Considering health insurance: how do dialysis initiates with Medicaid coverage differ from persons without Medicaid coverage?

BACKGROUND

Type of health insurance is an important mediator of medical outcomes in the United States. Medicaid, a jointly sponsored Federal/State programme, is designed to serve medically needy individuals. How these patients differ from non-Medicaid-enrolled incident dialysis patients and how these differences have changed over time have not been systematically examined.

METHODS

Using data from the United States Renal Data System, we identified individuals initiating dialysis from 1995 to 2004 and categorized their health insurance status. Longitudinal trends in demographic, risk behaviour, functional, comorbidity, laboratory and dialysis modality factors, as reported on the Medical Evidence Form (CMS-2728), were examined in all insurance groups. Polychotomous logistic regression was used to estimate adjusted generalized ratios (AGRs) for these factors by insurance status, with Medicaid as the referent insurance group.

RESULTS

Overall, males constitute a growing percentage of both Medicaid and non-Medicaid patients, but in contrast to other insurance groups, Medicaid has a higher proportion of females. Non-Caucasians also constitute a higher proportion of Medicaid patients than non-Medicaid patients. Body mass index increased in all groups over time, and all groups witnessed a significant decrease in initiation on peritoneal dialysis. Polychotomous regression showed generally lower AGRs for minorities, risk behaviours and functional status, and higher AGRs for males, employment and self-care dialysis, for non-Medicaid insurance relative to Medicaid.

CONCLUSIONS

While many broad parallel trends are evident in both Medicaid and non-Medicaid incident dialysis patients, many important differences between these groups exist. These findings could have important implications for policy planners, providers and payers.

Hepatitis C virus infection in haemodialysis: the 'no-isolation' policy should not be generalized

Hepatitis C virus (HCV) infection is the most common blood-borne viral infection in haemodialysis. It causes significant morbidity and long-term mortality. Practice of universal precautions has been reported to be sufficient to prevent HCV seroconversion in dialysis units. However, the seroconversion rate remains very high in many dialysis units. A previous study from 1995 to 1998 at our own hospital without isolation showed that nosocomial transmission is the major cause of HCV seroconversion. The present study was therefore conducted with the aim to study the impact of isolation on HCV seroconversion. In this prospective cohort study, with non-probability consecutive sampling, patients with HCV infection were dialysed in an isolated room. In addition, standard universal precautions were practiced. HCV seroconversion rate was compared with the previous study. All patients with end-stage kidney disease (ESKD) admitted to our hospital for renal replacement therapy were included in the present study. At the time of admission, HCV screening was done. All anti-HCV-positive patients were dialysed in an isolated room. While on maintenance haemodialysis, all patients were monthly tested for anti-HCV, aspartate aminotransferase and alanine aminotransferase. Any patient who had HCV seroconversion was transferred to an isolated room for maintenance haemodialysis. Patients with HCV infection were managed by further testing for HCV-RNA and liver biopsy. Every patient who ultimately received renal transplantation at our hospital was also tested for HCV just prior to renal transplantation as well as 3 months after renal transplantation. HCV infection was diagnosed by detecting anti-HCV antibodies using an ELISA-based third-generation diagnostic test kit. Serum bilirubin, aspartate aminotransferase and alanine aminotransferase were assayed using standard laboratory techniques. From March 2003 to February 2006, 1,417 patients were admitted for haemodialysis in our unit. Of these 1,077 (76%) had ESKD. Mean age of patients was 42.47 +/- 16.2 (14-94) and 70.39% were males. Patients with ESKD had had more dialysis sessions (10.9 +/- 39.5 vs. 4.4 +/- 5.95, p = 0.009), more blood transfusions and more pre-existing HCV infections (4.72 vs. 1.5%, p = 0.009) than patients with acute renal failure. Of the ESKD patients, 65.7% were discharged, 9.47% died, 1.85% were shifted to chronic ambulatory peritoneal dialysis and 22.46% patients received renal transplantation. Of the patients who received renal transplantation, HCV seroconversion was detected in 2.75%. In the previous study without isolation practices, the HCV seroconversion rate in transplanted patients was 36.2%. The hazard of HCV seroconversion was 0.97 (95% CI 0.93-1.02, p = 0.2) for each additional dialysis and 1.09 (95% CI 0.88-1.36, p = 0.37) for each additional blood transfusion. The study concludes that isolation of HCV-infected patients during haemodialysis significantly decreases the HCV seroconversion rate.

