US Renal Data System 2018 Annual Data Report: Epidemiology of Kidney Disease in the United States

Nomogram for predicting 1-, 5-, and 10-year survival in hemodialysis (HD) patients: a single center retrospective study

Objectives

Risk of death is high for hemodialysis (HD) patients but it varies considerably among individuals. There is few clinical tool to predict long-term survival rates for HD patients yet. The aim of this study was to develop and validate a easy-to-use nomogram for prediction of 1-, 5-, and 10-year survival among HD patients.

Methods

This study retrospectively enrolled 643 adult HD patients who was randomly assigned to two cohorts: the training cohort (n = 438) and validation cohort (n = 205), univariate survival analyses were performed using Kaplan–Meier’s curve with log-rank test and multivariate Cox regression analyses were performed to identify predictive factors, and a easy-to-use nomogram was established. The performance was assessed using the area under the curve (AUC), calibration plots, and decision curve analysis.

Results

The score included seven commonly available predictors: age, diabetes, use of arteriovenous fistula (AVF), history of emergency temporary dialysis catheter placement, cardiovascular disease (CVD), hemoglobin (Hgl), and no caregiver. The score revealed good discrimination in the training and validation cohort (AUC 0.779 and 0.758, respectively) and the calibration plots showed well calibration, indicating suitable performance of the nomogram model. Decision curve analysis showed that the nomogram added more net benefit compared with the treat-all strategy or treat-none strategy with a threshold probability of 10% or greater.

Conclusions

This easy-to-use nomogram can accurately predict 1-, 5-, and 10-year survival for HD patients, which could be used in clinical decision-making and clinical care.

Abbreviations:

Cost-Effectiveness of Empagliflozin in Patients With Diabetic Kidney Disease in the United States: Findings Based on the EMPA-REG Outcome Trial

RATIONALE & OBJECTIVE

Benefits of sodium-glucose co-transporter 2 inhibitors on kidney outcomes have been demonstrated in clinical trials. Among patients with type 2 diabetes and established cardiovascular (CV) disease enrolled in EMPA-REG Outcome Study (NCT01131676), empagliflozin added to standard of care (SoC) reduced the risk of incident or worsening nephropathy compared to SoC alone. This analysis evaluated the cost-effectiveness of empagliflozin versus SoC alone in the subpopulation with diabetic kidney disease (DKD) from the perspective of United States (US) commercial insurers and Medicare.

STUDY DESIGN

Discrete event simulation model.

SETTING & POPULATION

Patients with DKD in a US healthcare system.

INTERVENTIONS

Empagliflozin 10 or 25 mg with SoC versus SoC alone. SoC included glucose-lowering therapies and medications to treat CV risk factors.

OUTCOMES

Incremental cost-effectiveness ratios (ICERs, 2020 US dollars per quality-adjusted life-year [QALY] gained). Costs and QALYs were discounted 3.0%/year. Model, Perspective, & Timeframe: Cost-effectiveness analysis, commercial insurers and Medicare perspective, lifetime horizon.

RESULTS

The ICER of empagliflozin with SoC versus SoC alone was $25,974/QALY. Empagliflozin added 0.67 QALYs and $17,322/patient over a lifetime horizon. Results were driven by fewer clinical events (including CV death, heart failure [HF] hospitalization, albuminuria progression, and a composite kidney outcome) experienced by patients receiving empagliflozin with SoC versus SoC alone. Results were sensitive to rates of CV death, non-fatal MI, and HF hospitalization, as well as to drug costs, and time horizon. Probabilistic sensitivity analyses indicated 91% of simulations falling below $50,000/QALY.

LIMITATIONS

The EMPA-REG Outcome Study was not powered to assess treatment benefits in a subgroup and excluded patients with estimated glomerular filtration rate <30 mL/min/1.73m².

CONCLUSION

Based on EMPA-REG Outcome Study, this cost-effectiveness analysis suggests that for commercial insurers and Medicare, adding empagliflozin to SoC may be a cost-effective treatment option for patients with DKD.

New Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race

BACKGROUND

Current equations for estimated glomerular filtration rate (eGFR) that use serum creatinine or cystatin C incorporate age, sex, and race to estimate measured GFR. However, race in eGFR equations is a social and not a biologic construct.

METHODS

We developed new eGFR equations without race using data from two development data sets: 10 studies (8254 participants, 31.5% Black) for serum creatinine and 13 studies (5352 participants, 39.7% Black) for both serum creatinine and cystatin C. In a validation data set of 12 studies (4050 participants, 14.3% Black), we compared the accuracy of new eGFR equations to measured GFR. We projected the prevalence of chronic kidney disease (CKD) and GFR stages in a sample of U.S. adults, using current and new equations.

RESULTS

In the validation data set, the current creatinine equation that uses age, sex, and race overestimated measured GFR in Blacks (median, 3.7 ml per minute per 1.73 m2 of body-surface area; 95% confidence interval [CI], 1.8 to 5.4) and to a lesser degree in non-Blacks (median, 0.5 ml per minute per 1.73 m2; 95% CI, 0.0 to 0.9). When the adjustment for Black race was omitted from the current eGFR equation, measured GFR in Blacks was underestimated (median, 7.1 ml per minute per 1.73 m2; 95% CI, 5.9 to 8.8). A new equation using age and sex and omitting race underestimated measured GFR in Blacks (median, 3.6 ml per minute per 1.73 m2; 95% CI, 1.8 to 5.5) and overestimated measured GFR in non-Blacks (median, 3.9 ml per minute per 1.73 m2; 95% CI, 3.4 to 4.4). For all equations, 85% or more of the eGFRs for Blacks and non-Blacks were within 30% of measured GFR. New creatinine-cystatin C equations without race were more accurate than new creatinine equations, with smaller differences between race groups. As compared with the current creatinine equation, the new creatinine equations, but not the new creatinine-cystatin C equations, increased population estimates of CKD prevalence among Blacks and yielded similar or lower prevalence among non-Blacks.

CONCLUSIONS

New eGFR equations that incorporate creatinine and cystatin C but omit race are more accurate and led to smaller differences between Black participants and non-Black participants than new equations without race with either creatinine or cystatin C alone. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.).

Cost-Effectiveness of Targeted Exome Analysis as a Diagnostic Test in Glomerular Diseases

BACKGROUND

Despite the emergence of diagnostic and clinical utility evidence in nephrology, publicly funded access to genomic testing is restricted in most health care systems. To establish genomic sequencing as a clinical test, an evaluation of cost-effectiveness is urgently required.

METHODS

An economic evaluation, informed by a primary clinical study and available clinical evidence and guidelines in nephrology, was performed to evaluate the cost-effectiveness and optimal timing of exome sequencing (ES) in adults and children with suspected monogenic glomerular diseases compared with nongenomic investigations (NGIs). Six diagnostic strategies reflecting current practice and recommended models of care in Australia were modeled: (i) NGIs, (ii) late gene panel followed by ES, (iii) late ES, (iv) early gene panel, (v) early gene panel followed by ES, and (vi) early ES.

RESULTS

ES with targeted analysis achieved a diagnosis in 23 of 63 (36.5%) adults and 10 of 24 (41.6%) children. NGIs were estimated to diagnose 4.0% of children, with an average estimated cost of AU$6120 per child. Integrating ES as a first-line test in children was cost saving, with an incremental cost saving of AU$3230 per additional diagnosis compared with NGIs. In adults, NGIs was estimated to diagnose 8% of patients, with an average estimated cost of AU$1830 per person. In adults, integrating ES early resulted in an incremental cost per additional diagnosis of AU$5460 relative to NGIs.

CONCLUSIONS

Early ES with targeted analysis was effective for diagnosing monogenic kidney disease, with substantial cost savings in children.

Effects of calcitriol on peripheral endothelial progenitor cells and renal renovation in rats with chronic renal failure

BACKGROUND

The role of calcitriol (1,25-dihydroxyvitamin D₃ or 1,25-(OH)₂D₃) in physiological processes, such as anti-fibrosis, anti-inflammation, and immunoregulation is known; however, its role in the remodeling of the glomerular capillary endothelium in rats with chronic renal failure (CRF) remains unclear.

METHODS

Here, we analyzed the role/number of endothelial progenitor cells (EPCs), renal function, and pathological alterations in rats with CRF, and compared the results before and after supplementation with calcitriol in vivo.

