Gastrointestinal bleeding in patients on long-term dialysis

BACKGROUND

The epidemiology of gastrointestinal bleeding (GIB) in end-stage renal disease (ESRD) has not been adequately characterized. Using United States Renal Data System data we investigated the epidemiology of GIB in hospitalized patients receiving long-term dialysis.

METHODS

Medicare ESRD patients who began dialysis between 1996 and 2005 were followed from 90 days after starting dialysis to death, transplant, loss of Medicare, or December 31, 2006. GIB events were identified using claims data. Predictors of GIB incidence were analyzed using over-dispersed Poisson regression and Cox regression was used to evaluate the effect on survival. Repeat episodes were modeled using a partially conditional Cox regression model.

RESULTS

406,836 patients were followed for 832,131 person-years, during which 133,967 events were identified. The incidence of GIB was stable through year 2000 but steadily increased thereafter. Chronic gastric ulcer and colonic diverticulosis were the commonest defined causes of upper and lower GIB respectively. Age >49 years, female gender, hypertension as the cause of ESRD, and initiation on hemodialysis was associated with a greater risk of GIB. An episode of GIB conferred a increased hazard of death (hazard ratio 1.9, 95% CI 1.86-1.93). A previous episode of GIB was associated with greater hazard of another episode (hazard ratio 3.93, 95% CI 3.82-4.05).

CONCLUSIONS

In ESRD patients incident to long-term dialysis the incidence of hospital-associated GIB is increasing, is associated with a greater hazard of death, and carries a great hazard of repeat episodes.

Chronic kidney disease and support provided by home care services: a systematic review

BACKGROUND

Chronic diseases, such as chronic kidney disease (CKD), are growing in incidence and prevalence, in part due to an aging population. Support provided through home care services may be useful in attaining a more efficient and higher quality care for CKD patients.

METHODS

A systematic review was performed to identify studies examining home care interventions among adult CKD patients incorporating all outcomes. Studies examining home care services as an alternative to acute, post-acute or hospice care and those for long-term maintenance in patients' homes were included. Studies with only a home training intervention and those without an applied research component were excluded.

RESULTS

Seventeen studies (10 cohort, 4 non-comparative, 2 cross-sectional, 1 randomized) examined the support provided by home care services in 15,058 CKD patients. Fourteen studies included peritoneal dialysis (PD), two incorporated hemodialysis (HD) and one included both PD and HD patients in their treatment groups. Sixteen studies focused on the dialysis phase of care in their study samples and one study included information from both the dialysis and pre-dialysis phases of care. Study settings included nine single hospital/dialysis centers and three regional/metropolitan areas and five were at the national level. Studies primarily focused on nurse assisted home care patients and mostly examined PD related clinical outcomes. In PD studies with comparators, peritonitis risks and technique survival rates were similar across home care assisted patients and comparators. The risk of mortality, however, was higher for home care assisted PD patients. While most studies adjusted for age and comorbidities, information about multidimensional prognostic indices that take into account physical, psychological, cognitive, functional and social factors among CKD patients was not easily available.

CONCLUSIONS

Most studies focused on nurse assisted home care patients on dialysis. The majority were single site studies incorporating small patient populations. There are gaps in the literature regarding the utility of providing home care to CKD patients and the impact this has on healthcare resources.

Developments towards an artificial kidney

This article reviews the present state of renal failure and its treatment in the industrialized world. Novel and experimental therapies for the treatment of renal failure are covered, with special emphasis on a hybrid bioartificial kidney currently undergoing clinical trials in the USA. Preclinical data, results from human trials and work on miniaturization of the bioartificial kidney for implantation are presented. Research on microfluidics and nanotechnology applied to dialysis is ongoing in many academic centers, and several promising approaches are discussed. After 10 years of incremental improvements in end-stage renal disease care, several revolutionary technologies are on the horizon and approaching the marketplace.