Influence of age and nutritional status on glycated albumin values in hemodialysis patients

OBJECTIVE

Several studies have shown glycated albumin (GA) to be a more accurate glycemic marker than HbA(1c) in diabetic patients with end-stage renal disease (ESRD). However GA values are influenced by several factors associated with albumin turnover independent of glycemia. We tried to clarify the factors other than glycemic control affecting GA values in ESRD patients.

PATIENTS AND METHODS

We examined the associations between GA values and several clinical variables related to albumin metabolism in 41 non-diabetic patients on maintenance hemodialysis.

RESULTS

Although there were no significant correlations between glucose, albumin, and GA values, there were significant correlations between age, cholinesterase (ChE) values, BMI, and GA values (r=0.515, p=0.0004, r=-0.394, p=0.010, r=-0.327, p=0.036). Stepwise multivariate regression analysis showed that age and ChE values were significant independent variables associated with GA values (beta=0.479, -0.343, R(2)=0.382).

CONCLUSION

GA values are influenced by age and nutritional status independent of glycemia in non-diabetic ESRD patients. We should be aware of factors other than glycemic control affecting GA values.

Dialysis status in China: a report from the Shanghai Dialysis Registry (2000-2005)

INTRODUCTION

As economic development continues in China, it is important to evaluate recent changes in dialysis status. However, China lacks a national dialysis registry. This elevates the need to use local registry systems like the Shanghai Dialysis Registry to gain an overview of dialysis status in developed cities in China.

METHODS

Data were collected from the Shanghai Dialysis Registry from the beginning of 2000 to the end of 2005. All dialysis centers (n = 58) in Shanghai are included in the registry system.

RESULTS

Point prevalence of dialysis on December 31, 2005, was 5496, compared with 4842 in 2000. In 2005, 3746 patients began dialysis, yielding a treatment rate of 275.4 patients per million population. The percentage of peritoneal dialysis patients was 18% in 2005, compared with 14% in 2000. The main cause for end-stage renal disease was chronic glomerulonephritis. However, the incidence of diabetic nephropathy increased from 9.9% in 2000 to 17.2% in 2005 and counts as the second major cause of end-stage renal disease. The death rate of patients on dialysis decreased from 9.2% in 2000 to 7.5% in 2005. Cerebrovascular disease was still the leading cause of death and decreased significantly from 2.4% in 2000 to 1.5% in 2005. Dialysis adequacy, hepatitis infection control, and anemia treatment improved.

CONCLUSIONS

The Shanghai dialysis population grew continuously during the period covered by this study (2000 to 2005). Clinical outcomes improved because of prompt treatment for co-morbidities.

What a difference a year makes--for better and for worse

These are times of turbulence and change at many levels-for the nation at large, within the health care delivery arena broadly, and for nephrology specifically. The factors outlined above have created a degree of complexity in developing solutions for these issues never seen before. We'll see how the next 12 months unfolds.

Increased hemodialysis catheter use in Canada and associated mortality risk: data from the Canadian Organ Replacement Registry 2001-2004

BACKGROUND AND OBJECTIVES

The 1999 Canadian vascular access guidelines recommend the fistula as the access of choice. The study describes the trends in hemodialysis access use, variation among provinces, and the association with mortality from 2001 to 2004.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

An observational study of adult patients registered in Canadian Organ Replacement Registry on hemodialysis. Access trends were examined among incident and prevalent hemodialysis patients adjusted for age, sex, body mass index, late referral, race, smoking status, province, etiology of end-stage renal disease, and comorbidities. Cox proportional hazard regression analysis was used to analyze risk for death for patients followed to December 31, 2005.

RESULTS

From 2001 to 2004, incident catheter use increased from 76.8% to 79.1%, fistulas decreased from 21.6% to 18.6%, and grafts remained between 2.1% to 2.6%. Prevalent catheter use increased from 41.8% to 51.7%, and fistulas and grafts decreased from 46.8% to 41.6% and 11.4% to 6.7%, respectively. There was significant variation in incident and prevalent fistulae use among the provinces. Adjustment for differences in patient characteristics did not change these trends. Incident catheter use was associated with a 6 times greater risk of death compared with fistula or graft use combined.

CONCLUSIONS

In Canada there has been a decrease in fistulae and grafts with a subsequent increase in catheters that is not explained by changes in patient characteristics. Vascular access use varied by province, suggesting differences in practice patterns. Because incident catheter use was associated with increased mortality, urgent measures are needed to develop strategies to decrease catheter use.

[Pro convection: are convective therapies like hemodiafiltration and hemofiltration the future of extracorporeal blood purification?]