RESULTS

Amongst the three experimental groups (sham group, CRF group, and calcitriol-treated group (0.03 μg/kg/d), we observed substantially elevated cell adhesion and vasculogenesis in vivo in the calcitriol-treated group. Additionally, lower levels of serum creatinine (Scr) and blood urea nitrogen (BUN) was recorded in the calcitriol-treated group than the CRF group (p > 0.05). Calcitriol treatment also resulted in an improvement in renal pathological injury.

CONCLUSIONS

Thus, calcitriol could ameliorate the damage of glomerular arterial structural and renal tubules vascular network integrity, maybe through regulating the number and function of EPCs in the peripheral blood of CRF rats. Treatment with it may improve outcomes in patients with renal insufficiency or combined cardiac insufficiency. Calcitriol could ameliorate CRF-induced renal pathological injury and renal dysfunction by remodeling of the glomerular capillary endothelium, thus, improving the function of glomerular endothelial cells.

Kidney disease in diabetes: From mechanisms to clinical presentation and treatment strategies

Metabolic and haemodynamic perturbations and their interaction drive the development of diabetic kidney disease (DKD) and its progression towards end stage renal disease (ESRD). Increased mitochondrial oxidative stress has been proposed as the central mechanism in the pathophysiology of DKD, but other mechanisms have been implicated. In parallel to increased oxidative stress, inflammation, cell apoptosis and tissue fibrosis drive the relentless progressive loss of kidney function affecting both the glomerular filtration barrier and the renal tubulointerstitium. Alteration of glomerular capillary autoregulation is at the basis of glomerular hypertension, an important pathogenetic mechanism for DKD. Clinical presentation of DKD can vary. Its classical presentation, often seen in patients with type 1 diabetes (T1DM), features hyperfiltration and albuminuria followed by progressive fall in renal function. Patients can often also present with atypical features characterised by progressive reduction in renal function without albuminuria, others in conjunction with non-diabetes related pathologies making the diagnosis, at times, challenging. Metabolic, lipid and blood pressure control with lifestyle interventions are crucial in reducing the progressive renal function decline seen in DKD. The prevention and management of DKD (and parallel cardiovascular disease) is a huge global challenge and therapies that target haemodynamic perturbations, such as inhibitors of the renin-angiotensin-aldosterone system (RAAS) and SGLT2 inhibitors, have been most successful.

Impact of Social Vulnerability on Access to Educational Programming Designed to Enhance Living Donation

INTRODUCTION

Transplant candidate participation in the Living Donor Navigator Program is associated with an increased likelihood of achieving living donor kidney transplantation; yet not every transplant candidate participates in navigator programming.

RESEARCH QUESTION

We sought to assess interest and ability to participate in the Living Donor Navigator Program by the degree of social vulnerability.

DESIGN

Eighty-two adult kidney-only candidates initiating evaluation at our center provided Likert-scaled responses to survey questions on interest and ability to participate in the Living Donor Navigator Program. Surveys were linked at the participant-level to the Centers for Disease Control and Prevention Social Vulnerability Index and county health rankings and overall social vulnerability and subthemes, individual barriers, telehealth capabilities/ knowledge, interest, and ability to participate were assessed utilizing nonparametric Wilcoxon ranks sums tests, chi-square, and Fisher's exact tests.

RESULTS

Participants indicating distance as a barrier to participation in navigator programming lived approximately 82 miles farther from our center. Disinterested participants lived in areas with the highest social vulnerability, higher physical inactivity rates, lower college education rates, and higher uninsurance (lack of insurance) and unemployment rates. Similarly, participants without a computer, who never heard of telehealth, and who were not encouraged to participate in telehealth resided in areas of highest social vulnerability.

CONCLUSION

These data suggest geography combined with being from under-resourced areas with high social vulnerability was negatively associated with health care engagement. Geography and poverty may be surrogates for lower health literacy and fewer health care interactions.

Estimation of the prevalence of type 2 diabetes in combination with diabetic kidney disease and identification of the associated factors in patients attending primary hospitals in Anhui Province, China

Objective

To evaluate the prevalence of type 2 diabetes mellitus (T2DM) with chronic kidney disease (DM-CKD) and identify the associated factors in patients attending primary hospitals in Anhui Province, China.

Methods

A multi-stage sampling method was used to collect the demographic information, general clinical data, and details of the kidney disease of patients in 2019 through a questionnaire survey, physical examination, and laboratory examination.

Results

A total of 1067 patients with T2DM were studied, of whom 345 had chronic kidney disease (CKD; 32.33%); 18.8%, 12.2%, 58.0%, 9.9% and 1.2% of the participants had stages 1 to 5 CKD. Fifty-point-three percent of the participants were female and they were 59 ± 11.3 years old. Multivariate regression analysis revealed that age, systolic blood pressure, the duration of diabetes, hyperlipidaemia, and smoking were associated with DM-CKD. The duration of diabetes was positively associated with body mass index, 2-hour postprandial glucose, fasting blood glucose concentration, glycosylated haemoglobin, total cholesterol concentration and triglyceride concentration.

Conclusions

The incidence of DM-CKD is relatively high in primary hospitals in Anhui Province. Appropriate preventive and therapeutic measures should be instituted according to the age, the duration of diabetes, sex, hypertension, smoking habits, and lipidaemia of patients.

Shared decision making for the initiation and continuation of dialysis: a proposal from the Japanese Society for Dialysis Therapy

Background

In Japan, forgoing life-sustaining treatment to respect the will of patients at the terminal stage is not stipulated by law. According to the Guidelines for the Decision-Making Process in Terminal-Stage Healthcare published by the Ministry of Health, Labor and Welfare in 2007, the Japanese Society for Dialysis Therapy (JSDT) developed a proposal that was limited to patients at the terminal stage and did not explicitly cover patients with dementia. This proposal for the shared decision-making process regarding the initiation and continuation of maintenance hemodialysis was published in 2014.

Methods and results

In response to changes in social conditions, the JSDT revised the proposal in 2020 to provide guidance for the process by which the healthcare team can provide the best healthcare management and care with respect to the patient's will through advance care planning and shared decision making. For all patients with end-stage kidney disease, including those at the nonterminal stage and those with dementia, the decision-making process includes conservative kidney management.

Conclusions

The proposal is based on consensus rather than evidence-based clinical practice guidelines. The healthcare team is therefore not guaranteed to be legally exempt if the patient dies after the policies in the proposal are implemented and must respond appropriately at the discretion of each institution.

Chronic Kidney Disease on Health-Related Quality of Life in Patients with Diabetes Mellitus: A National Representative Study

Importance: With an increasing prevalence of diabetes mellitus (DM) and comorbid chronic kidney disease (CKD), health-related quality of life (HRQoL) in patients with DM and CKD needs to be better understood. Objective: To investigate the association between the severity of CKD on HRQoL in DM patients. Design: A cross-sectional study of a nationally representative population-based survey, the Korea National Health and Nutrition Examination Survey (KNHANES). Setting: Data collected between 2007 and 2018 from the KNHANES. Participants: Adult participants with DM who completed the self-administered European Quality of Life Questionnaire Five Dimension (EQ-5D) questionnaire (n = 7243). Exposures: CKD stages defined by the Kidney Disease Improving Global System (KDIGO) staging system. Main Outcomes and Measures: We estimated the odds ratios (ORs) and 95% confidence intervals (CIs) of the presence of having problems in the 5 dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) of EQ-5D by CKD stage after adjusting for socio-demographic parameters and comorbid conditions. In addition, the EQ-5D index, reflecting the overall health status, was compared across CKD stages. Results: Among 7243 participants (mean (standard error) age 58.2 (0.2) 56.9% male), 24.0% (n = 1768) had CKD and 8.6% (n = 775) had stage 3–5 CKD. Pain/discomfort was the most common problem (30.5%) among patients with DM. Participants with more advanced CKD were more likely to experience problems in all dimensions of EQ-5D except the anxiety/depression dimension. In particular, compared to those without CKD, the adjusted ORs (95% CI) for any problem in the usual activities dimension was 1.65 (1.30, 2.10) in CKD stage 3 and 4.23 (2.07, 8.67) in CKD stage 4–5. Moreover, participants with stage 3 (−0.016 (−0.029, −0.003)) and stage 4–5 CKD (−0.088 (−0.129, −0.048)) had significantly lower EQ-5D index than those without CKD. However, compared with no CKD, CKD stage 1–2 was not significantly associated with having any problem in any dimensions. Conclusions and Relevance: In this nationally representative study, patients with DM had a high prevalence of self-reported poor HRQoL and the prevalence increased with more advanced stages of CKD. Therefore, assessment of HRQoL and interventions are necessary at early stages of CKD in DM patients.