Dialysis patients and cardiovascular problems: can technology solve the complex equation?

Patients with end-stage kidney disease undergoing chronic hemodialysis present higher mortality rates compared with the general population. Once patients are on hemodialysis, the risk of cardiovascular death is approximately 30-times higher than the general population, and still remains 10- to 20-times higher after stratification for age, gender and presence of diabetes. Approximately half of patient deaths on dialysis are attributed to cardiovascular causes, including coronary heart disease, cerebrovascular disease, peripheral vascular disease and heart failure. The cardiovascular burden of the hemodialysis patient arises from three different sources: risks inherent to the patient and the uremic syndrome, traditional risk factors and risk factors related to the dialysis therapy. Based on these considerations and the fact that several aspects of the dialysis procedure can cause either a cardiovascular burden or modify the burden already present, new technologies should be directed towards the approach of a possible 'cardioprotective dialysis therapy'. This approach may significantly contribute new techniques and new dialysis machines. Born to make dialysis easy and safe, the new machines feature several options that make monitoring and online hemodiafiltration a simple routine. These and other features could make dialysis better tolerated and more efficient in protecting from fatal cardiovascular events.

[Chairmen's introductory remarks]

Recently, mild to moderate renal dysfunction has attracted attention as a new common disease in Japan as well as all over the world. Also, the morbidity of endstage renal disease and progression to dialysis is increasing each year. It is now widely recognized that renal dysfunction is a major risk for cardiovascular disease; therefore, cardio-renal relationships should be investigated. To elucidate the pathophysiology of this relationship and develop new methods for early diagnosis, treatment and prevention can promise a long and healthy life. It is also important to provide high quality data on urinalysis and kidney function.

The clinical status and survival in elderly dialysis: example of the oldest region of France

BACKGROUND

The number of elderly (≥75 years) patients with end-stage renal disease (ESRD) has increased markedly, including in the Limousin region, which has the oldest population in France. We retrospectively compared outcomes in elderly and non-elderly ESRD patients who started dialysis during two time periods.

METHODS

Baseline clinical characteristics, care, and survival rates were assessed in 557 ESRD patients aged ≥75 and <75 years who started dialysis in 2002-2004 and 2005-2007. Survival curves and Cox proportional hazards model were used to assess survival and factors associated with survival.

RESULTS

Of the 557 patients, 343 and 214 were <75 years and ≥75 years, respectively. Dialysis was started in 2002-2004 and 2005-2007 by 197 and 146 patients <75 years, respectively, and by 96 and 118 patients ≥75 years, respectively. Median age (73.4 years [interquartile range [IQR] 61.7-79.5 years] vs 69.5 years [IQR 57.4-77.4 years] p = 0.001) and the proportion aged ≥75 years (44.7% vs 32.8%, p = 0.004) were significantly higher in 2005-2007 than in 2002-2004. Improved initial status during 2005-2007 was observed only in patients ≥75 years, with a decrease in some co-morbidities, improved walking and better preparation for dialysis. Mortality rates were significantly lower in 2005-2007 than in 2002-2004 (hazard ratio 0.81, 95% confidence interval 0.69-0.95; p = 0.008), with the difference due to factors associated with clinical status and care.

CONCLUSIONS

Improved initial clinical status and better preparation for dialysis, accompanied by increased survival, were observed for patients ≥75 years who started dialysis more recently, perhaps because of early referral to a nephrologist.

Results of low-dose carperitide infusion in high-risk patients undergoing coronary artery bypass grafting

BACKGROUND

This study investigated the efficacy of human atrial natriuretic peptide (hANP, carperitide) for high-risk patients undergoing coronary artery bypass grafting (CABG).

METHODS

This was a randomized controlled trial of 367 high-risk patients (European System for Cardiac Operative Risk Evaluation above 6) undergoing CABG. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE). Secondary endpoints were (1) postoperative death, (2) MACCE + hemodialysis, and (3) serum creatinine and brain natriuretic peptide (BNP) levels. Logistic regression analysis was conducted to identify preoperative and perioperative factors related to early death and MACCE.

