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Abstract
Current views regarding hemodialysis adequacy reach beyond indices of small solute removal such as Kt/V. Nevertheless, new Kt/V-based constructs such as the standard Kt/V, which adjusts not only for dialysis frequency, but which also represents removal of sequestered solutes rather than easily removed urea, continue to be useful. The scaling of dialysis dose to measures of size other than body water results in higher recommended doses of dialysis for children, small patients, and women, compared with the current body water-based scaling approach. Aside from small solute removal, increasing weekly time on dialysis results in slower removal of fluid with better tolerance and with increased removal of phosphorus, although both salt and water and phosphorus control often respond to efforts to reduce intake. The intermediate term benefits of removing larger middle molecules such as beta-2-microglobulin appear to be modest, and the benefits of removal of protein-bound uremic toxins remain to be proved in controlled trials.
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202
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Palmer SC, Palmer AR, Craig JC, Johnson DW, Stroumza P, Frantzen L, Leal M, Hoischen S, Hegbrant J, Strippoli GFM. Home versus in-centre haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev 2014; 2014:CD009535. [PMID: 25412074 PMCID: PMC7390476 DOI: 10.1002/14651858.cd009535.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Home haemodialysis is associated with improved survival and quality of life in uncontrolled studies. However, relative benefits and harms of home versus in-centre haemodialysis in randomised controlled trials (RCTs) are uncertain. OBJECTIVES To evaluate the benefits and harms of home haemodialysis versus in-centre haemodialysis in adults with end-stage kidney disease (ESKD). SEARCH METHODS The Cochrane Renal Group's Specialised Register was searched up to 31 October 2014. SELECTION CRITERIA RCTs of home versus in-centre haemodialysis in adults with ESKD were included. DATA COLLECTION AND ANALYSIS Data were extracted by two investigators independently. Study risk of bias and other patient-centred outcomes were extracted. Insufficient data were available to conduct meta-analyses. MAIN RESULTS We identified a single cross-over RCT (enrolling 9 participants) that compared home haemodialysis (long hours: 6 to 8 hours, 3 times/week) with in-centre haemodialysis (short hours: 3.5 to 4.5 hours, 3 times/weeks) for 8 weeks in prevalent home haemodialysis patients. Outcome data were limited and not available for the end of the first phase of treatment in this cross-over study which was at risk of bias due to differences in dialysate composition between the two treatment comparisons.Overall, home haemodialysis reduced 24 hour ambulatory blood pressure and improved uraemic symptoms, but increased treatment-related burden of disease and interference in social activities. Insufficient data were available for mortality, hospitalisation or dialysis vascular access complications or treatment durability. AUTHORS' CONCLUSIONS Insufficient randomised data were available to determine the effects of home haemodialysis on survival, hospitalisation, and quality of life compared with in-centre haemodialysis. Given the consistently observed benefits of home haemodialysis on quality of life and survival in uncontrolled studies, and the low prevalence of home haemodialysis globally, randomised studies evaluating home haemodialysis would help inform clinical practice and policy.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Andrew R Palmer
- Consorzio Mario Negri SudDepartment of Clinical Pharmacology and EpidemiologyVia Nationale 8/aMaria ImbaroItaly66030
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - David W Johnson
- Princess Alexandra HospitalDepartment of NephrologyIpswich RdWoolloongabbaQueenslandAustralia4102
| | - Paul Stroumza
- Diaverum MarseilleMedical OfficeRue Gaston BergerMarseilleFrance13010
| | - Luc Frantzen
- Diaverum MarseilleMedical OfficeRue Gaston BergerMarseilleFrance13010
| | - Miguel Leal
- Diaverum PortugalMedical OfficeSintra Business Park, Zona Industrial da AbrunheiraEdificio 4 ‐ Escritorio 2CSintraPortugal2710‐089
| | | | - Jorgen Hegbrant
- Diaverum Renal Services GroupMedical OfficePO Box 4167LundSwedenSE‐227 22
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- Mario Negri Sud ConsortiumDepartment of Clinical Pharmacology and EpidemiologySanta Maria ImbaroItaly
- DiaverumMedical‐Scientific OfficeLundSweden
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203
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Tsai YC, Chiu YW, Kuo HT, Chen SC, Hwang SJ, Chen TH, Kuo MC, Chen HC. Fluid overload, pulse wave velocity, and ratio of brachial pre-ejection period to ejection time in diabetic and non-diabetic chronic kidney disease. PLoS One 2014; 9:e111000. [PMID: 25386836 PMCID: PMC4227653 DOI: 10.1371/journal.pone.0111000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 09/22/2014] [Indexed: 11/19/2022] Open
Abstract
Fluid overload is one of the characteristics in chronic kidney disease (CKD). Changes in extracellular fluid volume are associated with progression of diabetic nephropathy. Not only diabetes but also fluid overload is associated with cardiovascular risk factors The aim of the study was to assess the interaction between fluid overload, diabetes, and cardiovascular risk factors, including arterial stiffness and left ventricular function in 480 patients with stages 4–5 CKD. Fluid status was determined by bioimpedance spectroscopy method, Body Composition Monitor. Brachial-ankle pulse wave velocity (baPWV), as a good parameter of arterial stiffness, and brachial pre-ejection period (bPEP)/brachial ejection time (bET), correlated with impaired left ventricular function were measured by ankle-brachial index (ABI)-form device. Of all patients, 207 (43.9%) were diabetic and 240 (50%) had fluid overload. For non-diabetic CKD, fluid overload was associated with being female (β = –2.87, P = 0.003), heart disease (β = 2.69, P = 0.04), high baPWV (β = 0.27, P = 0.04), low hemoglobin (β = –1.10, P<0.001), and low serum albumin (β = –5.21, P<0.001) in multivariate analysis. For diabetic CKD, fluid overload was associated with diuretics use (β = 3.69, P = 0.003), high mean arterial pressure (β = 0.14, P = 0.01), low bPEP/ET (β = –0.19, P = 0.03), low hemoglobin (β = –1.55, P = 0.001), and low serum albumin (β = –9.46, P<0.001). In conclusion, baPWV is associated with fluid overload in non-diabetic CKD and bPEP/bET is associated with fluid overload in diabetic CKD. Early and accurate assessment of these associated cardiovascular risk factors may improve the effects of entire care in late CKD.
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Affiliation(s)
- Yi-Chun Tsai
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Tien Kuo
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Szu-Chia Chen
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Shang-Jyh Hwang
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
- Institute of Population Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Tzu-Hui Chen
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Mei-Chuan Kuo
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
- * E-mail:
| | - Hung-Chun Chen
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
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204
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Pun PH. The interplay between CKD, sudden cardiac death, and ventricular arrhythmias. Adv Chronic Kidney Dis 2014; 21:480-8. [PMID: 25443573 DOI: 10.1053/j.ackd.2014.06.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 06/04/2014] [Accepted: 06/27/2014] [Indexed: 12/23/2022]
Abstract
CKD patients face an increased risk of cardiovascular disease mortality, and the risk of sudden cardiac death (SCD) increases as kidney function declines. Risk factors for SCD are poorly understood and understudied among CKD patients. In the general population, coronary heart disease-associated risk factors are the most important determinants of SCD risk, but among CKD patients, there is evidence that these factors play a much smaller role. Complex relationships between CKD-specific risk factors, structural heart disease, and arrhythmic triggers contribute to the high risk of SCD and ventricular arrhythmias and modulate the effectiveness of available therapies. This review examines recent data on the epidemiology, pathophysiology, and mechanisms of SCD among CKD patients and examines current evidence regarding the use of pharmacologic and device-based therapies for management of SCD risk.