In recent years, the age and clinical gravity of hemodialysis patients have been steadily increasing. This unavoidable phenomenon is progressively leading Italian and European nephrologists to perform negative patient selection by treating symptomatic and/or critical cases with extracorporeal blood purification methods that decrease symptoms during sessions and result in reduced morbidity and mortality. While recent studies have failed to confirm the effectiveness of convective therapies in terms of mortality, more recently the advent of online convective therapies has enabled high fluid volume exchange, leading to improved clinical status and purification outcome. These therapies could offer a valid, perhaps even better alternative to mainly diffusive extracorporeal treatments, whether intermittent, daily or 'long and slow'. Indeed, convective therapies, especially biofiltration and/or acetate-free procedures, are able to efficiently purify the blood from molecules that have a major impact on patients' clinical-nutritional and inflammatory status, such as AGEs, myoglobin, osteocalcin, TNF-alpha, homocysteine, ADMA, complement factor D, and phosphates. Moreover, many studies have reduced the adverse effects of convection in terms of mortality: some aspects of the HEMO trial, the DOPPS study and many other European studies have been reassessed. Convective therapies in Europe and Italy differ from the high-flux methods used in the USA, where the convective component is markedly lower than that used in the European trials thanks to the possibility of performing high-infusate online exchanges at no cost. The indicators used for assessing the dialytic suitability of convective procedures should also be reassessed: urea Kt/V should be considerably downsized, and different markers could be used for more complete assessment, especially for medium- and large-molecular-weight uremic toxins, without neglecting the clinical and nutritional status of dialyzed patients. In the nephrologist's daily routine more time should be devoted to clinical assessment so that therapy can be personalized according to the needs of each patient.

[Anti convection: convective therapies aren't the future of extracorporeal blood purification]

Despite technological advances in dialysis therapies and modalities, the mortality and morbidity among patients on hemodialysis (HD) are still high. Membrane permeability, convection techniques, and the number and duration of dialysis sessions have been considered as being potentially related to patient outcome. The available data from 2 randomized controlled clinical trials suggest that treatment with high-flux membranes does not significantly reduce all-cause mortality in kidney patients. However, subgroups of patients such as diabetics, malnourished patients and patients with >3.7 years of dialysis could have a greater survival advantage with high-flux membranes. Interest in alternative hemodialysis regimens has grown substantially during the past decade. Delivered as either daily (1.5 to 2.5 h, 6 d/wk) or nocturnal (6 to 8 h, 6 d/wk) treatment, alternative HD has shown promising results with better control of blood pressure, reduction of left ventricular hypertrophy, and easier control of phosphate metabolism. Elderly patients, patients with heart disease and those with vascular instability during HD could benefit from daily regimens. If well motivated, young patients may improve their dialysis efficiency, nutritional status and work capacity mainly with long nocturnal HD while waiting for a kidney transplant. However, before significant resources are invested in initiating alternative hemodialysis programs, further data on mortality and cardiovascular morbidity, preferably from randomized clinical trials, are required.

Immunogenicity of advanced glycation end products in diabetic patients and in nephropathic non-diabetic patients on hemodialysis or after renal transplantation

Advanced glycation end products (AGE) increase as a consequence of diabetic hyperglycemia and, in nephropathic patients, following renal function loss. Protein-bound AGE behave as immunogens, inducing formation of specific antibodies (Ab-AGE). In this work AGE immunogenicity was studied in 42 diabetic patients, 26 nephropathic patients on hemodialysis and 26 patients with end-stage renal disease who underwent kidney transplantation and in 20 normal subjects. Non-oxidation-derived AGE (nox-AGE), oxidation-derived AGE (ox-AGE) and Ab-AGE were measured by competitive or direct enzyme-linked immunosorbent assay (ELISA) and circulating immune complexes (CIC) by C1q ELISA. Nox- AGE increased significantly in all patient groups (p < or = 0.05 to < or = 0.0001) except in patients on hemodialysis for less than 6 yr. Ox-AGE were only significantly increased in patients transplanted more than 3 yr previously (p < 0.05). Ab-AGE were significantly lower than controls in both diabetic groups and in patients on hemodialysis for more than 6 yr (p < 0.005 to < 0.0001) and not unlike controls in the other groups. These results demonstrate that hemodialysis or renal transplantation can, initially, reduce either nox- or ox-AGE levels, which however go back to being high in time. Renal transplantation fails to normalize nox-AGE. More importantly, plasma Ab-AGE levels are reduced or unchanged in all patient groups in comparison with controls, despite higher circulating AGE levels. This suggests the importance of tissue-bound AGE as Ab-AGE targets. Additional interventions are needed to control AGE levels in treated nephropathic patients. The search and quantification of specific Ab-AGE would give more meaningful results if performed over specific tissue specimens.

Renal transplantation today

BACKGROUND

The first successful renal transplant was carried out more than five decades ago between identical twins. At these early days, acute rejection was the limiting factor.