RESULTS

There was no significant difference of survival between the hANP and placebo groups (p = 0.1651), but the MACCE-free rate was significantly higher in the hANP group than in the placebo group (p < 0.0001). No patient from the hANP group started hemodialysis after operation, but 7 patients did in the placebo group, and the dialysis rate was significantly lower in the hANP group (p = 0.0147). Serum creatinine and BNP were also significantly lower in the hANP group at 1 year postoperatively. MACCE were strongly associated with age 75 years or older, chronic kidney disease, hemodialysis, left ventricular dysfunction, and nonuse of carperitide.

CONCLUSIONS

In the early postoperative period, carperitide has a cardiorenal protective effect that prevents postoperative MACCE and hemodialysis. Perioperative low-dose carperitide infusion may be useful in high-risk patients undergoing on-pump CABG.

An assessment of non-communicable diseases, diabetes, and related risk factors in the territory of American Samoa: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in American Samoa and describes the burden of selected NCDs (ie, diabetes, heart disease, hypertension, stroke, and chronic kidney disease); and assesses the system of service capacity and activities regarding service delivery, data collection and reporting as well as identifies the issues needing to be addressed. Findings reveal that nutrient-poor diet, lack of physical activity, and other lifestyle behaviors are associated with overweight and obesity and subsequent NCDs that impact the morbidity and mortality of the population. The leading causes of death include heart disease, diabetes, cancer and stroke. Population surveys show that 93% of the adults are overweight or obese and 47% have diabetes. Among public school children, 44.6% are overweight or obese. Other data show that between 2006 and 2010, there was a 33% increase in the number of patients receiving hemodialysis. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCDs. There is a paucity of health plans, policy and procedure manuals, coordination among providers, and lack of common standards of care. The combined administrative and clinical system of service needs were identified and prioritized. They include the need for a Territory-wide health strategy and plan, need for standards of care, and a need for collaborative team approach for the treatment and management of patients with diabetes and other chronic diseases.

[News on single needle dialysis: technique, indications, precautions and limits]

The technique of single needle dialysis (SN) was invented in the 1960s and enjoyed great success during the 1970s and '80s in northern Europe, particularly in Belgium. In recent years, the double needle mode has awakened new interest in this technique, as it may represent a good alternative to the use of a central venous catheter at the beginning of dialysis, while waiting for the growth of the arteriovenous fistula. For today's dialysis patients, mostly elderly with ever greater numbers of co-morbid conditions, in particular vascular disease, treatments have become ever more flexible and individually tailored. A single needle approach can be also used in the case of native fistula dislocation. The single needle technique requires careful control of dialysis dose, keeping recirculation into account. If the technique is used for long periods of time, there is the risk of inadequate dialysis dose and it is necessary to pay particular attention to the sampling of post dialysis urea for the KT/V calculation (always 20 minutes after the end of dialysis). Modern dialysis machines have greatly reduced the risk of hemolysis (which can be evaluated with the control of LDH pre and post dialysis) and of back-filtration which no longer represents a problem thanks to ultrapure dialysate. The probability of of blood circuit coagulation has also been greatly reduced thanks to citrate dialysis baths and membranes treated with heparin or vitamin E, and systems often do not require an increase of anticoagulants. The technique is, therefore, particularly reliable and easy to use thanks to its simplicity.