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205
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Weiner DE, Brunelli SM, Hunt A, Schiller B, Glassock R, Maddux FW, Johnson D, Parker T, Nissenson A. Improving Clinical Outcomes Among Hemodialysis Patients: A Proposal for a “Volume First” Approach From the Chief Medical Officers of US Dialysis Providers. Am J Kidney Dis 2014; 64:685-95. [DOI: 10.1053/j.ajkd.2014.07.003] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 07/07/2014] [Indexed: 01/03/2023]
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206
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Marcelli D, Scholz C, Ponce P, Sousa T, Kopperschmidt P, Grassmann A, Pinto B, Canaud B. High-volume postdilution hemodiafiltration is a feasible option in routine clinical practice. Artif Organs 2014; 39:142-9. [PMID: 25277688 PMCID: PMC4354295 DOI: 10.1111/aor.12345] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hemodiafiltration (HDF) with 20-22 L of substitution fluid is increasingly recognized as associated with significant benefits regarding patient outcome. However, some doubt exists as to whether these high volumes can be achieved in routine clinical practice. A total of 4176 sessions with 366 patients on postdilution HDF were analyzed in this 1-month observational cohort study with prospective data collection. All dialysis machines were equipped with AutoSub plus signal analysis software that automatically and continuously adapts the substitution fluid flow according to the blood flow, blood viscosity, and dialyzer characteristics. Percentages of sessions with different types of vascular access were compared regarding achievement of ≥21 L substitution fluid. Logistic regression analysis was conducted to study the independent relationship of selected variables with achievement of ≥21 L substitution volume. Patient- and dialysis-related variables that showed an association with the convection volume were entered in a multivariable model that included hematocrit up front. Respectively, 87%, 84%, and 33% of routine sessions conducted with fistulas, grafts, and catheters qualified as high-volume HDF. Serum albumin levels ≥4.2 g/dL were positively associated with the achievement of at least 21 L substitution volume. Positive associations were also observed for blood flows in the ranges 350-399 and ≥400 mL/min compared with the reference range (300-350 mL/min), for longer treatment time, for fistula versus catheter, for higher filtration fraction, and for dialysis conducted at the end of the week versus Monday. It can be concluded that implementation and sustainability of high-volume HDF is possible in routine clinical practice for almost all patients treated with fistulas and grafts.
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207
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Castledine C, Caskey FJ. Dialysis modality after renal transplant failure. Perit Dial Int 2014; 33:600-3. [PMID: 24335121 DOI: 10.3747/pdi.2013.00087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Clare Castledine
- Nephrology1 Royal London Hospital London, UK Nephrology2 Richard Bright Renal Unit Bristol UK
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208
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Chazot C, Vo-Van C, Hurot J, Lorriaux C, Mayor B, Deleaval P, Jean G. Ultrafiltration intermittente en hémodialyse : où est le seuil de sécurité ? Nephrol Ther 2014. [DOI: 10.1016/j.nephro.2014.07.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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209
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Port FK. Practice-based versus patient-level outcomes research in hemodialysis: the DOPPS (Dialysis Outcomes and Practice Patterns Study) experience. Am J Kidney Dis 2014; 64:969-77. [PMID: 25151407 DOI: 10.1053/j.ajkd.2014.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 05/27/2014] [Indexed: 11/11/2022]
Abstract
When randomized controlled trials are unavailable, clinicians have to rely on observational studies. However, analyses using observational data to evaluate specific treatments and their associations with outcomes often are biased through confounding by clinical indication for the treatment of interest. Given the rich observational data and limited clinical trial data available in the dialysis population, successfully accounting for this bias can lead to substantial knowledge generation. In recent decades, much has been learned about statistical methods for observational data, including the fact that even extensive adjustments may not always overcome this bias, particularly when unmeasured confounders exist. In this article, examples based on the international DOPPS (Dialysis Outcomes and Practice Patterns Study) are used to demonstrate the value of practice-based instrumental variable analyses. This methodology leverages the marked differences in practice patterns among dialysis facilities and uses the reasonable assumption that patients are assigned to a dialysis facility without consideration of its specific treatment pattern in order to minimize bias in analyses relying on observational data. Examples using the dialysis facility as an instrument that are reviewed in depth in this article include studies of dialysate sodium concentration, systolic blood pressure targets, and treatment time, demonstrate the value of this methodology to produce advanced knowledge. However, practice-based analyses have potential limitations. Specifically, observation of sufficiently large differences in practice patterns is required and these analyses should consider that the treatment of interest may be associated with other facility treatment practices. These examples from the DOPPS hopefully will stimulate advances in methodologies and critical clinical work toward improving patient care by identifying beneficial treatment practices applicable to dialysis, chronic kidney disease, and beyond.
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210
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Dunlop JL, Vandal AC, de Zoysa JR, Gabriel RS, Gerber LM, Haloob IA, Hood CJ, Irvine JH, Matheson PJ, McGregor DOR, Rabindranath KS, Schollum JBW, Semple DJ, Marshall MR. Rationale and design of the Myocardial Microinjury and Cardiac Remodeling Extension Study in the Sodium Lowering in Dialysate trial (Mac-SoLID study). BMC Nephrol 2014; 15:120. [PMID: 25047825 PMCID: PMC4114800 DOI: 10.1186/1471-2369-15-120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 07/14/2014] [Indexed: 01/19/2023] Open
Abstract
Background The Sodium Lowering in Dialysate (SoLID) trial is an ongoing a multi-center, prospective, randomised, single-blind (assessor), controlled, parallel assignment clinical trial, enrolling 96 home and self-care hemodialysis (HD) patients from 7 centers in New Zealand. The trial will evaluate the hypothesis that lower dialysate [Na+] during HD results in lower left ventricular (LV) mass. Since it’s inception, observational evidence has suggested increased mortality risk with lower dialysate [Na+], possibly due to exacerbation of intra-dialytic hypotension and subsequent myocardial micro-injury. The Myocardial Micro-injury and Cardiac Remodeling Extension Study in the Sodium Lowering In Dialysate Trial (Mac-SoLID study) aims to determine whether lower dialysate [Na+] results in (i) increased levels of high-sensitivity Troponin T (hsTnT), a well-established marker of intra-dialytic myocardial micro-injury in HD populations, and (ii) increased fixed LV segmental wall motion abnormalities, a marker of recurrent myocardial stunning and micro-injury, and (iii) detrimental changes in LV geometry due to maladaptive homeostatic mechanisms. Methods/design The SoLID trial and the Mac-SoLID study are funded by the Health Research Council of New Zealand. Key exclusion criteria: patients who dialyse > 3.5 times per week, pre-dialysis serum sodium <135 mM, and maintenance haemodiafiltration. In addition, some medical conditions, treatments or participation in other dialysis trials that contraindicate the study intervention or confound its effects, will be exclusion criteria. The intervention and control groups will receive dialysate sodium 135 mM and 140 mM respectively, for 12 months. The primary outcome measure for the Mac-SOLID study is repeated measures of [hsTnT] at 0, 3, 6, 9, and 12 months. The secondary outcomes will be assessed using cardiac magnetic resonance imaging (MRI), and comprise LV segmental wall motion abnormality scores, LV mass to volume ratio and patterns of LV remodeling at 0 and 12 months. Discussion The Mac-SoLID study enhances and complements the SoLID trial. It tests whether potential gains in cardiovascular health (reduced LV mass) which low dialysate [Na+] is expected to deliver, are counteracted by deterioration in cardiovascular health through alternative mechanisms, namely repeated LV stunning and micro-injury. Trial registration Australian and New Zealand Clinical Trials Registry number: ACTRN12611000975998.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Mark Roger Marshall
- Faculty of Medical and Health Sciences, University of Auckland, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand.
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211
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Sibbel SP, Ficociello LH, Black M, Thakuria M, Mullon C, Diaz-Buxo J, Alfieri TJ. Effects of Crit-Line® monitor use on patient outcomes and epoetin alfa dosing following onset of hemodialysis: a propensity score-matched study. Blood Purif 2014; 37:249-57. [PMID: 24970017 DOI: 10.1159/000362107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 03/06/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Crit-Line® monitor (CLM) is a device for monitoring hematocrit, oxygen saturation and change in intravascular blood volume during hemodialysis. Prior studies have evaluated CLM use in dialysis patients, but not specifically in those new to dialysis. METHODS In this retrospective analysis, 199 patients initiating dialysis at 8 facilities routinely using CLM were compared with 796 propensity score-matched non-CLM patients initiating dialysis at facilities not using CLM. Outcomes were considered over the first 180 days on dialysis. RESULTS Overall, the CLM group had higher StdKt/V (p = 0.06) and received lower doses of intravenous iron than the non-CLM group (p < 0.001). Erythropoiesis-stimulating agent doses were lower in the CLM group in months 1-5. Serum iron and transferrin saturation levels were higher overall for the CLM group than the non-CLM group (p = 0.004 and 0.01, respectively). Hemoglobin levels and time to first hospitalization were similar for both groups. CONCLUSION Use of CLM is associated with lower erythropoiesis-stimulating agent and iron use in incident hemodialysis patients.
