenance dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using provincial-linked administrative databases in Ontario, Canada, we conducted a population-based study of incident patients who initiated maintenance dialysis between 2005 and 2014 and survived for at least 90 days. We defined high primary care physician continuity as both a high usual provider of care index (where >75% of primary care physician visits occurred with the same primary care physician) in the 2 years before dialysis (an established measure of primary care physician continuity) and at least one visit with the same primary care physician in the 90 days after dialysis initiation. We used propensity scores to match a group of patients with high and low continuity so that indicators of baseline health were similar. The primary outcome was all-cause mortality, and secondary outcomes included all-cause and disease-specific hospitalizations during the 2 years after maintenance dialysis initiation. RESULTS We identified 19,099 eligible patients. There were 6612 patients with high primary care physician continuity, of whom 6391 (97%) were matched to 6391 patients with low primary care physician continuity. High primary care physician continuity was not associated with a lower risk of mortality (14.5 deaths per 100 person-years versus 15.2 deaths per 100 person-years; hazard ratio, 0.96; 95% confidence interval, 0.89 to 1.02). There was no difference in the rate of all-cause hospitalizations (hazard ratio, 0.96; 95% confidence interval, 0.92 to 1.01), and high primary care physician continuity was not associated with a lower risk of any disease-specific hospitalization, except for those related to diabetes (hazard ratio, 0.88; 95% confidence interval, 0.80 to 0.97). CONCLUSIONS High primary care physician continuity before and during the transition to maintenance dialysis was not associated with a lower risk of mortality or all-cause hospitalization.
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Affiliation(s)
- Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada; .,ICES, Toronto, Ontario, Canada
| | | | | | - Kristin K Clemens
- ICES, Toronto, Ontario, Canada.,Division of Endocrinology and Metabolism and Department of Epidemiology and Biostatistics and
| | - Ziv Harel
- ICES, Toronto, Ontario, Canada.,Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; and
| | | | - Manish M Sood
- ICES, Toronto, Ontario, Canada.,Department of Medicine and Clinical Epidemiology Program of the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Amit X Garg
- ICES, Toronto, Ontario, Canada.,Division of Nephrology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Ron Wald
- ICES, Toronto, Ontario, Canada.,Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; and
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Vinson AJ, Bartolacci J, Goldstein J, Swain J, Clark D, Tennankore KK. Predictors of Need for First and Recurrent Emergency Medical Service Transport to Emergency Department after Dialysis Initiation. PREHOSP EMERG CARE 2019; 24:822-830. [PMID: 31800335 DOI: 10.1080/10903127.2019.1701157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Dialysis patients are frequently transported to the emergency department (ED) by Emergency Medical Services (EMS) due to acute and severe illness. However, little is known about predictors of first and recurrent transport to the ED (EMS-ED), based on characteristics at the time of dialysis initiation.Methods: We analyzed a cohort of adult (≥18 years) patients affiliated with a large quaternary care center who initiated chronic dialysis from 2009 to 2013 (last follow-up: 2015). Data on patient characteristics at the time of dialysis initiation were linked to regional EMS data. Candidate predictors of first and recurrent EMS-ED transport included comorbid conditions, dialysis characteristics and frailty severity (using the first version of the clinical frailty scale score; CFS). Time to first EMS-ED was analyzed using a multivariable sub-hazards regression model accounting for competing events (transplantation or death). Time to recurrent EMS-ED was analyzed using the Anderson-Gill counting approach, accounting for competing risks.Results: A total of 455 patients were included in the study, 243 (53%) had 1+ EMS-ED events, 90 (20%) never required an EMS-ED at last follow-up, and 69 (15%) and 53 (12%) experienced transplant or death as their first event, respectively. The mean age of the cohort was 62 ± 15 years, 89% were Caucasian, and 35% were female sex. Patients were highly comorbid and 97/381 (25.5%) with available data on frailty severity had a CFS score of ≥5, inclusive of CFS scores ranging from mildly to severely frail. After adjustment, a CFS score of ≥5 (relative to 1-2) was associated with a > 2-fold increase in the risk of first EMS-ED (subdistribution relative hazard; SHR 2.28, 95% confidence interval; CI 1.30-3.98). A history of peripheral vascular disease (SHR 1.43, 95% CI 1.00-2.03) and rheumatologic disease (SHR 1.84, 95% CI 1.00-3.38) was also associated with first EMS-ED. Frailty severity was the only factor associated with recurrent EMS-ED.Conclusion: Patients are at a high risk of EMS-ED after dialysis initiation. Frailty severity (at the time of dialysis initiation) is a strong predictor of first and recurrent EMS-ED and this may be important to guide informed decision making and resource planning for dialysis patients who require EMS.
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Hazara AM, Bhandari S. Early Mortality Rates After Commencement of Maintenance Hemodialysis: A Systematic Review and Meta-Analysis. Ther Apher Dial 2019; 24:275-284. [PMID: 31574577 DOI: 10.1111/1744-9987.13437] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/10/2019] [Accepted: 09/17/2019] [Indexed: 12/13/2022]
Abstract
Mortality rates are reported to be high soon after the commencement of maintenance HD for ESRD. Our aim was to estimate early mortality rates (deaths within 180 days of starting therapy), through a systematic review of literature, in this patient population. Medline and EMBASE were searched for publications between 1 January 1985 and 31 December 2017. Observational studies reporting deaths involving adults commencing HD were included. The Quality in Prognosis Studies tool was used to assess risk of bias in studies. Crude mortality rates (expressed in 100 person-years) and age-standardized mortality ratios (SMR) were calculated. Meta-analyses of these rates were conducted for studies with lowest risk of bias (i.e. highest quality). In total, 32 studies were included (combined population: 1 083 264) representing 283 277 person-years of observation; median follow-up: 90 days. Mortality rates ranged between 12.8 and 55.6 per 100 person-years. Cardiovascular causes accounted for the majority of early deaths. Meta-analysis of high-quality studies showed an overall crude mortality rate of 32.6 per 100 person-years (95% CI 32.4-32.8). This equates to 16.3% mortality in first 180 days of starting HD. Six high-quality studies contained sufficient data for calculation of SMR. Meta-analysis of SMRs showed that patients starting HD therapy sustain 8.8 times higher mortality rates compared to the general population. We have combined the results of high-quality studies to produce new estimates of early mortality rates after commencement of HD therapy. This information can help relay more reliable prognostic information to this patient population.
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Affiliation(s)
- Adil M Hazara
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK.,Hull York Medical School, Hull, UK
| | - Sunil Bhandari
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK.,Hull York Medical School, Hull, UK
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