DISCUSSION

Due to tremendous progress in immunosuppressive therapy and surgical technique, today, renal transplantation is the gold standard therapy for patients with end-stage renal disease. In fact, in comparison with chronic hemodialysis, renal transplantation offers an increase in quality of life while reducing comorbidities associated with dialysis treatment.

RESULTS

Despite numerous beneficial achievements, no further improvement regarding patient outcome can be observed over the last two decades. Graft survival rates remain unchanged. The leading causes for graft loss are chronic allograft nephropathy and death with functioning graft. This might be related to a constant increase of the proportion of donors presenting extended donor criteria as well as a more liberal acceptance of candidates for a renal transplant.

CONCLUSION

In the near future, one has to focus more closely on the posttransplant patient care to minimize factors associated with chronic allograft damage. These include post-transplant diabetes, hyperlipidemia, high blood pressure, cytomegalovirus infection, etc.

[Twenty years of research in the field of haemodialysis: the contribution of the Nephrology Department of Erasme Hospital]

This article summarizes the contribution of the Department of Nephrology, Dialysis, and renal Transplantation to the research in the field of haemodialysis during the last twenty years. The most important contributions are devoted, on the one hand, to the infections and immune defenses of the dialysis patient, on the other hand, to the biocompatibility of the materials used for haemodialysis and to the adverse reactions of the patient to these materials.

[Updates in hemodialysis]

One of the topics of most concern for nephrologists today is how to reduce the mortality of our patients and we try to have markers to help us know which patients are at greatest risk. Cardiovascular disease is one of the main causes of morbidity and mortality in patients with chronic kidney disease. Oxidative stress, inflammation and endothelial dysfunction have been recognized as nontraditional cardiovascular risk factors, but they are achieving growing importance. On the other hand, quality management systems are being applied on an increasing basis in routine clinical practice, demonstrating that the way of working in the center may be a key factor in the results obtained.

The International Quotidian Dialysis Registry: annual report 2007

In view of the need to study both intermediate and definitive outcomes associated with daily and extended-hours hemodialysis (HD), our group has undertaken the design and implementation of an international registry to collect data describing the treatments and outcomes of patients treated with these regimens. The International Quotidian Dialysis Registry began recruiting patients in June 2004. There are currently 229 patients enrolled in the registry, up from 199 last year. The projected growth is 2000 patients by 2008. This paper constitutes the third annual report of progress of patient and center recruitment, and includes descriptive data drawn from the 3 primary patient groups currently tracked by the registry: home nocturnal, home short-daily, and in-center short-daily HD. As the cohort grows, patients will be compared with control subjects drawn from their respective national registries, and comparative analyses will follow.

Trends in hemodialysis vascular access from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) 2000 to 2005

BACKGROUND

Australia historically has been recognized for its high fistula use.

STUDY DESIGN

Observational study using registry data.

SETTING & PARTICIPANTS

Adult patients registered in the Australia and New Zealand Dialysis and Transplant Association Registry on hemodialysis in Australia.

PREDICTOR

Cohort year.

OUTCOMES & MEASUREMENT

Hemodialysis access trends were examined from 2000 to 2005 for incident patients (within 60 days of hemodialysis therapy start), patients on hemodialysis therapy for 6 to 8 months, and prevalent hemodialysis patients. Multivariate analyses were performed to examine the relationship between access type and cohort year for each group, with adjustment for age, sex, race, body mass index, late referral, smoking status, cause of end-stage renal disease, comorbidities, and dialysis vintage.

RESULTS

During 2000 to 2005, catheter use increased from 39% to 53% in incident patients, 10% to 22% in the 6- to 8-month groups, and 6% to 13% in prevalent patients. Fistula use decreased from 56% to 43% in incident patients and 78% to 67% in the 6- to 8-month group and remained at 73% to 75% in prevalent patients. Graft use decreased in all groups. Adjustment for factors associated with access type did not significantly change these results.

LIMITATIONS

The registry collects only the access in use at the end of the survey period; thus, it was not possible to determine whether another access had failed or was present, but not in use. The small number of incident numbers prevented separate analysis of arteriovenous fistulas and arteriovenous grafts.

CONCLUSION

Incident use of fistulas and grafts decreased, with an unexpected increase in both incident and prevalent catheters between 2000 and 2005. Adjustment for factors associated with access type did not significantly alter the trends. Changes in unidentified practice patterns, attitudes, or preferences are contributing to these trends. Ongoing evaluation of data and investigation into processes of care are required to increase functioning fistulas, together with reevaluation of the role of grafts in patients without a fistula.