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212
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Flythe JE, Mangione TW, Brunelli SM, Curhan GC. Patient-stated preferences regarding volume-related risk mitigation strategies for hemodialysis. Clin J Am Soc Nephrol 2014; 9:1418-25. [PMID: 24903386 DOI: 10.2215/cjn.03280314] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Larger weight gain and higher ultrafiltration rates have been associated with poorer outcomes among patients on dialysis. Dietary restrictions reduce fluid-related risk; however, adherence is challenging. Alternative fluid mitigation strategies include treatment time extension, more frequent dialysis, adjunct peritoneal dialysis, and wearable ultrafiltration devices. No data regarding patient preferences for fluid management exist. A survey was designed, tested, and administered to assess patient-stated preferences regarding fluid mitigation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A written survey concerning fluid-related symptoms, patient and treatment characteristics, and fluid management preferences was developed. The cross-sectional survey was completed by 600 patients on hemodialysis at 18 geographically diverse ambulatory facilities. Comparisons of patient willingness to engage in volume mitigation strategies across fluid symptom burden, dietary restriction experience, and patient characteristics were performed. RESULTS Final analyses included 588 surveys. Overall, if allowed to liberalize fluid intake, 44.6% of patients were willing to extend treatment time by 15 minutes. Willingness to extend treatment time was incrementally less for longer treatment extensions; 12.2% of patients were willing to add a fourth weekly treatment session, and 13.5% of patients were willing to participate in nocturnal dialysis three nights per week. Patients more bothered by their fluid restrictions (versus less bothered) were more willing to engage in fluid mitigation strategies. Demographic characteristics and symptoms, such as cramping and dyspnea, were not consistently associated with willingness to engage in the proposed strategies. More than 25% of patients were unsure of their dry weights and typical interdialytic weight gains. CONCLUSIONS Patients were generally averse to treatment time extension>15 minutes. Patients more bothered (versus less bothered) by their prescribed fluid restrictions were more willing to engage in volume mitigation strategies. Additional study of patient-stated preferences in hemodialysis treatment practices is needed to guide patient care and identify deficiencies in patient treatment and disease-related knowledge.
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Affiliation(s)
| | - Thomas W Mangione
- Health Services Division, John Snow, Inc., Boston, Massachusetts; and
| | | | - Gary C Curhan
- Renal Division and Harvard Medical School, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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213
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Abstract
PURPOSE OF REVIEW This review examines recent advances in understanding of how clinical outcomes for hemodialysis patients may be improved by achieving longer or more frequent treatment times, lower ultrafiltration rates (UFRs), improving nutritional status, and individualizing dialysate composition. This review also discusses the controversy related to timing of dialysis initiation. RECENT FINDINGS Many observational studies and several randomized controlled trials indicate longer dialysis treatment times, particularly nocturnal dialysis, and/or more frequent dialysis improve morbidity and mortality. Recent evidence also suggests that lower UFR and more consistent achievement of 'dry weight' may help minimize the damage from myocardial stunning and chronic volume overload that occurs in the majority of patients who receive conventional hemodialysis during the day with a standard schedule of 3-5 h, 3 times a week. Other aspects of the dialysis procedure such as appropriate estimated glomerular filtration rate for dialysis initiation and individualizing dialysate composition may also minimize cardiovascular risk. Finally, several studies have highlighted the benefits of oral nutritional supplementation (ONS) during dialysis. SUMMARY Greater treatment times per week with slower UFR, consistent attainment of 'dry weight', individualized dialysate prescriptions, and administration of ONS to malnourished patients are likely to reduce hospitalizations and improve survival in this high-risk population of end-stage renal disease patients.
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214
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Lertdumrongluk P, Streja E, Rhee CM, Park J, Arah OA, Brunelli SM, Nissenson AR, Gillen D, Kalantar-Zadeh K. Dose of hemodialysis and survival: a marginal structural model analysis. Am J Nephrol 2014; 39:383-91. [PMID: 24776927 DOI: 10.1159/000362285] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 03/16/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Observational studies have consistently demonstrated the survival benefits of a greater dialysis dose in maintenance hemodialysis (MHD) patients, whereas randomized controlled trials have shown conflicting results. The possible causal impact of dialysis dose on mortality needs to be investigated using rich cohort data analyzed with novel statistical methods such as marginal structural models (MSMs) that account for time-varying confounding and exposure. METHODS We quantified the effect of delivered dose of hemodialysis (HD) [single-pool Kt/V (spKt/V)] on mortality risk in a contemporary cohort of 68,110 patients undergoing HD 3 times weekly (7/2001- 9/2005). We compared conventional Cox proportional hazard and MSM survival analyses, accounting for time-varying confounding by applying longitudinally modeled inverse-probability-of-dialysis-dose weights to each observation. RESULTS In conventional Cox models, baseline spKt/V showed a weak negative association with mortality, while higher time-averaged spKt/V was strongly associated with lower mortality risk. In MSM analyses, compared to a spKt/V range of 1.2 - <1.4, a spKt/V range of <1.2 was associated with a higher risk of mortality [HR (95% CI) 1.67 (1.54 - 1.80)], whereas mortality risks were significantly lower with higher spKt/V [HRs (95% CI): 0.74 (0.70-0.78), 0.63 (0.59-0.66), 0.56 (0.52-0.60), and 0.56 (0.52-0.61) for spKt/V ranges of 1.4 - <1.6, 1.6-<1.8, 1.8 - <2.0, and ≥2.0, respectively]. Thus, MSM analyses showed that the greatest survival advantage of a higher dialysis dose was observed for a spKt/V range of 1.8-<2.0, and the dialysis dose-mortality relationship was robust in almost all subgroups of patients. CONCLUSIONS Higher HD doses were robustly associated with greater survival in MSM analyses that more fully and appropriately accounted for time-varying confounding.
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215
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Chan KE, Thadhani RI, Maddux FW. Adherence barriers to chronic dialysis in the United States. J Am Soc Nephrol 2014; 25:2642-8. [PMID: 24762400 DOI: 10.1681/asn.2013111160] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hemodialysis patients often do not attend their scheduled treatment session. We investigated factors associated with missed appointments and whether such nonadherence poses significant harm to patients and increases overall health care utilization in an observational analysis of 44 million hemodialysis treatments for 182,536 patients with ESRD in the United States. We assessed the risk of hospitalization, emergency room visit, or intensive-coronary care unit (ICU-CCU) admission in the 2 days after a missed treatment relative to the risk for patients who received hemodialysis. Over the 5-year study period, the average missed treatment rate was 7.1 days per patient-year. In covariate adjusted logistic regression, the risk of hospitalization (odds ratio [OR], 3.98; 95% confidence interval [95% CI], 3.93 to 4.04), emergency room visit (OR, 2.00; 95% CI, 1.87 to 2.14), or ICU-CCU admission (OR, 3.89; 95% CI, 3.81 to 3.96) increased significantly after a missed treatment. Overall, 0.9 missed treatment days per year associated with suboptimal transportation to dialysis, inclement weather, holidays, psychiatric illness, pain, and gastrointestinal upset. These barriers also associated with excess hospitalization (5.6 more events per patient-year), emergency room visits (1.1 more visits), and ICU-CCU admissions (0.8 more admissions). In conclusion, poor adherence to hemodialysis treatments may be a substantial roadblock to achieving better patient outcomes. Addressing systemic and patient barriers that impede access to hemodialysis care may decrease missed appointments and reduce patient morbidity.
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Affiliation(s)
- Kevin E Chan
- Clinical Research Division, Fresenius Medical Care North America, Waltham, Massachusetts; and Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Ravi I Thadhani
- Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Franklin W Maddux
- Clinical Research Division, Fresenius Medical Care North America, Waltham, Massachusetts; and
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Alquist M, Bosch JP, Barth C, Combe C, Daugirdas JT, Hegbrant JB, Martin G, McIntyre CW, O'Donoghue DJ, Rodriguez HJ, Santoro A, Tattersall JE, Vantard G, Van Wyck DB, Canaud B. Knowing What We Do and Doing What We Should: Quality Assurance in Hemodialysis. ACTA ACUST UNITED AC 2014; 126:135-43. [DOI: 10.1159/000361050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 02/24/2014] [Indexed: 11/19/2022]
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217
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Abstract
Children with chronic kidney disease stage 5 requiring dialysis can be treated by peritoneal or hemodialysis. In the United Kingdom nearly twice as many children receive peritoneal dialysis compared with hemodialysis. Technical aspects of pediatric hemodialysis are challenging and include the relative size of extracorporeal circuit and child's blood volume, assessment of adequacy,technical and complications of vascular access. Alternatives to standard hospital-based hemodialysis are also increasingly available. Optimizing nutritional status with the support of specialist pediatric dietitians is key to the management of children receiving hemodialysis. The effects of chronic illness on growth and school achievement, as well as the psychological, emotional, and social development of the child should not be underestimated. This review focuses on the above elements and highlights common pediatric practice in the United Kingdom.