Oral disease in adults treated with hemodialysis: prevalence, predictors, and association with mortality and adverse cardiovascular events: the rationale and design of the ORAL Diseases in hemodialysis (ORAL-D) study, a prospective, multinational, longitudinal, observational, cohort study

BACKGROUND

People with end-stage kidney disease treated with dialysis experience high rates of premature death that are at least 30-fold that of the general population, and have markedly impaired quality of life. Despite this, interventions that lower risk factors for mortality (including antiplatelet agents, epoetins, lipid lowering, vitamin D compounds, or dialysis dose) have not been shown to improve clinical outcomes for this population. Although mortality outcomes may be improving overall, additional modifiable determinants of health in people treated with dialysis need to be identified and evaluated. Oral disease is highly prevalent in the general population and represents a potential and preventable cause of poor health in dialysis patients. Oral disease may be increased in patients treated with dialysis due to their lower uptake of public dental services, as well as increased malnutrition and inflammation, although available exploratory data are limited by small sample sizes and few studies evaluating links between oral health and clinical outcomes for this group, including mortality and cardiovascular disease. Recent data suggest periodontitis may be associated with mortality in dialysis patients and well-designed, larger studies are now required.

METHODS/DESIGN

The ORAL Diseases in hemodialysis (ORAL-D) study is a multinational, prospective (minimum follow-up 12 months) study. Participants comprise consecutive adults treated with long-term in-center hemodialysis. Between July 2010 and February 2012, we recruited 4500 dialysis patients from randomly selected outpatient dialysis clinics in Europe within a collaborative network of dialysis clinics administered by a dialysis provider, Diaverum, in Europe (France, Hungary, Italy, Poland, Portugal, and Spain) and South America (Argentina). At baseline, dental surgeons with training in periodontology systematically assessed the prevalence and characteristics of oral disease (dental, periodontal, mucosal, and salivary) in all participants. Oral hygiene habits and thirst were evaluated using self-administered questionnaires. Data for hospitalizations and mortality (total and cause-specific) according to baseline oral health status will be collected once a year until 2022.

DISCUSSION

This large study will estimate the prevalence, characteristics and correlations of oral disease and clinical outcomes (mortality and hospitalization) in adults treated with dialysis. We will further evaluate any association between periodontitis and risk of premature death in dialysis patients that has been suggested by existing research. The results from this study should provide powerful new data to guide strategies for future interventional studies for preventative and curative oral disease strategies in adults who have end-stage kidney disease.

Overview 2012. A year of dialysis industry alignment and government enforcement

All in all, in the health care industry, the Department of Justice, and related agencies increased enforcement activities in 2012. In December 2012 the Justice Department announced that it had secured $4.9 billion in settlements and judgments in civil cases involving fraud against the government in the fiscal year ending September 30, 2012. This figure is a record recovery for a single year, eclipsing the previous record by more than $1.7 billion. While this activity increased, in many False Claims Act cases, including those noted above in which the courts reached the merits of the cases, health care providers had some victories, including successful results at the trial and appellate levels. As a result, providers may take some comfort that the judicial skepticism towards the most aggressive False Claims Act prosecutions may be growing, and with it, the likelihood of providers' success in certain cases.

[Dialysis and ecology: can we do better in the future?]

Development of dialysis has saved the lives of many patients. However, haemodialysis and peritoneal dialysis are very demanding in resources such as water and electricity, and generate a large amount of waste. In this article, we will review the environmental aspects of dialysis. Different solutions will be discussed, such as recycling of water discharged during reverse osmosis, the integration of solar energy, recycling of waste plastics, and the use of other techniques such as sorbent dialysis. In a world where natural resources are precious and where global warming is a major problem, it is important that not only dialysis, but all branches of medicine become more attentive to ecology.

Universal coverage of renal dialysis in Thailand: promise, progress, and prospects

Thailand's experience in introducing renal replacement therapy as part of its universal health coverage scheme shows the importance of evidence and stakeholders' active participation in all phases of policy development, say Sripen Tantivess and colleagues:

A model for initiating change in the dialysis setting

Implementing a significant change in an organization is one of the most challenging endeavors that faces a manager. If the change involves the establishment of new paradigms that will replace the existing ways of doing business, the challenge is particularly daunting. Change theory is a process that can be used to facilitate change in an organization. It provides a guide for the manager to follow in attaining a desired outcome. Several change theorists and their works are discussed. An example is provided using change theory to identify strategies for delivering a medication once per month from once a treatment.