Effect of Marital Status on Depression and Mortality among Patients with Chronic Kidney Disease from National Health and Nutrition Examination Survey 2005-2014

BACKGROUND

The relationship between marital status and CKD is rarely studied. We aimed to explore the effect of marital status on the depression and mortality of patients with CKD.

METHODS

The data sources came from the NHANES database during 2005-2014 and 3,865 participants were included in this study. We used logistic regression models to examine the relationship between marital status and depression of CKD patients. The Cox proportional hazard models were used to evaluate the association between marital status and mortality of CKD patients.

RESULTS

In terms of depression in CKD patients, unmarried patients had a worse situation than married patients. Meanwhile, after adjusting the covariables, unmarried patients had increased risk of depression (OR = 1.26, 95% CI: 1.01-1.57) compared with married CKD patients, especially in males (OR = 1.45, 95% CI: 1.02-2.06) and patients with more than college education level (OR = 12.4, 95% CI: 3.75-41.02). There was a significant relationship between marital status and mortality of general CKD patients (HR = 1.36, 95% CI: 1.17-1.58). Moreover, marriage showed a protective effect against death among male patients, patients with school graduate or less and more than college educational level, patients with high income, and patients in different estimated glomerular filtration rate groups.

CONCLUSIONS

The use of large numbers of participants has revealed the effect of marital status on CKD patients. Unmarried ones had a higher risk of depression than married ones among CKD patients. Meanwhile, the risk of death was higher in unmarried ones than married ones among CKD patients in this study.

Delay Early CKD with Lifestyle Intervention in African Americans with Diabetic Kidney Disease (DELAY DKD): A Pre-Post Pilot Study (Preprint)

Background

Behavioral factors, such as lifestyle, have been shown to explain approximately 24% of the excess risk of chronic kidney disease (CKD) among African Americans. However, there are limited intervention studies culturally tailored to African Americans with type 2 diabetes mellitus and CKD.

Objective

The main objective of this study was to examine the feasibility and preliminary efficacy of a culturally tailored lifestyle intervention among African Americans with type 2 diabetes mellitus and CKD.

Methods

A pre-post design was used to test the feasibility of a lifestyle intervention in 30 African American adults recruited from the Medical University of South Carolina between January 2017 and February 2017. A research nurse delivered the manualized study intervention weekly for 6 weeks. Clinical outcomes (hemoglobin A_1c, blood pressure, and estimated glomerular filtration rate [eGFR]) were measured at baseline and postintervention. Disease knowledge, self-care, and behavior outcomes were also measured using validated structured questionnaires at baseline and postintervention. Descriptive statistics and effect sizes were calculated to determine clinically important changes from baseline.

Results

Significant pre-post mean differences and decreases were observed for hemoglobin A_1c (mean 0.75%, 95% CI 0.16-1.34; P=.01), total cholesterol (mean 16.38 mg/dL, 95% CI 5.82-26.94; P=.004), low-density lipoprotein (mean 13.73 mg/dL, 95% CI 3.91-23.54; P=.008), and eGFR (mean 6.73 mL/min/1.73m², 95% CI 0.97-12.48; P=.02). Significant pre-post mean differences and increases were observed for CKD self-efficacy (mean −11.15, 95% CI −21.55 to −0.75; P=.03), CKD knowledge (mean −2.62, 95% CI −3.98 to −1.25; P<.001), exercise behavior (mean −1.21, 95% CI −1.96 to −0.46; P=.003), and blood sugar testing (mean −2.15, 95% CI −3.47 to −0.83; P=.003).

Conclusions

This study provides preliminary data for a large-scale appropriately powered randomized controlled trial to examine a culturally tailored lifestyle intervention in African Americans with type 2 diabetes mellitus and CKD in order to improve clinical, knowledge, self-care, and behavior outcomes in this population.

Acute kidney injury and aging

Our aging population is growing and developing treatments for age-related diseases such as Alzheimer's and Parkinson's disease has taken on an increasing urgency and is accompanied by high public awareness. The already high and rising incidence of acute kidney injury (AKI) in the elderly, however, has received relatively little attention despite the potentially fatal outcomes associated with an episode of AKI in this age group. When discussing AKI and aging, one should consider two aspects: first, elderly patients have an increased susceptibility to an AKI episode, and second, they have decreased kidney repair after AKI given the high incidence of progression to chronic kidney disease (CKD). It is unclear if the same factors that drive the increased susceptibility to AKI could be playing a role in the decreased repair capacity or if they are totally different and unrelated. This review will examine current knowledge on the risk factors for the increased susceptibility to AKI in the elderly and will also explore potential aspects that might contribute to a decreased kidney repair response in this age group.

Hemodialysis leads to plasma depletion of lectin complement pathway initiator molecule ficolin-2

INTRODUCTION

This study aimed to investigate changes in complement system-related molecules in patients undergoing hemodialysis.

METHODS

Patients >18 years of age on maintenance hemodialysis were included. Using enzyme-linked immunosorbent assays (ELISA) methods complement related molecules ficolin-1, ficolin-2, ficolin-3 mannose-binding lectin, long pentraxin 3, complement activation products C3c, and complement activation potentials were measured before and after a single hemodialysis treatment. All patients were dialyzed with synthetic high flux filters >1.6 m2 , respectively, Polyamix and Polysulfone, and the Kt/V was maintained >1.3.

FINDINGS

Three hundred and four patients were included. There was a modest decrease in plasma level of ficolin-1 (p < 0.001). Ficolin-2 was virtually depleted with median 3.9 (interquartile range [IQR]: 2.6-6.1, range 0.3-13.5) μg/ml before dialysis to median 0.0 (IQR: 0.0-0.5, range 0.0-5.5) μg/ml after dialysis (p < 0.001). No significant difference before and after hemodialysis was seen for mannose-binding lectin and long pentraxin 3 (p > 0.05). In a random subgroup of 160 patients ficolin-2-binding, ficolin-3-mediated lectin pathway capacity and classical pathway capacity were significantly decreased due to hemodialysis. The complement capacity of the alternative pathway was increased after hemodialysis (p = 0.0101), while mannose-binding lectin-mediated lectin pathway capacity was unaltered (p = 0.79). There was an increase in the complement activation product C3c (p < 0.0001), while the concentration of total C4 and C3 did not change (p > 0.158). Multivariate Cox proportional hazard analyses showed an increased risk for all-cause mortality with increasing ficolin-2 (p = 0.002) after hemodialysis.

DISCUSSION

Plasma ficolin-2 was virtually depleted from the circulation after hemodialysis. However, elevated plasma ficolin-2 levels after hemodialysis was independently associated with increased mortality.

Association of dyskalemias with short-term health care utilization in patients with advanced CKD