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Affiliation(s)
- Amrit Kaur
- Birmingham Childrens' Hospital, Birmingham, UK
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218
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Moledina D, Geller D. Is low dialysate potassium ever indicated in outpatient hemodialysis? Semin Dial 2014; 27:263-5. [PMID: 24635442 DOI: 10.1111/sdi.12212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Dennis Moledina
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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219
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Eloot S, Ledebo I, Ward RA. Extracorporeal Removal of Uremic Toxins: Can We Still Do Better? Semin Nephrol 2014; 34:209-27. [DOI: 10.1016/j.semnephrol.2014.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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220
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Kimata N, Karaboyas A, Bieber BA, Pisoni RL, Morgenstern H, Gillespie BW, Saito A, Akizawa T, Fukuhara S, Robinson BM, Port FK, Akiba T. Gender, low Kt/V, and mortality in Japanese hemodialysis patients: Opportunities for improvement through modifiable practices. Hemodial Int 2014; 18:596-606. [DOI: 10.1111/hdi.12142] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Brian A. Bieber
- Arbor Research Collaborative for Health; Ann Arbor Michigan USA
| | | | - Hal Morgenstern
- Arbor Research Collaborative for Health; Ann Arbor Michigan USA
- Departments of Epidemiology and Environmental Health Sciences; School of Public Health; University of Michigan; Ann Arbor Michigan USA
| | - Brenda W. Gillespie
- Arbor Research Collaborative for Health; Ann Arbor Michigan USA
- Department of Biostatistics; School of Public Health; University of Michigan; Ann Arbor Michigan USA
| | | | - Tadao Akizawa
- Division of Nephrology; Department of Medicine; Showa University School of Medicine; Tokyo Japan
| | - Shunichi Fukuhara
- Department of Epidemiology and Healthcare Research; Kyoto University Graduate School of Medicine and Public Health; Kyoto Japan
| | - Bruce M. Robinson
- Arbor Research Collaborative for Health; Ann Arbor Michigan USA
- Department of Internal Medicine-Nephrology; University of Michigan; Ann Arbor Michigan USA
| | - Friedrich K. Port
- Arbor Research Collaborative for Health; Ann Arbor Michigan USA
- Department of Internal Medicine-Nephrology; University of Michigan; Ann Arbor Michigan USA
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221
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Lu DY, Chen EY, Wong DJ, Yamamoto K, Protack CD, Williams WT, Assi R, Hall MR, Sadaghianloo N, Dardik A. Vein graft adaptation and fistula maturation in the arterial environment. J Surg Res 2014; 188:162-73. [PMID: 24582063 DOI: 10.1016/j.jss.2014.01.042] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/25/2013] [Accepted: 01/24/2014] [Indexed: 12/21/2022]
Abstract
Veins are exposed to the arterial environment during two common surgical procedures, creation of vein grafts and arteriovenous fistulae (AVF). In both cases, veins adapt to the arterial environment that is characterized by different hemodynamic conditions and increased oxygen tension compared with the venous environment. Successful venous adaptation to the arterial environment is critical for long-term success of the vein graft or AVF and, in both cases, is generally characterized by venous dilation and wall thickening. However, AVF are exposed to a high flow, high shear stress, low-pressure arterial environment and adapt mainly via outward dilation with less intimal thickening. Vein grafts are exposed to a moderate flow, moderate shear stress, high-pressure arterial environment and adapt mainly via increased wall thickening with less outward dilation. We review the data that describe these differences, as well as the underlying molecular mechanisms that mediate these processes. Despite extensive research, there are few differences in the molecular pathways that regulate cell proliferation and migration or matrix synthesis, secretion, or degradation currently identified between vein graft adaptation and AVF maturation that account for the different types of venous adaptation to arterial environments.
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Affiliation(s)
- Daniel Y Lu
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Elizabeth Y Chen
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Daniel J Wong
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Kota Yamamoto
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Clinton D Protack
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Willis T Williams
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Roland Assi
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael R Hall
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Nirvana Sadaghianloo
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut; Department of Vascular Surgery, University Hospital of Nice, Nice, France
| | - Alan Dardik
- Yale University Vascular Biology and Therapeutics Program, New Haven, Connecticut; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut.
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222
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Chazot C, Jean G. How is the heart best protected in chronic dialysis patients?: Control of extracellular volume. Semin Dial 2014; 27:335-9. [PMID: 24438057 DOI: 10.1111/sdi.12179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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223
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Golper TA, Fissell R, Fissell WH, Hartle PM, Sanders ML, Schulman G. Hemodialysis: core curriculum 2014. Am J Kidney Dis 2014; 63:153-63. [PMID: 24268927 PMCID: PMC4276338 DOI: 10.1053/j.ajkd.2013.07.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/01/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Thomas A Golper
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN.
| | - Rachel Fissell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - William H Fissell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - P Matthew Hartle
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - M Lee Sanders
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Gerald Schulman
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
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224
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Tsai YC, Tsai JC, Chiu YW, Kuo HT, Chen SC, Hwang SJ, Chen TH, Kuo MC, Chen HC. Is fluid overload more important than diabetes in renal progression in late chronic kidney disease? PLoS One 2013; 8:e82566. [PMID: 24349311 PMCID: PMC3857275 DOI: 10.1371/journal.pone.0082566] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 10/24/2013] [Indexed: 12/22/2022] Open
Abstract
Fluid overload is one of the major presentations in patients with late stage chronic kidney disease (CKD). Diabetes is the leading cause of renal failure, and progression of diabetic nephropathy has been associated with changes in extracellular fluid volume. The aim of the study was to assess the association of fluid overload and diabetes in commencing dialysis and rapid renal function decline (the slope of estimated glomerular filtration rate (eGFR) less than -3 ml/min per 1.73 m(2)/y) in 472 patients with stages 4-5 CKD. Fluid status was determined by bioimpedance spectroscopy method, Body Composition Monitor. The study population was further classified into four groups according to the median of relative hydration status (△HS =fluid overload/extracellular water) and the presence or absence of diabetes. The median level of relative hydration status was 7%. Among all patients, 207(43.9 %) were diabetic. 71 (15.0%) subjects had commencing dialysis, and 187 (39.6%) subjects presented rapid renal function decline during a median 17.3-month follow-up. Patients with fluid overload had a significantly increased risk for commencing dialysis and renal function decline independent of the presence or absence of diabetes. No significantly increased risk for renal progression was found between diabetes and non-diabetes in late CKD without fluid overload. In conclusion, fluid overload has a higher predictive value of an elevated risk for renal progression than diabetes in late CKD.
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Affiliation(s)
- Yi-Chun Tsai
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Jer-Chia Tsai
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Tien Kuo
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Szu-Chia Chen
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Hui Chen
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Mei-Chuan Kuo
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Chun Chen
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
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226
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Harley KT, Streja E, Rhee CM, Molnar MZ, Kovesdy CP, Amin AN, Kalantar-Zadeh K. Nephrologist caseload and hemodialysis patient survival in an urban cohort. J Am Soc Nephrol 2013; 24:1678-87. [PMID: 23929773 PMCID: PMC3785281 DOI: 10.1681/asn.2013020123] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 05/24/2013] [Indexed: 12/16/2022] Open
Abstract
Physician caseload may be a predictor of patient outcomes associated with various medical conditions and procedures, but the association between patient-physician ratio and mortality among patients undergoing hemodialysis has not been determined. We examined whether a higher patient-nephrologist ratio affects patient mortality risk using de-identified data from DaVita dialysis clinics and the U.S. Renal Data System. A total of 41 nephrologists with a caseload of 50-200 hemodialysis patients from an urban California region were retrospectively ranked according to their hemodialysis patient mortality rate during a 6-year period between 2001 and 2007. We calculated all-cause mortality hazard ratios for each nephrologist and compared patient- and provider-level characteristics between the 10 nephrologists with the highest patient mortality rates and the 10 nephrologists with the lowest patient mortality rates. Nephrologists with the lowest patient mortality rates had significantly lower patient caseloads than nephrologists with the highest mortality rates (median [interquartile range], 65 [55-76] versus 103 [78-144] patients per nephrologist, respectively; P<0.001). Additionally, patients treated by nephrologists with the lowest patient mortality rates received higher dialysis doses, had longer sessions, and received more kidney transplants. In demographic characteristic-adjusted analyses, each 50-patient increase in caseload was associated with a 2% increase in patient mortality risk (hazard ratio, 1.02; 95% confidence interval, 1.00 to 1.04; P<0.001). Hence, these results suggest that nephrologist caseload influences hemodialysis patient outcomes, and future research should focus on identifying the factors underlying this association.