Epidemiologic trends in chronic renal replacement therapy over forty years: a Swiss dialysis experience

BACKGROUND

Long term longitudinal data are scarce on epidemiological characteristics and patient outcomes in patients on maintenance dialysis, especially in Switzerland. We examined changes in epidemiology of patients undergoing renal replacement therapy by either hemodialysis or peritoneal dialysis over four decades.

METHODS

Single center retrospective study including all patients which initiated dialysis treatment for ESRD between 1970 and 2008. Analyses were performed for subgroups according to dialysis vintage, based on stratification into quartiles of date of first treatment. A multivariate model predicting death and survival time, using time-dependent Cox regression, was developed.

RESULTS

964 patients were investigated. Incident mean age progressively increased from 48 ± 14 to 64 ± 15 years from 1st to 4th quartile (p < 0.001), with a concomitant decrease in 3- and 5-year survival from 72.2 to 67.7%, and 64.1 to 54.8%, respectively. Nevertheless, live span continuously increased from 57 ± 13 to 74 ± 11 years (p < 0.001). Patients transplanted at least once were significantly younger at dialysis initiation, with significantly better survival, however, shortened live span vs. individuals remaining on dialysis. Among age at time of initiating dialysis therapy, sex, dialysis modality and transplant status, only transplant status is a significant independent covariate predicting death (HR: 0.10 for transplanted vs. non-transplanted patients, p = 0.001). Dialysis vintage was associated with better survival during the second vs. the first quartile (p = 0.026).

DISCUSSION

We document an increase of a predominantly elderly incident and prevalent dialysis population, with progressively shortened survival after initiation of renal replacement over four decades, and, nevertheless, a prolonged lifespan. Analysis of the data is limited by lack of information on comorbidity in the study population.

CONCLUSIONS

Survival in patients on renal replacement therapy seems to be affected not only by medical and technical advances in dialysis therapy, but may mostly reflect progressively lower mortality of individuals with cardiovascular and metabolic complications, as well as a policy of accepting older and polymorbid patients for dialysis in more recent times. This is relevant to make demographic predictions in face of the ESRD epidemic nephrologists and policy makers are facing in industrialized countries.

Dialysis adequacy today: a European perspective

The need to improve haemodialysis (HD) therapies and to reduce cardiovascular and all-cause mortality frequently encountered by dialysis patients has been recognized and addressed for many years. A number of approaches, including increasing the frequency versus duration of treatment, have been proposed and debated in terms of their clinical efficacy and economic feasibility. Future prescription of dialysis to an expanding end-stage chronic kidney disease (CKD-5D) population needs a re-evaluation of existing practices while maintaining the emphasis on patient well-being both in the short and in the long term. Efficient cleansing of the blood of all relevant uraemic toxins, including fluid and salt overload, remains the fundamental objective of all dialysis therapies. Simultaneously, metabolic disorders (e.g. anaemia, mineral bone disease, oxidative stress) that accompany renal failure need to be corrected also as part of the delivery of dialysis therapy itself. Usage of high-flux membranes that enable small and large uraemic toxins to be eliminated from the blood is the first prerequisite towards the aforementioned goals. Application of convective therapies [(online-haemodiafiltration (OL-HDF)] further enhances the detoxification effects of high-flux haemodialysis (HF-HD). However, despite an extended clinical experience with both HF-HD and OL-HDF spanning more than two decades, a more widespread prescription of convective treatment modalities awaits more conclusive evidence from large-scale prospective randomized controlled trials. In this review, we present a European perspective on the need to implement optimal dialysis and to improve it by adopting high convective therapies and to discuss whether inertia to implement these practice patterns may deprive patients of significantly improved well-being and survival.