BACKGROUND: Patients with advanced chronic kidney disease (CKD) are at high risk for dyskalemias, which may induce arrhythmias that require immediate emergent or hospital care. The association of dyskalemias with short-term hospital/emergency room (ER) visits in advanced CKD is understudied. OBJECTIVE: To assess the association of dyskalemias with short-term hospital/ER visits in an advanced CKD population. METHODS: From among 102,477 US veterans transitioning to dialysis from 2007 to 2015, we identified 21,366 patients with 2 predialysis outpatient eGFR < 30 ml/min/1.73m2 90-365 days apart (with the second eGFR serving as the index date) and at least 1 potassium (K) in the baseline period (1 year before index) and 1 outpatient K (oK) in the follow-up (1 year after the index but before dialysis initiation). We examined the association of time-varying hypokalemia (K < 3.5 mEq/L) and hyperkalemia (K > 5.5 mEq/L) vs referent (3.5-5.5 mEq/L) with separate hospital and ER visits within 2 calendar days following each oK value over the 1-year follow-up period from the index. We used generalized estimating equations with binary distribution and logit link to model the exposure-outcome relationship adjusted for various confounders. We conducted various subgroup and sensitivity analyses to test the robustness of our results. RESULTS: Over the 1-year follow-up, 125,266 oK measurements were observed, of which 6.8% and 3.7% were classified as hyper- and hypokalemia, respectively. In the multivariable-adjusted model, hyperkalemia (adjusted odds ratio [aOR] = 2.04; 95% CI = 1.88-2.21) and hypokalemia (aOR = 1.66; 95% CI = 1.48-1.86) were associated with significantly higher odds of hospital visits. Similarly, hyperkalemia (aOR = 1.83; 95% CI = 1.65-2.03) and hypokalemia (aOR = 1.24; 95% CI = 1.07-1.44) were associated with significantly higher odds of ER visits. Results were robust to subgroups and sensitivity analyses. CONCLUSIONS: In patients with advanced CKD, dyskalemias are associated with higher risk of hospital/ER visits. Interventions targeted at lowering the risk of dyskalemias might help in reducing the health care utilization and associated economic burden among patients with advanced CKD experiencing dyskalemias. DISCLOSURES: This study was supported by grant 5U01DK102163 from the National Institute of Health (NIH) to Kamyar Kalantar-Zadeh and Csaba P. Kovesdy and by resources from the US Department of Veterans Affairs. The data reported here have been supplied in part by the United States Renal Data System (USRDS). Support for VA/CMS data were provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (project numbers SDR 02-237 and 98-004). Opinions expressed in this article are those of the authors and do not necessarily represent the opinion of the Department of Veterans Affairs or the funding institution. Kovesdy has received honoraria from Akebia, Ardelyx, Astra Zeneca, Bayer, Boehringer-Ingelheim, Cara Therapeutics, Reata, and Tricida unrelated to this study. Kalantar-Zadeh has received honoraria and/or support from Abbott, Abbvie, ACI Clinical (Cara Therapeutics), Akebia, Alexion, Amgen, American Society of Nephrology, Astra-Zeneca, Aveo, BBraun, Chugai, Cytokinetics, Daiichi, DaVita, Fresenius, Genentech, Haymarket Media, Hofstra Medical School, International Federation of Kidney Foundations, International Society of Hemodialysis, International Society of Renal Nutrition & Metabolism, Japanese Society of Dialysis Therapy, Hospira, Kabi, Keryx, Kissei, Novartis, OPKO, National Institutes of Health, National Kidney Foundations, Pfizer, Regulus, Relypsa, Resverlogix, Dr Schaer, Sandoz, Sanofi, Shire, Veterans Affairs, Vifor, UpToDate, and ZS-Pharma, unrelated to this study. Gatwood has received research support from AstraZeneca, Merck & Co., and GlaxoSmithKline unrelated to this study. Obi has received research support from Relypsa/Vifor Pharma Inc. The remaining authors declare that they have no relevant financial interests.

Super high-flux membrane dialyzers improve mortality in patients on hemodialysis: a 3-year nationwide cohort study

Introduction

In Japan, dialyzers are classified based on β₂-microglobulin clearance. Type I dialyzers are classified as low-flux dialyzers (<10 mL/min clearance), type II and III as high-flux dialyzers (≥10 to <30 mL/min and ≥30 to <50 mL/min clearance, respectively), and type IV and V as super high-flux dialyzers (≥50 to <70 mL/min and ≥70 mL/min clearance, respectively). Super high-flux dialyzers are commonly used, but their superiority over low-flux dialyzers is controversial.

Methods

In this nationwide prospective cohort study, we analyzed Japanese Society for Dialysis Therapy Renal Data Registry data collected at the end of 2008 and 2011. We enrolled 242,467 patients on maintenance hemodialysis and divided them into five groups by dialyzer type. We assessed the associations of each dialyzer type with 3-year all-cause mortality using Cox proportional hazards models and performed propensity score matching analysis, adjusting for potential confounders.

Results

By the end of 2011, 53,172 (21.9%) prevalent dialysis patients had died. Mortality significantly decreased according to dialyzer type. Hazard ratios (HRs) were significantly higher for type I, II and III compared with type IV (reference) after adjustment for basic factors and further adjustment for dialysis-related factors. HR was significantly higher for type I, but significantly lower for type V, after further adjustment for nutrition- and inflammation-related factors. These significant findings were also evident after propensity score matching.

Conclusions

Hemodialysis using super high-flux dialyzers might reduce mortality. Randomized controlled trials are warranted to clarify whether these type V dialyzers can improve prognosis.

Caveolin-1 in Kidney Chronic Antibody-Mediated Rejection: An Integrated Immunohistochemical and Transcriptomic Analysis Based on the Banff Human Organ Transplant (B-HOT) Gene Panel

Caveolin-1 overexpression has previously been reported as a marker of endothelial injury in kidney chronic antibody-mediated rejection (c-ABMR), but conclusive evidence supporting its use for daily diagnostic practice is missing. This study aims to evaluate if Caveolin-1 can be considered an immunohistochemical surrogate marker of c-ABMR. Caveolin-1 expression was analyzed in a selected series of 22 c-ABMR samples and 11 controls. Caveolin-1 immunohistochemistry proved positive in peritubular and glomerular capillaries of c-ABMR specimens, irrespective of C4d status whereas all controls were negative. Multiplex gene expression profiling in c-ABMR cases confirmed Caveolin-1 overexpression and identified additional genes (n = 220) and pathways, including MHC Class II antigen presentation and Type II interferon signaling. No differences in terms of gene expression (including Caveolin-1 gene) were observed according to C4d status. Conversely, immune cell signatures showed a NK-cell prevalence in C4d-negative samples compared with a B-cell predominance in C4d-positive cases, a finding confirmed by immunohistochemical assessment. Finally, differentially expressed genes were observed between c-ABMR and controls in pathways associated with Caveolin-1 functions (angiogenesis, cell metabolism and cell–ECM interaction). Based on our findings, Caveolin-1 resulted as a key player in c-ABMR, supporting its role as a marker of this condition irrespective of C4d status.

Effectiveness of a brief positive skills intervention to improve psychological adjustment in patients with end-stage kidney disease newly initiated on haemodialysis: protocol for a randomised controlled trial (HED-Start)

INTRODUCTION

Initiation onto haemodialysis is a critical transition that entails multiple psychosocial and behavioural demands that can compound mental health burden. Interventions guided by self-management and cognitive-behavioural therapy to improve distress have been variably effective yet are resource-intensive or delivered reactively. Interventions with a focus on positive affect for patients with end-stage kidney disease are lacking. This study will seek (1) to develop a positive life skills intervention (HED-Start) combining evidence and stakeholder/user involvement and (2) evaluate the effectiveness of HED-Start to facilitate positive life skills acquisition and improve symptoms of distress and adjustment in incident haemodialysis patients.

METHODS AND ANALYSIS

This is a single/assessor-blinded randomised controlled trial (RCT) to compare HED-Start to usual care. In designing HED-Start, semistructured interviews, a codesign workshop and an internal pilot will be undertaken, followed by a two-arm parallel RCT to evaluate the effectiveness of HED-Start. A total of 148 incident HD patients will be randomised using a 1:2 ratio into usual care versus HED-Start to be delivered in groups by trained facilitators between January 2021 and September 2022. Anxiety and depression will be the primary outcomes; secondary outcomes will be positive and negative affect, quality of life, illness perceptions, self-efficacy, self-management skills, benefit finding and resilience. Assessments will be taken at 2 weeks prerandomisation (baseline) and 3 months postrandomisation (2 weeks post-HED-Start completion). Primary analyses will use an intention-to-treat approach and compare changes in outcomes from baseline to follow-up relative to the control group using mixed-effect models.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Nanyang Technological University Institutional Review Board (IRB-2019-01-010). Written informed consent will be obtained before any research activities. Trial results will be disseminated via publications in peer-reviewed journals and conference presentations and will inform revision(s) in renal health services to support the transition of new patients to haemodialysis.

TRIAL REGISTRATION NUMBER

NCT04774770.

Sacubitril/valsartan in chronic kidney disease: From pharmacological mechanism to clinical application

Chronic kidney disease (CKD) is an irreversible, progressive disease characterized by persistent kidney damage, and significantly increased risks of cardiovascular event. However, therapeutic strategies to prevent or slow the progression of CKD remain limited. Sacubitril/valsartan (LCZ696), the representative of the first novel angiotensin receptor-neprilysin inhibitor, has been incorporated into clinical practice guidelines for improving outcomes as a milestone in patients with heart failure. Considering the complex and close relationship between CKD and heart failure, LCZ696 may be beneficial in the treatment of CKD. This review summarizes the pharmacological mechanism and clinical application of LCZ696 in patients with CKD, including its effect on cardiovascular risk and renal outcome, together with potential adverse events. Additionally, due to the influence of serum creatinine and estimated glomerular filtration rate on LCZ696 in patients with heart failure, we also discussed the effects of LCZ696 in patients with advanced CKD and end-stage renal disease. It should be noted that, current clinical studies on LCZ696 are mostly carried out in patients with heart failure, and renal indicators are selected as secondary outcomes. Therefore, more researches should be conducted in patients with CKD alone in the future, to determine the efficacy and safety of LCZ696 in patients with CKD.