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Affiliation(s)
- Kevin T. Harley
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Harold Simmons Center, LABioMed at Harbor-UCLA, Torrance, California
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Division of Nephrology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Miklos Z. Molnar
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Csaba P. Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | - Alpesh N. Amin
- Department of Medicine, University of California Irvine School of Medicine, Irvine, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Harold Simmons Center, LABioMed at Harbor-UCLA, Torrance, California
- Department of Medicine, University of California Irvine School of Medicine, Irvine, California
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227
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Tijink MS, Wester M, Glorieux G, Gerritsen KG, Sun J, Swart PC, Borneman Z, Wessling M, Vanholder R, Joles JA, Stamatialis D. Mixed matrix hollow fiber membranes for removal of protein-bound toxins from human plasma. Biomaterials 2013; 34:7819-28. [DOI: 10.1016/j.biomaterials.2013.07.008] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
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228
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Tentori F, Karaboyas A, Robinson BM, Morgenstern H, Zhang J, Sen A, Ikizler TA, Rayner H, Fissell RB, Vanholder R, Tomo T, Port FK. Association of dialysate bicarbonate concentration with mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2013; 62:738-46. [PMID: 23707043 PMCID: PMC3832240 DOI: 10.1053/j.ajkd.2013.03.035] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 03/21/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Most hemodialysis patients worldwide are treated with bicarbonate dialysis using sodium bicarbonate as the base. Few studies have assessed outcomes of patients treated with different dialysate bicarbonate levels, and the optimal concentration remains uncertain. STUDY DESIGN The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international prospective cohort study. SETTING & PARTICIPANTS This study included 17,031 patients receiving thrice-weekly in-center hemodialysis from 11 DOPPS countries (2002-2011). PREDICTOR Dialysate bicarbonate concentration. OUTCOMES All-cause and cause-specific mortality and first hospitalization, using Cox regression to estimate the effects of dialysate bicarbonate concentration, adjusting for potential confounders. MEASUREMENTS Demographics, comorbid conditions, laboratory values, and prescriptions were abstracted from medical records. RESULTS Mean dialysate bicarbonate concentration was 35.5 ± 2.7 (SD) mEq/L, ranging from 32.2 ± 2.3 mEq/L in Germany to 37.0 ± 2.6 mEq/L in the United States. Prescription of high dialysate bicarbonate concentration (≥38 mEq/L) was most common in the United States (45% of patients). Approximately 50% of DOPPS facilities used a single dialysate bicarbonate concentration. 3,913 patients (23%) died during follow-up. Dialysate bicarbonate concentration was associated positively with mortality (adjusted HR, 1.08 per 4 mEq/L higher [95% CI, 1.01-1.15]; HR for dialysate bicarbonate ≥38 vs 33-37 mEq/L, 1.07 [95% CI, 0.97-1.19]). Results were consistent across levels of pre-dialysis session serum bicarbonate and between facilities that used a single dialysate bicarbonate concentration and those that prescribed different concentrations to individual patients. The association of dialysis bicarbonate concentration with mortality was stronger in patients with longer dialysis vintage. LIMITATIONS Due to the observational nature of the present study, we cannot rule out that the reported associations may be biased by unmeasured confounders. CONCLUSIONS High dialysate bicarbonate concentrations, especially prolonged exposure, may contribute to adverse outcomes, likely through the development of postdialysis metabolic alkalosis. Additional studies are warranted to identify the optimal dialysate bicarbonate concentration.
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Affiliation(s)
- Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI; Vanderbilt University Medical Center, Nashville, TN.
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Tsai YC, Tsai JC, Chen SC, Chiu YW, Hwang SJ, Hung CC, Chen TH, Kuo MC, Chen HC. Association of fluid overload with kidney disease progression in advanced CKD: a prospective cohort study. Am J Kidney Dis 2013; 63:68-75. [PMID: 23896483 DOI: 10.1053/j.ajkd.2013.06.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/12/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Fluid overload is a common phenomenon in patients in a late stage of chronic kidney disease (CKD). However, little is known about whether fluid overload is related to kidney disease progression in patients with CKD. Accordingly, the aim of the study was to assess the association of the severity of fluid status and kidney disease progression in an advanced CKD cohort. STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS This cohort study enrolled 472 non-dialysis-dependent patients with CKD stages 4-5 who were in an integrated CKD care program from January 2011 to December 2011 and followed up until December 2012 or initiation of renal replacement therapy (RRT). PREDICTORS Tertile of fluid overload, with cutoff values at 0.6 and 1.6 L. OUTCOMES RRT, rapid estimated glomerular filtration rate (eGFR) decline (faster than 3 mL/min/1.73 m(2) per year), and change in eGFR. MEASUREMENTS The severity of fluid overload was measured by a bioimpedance spectroscopy method. eGFR was computed using the 4-variable MDRD (Modification of Diet in Renal Disease) Study equation. RESULTS During a median 17.3-month follow-up, 71 (15.0%) patients initiated RRT and 187 (39.6%) experienced rapid eGFR decline. The severity of fluid overload was associated with increased risk of RRT (tertile 3 vs tertile 1: adjusted HR, 3.16 [95% CI, 1.33-7.50]). Fluid overload value was associated with increased risk of rapid eGFR decline (tertile 3 vs tertile 1: adjusted OR, 4.68 [95% CI, 2.30-9.52]). Furthermore, the linear mixed-effects model showed that the reduction in eGFR over time was faster in tertile 3 than in tertile 1 (P=0.02). LIMITATIONS The effect of fluid volume variation over time must be considered. CONCLUSIONS Fluid overload is an independent risk factor associated with initiation of RRT and rapid eGFR decline in patients with advanced CKD.
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Affiliation(s)
- Yi-Chun Tsai
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Jer-Chia Tsai
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Szu-Chia Chen
- Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chi-Chih Hung
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Hui Chen
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Mei-Chuan Kuo
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Hung-Chun Chen
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan
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Abstract
BACKGROUND Clinical outcomes for patients treated in public and private hospitals may be different. AIM The aim of the study was to compare the characteristics and outcomes of patients receiving dialysis at public and private hospitals in Queensland. METHODS Incident adult dialysis patients in Queensland registered with the Australia and New Zealand Dialysis and Transplant Registry between 1999 and 2009 were classified by dialysis modality at either a public or private hospital. Outcomes were dialysis patient characteristics and survival. RESULTS Three thousand, three hundred and ten patients commenced dialysis in public hospitals, 1939 haemodialysis (HD) and 1371 peritoneal dialysis (PD). Seven hundred and ninety-three patients commenced dialysis in private hospitals, 757 HD and 36 PD. Compared with public HD, private HD patients were older, had more coronary artery disease and less diabetes, and were more likely to live in an urban area. Public HD patients were more likely to be obese and referred late to a nephrologist. Nearly all indigenous patients were managed in public hospitals. Private patients were more likely to have an arteriovenous fistula or graft at first HD (P < 0.001) but not after excluding late referrals (P = 0.09). Public hospitals provided longer HD sessions and more HD hours per week for all age groups except 75+ years. Compared with public hospital HD, patient survival adjusted for multiple variables was comparable for private hospital HD (hazard ratio 1.20 (95% confidence interval 0.98-1.46, P = 0.07)) but worse for public PD (hazard ratio 1.14 (95% confidence interval 1.05-1.24, P = 0.002)). CONCLUSION Private HD patients are older and less likely to be diabetic than public patients. Patient survival is worse for public PD than public HD.
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Affiliation(s)
- N A Gray
- Department of Renal Medicine, and The University of Queensland, Sunshine Coast Clinical School, Nambour General Hospital, Nambour, Queensland, Australia.
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231
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Hecking M, Karaboyas A, Antlanger M, Saran R, Wizemann V, Chazot C, Rayner H, Hörl WH, Pisoni RL, Robinson BM, Sunder-Plassmann G, Moissl U, Kotanko P, Levin NW, Säemann MD, Kalantar-Zadeh K, Port FK, Wabel P. Significance of interdialytic weight gain versus chronic volume overload: consensus opinion. Am J Nephrol 2013; 38:78-90. [PMID: 23838386 DOI: 10.1159/000353104] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 04/04/2013] [Indexed: 12/13/2022]
Abstract
Predialysis volume overload is the sum of interdialytic weight gain (IDWG) and residual postdialysis volume overload. It results mostly from failure to achieve an adequate volume status at the end of the dialysis session. Recent developments in bioimpedance spectroscopy and possibly relative plasma volume monitoring permit noninvasive volume status assessment in hemodialysis patients. A large proportion of patients have previously been shown to be chronically volume overloaded predialysis (defined as >15% above 'normal' extracellular fluid volume, equivalent to >2.5 liters on average), and to exhibit a more than twofold increased mortality risk. By contrast, the magnitude of the mortality risk associated with IDWG is much smaller and only evident with very large weight gains. Here we review the available evidence on volume overload and IDWG, and question the use of IDWG as an indicator of 'nonadherence' by describing its association with postdialysis volume depletion. We also demonstrate the relationship between IDWG, volume overload and predialysis serum sodium concentration, and comment on salt intake. Discriminating between volume overload and IDWG will likely lead to a more appropriate management of fluid withdrawal during dialysis. Consensually, the present authors agree that this discrimination should be among the primary goals for dialysis caretakers today. In consequence, we recommend objective measures of volume status beyond mere evaluations of IDWG.
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Affiliation(s)
- Manfred Hecking
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
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232
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Abstract
Dialysis time is increasingly being appreciated as an important measure of dialysis adequacy. Increased dialysis time leads to better control of volume excess, to reduced occurrence of intradialytic hypotension, and to better control of serum phosphorus. Nevertheless, the amount of benefit obtainable by moderate increases in dialysis time in patients following a three-times-per-week schedule has not been well established, and the analysis is confounded by associations between prescribed and/or delivered dialysis time and factors related to patient mortality.
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233
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Kleophas W, Karaboyas A, Li Y, Bommer J, Reichel H, Walter A, Icks A, Rump LC, Pisoni RL, Robinson BM, Port FK. Changes in dialysis treatment modalities during institution of flat rate reimbursement and quality assurance programs. Kidney Int 2013; 84:578-84. [PMID: 23636176 DOI: 10.1038/ki.2013.143] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 02/12/2013] [Accepted: 02/21/2013] [Indexed: 11/09/2022]
Abstract
Dialysis procedure rates in Germany were changed in 2002 from per-session to weekly flat rate payments, and quality assurance was introduced in 2009 with defined treatment targets for spKt/V, dialysis frequency, treatment time, and hemoglobin. In order to understand trends in treatment parameters before and after the introduction of these changes, we analyzed data from 407 to 618 prevalent patients each year (hemodialysis over 90 days) in 14-21 centers in cross-sections of the Dialysis Outcomes and Practice Patterns Study (phases 1-4, 1998-2011). Descriptive statistics were used to report differences over time in the four quality assurance parameters along with erythropoietin-stimulating agent (ESA) and intravenous iron doses. Time trends were analyzed using linear mixed models adjusted for patient demographics and comorbidities. The proportion of patients with short treatment times (less than 4 h) and low spKt/V (below 1.2) improved throughout the study and was lowest after implementation of quality assurance. Hemoglobin levels have increased since 1998 and remained consistent since 2005, with only 8-10% of patients below 10 g/dl. About 90% of patients were prescribed ESAs, with the dose declining since peaking in 2006. Intravenous iron use was highest in 2011. Hence, trends to improve quality metrics for hemodialysis have been established in Germany even after introduction of flat rate reimbursement. Thus, analysis of facility practice patterns is needed to maintain quality of care in a cost-containment environment.
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234
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Hothi DK, Stronach L, Harvey E. Home haemodialysis. Pediatr Nephrol 2013; 28:721-30. [PMID: 23124511 DOI: 10.1007/s00467-012-2322-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Revised: 08/12/2012] [Accepted: 08/13/2012] [Indexed: 11/29/2022]
Abstract
Haemodialysis (HD) began as an intensive care treatment offered to a very select number of patients in an attempt to keep them alive. Outcomes were extremely poor, and the procedure was cumbersome and labor intensive. With increasing expertise and advances in dialysis equipment, HD is now recognised as a life-sustaining treatment that is considered a standard of care for children with end stage renal disease (ESRD). Assessment of efficacy has evolved from mere survival, through achieving minimal standards of "adequate" dialysis with reduced morbidity, towards the provision of "optimal dialysis", which includes attempts to more closely mimic normal renal function, and of individualised care that maximizes the patient's health, psychosocial well-being and life potential. There is a renewed interest in dialysis, and the research profile has extended, exploring themes around convective versus diffusive treatments, HD time versus frequency and home versus in-centre dialysis. The results thus far have led dialysis care full circle from prolonged, home-based therapies to shorter, intense in-centre dialysis back to the belief that long or frequent HD at home achieves the best outcomes.
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Affiliation(s)
- Daljit K Hothi
- Nephrology Department, Great Ormond Street Hospital for Children Foundation Trust, Great Ormond Street, London, UK.
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235
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Murray AM, Seliger S, Lakshminarayan K, Herzog CA, Solid CA. Incidence of stroke before and after dialysis initiation in older patients. J Am Soc Nephrol 2013; 24:1166-73. [PMID: 23620399 DOI: 10.1681/asn.2012080841] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The incidence of stroke is substantially higher among hemodialysis patients than among patients with earlier stages of CKD, but to what extent the initiation of dialysis accelerates the risk for stroke is not well understood. In this cohort study, we analyzed data from incident hemodialysis and peritoneal dialysis patients in 2009 who were at least 67 years old and had Medicare as primary payer. We noted whether each of the 20,979 hemodialysis patients initiated dialysis as an outpatient (47%) or inpatient (53%). One year before initiation, the baseline stroke rate was 0.15%-0.20% of patients per month (ppm) for both outpatient and inpatient initiators. Among outpatient initiators, stroke rates began rising approximately 90 days before initiation, reached 0.5% ppm during the 30 days before initiation, and peaked at 0.7% ppm (8.4% per patient-year) during the 30 days after initiation. The pattern was similar among inpatient initiators, but the stroke rate peaked at 1.5% ppm (18% per patient-year). For both hemodialysis groups, stroke rates rapidly declined by 1-2 months after initiation, fluctuated, and stabilized at approximately twice the baseline rate by 1 year. Among the 620 peritoneal dialysis patients, stroke rates were slightly lower and variable, but approximately doubled after initiation. In conclusion, these data suggest that the process of initiating dialysis may cause strokes. Further studies should evaluate methods to mitigate the risk for stroke during this high-risk period.
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Affiliation(s)
- Anne M Murray
- Divisions of Geriatrics, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.
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236
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Chazot C, Ok E, Lacson E, Kerr PG, Jean G, Misra M. Thrice-weekly nocturnal hemodialysis: the overlooked alternative to improve patient outcomes. Nephrol Dial Transplant 2013; 28:2447-55. [DOI: 10.1093/ndt/gft078] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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237
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Rydell H, Krützen L, Simonsen O, Clyne N, Segelmark M. Excellent long time survival for Swedish patients starting home-hemodialysis with and without subsequent renal transplantations. Hemodial Int 2013; 17:523-31. [PMID: 23577698 DOI: 10.1111/hdi.12046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Survival for patients on dialysis is poor. Earlier reports have indicated that home-hemodialysis is associated with improved survival but most of the studies are old and report only short-time survival. The characteristics of patient populations are often incompletely described. In this study, we report long-term survival for patients starting home-hemodialysis as first treatment and estimate the impact on survival of age, comorbidity, decade of start of home-hemodialysis, sex, primary renal disease and subsequent renal transplantation. One hundred twenty-eight patients starting home-hemodialysis as first renal replacement therapy 1971-1998 in Lund were included. Data were collected from patient files, the Swedish Renal Registry and Swedish census. Survival analysis was made as intention-to-treat analysis (including survival after transplantation) and on-dialysis-treatment analysis with patients censored at the day of transplantation. Ten-, twenty- and thirty-year survival were 68%, 36% and 18%. Survival was significantly affected by comorbidity, age and what decade the patients started home-hemodialysis. For patients younger than 60 years and with no comorbidities, the corresponding figures were 75%, 47% and 23% and a subsequent renal transplantation did not significantly influence survival. Long-term survival for patients starting home-hemodialysis is good, and improves decade by decade. Survival is significantly affected by patient age and comorbidity, but the contribution of subsequent renal transplantation was not significant for younger patients without comorbidities.