Risk factors and outcomes of cardiovascular disease readmission within the first year after dialysis in peritoneal dialysis patients

Background

In the first year of dialysis, patients are vulnerable to cardiovascular disease (CVD) hospitalization, but knowledge regarding the risk factors and long-term outcomes of cardiovascular readmission within the first year after dialysis in incident continuous ambulatory peritoneal dialysis (CAPD) patients is limited.

Methods

This retrospective cohort study was conducted in incident CAPD patients. The demographic characteristics, laboratory parameters, and CVD readmission were collected and analyzed. The primary outcome was all-cause mortality, and the secondary outcomes included CVD mortality, infection-related mortality and technique failure. A logistic regression was used to identify the risk factors associated with CVD readmission within the first year after dialysis. Cox proportional hazards models were used to evaluate the association between CVD readmission and the outcomes.

Results

In total, 1589 peritoneal dialysis (PD) patients were included in this study, of whom 120 (7.6%) patients had at least one episode of CVD readmission within the first year after dialysis initiation. Advanced age, CVD history, and a lower level of serum albumin were independently associated with CVD readmission. CVD readmission within the first year after dialysis was significantly associated with all-cause (HR 2.66, 95%CI 1.91–3.70, p < 0.001) and CVD (HR 3.42, 95%CI 2.20–5.31, p < 0.001) mortality, but not infection-related mortality or technique failure, after adjusting for confounders.

Conclusions

Our findings suggest that an advanced age, a history of CVD, and a lower level of serum albumin were independently associated with CVD readmission. Moreover, CVD readmission was associated with all-cause and cardiovascular mortality in incident CAPD patients.

Cardiac geometry, function, and remodeling patterns in patients under maintenance hemodialysis and peritoneal dialysis treatment

Cardiovascular disease is the leading cause of mortality in patients with end-stage-kidney disease. Evidence on the possible echocardiographic differences between hemodialysis and peritoneal dialysis (PD) is scarce. This study aimed to evaluate differences in left (LA) and right atrial (RA), left (LV) and right ventricular (RV) geometry, systolic and diastolic function in hemodialysis, and PD patients. Thirty-eight hemodialysis and 38 PD patients were matched for age, sex, and dialysis vintage. Two-dimensional and tissue-Doppler echocardiography, and lung ultrasound were performed during an interdialytic day in hemodialysis and before a programmed follow-up visit in PD patients. Vena cava diameter (11.09 ± 4.53 vs. 14.91 ± 4.30 mm; p < 0.001) was significantly lower in hemodialysis patients. Indices of LA, RA, LV, and RV dimensions were similar between the two groups. LVMi (116.91 [38.56] vs. 122.83 [52.33] g/m² ; p = 0.767) was similar, but relative wall thickness was marginally (0.40 [0.14] vs. 0.45 [0.15] cm; p = 0.055) lower in hemodialysis patients. LV hypertrophy prevalence was similar between groups (73.7% vs. 71.1%; p = 0.798), but hemodialysis patients presented eccentric and PD patients concentric LVH. Regarding ventricular systolic function, stroke volume (p = 0.030) and cardiac output (p = 0.036) were higher in hemodialysis, while RV systolic pressure (RVSP) (20.37 [22.54] vs. 27.68 [14.32] mm Hg; p = 0.009) was higher in PD. No significant differences were evidenced in diastolic function indices and lung water excess between the two groups. A moderate association was noted between ultrasound B-lines score and LA volume index (r = 0.465, p < 0.001), RVSP (r = 0.431, p < 0.001), and E/e' ratio (r = 0.304, p = 0.009). Hemodialysis and PD patients present largely similar echocardiographic indices reflecting cardiac geometry, systolic, and diastolic function, but different patterns of abnormal LV remodeling.

Preoperative renal dysfunction and long-term survival after surgery for non-small cell lung cancer

OBJECTIVE

To investigate the association of preoperative renal dysfunction and long-term outcomes following lung cancer surgery.

METHODS

Using the Japanese Lung Cancer Registry data, we retrospectively examined 16,377 patients who underwent surgery for non-small cell lung cancer during 2010. Patients' renal function status was categorized as follows: serum creatinine <1.5 mg/dL (control, n = 16,169), serum creatinine ≥1.5 mg/dL with no dialysis (nondialysis-dependent chronic kidney disease, n = 113), and dialysis-dependent end-stage renal disease (n = 95). The association of patients' characteristics with overall survival was evaluated using multivariate Cox proportional hazard model.

RESULTS

The 5-year overall survival rates in patients with dialysis-dependent end-stage renal disease and with nondialysis-dependent chronic kidney disease were significantly worse than that in the control group (52.9% and 57.5% vs 78.0%; P < .001 for both comparisons), but were comparable to the reported 5-year overall survival rates in the natural history of end-stage renal disease (∼60%) and moderate to severe chronic kidney disease (∼50%). Cancer causes not related to lung cancer accounted for 62.2% of deaths in dialysis-dependent end-stage renal disease, which was more frequent than that in the control group (P = .002). Dialysis-dependent end-stage renal disease and nondialysis-dependent chronic kidney disease were independent risk factors for overall survival after lung cancer surgery (hazard ratio, 2.05 [P < .001] and hazard ratio, 2.04 [P = .001], respectively).

CONCLUSIONS

Preoperative renal dysfunction may be adversely associated with overall survival after lung cancer surgery. Our findings could aid patients to set proper expectation of the risks and benefits about surgery for lung cancer.

Use of Sertraline in Hemodialysis Patients

Depression and anxiety are the most common psychiatric disorders in end-stage renal disease (ESRD) patients treated with hemodialysis (HD) and may correlate with lower quality of life and increased mortality. Depression treatment in HD patients is still a challenge both for nephrologists and psychiatrists. The possible treatment of depressive disorders can be pharmacological and non-pharmacological. In our article, we focus on the use of sertraline, the medication which seems to be relatively safe and efficient in the abovementioned population, taking under consideration several limitations regarding the use of other selective serotonin reuptake inhibitors (SSRIs). In our paper, we discuss different aspects of sertraline use, taking into consideration possible benefits and side effects of drug administration like impact on QTc (corrected QT interval) prolongation, intradialytic hypotension (IDH), chronic kidney disease-associated pruritus (CKD-aP), bleeding, sexual functions, inflammation, or fracture risk. Before administering the medication, one should consider benefits and possible side effects, which are particularly significant in the treatment of ESRD patients; this could help to optimize clinical outcomes. Sertraline seems to be safe in the HD population when provided in proper doses. However, we still need more studies in this field since the ones performed so far were usually based on small samples and lacked placebo control.

Effect of profit status in facilities on the mortality of patients on long-term haemodialysis: a nationwide cohort study

OBJECTIVES

Over the past two decades, debates on whether the profit status of dialysis facilities influences patient prognosis have been popular in the USA. Taiwan is one of the regions with the highest rate per capita of kidney replacement therapy worldwide, but no similar research has been conducted to date. This is the first study to address this issue.

DESIGN

This was a nationwide retrospective cohort study based on the Taiwan Renal Registry Data System.

SETTING

Patients were categorised into two groups based on the profit status (for-profit, not-for-profit (NFP)) of dialysis facilities, with 31 350 patients in each group. The patients were followed up from 2005 to 2012.

PARTICIPANTS

Patients with uraemia who underwent long-term haemodialysis in private dialysis facilities and public facilities were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Survival analyses were performed to compare prognosis between the two groups. Adjustments to patients' basic profile, and facilities' geographical distribution, level, and length of ownership were carried out to minimise possible confounding effects.

RESULTS

Analysis revealed that NFP dialysis facilities had better outcomes (HR=0.91, 95% CI (0.89 to 0.93)). A favourable effect remains with the adjustment of the facilities' level, geographical distribution (HR=0.89, 95% CI (0.86 to 0.93)) or length of ownership (HR=0.95, 95% CI (0.89 to 0.95)). Survival analysis based on the geographical distribution and level of facilities was also conducted, which showed better prognosis in medical centres in the six municipalities, whereas worse prognosis was found in local hospitals not located in these municipalities.

CONCLUSION

Our findings suggest that in contemporary settings in Taiwan, treatment at NFP dialysis facilities was associated with a better prognosis. The results should be interpreted with caution since the possibility of residual confounding effects and uncertainty of casual relations exist due to the nature of observational studies.

Role of different types of nanomaterials against diagnosis, prevention and therapy of COVID-19

In 2019, a novel type of coronavirus emerged in China called SARS-COV-2, known COVID-19, threatens global health and possesses negative impact on people's quality of life, leading to an urgent need for its diagnosis and remedy. On the other hand, the presence of hazardous infectious waste led to the increase of the risk of transmitting the virus by individuals and by hospitals during the COVID-19 pandemic. Hence, in this review, we survey previous researches on nanomaterials that can be effective for guiding strategies to deal with the current COVID-19 pandemic and also decrease the hazardous infectious waste in the environment. We highlight the contribution of nanomaterials that possess potential to therapy, prevention, detect targeted virus proteins and also can be useful for large population screening, for the development of environmental sensors and filters. Besides, we investigate the possibilities of employing the nanomaterials in antiviral research and treatment development, examining the role of nanomaterials in antiviral- drug design, including the importance of nanomaterials in drug delivery and vaccination, and for the production of medical equipment. Nanomaterials-based technologies not only contribute to the ongoing SARS- CoV-2 research efforts but can also provide platforms and tools for the understanding, protection, detection and treatment of future viral diseases.

Plasma and Urine Biomarkers of CKD: A Review of Findings in the CKiD Study

Serum creatinine and level of proteinuria, as biomarkers of chronic kidney disease (CKD) progression, inadequately explain the variability of glomerular filtration rate decline, and are late markers of glomerular filtration rate decline. Recent studies have identified plasma and urine biomarkers at higher levels in children with CKD and also associate independently with CKD progression, even after adjustment for serum creatinine and proteinuria. These novel biomarkers represent diverse biologic pathways of tubular injury, tubular dysfunction, inflammation, and tubular health, and can be used as a liquid biopsy to better characterize CKD in children. In this review, we highlight the biomarker findings from the Chronic Kidney Disease in Children cohort, a large longitudinal study of children with CKD, and compare results with those from other pediatric CKD cohorts. The biomarkers in focus in this review include plasma kidney injury molecule-1, monocyte chemoattractant protein-1, fibroblast growth factor-23, tumor necrosis factor receptor-1, tumor necrosis factor receptor-2, soluble urokinase plasminogen activator receptor, and chitinase-3-like protein 1, as well as urine epidermal growth factor, α-1 microglobulin, kidney injury molecule-1, monocyte chemoattractant protein-1, and chitinase-3-like protein 1. Blood and urine biomarkers improve our ability to prognosticate CKD progression and may improve our understanding of CKD pathophysiology. Further research is required to establish how these biomarkers can be used in the clinical setting to improve the clinical management of CKD.

Spiritual well-being of patients with chronic renal failure: A cross-sectional study

AIMS

The study aimed to investigate the relationship among physical symptom distress, sleep quality, depression and spiritual well-being of patients with chronic renal failure (CRF) and analyse the predictors of the spiritual well-being.

DESIGN

A cross-sectional study.

METHODS

A total of 188 patients were selected. The collection tools were the Physical Symptom Distress Scale, the Chinese version of PSQI, the Geriatric Depression Scale and the Spiritual Well-Being Scale. Hierarchical regression analysis was conducted using SPSS 20.0.

RESULTS

Patients with different treatments exhibited significantly different physical symptom distress. Furthermore, spiritual well-being was significantly negatively correlated with physical symptom distress, poor sleep disturbances and depression. After controlling for the variables, sleep quality and haemodialysis treatment were the key predictors of spiritual well-being.

CONCLUSION

To achieve holistic caregiving for patients' physiological, psychological and spiritual health, Nurses should evaluate patients' symptom distress and depression when providing care for these patients to enhance their spiritual well-being.

Quantifying Regional and Health Care Variations to Identify Ways to Improve Hemodialysis Service Quality and Survival Outcomes

The authors examined variations in hemodialysis care and quantified the effect of these variations on all-cause mortality. Insurance claims data from April 1, 2017 to March 30, 2018 were reviewed. In total, 2895 hospital patients were identified, among whom 398 died from various causes. Controlling effects of the facility and secondary medical care areas, all-cause mortality was associated with older age, heart failure, malignancy, cerebral stroke, severe comorbidity, and the first and ninth centile of physician density. Multilevel analyses indicated a significant variation at facility level (σ22 0.27, 95% confidence interval: 0.09-0.49). Inclusion of all covariates in the final model significantly reduced facility-level variance. Physician density emerged as an important factor affecting survival outcome; thus, a review of workforce and resource allocation policies is needed. Better clinical management and standardized work processes are necessary to attenuate differences in hospital practice patterns.

Urgent start peritoneal dialysis: Is there room for more?

BACKGROUND

Despite the increasing prevalence of end-stage renal disease, peritoneal dialysis (PD) is still offered to a minor subset of patients. One way to increment the utilization rates of this technique is the early start of PD after catheter placement, but there are several concerns related to this approach.

METHODS

Retrospective analysis in a single-center; 52 patients, 34.6% of the patients started in the first 14 days after catheter placement (Urgent start Group - Group 1) and percentage started PD in a conventional mode (Non-urgent start Group - Group 2). Baseline data, short-term (90-day) clinical outcomes, mechanical complications and infectious episodes were compared among Groups.

RESULTS

At baseline, Group 1 had an higher Charlson Comobidity Index (CCI). Exchange volumes were significantly lower in Group 1, as expected. Short-term outcomes were equal except for iPTH and albumin, both lower in urgent-start Group (p<0.05). Episodes of leak, catheter dysfunction and rate of infections were similar among Groups (p>0.05). In Urgent-start Group we didn't observed a higher risk for the first peritonitis episode (HR 0.68; 95% CI 0.24-1.99; p>0.05), higher dropout rate or risk to quit the technique (long rank test, p>0.05; HR 0.57; 95% CI 0.29-1.13; p>0.05).

CONCLUSION

According to our observations, urgent-start PD seems to be a valid and safe alternative to urgent hemodialysis with central venous catheter and should be offered to patients without major contraindications.

Obesity-related indices are associated with albuminuria and advanced kidney disease in type 2 diabetes mellitus

Obesity is an important risk factor for the development of diseases including diabetes, hypertension, and cardiovascular disease. However, few reports have investigated the relationships between these obesity-related indices and diabetic nephropathy. The aim of this study was to evaluate associations between obesity-related markers with albuminuria and advanced kidney disease in patients with type 2 diabetes mellitus (DM). Obesity-related indices including body mass index (BMI), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), body roundness index (BRI), conicity index (CI), lipid accumulation product (LAP), visceral adiposity index (VAI), body adiposity index (BAI), abdominal volume index (AVI), body shape index (BSI), and triglyceride glucose (TyG) index were measured. Albuminuria was defined as a urine albumin/creatinine ratio of ≥30 mg/g. Advanced kidney disease was defined as an estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m². A total of 1872 patients with type 2 DM (mean age 64.0 ± 11.3 years, 809 males and 1063 females) were enrolled. In multivariable analysis, 11 high obesity-related indices (BMI, WHR, WHtR, LAP, BRI, CI, VAI, BAI, AVI, ABSI, and TyG index) were significantly associated with albuminuria. In addition, high BMI, WHR, WHtR, LAP, BRI, CI, VAI, and AVI were significantly associated with eGFR <30 ml/min/1.73 m². The results of this study showed that various obesity-related indices were significantly associated with albuminuria and advanced kidney disease in patients with type 2 DM. Screening may be considered in public health programs to recognize and take appropriate steps to prevent subsequent complications.

Cost-effectiveness analysis of hemodialysis plus hemoperfusion versus hemodialysis alone in adult patients with end-stage renal disease in China

Background

This study evaluates the cost-effectiveness of hemodialysis (HD) plus hemoperfusion (HP) with HD alone in adult patients with end-stage renal disease (ESRD) in China.

Methods

A Markov model was constructed to assess the cost-effectiveness of interventions over a lifetime horizon. Model parameters were informed by the HD/HP trial, the first randomized, open-label multicenter trial comparing survival outcomes and incidence of cardiovascular disease (CVD) for HD + HP versus HD alone, and supplemented by published literature and expert opinion. The primary outcome was the incremental cost-effectiveness ratio (ICER) with respect to quality adjusted life-years (QALY). The robustness of the results was examined in extensive sensitivity analyses. Analyses were conducted from a healthcare perspective. Costs were reported in both Chinese Renminbi (RMB) and US Dollars (USD) in 2019 values.