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Affiliation(s)
- Helena Rydell
- Department of Nephrology and Transplantation, Skane University Hospital; Department of Clinical Sciences, Lund University, Lund
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238
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Paniagua R, Ventura MDJ, Ávila-Díaz M, Hinojosa-Heredia H, Méndez-Duran A, Cisneros A, Gómez AM, Cueto-Manzano A, Trinidad P, Obrador GT, García-López E, Lindholm B. Reaching Targets for Mineral Metabolism Clinical Practice Guidelines and Its Impact on Outcomes Among Mexican Chronic Dialysis Patients. Arch Med Res 2013; 44:229-34. [DOI: 10.1016/j.arcmed.2013.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 01/23/2013] [Indexed: 11/30/2022]
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239
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Twardowski ZJ, Misra M, Singh AK. Con: Randomized controlled trials (RCT) have failed in the study of dialysis methods. Nephrol Dial Transplant 2013; 28:826-32; discussion 832. [DOI: 10.1093/ndt/gfs307] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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240
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Flythe JE, Curhan GC, Brunelli SM. Disentangling the ultrafiltration rate-mortality association: the respective roles of session length and weight gain. Clin J Am Soc Nephrol 2013; 8:1151-61. [PMID: 23493384 DOI: 10.2215/cjn.09460912] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Rapid ultrafiltration rate is associated with increased mortality among hemodialysis patients. Ultrafiltration rates are determined by interdialytic weight gain and session length. Although both interdialytic weight gain and session length have been linked to mortality, the relationship of each to mortality, independent of the other, is not adequately defined. This study was designed to evaluate whether shorter session length independent of weight gain and larger weight gain independent of session length are associated with increased mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were taken from a national cohort of 14,643 prevalent, thrice-weekly, in-center hemodialysis patients dialyzing from 2005 to 2009 (median survival time, 25 months) at a single dialysis organization. Patients with adequate urea clearance and delivered dialysis session ≥240 and <240 minutes were pair-matched on interdialytic weight gain (n=1794), and patients with weight gain ≤3 and >3 kg were pair-matched on session length (n=2114); mortality associations were estimated separately. RESULTS Compared with delivered session length ≥240, session length <240 minutes was associated with increased all-cause mortality (adjusted hazard ratio [95% confidence interval], 1.32 [1.03 to 1.69]). Compared with weight gain ≤3, weight gain >3 kg was associated with increased mortality (1.29 [1.01 to 1.65]). The associations were consistent across strata of age, sex, weight, and weight gain and session length. Secondary analyses demonstrated dose-response relationships between both and mortality. CONCLUSIONS Among patients with adequate urea clearance, shorter dialysis session length and greater interdialytic weight gain are associated with increased mortality; thus, both are viable targets for directed intervention.
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Affiliation(s)
- Jennifer E Flythe
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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241
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Pickering W. Home haemodialysis dose: how much of a good thing? J Ren Care 2013; 39 Suppl 1:35-41. [PMID: 23464912 DOI: 10.1111/j.1755-6686.2013.00344.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Home dialysis (peritoneal or haemodialysis) in any reasonable guise offers potential benefits compared with in-centre dialysis. Benefits may be overtly patient centred (independence, quality of life), outcome oriented (survival, resolution of left ventricular hypertrophy) or resource friendly (savings on staff costs). The priority placed on each of these areas is likely to vary from patient to patient, and possibly provider to provider. This is the one strength of home haemodialysis (HHD) rather than being viewed as a weakness, as it can offer different benefits to different people. Intuitively, more haemodialysis is better than less, and this is most realistically achieved at home. Indications are that both long nocturnal dialysis and short daily dialysis can offer real objective benefits. LITERATURE REVIEW Critics argue correctly that there is a paucity of robust randomised controlled study data. The complexity of HHD regimens and practice and in-homogeneity of patients means such firm data are unlikely to be forthcoming. However, the positive reports both subjective and objective of patients dialysing at home, and results from the available research suggest that advantages may be seen purely with changing the location of dialysis to home, and independently with enhancing dialysis schedules. CONCLUSION The logical conclusion is that patients undertaking haemodialysis at home should have at least the recommended minimum of four hours three times per week (or equivalent), preferably avoiding the long inter-dialytic interval, but beyond that rigid adherence to a schedule as dogma should be subjugated to patient choice and flexibility, albeit by prior agreement with supervising medical and nursing staff.
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Affiliation(s)
- Warren Pickering
- Northampton General Hospital NHS Trust, Cliftonville, Northampton, UK.
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242
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Tandon T, Sinha AD, Agarwal R. Shorter delivered dialysis times associate with a higher and more difficult to treat blood pressure. Nephrol Dial Transplant 2013; 28:1562-8. [PMID: 23348881 DOI: 10.1093/ndt/gfs597] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Shorter delivered dialysis times are associated with increased all-cause mortality. Whether shorter delivered dialysis times also associate with an increase in blood pressure (BP) and reduce the ability of probing dry weight to lower BP is unclear. METHODS Among patients participating in the Dry-Weight Reduction in Hypertensive Hemodialysis Patients (DRIP) trial, interdialytic ambulatory BP was recorded at baseline, 4 weeks and 8 weeks. Median intradialytic BP was also calculated at each dialysis treatment and associated with the delivered daily dialysis time. RESULTS The median time on dialysis at baseline was 3.6 h per treatment (range 2.5-4.5 h). At baseline, modeled median intradialytic systolic BPs were higher among those who received fewer hours of dialysis. Among subjects who did not have their dry weight probed (control group), the median intradialytic systolic BP continued to be elevated. Probing dry weight (ultrafiltration group) provoked a drop in median intradialytic systolic BP regardless of the delivered dialysis time. However, the reduction in BP was achieved after fewer sessions of dialysis when delivered dialysis was longer in duration. The pattern of change was confirmed using interdialytic ambulatory BP monitoring. CONCLUSIONS Fewer hours of delivered dialysis are associated with a higher systolic BP. Upon probing dry weight, compared with shorter dialysis treatment times, 4 h of delivered dialysis per session provokes reductions in systolic BP over fewer dialysis treatment sessions. Reduction of BP may lag dry-weight reduction when shorter dialysis is delivered.
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Affiliation(s)
- Teena Tandon
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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243
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Fishbane S, Hazzan A. Meeting the 2012 QIP (Quality Incentive Program) clinical measures: strategies for dialysis centers. Am J Kidney Dis 2012; 60:S5-13; quiz S14-7. [PMID: 23063058 DOI: 10.1053/j.ajkd.2012.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 07/11/2012] [Indexed: 11/11/2022]
Abstract
The US Centers for Medicare & Medicaid Services end-stage renal disease Quality Incentive Program (QIP) is a pay-for-performance program that reduces dialysis center payments by up to 2% for suboptimal patient care. In January 2012, the performance year began for payment year 2014, bringing significant changes to the QIP by introducing 6 quality indicators (3 clinical measures and 3 reporting measures) and a new scoring methodology. To succeed under the new QIP, dialysis facilities must meet 3 clinical measures that assess anemia management, hemodialysis adequacy, and vascular access type in patients receiving dialysis treatment, as well as 3 reporting measures that involve the reporting of dialysis safety events, attestation of administering a patient satisfaction survey, and attestation of patient mineral metabolism monitoring. To help dialysis providers reach these targets, this article provides an overview of the 3 clinical measures and the QIP scoring methodology, as well as a description of patient claims that are excluded when the scores for these measures are calculated. Strategies and solutions that address provider- and patient-related factors also are discussed to help ensure that more dialysis centers meet the new QIP clinical measures for performance year 2012/payment year 2014.
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Affiliation(s)
- Steven Fishbane
- North Shore-LIJ Health System, Department of Medicine, Division of Nephrology, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA.