Results

The base case ICER of HD + HP is RMB 174,486 (USD 25,251) per QALY, which is lower than the RMB 212,676 (USD 30,778) willingness-to-pay threshold of three times Gross Domestic Product. This conclusion is sensitive to the mortality for patients with no severe CVD events, the incidence of CVD events, and the cost of HP and HD. At a willingness-to-pay threshold of RMB 212,676 (USD 30,778) per QALY gained, the probability that HD + HP is cost-effective is 58%.

Conclusions

Our results indicate a potential for HD + HP to be cost-effective for patients with ESRD. Further evidence on the longer-term impact of HD + HP on CVD event rates and mortality unrelated to CVD is needed to robustly demonstrate the cost-effectiveness of HD + HP.

Trial Registration

The HD/HP trial was registered with the Chinese Clinical Trial Registry (ChiCTR-IOR-16009332).

Positive correlation of serum indoxyl sulfate level with peripheral arterial disease in hemodialysis patients

OBJECTIVES

Indoxyl sulfate, known for its cardiovascular toxicity, is associated with vascular and coronary artery diseases and increased mortality. Peripheral arterial disease, defined by low ankle-brachial index, is associated with increased mortality in patients on hemodialysis. The present study aimed to determine the relationship between the serum indoxyl sulfate level and peripheral arterial disease in patients on maintenance hemodialysis.

METHODS

The present cross-sectional, single-center study included 75 patients on maintenance hemodialysis. Serum indoxyl sulfate levels were determined by high-performance liquid chromatography-mass spectrometry. Ankle-brachial index values were measured using an automated oscillometric device. Patients with ankle-brachial indexes of < 0.9 were categorized into the low ankle-brachial index group.

RESULTS

In the study cohort, 12 of the 75 patients (16.0%) had low ankle-brachial indexes. The rates of diabetes mellitus (p = 0.010) as well as the serum levels of C-reactive protein (p < 0.001) and indoxyl sulfate (p < 0.001) were higher in the low ankle-brachial index group than the normal ankle-brachial index group. The multivariable logistic regression analysis revealed that serum levels of indoxyl sulfate (odds ratio = 1.123, 95% confidence interval 1.011-1.249, p = 0.031) and C-reactive protein (each 0.1 mg/dL increase, odds ratio = 1.169, 95% confidence interval 1.018-1.343, p = 0.027) were independently associated with peripheral arterial disease in patients on maintenance hemodialysis.

CONCLUSIONS

Serum indoxyl sulfate levels were associated with peripheral arterial disease in patients on maintenance hemodialysis.

Statin initiation and all-cause mortality in incident statin-naïve dialysis patients

BACKGROUND AND AIMS

Cardiovascular disease is the main cause of death in end-stage kidney disease (ESKD) patients. We aimed to explore the association between statin initiation after starting dialysis and all-cause mortality in statin-naïve ESKD patients.

METHODS

We analyzed nationwide claims data of incident dialysis patients from 2010 to 2017 in South Korea. Patients who had previous cardiovascular events or were administered statins before dialysis were excluded. The study group included dialysis patients receiving statins within 1 year after dialysis initiation. The control group was organized after propensity-score matching with age, sex, time of dialysis initiation, and underlying diabetes mellitus and hypertension. The main outcomes were all-cause mortality and major cardiovascular events.

RESULTS

We included 1596 patients who started statin treatment and 1:1 matched statin-nonusers. During the 9438 person-year follow-up, 468 deaths and 264 major adverse cardiovascular events (MACEs) occurred. Statin initiation was associated with a reduced risk of all-cause mortality (adjusted hazard ratio (aHR) 0.72, 95% confidence interval (CI) 0.60-0.87, p = 0.001), but not with MACE incidence (aHR 1.06, 95% CI 0.83-1.36, p = 0.62). In particular, patients prescribed the recommended dosage of statins according to the Kidney Disease Improving Global Outcomes guidelines showed the lowest mortality risk (aHR 0.55, 95% CI 0.40-0.75, p < 0.001).

CONCLUSIONS

Statin initiation was associated with lower risk of all-cause mortality in statin-naïve ESKD patients. As indication bias may be present in observational study setting, further prospective studies are warranted to validate the association of statin initiation with mortality in incident dialysis cases.

Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors

Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.

Interventions to empower cardiorenal patients: A systematic review

AIMS

To identify the most effective interventions to empower cardiorenal patients.

DESIGN

A systematic review of the literature has been carried out.

DATA SOURCES

The PubMed, CINAHL, PsycINFO and Cochrane databases were reviewed, and journals in the field were manually searched between January and February 2020.

REVIEW METHODS

Five randomized clinical trials and quasi-experimental studies that met the selection and CONSORT & TREND methodological quality criteria were selected.

RESULTS

The evidence supports that there are no existing interventions aimed at empowering cardiorenal patients. However, the interventions to empower people with chronic kidney disease and heart failure suggest that their integration should address seven domains: patient education, sense of self-management, constructive coping, peer sharing, enablement, self-efficacy and quality of life.

CONCLUSION

A gap has been revealed in the literature regarding the empowerment of cardiorenal patients. This review provides relevant information to help design, implement and evaluate interventions to empower these patients by describing the strategies used to empower people experiencing both chronic conditions and the tools used for their assessment.

IMPACT

There is a need for further research to design, implement and evaluate a multidimensional intervention that favours the empowerment of cardiorenal patients by using valid and reliable instruments that measure the domains that constitute it in an integrated manner. Interventions aimed at empowering the cardiorenal patient should include seven domains: patient education, sense of self-management, constructive coping, peer sharing, enablement, self-efficacy and quality of life.

A long-term nationwide study on chronic kidney disease-related mortality in Italy: trends and associated comorbidity

BACKGROUND

Chronic kidney diseases (CKDs) represent a major public health concern worldwide with increasing incidence and prevalence. However, the epidemiological dimension of CKD in Italy is still under evaluation. By analyzing all the conditions reported on death certificates (multiple causes of death), we aimed to investigate the real burden of CKD mortality in Italy over 15 years and identify the main conditions contributing to death in association with CKD.

METHODS

Death certificates of all deaths occurring in Italy from 2003 to 2017 were analyzed. Certificates reporting CKD were identified as CKD-related deaths. CKD-related mortality was investigated through age-standardized mortality rates, by sex and age. Conditions associated with CKD were identified through an indicator (age-standardized proportion ratio) measuring the excess proportion (value > 1) of having such conditions mentioned in the death certificate with and without CKD.

RESULTS

From 2003 to 2017, multiple-cause-based CKD mortality rates increased by 60% in males and by 54% in females. The overall increase was mostly attributable to people aged 80 years or more. Several conditions were associated with CKD, the most relevant being diabetes (age-standardized proportion ratio = 2.2), obesity (2.1), systemic connective tissue disorders (2.3), anemia (2.7), and genitourinary system diseases (2.6).

CONCLUSIONS

Multiple-cause-of-death data revealed a significant increase in CKD-related mortality in recent years, providing a measure of the burden of CKD on overall mortality in Italy. Moreover, multiple cause analysis allowed to identify the main conditions contributing to death in association with CKD, which should be aggressively targeted by clinicians to prevent CKD adverse outcomes.

Medical malpractice related to dialysis and vascular access: An analysis of lawsuit judgements in South Korea

BACKGROUND

Hemodialysis is a life-saving renal replacement treatment for patients with chronic kidney disease, but various complications occur during hemodialysis and associated procedures. This study was conducted to analyze the specific characteristics of hemodialysis-related complications and malpractice that have led to legal disputes.

METHODS

Judgments from cases litigated between 1991 and 2019 due to complications related to hemodialysis or vascular access were analyzed using the database of the Korean Supreme Court Judgment System.

RESULTS

Of 32 dialysis-related litigation cases, 14 cases were dismissed and malpractice was recognized in 18 cases. Among all cases and those in which malpractice was recognized, the most common clinical complication was associated with central venous catheter (CVC) insertion (25.0% and 42.9%, respectively). In 22 of 32 (68.8%) cases, complications occurred before or after (not during) dialysis, and performance error was the most common clinical error leading to legal disputes (58.3%). Complications resulted in death in 59.4% of cases, and CVC-related complications were associated with the largest proportion (63.2%) of deaths.

CONCLUSIONS

Hemodialysis was implicated in various medical disputes, and CVC-related complications were the most common and serious adverse events. Clinicians' awareness of the incidence and severity of possible complications of hemodialysis procedures should be increased.