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244
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Ramirez SPB, Kapke A, Port FK, Wolfe RA, Saran R, Pearson J, Hirth RA, Messana JM, Daugirdas JT. Dialysis dose scaled to body surface area and size-adjusted, sex-specific patient mortality. Clin J Am Soc Nephrol 2012; 7:1977-87. [PMID: 22977208 PMCID: PMC3513738 DOI: 10.2215/cjn.00390112] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 08/15/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES When hemodialysis dose is scaled to body water (V), women typically receive a greater dose than men, but their survival is not better given a similar dose. This study sought to determine whether rescaling dose to body surface area (SA) might reveal different associations among dose, sex, and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Single-pool Kt/V (spKt/V), equilibrated Kt/V, and standard Kt/V (stdKt/V) were computed using urea kinetic modeling on a prevalent cohort of 7229 patients undergoing thrice-weekly hemodialysis. Data were obtained from the Centers for Medicare & Medicaid Services 2008 ESRD Clinical Performance Measures Project. SA-normalized stdKt/V (SAN-stdKt/V) was calculated as stdKt/V × ratio of anthropometric volume to SA/17.5. Patients were grouped into sex-specific dose quintiles (reference: quintile 1 for men). Adjusted hazard ratios (HRs) for 1-year mortality were calculated using Cox regression. RESULTS spKt/V was higher in women (1.7 ± 0.3) than in men (1.5 ± 0.2; P<0.001), but SAN-stdKt/V was lower (women: 2.3 ± 0.2; men: 2.5 ± 0.3; P<0.001). For both sexes, mortality decreased as spKt/V increased, until spKt/V was 1.6-1.7 (quintile 4 for men: HR, 0.62; quintile 3 for women: HR, 0.64); no benefit was observed with higher spKt/V. HR for mortality decreased further at higher SAN-stdKt/V in both sexes (quintile 5 for men: HR, 0.69; quintile 5 for women: HR, 0.60). CONCLUSIONS SA-based dialysis dose results in dose-mortality relationships substantially different from those with volume-based dosing. SAN-stdKt/V analyses suggest women may be relatively underdosed when treated by V-based dosing. SAN-stdKt/V as a measure for dialysis dose may warrant further study.
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245
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Transpiration stimulée afin d’améliorer l’équilibre hydro-sodé chez les patients hémodialysés : à propos d’un cas. Nephrol Ther 2012; 8:472-5. [DOI: 10.1016/j.nephro.2012.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 01/24/2012] [Accepted: 02/13/2012] [Indexed: 11/22/2022]
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246
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Tentori F, Zhang J, Li Y, Karaboyas A, Kerr P, Saran R, Bommer J, Port F, Akiba T, Pisoni R, Robinson B. Longer dialysis session length is associated with better intermediate outcomes and survival among patients on in-center three times per week hemodialysis: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2012; 27:4180-8. [PMID: 22431708 PMCID: PMC3529546 DOI: 10.1093/ndt/gfs021] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 01/16/2012] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Longer dialysis session length (treatment time, TT) has been associated with better survival among hemodialysis (HD) patients. The impact of TT on clinical markers that may contribute to this survival advantage is not well known. METHODS Using data from the international Dialysis Outcomes and Practice Patterns Study, we assessed the association of TT with clinical outcomes using both standard regression analyses and instrumental variable approaches. The study included 37,414 patients on in-center HD three times per week with prescribed TT from 120 to 420 min. RESULTS Facility mean TT ranged from 214 min in the USA to 256 min in Australia-New Zealand. Accounting for country effects, mortality risk was lower for patients with longer TT {hazard ratio for every 30 min: all-cause mortality: 0.94 [95% confidence interval (CI): 0.92-0.97], cardiovascular mortality: 0.95 (95% CI: 0.91-0.98) and sudden death: 0.93 (95% CI: 0.88-0.98)}. Patients with longer TT had lower pre- and post-dialysis systolic blood pressure, greater intradialytic weight loss, higher hemoglobin (for the same erythropoietin dose), serum albumin and potassium and lower serum phosphorus and white blood cell counts. Similar associations were found using the instrumental variable approach, although the positive associations of TT with weight loss and potassium were lost. CONCLUSIONS Favorable levels of a variety of clinical markers may contribute to the better survival of patients receiving longer TT. These findings support longer TT prescription in the setting of in-center, three times per week HD.
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247
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Robinson BM, Bieber B, Pisoni RL, Port FK. Dialysis Outcomes and Practice Patterns Study (DOPPS): its strengths, limitations, and role in informing practices and policies. Clin J Am Soc Nephrol 2012; 7:1897-905. [PMID: 23099654 DOI: 10.2215/cjn.04940512] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan 48104, USA.
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248
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Damasiewicz MJ, Polkinghorne KR, Kerr PG. Water quality in conventional and home haemodialysis. Nat Rev Nephrol 2012; 8:725-34. [PMID: 23090444 DOI: 10.1038/nrneph.2012.241] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Dialysis water can be contaminated by chemical and microbiological factors, all of which are potentially hazardous to patients on haemodialysis. The quality of dialysis water has seen incremental improvements over the years, with advances in water preparation, monitoring and disinfection methods, and high standards are now readily achievable in clinical practice. Advances in dialysis membrane technology have refocused attention on water quality and its potential role in the bioincompatibility of haemodialysis circuits and adverse patient outcomes. The role of ultrapure dialysate is increasingly being advocated, given its proposed clinical benefits and relative ease of production as a result of the widespread use of reverse osmosis and ultrafiltration. Many of the issues pertaining to water quality in hospital-based dialysis units are also pertinent to haemodialysis in the home. Furthermore, an increased awareness of the environmental and financial consequences of home haemodialysis has resulted in the development of automated and more efficient dialysis machines. These new machines have an increased emphasis on water conservation and recycling along with a decreased need for a complex infrastructure for water purification and maintenance.
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Affiliation(s)
- Matthew J Damasiewicz
- Department of Nephrology, Monash Medical Centre, Locked Bag 29, Clayton, VIC 3168, Australia
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249
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Shorter length dialysis sessions are associated with increased mortality, independent of body weight. Kidney Int 2012; 83:104-13. [PMID: 23014457 PMCID: PMC3532519 DOI: 10.1038/ki.2012.346] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hemodialysis patients have high rates of mortality that may be related to aspects of the dialytic procedure. In prior studies, shorter length dialysis sessions have been associated with decreased survival, but these studies may have been confounded by body size differences. Here we tested whether in-center three-times-weekly hemodialysis patients with adequate urea clearances but shorter dialysis session length is associated with mortality independent of body size. Data were taken from a large national cohort of patients from a large dialysis organization undergoing three-times-weekly in-center hemodialysis. In the primary analysis, patients with prescribed dialysis sessions greater and less than 240 min were pair-matched on post-dialysis weight as well as on age, gender, and vascular access type. Compared to prescribed longer dialysis sessions, session lengths less than 240 min were significantly associated with increased all-cause mortality (adjusted hazard ratio 1.26). The association was consistent across strata of age, gender, and dialysis post-weight. Secondary analyses found a dose-response between prescribed session length and survival. Thus, among patients with adequate urea clearance, shorter dialysis session lengths are associated with increased mortality independent of body weight.
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250
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Lewicki MC, Kerr PG, Polkinghorne KR. Blood pressure and blood volume: acute and chronic considerations in hemodialysis. Semin Dial 2012; 26:62-72. [PMID: 23004343 DOI: 10.1111/sdi.12009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hypertension is highly prevalent yet poorly controlled in the majority of dialysis patients and represents a significant burden of disease, with rates of morbidity and mortality greater than those in the general population. In dialysis, blood volume plays a critical role in the pathogenesis of hypertension, with expansion of extracellular volume increasingly recognized as an independent risk factor for morbidity and mortality. Within the current paradigm of dialysis prescription the majority of patients remain chronically volume expanded. However, management of blood pressure and volume state is difficult for clinicians with a paucity of randomized evidence adding to the complexity of nonlinear morbidity and mortality associations. With dialysis itself as a significant cardiac stressor, control of volume state is critical to minimize intradialytic hemodynamic instability, aid in preservation of cardiac anatomy and prevent progression to cardiovascular morbidity and mortality. This review explores the relationship of blood volume to blood pressure and potential targets for management in this at risk population.
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Affiliation(s)
- Michelle C Lewicki
- Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia
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