Home before Hospital: a whole of system re-design project to improve rates of home-based dialysis therapy: Experience and outcomes over 8 years

BACKGROUND

Despite evidence that clinical outcomes for patients treated with peritoneal dialysis (PD) or home haemodialysis are better than for patients treated with conventional satellite or hospital-based haemodialysis, rates of home-based dialysis therapies world-wide remain low. Home-based dialysis care is also cost-effective and indeed the favoured dialysis option for many patients.

METHODS & OBJECTIVES

Using a lean-thinking framework and established change management methodology, a project embracing a system-wide approach at making a change where a 'Home before Hospital' philosophy underpinned all approaches to dialysis care was undertaken. Three multidisciplinary working groups (pathway, outreach and hybrid) were established for re-design and implementation. The primary aim was to improve home-based dialysis therapy prevalence rates from a baseline of 14.8% by ≥2.5%/year to meet a target of 35%, whilst not only maintaining but improving the quality of care provided to patients requiring maintenance dialysis. A 'future' state pathway was developed after review of the 'current' state (Pathway Working Group) and formed the basis on which a nurse-led outreach service (Outreach Working Group) was established. With the support of the multidisciplinary team, the outreach service model focussed on early, consistent, and frequent education, patient support in decision-making, and clinician engagement.

RESULTS

A target prevalence of >30% for home-based therapies (mainly achieved with PD) was achieved within 2 years. This prevalence rate reached 35% within 3 years and was maintained at 8 years. In addition, selected patients already on maintenance satellite-based haemodialysis (Hybrid Working Group) were educated to achieve high levels of proficiencies in self-care.

CONCLUSION

Having the system-wide approach to a Quality Improvement Process and using established principles and change management processes, the successful implementation of a new sustainable model of care focussed on home-based dialysis therapy was achieved. A key feature of the model (through outreach) was early nurse-led education and support of patients in decision-making and ongoing support through multidisciplinary care.

A Medication Adherence Promotion System to Reduce Late Kidney Allograft Rejection: A Quality Improvement Study

RATIONALE AND OBJECTIVE

Adolescent and young adult kidney transplant recipients have high risk of rejection related to suboptimal adherence. Multi-component interventions improve adherence in controlled trials, but clinical implementation is lacking. We describe an initiative to reduce allograft rejection using evidence-based adherence promotion clinical strategies.

STUDY DESIGN

Interrupted time series.

SETTING AND PARTICIPANTS

Kidney transplant recipients cared for at Cincinnati Children's Hospital ≥1 year post-transplant and taking ≥1 immunosuppressive medication from 2014 through 2017.

QUALITY IMPROVEMENT ACTIVITIES

The following interventions were implemented over 14 months: 1) adherence promotion training for clinical staff, 2) EHR-supported adherence risk screening, 3) systematic assessment of medication adherence barriers, 4) designation of specific staff to address adherence barriers, 5) shared decision-making with the patients to overcome adherence barriers, 6) follow-up to assess progress, 7) optional electronic medication monitoring.

OUTCOMES

Primary Outcome: Late acute rejection. Process measures: barriers assessments performed, barriers identified, number of interventions performed. Secondary outcomes/balancing measures: de novo DSA, biopsy rate, rejections per biopsy.

ANALYTICAL APPROACH

Time series analysis using statistical process control, evaluated patient-days between acute rejections as well as monthly rejections per 100 patient-months before and after implementation. To control for known rejection risk factors including changes in treatment and case mix, multivariable analyses were performed.

RESULTS

The monthly rejection rate fell from 1.61 rejections/100 patient-months in the 26-months pre-implementation to 0.88 rejections/100 patient-months in the 22-months post-implementation. In multivariable analysis, MAPS was associated with a 50% reduction in rejection incidence (IRR 0.50, 95% CI: 0.27-0.91, p=0.02). DSA and time since transplant were also associated with rejection incidence (IRR 2.27, p=0.02 and IRR 0.87, p=0.02, respectively) LIMITATIONS: A single center study. Potential confounding by unmeasured variables.

CONCLUSIONS

Clinical implementation of evidence-based adherence-promotion strategies was associated with a 50% reduction in acute rejection incidence over two years.

In-hospital outcomes of transcatheter mitral valve repair in patients with and without end stage renal disease: A national propensity match study

OBJECTIVES

To study trends of utilization, outcomes, and cost of care in patients undergoing undergoing transcatheter mitral valve repair (TMVr) with end-stage renal disease (ESRD).

BACKGROUND

Renal disease has been known to be a predictor of poor outcome in patients with mitral valve disease. Outcome data for patients with ESRD undergoing TMVr remains limited. Therefore, our study aims to investigate trends of utilization, outcomes, and cost of care among patients with ESRD undergoing TMVr.

METHODS

We analyzed NIS data from January 2010 to December 2017 using the ICD-9-CM codes ICD-10-CM to identify patients who underwent TMVr. Baseline characteristics were compared using a Pearson 𝜒2 test for categorical variables and independent samples t-test for continuous variables. Propensity matched analysis was done for adjusted analysis to compare outcomes between TMVr with and without ESRD. Markov chain Monte Carlo was used to account for missing values.

RESULTS

A total of 15,260 patients (weighted sample) undergoing TMVr were identified between 2010 and 2017. Of these, 638 patients had ESRD compared to 14,631 patients who did not have ESRD. Adjusted in-hospital mortality was lower in non-ESRD group (3.9 vs. <1.8%). Similarly, ESRD patients were more likely to have non-home discharges (85.6 vs. 74.9%). ESRD patients also had a longer mean length of stay (7.9 vs. 13.5 days) and higher mean cost of stay ($306,300 vs. $271,503).

CONCLUSION

ESRD is associated with higher mortality, complications, and resource utilization compared to non-ESRD patients. It is important to include this data in shared decision-making process and patient selection.

Immunosuppression Regimen Use and Outcomes in Older and Younger Adult Kidney Transplant Recipients: A National Registry Analysis

BACKGROUND

Although the population of older transplant recipients has increased dramatically, there are limited data describing the impact of immunosuppression regimen choice on outcomes in this recipient group.

METHODS

National data for US Medicare-insured adult kidney recipients (N = 67 362; 2005-2016) were examined to determine early immunosuppression regimen and associations with acute rejection, death-censored graft failure, and mortality using multivariable regression analysis in younger (18-64 y) and older (>65 y) adults.

RESULTS

The use of antithymocyte globulin (TMG) or alemtuzumab (ALEM) induction with triple maintenance immunosuppression (reference) was less common in older compared with younger (36.9% versus 47.0%) recipients, as was TMG/ALEM + steroid avoidance (19.2% versus 20.1%) and mammalian target of rapamycin inhibitor (mTORi)-based (6.7% versus 7.7%) treatments. Conversely, older patients were more likely to receive interleukin (IL)-2-receptor antibody (IL2rAb) + triple maintenance (21.1% versus 14.7%), IL2rAb + steroid avoidance (4.1% versus 1.8%), and cyclosporine-based (8.3% versus 6.6%) immunosuppression. Compared with older recipients treated with TMG/ALEM + triple maintenance (reference regimen), those managed with TMG/ALEM + steroid avoidance (adjusted odds ratio [aOR], 0.440.520.61) and IL2rAb + steroid avoidance (aOR, 0.390.550.79) had lower risk of acute rejection. Older patients experienced more death-censored graft failure when managed with Tac + antimetabolite avoidance (adjusted hazard [aHR], 1.411.782.25), mTORi-based (aHR, 1.702.142.71), and cyclosporine-based (aHR, 1.411.782.25) regimens, versus the reference regimen. mTORi-based and cyclosporine-based regimens were associated with increased mortality in both older and younger patients.

CONCLUSIONS

Lower-intensity immunosuppression regimens (eg, steroid-sparing) appear beneficial for older kidney transplant recipients, while mTORi and cyclosporine-based maintenance immunosuppression are associated with higher risk of adverse outcomes.

Fish oil replacement prevents, while docosahexaenoic acid-derived protectin DX mitigates end-stage-renal-disease in atherosclerotic diabetic mice

Diabetic nephropathy (DN) remains the major cause of end-stage renal disease (ESRD). We used high-fat/high-sucrose (HFHS)-fed LDLr^-/- /ApoB^100/100 mice with transgenic overexpression of IGFII in pancreatic β-cells (LRKOB100/IGFII) as a model of ESRD to test whether dietary long chain omega-3 polyunsaturated fatty acids LCω3FA-rich fish oil (FO) could prevent ESRD development. We further evaluated the potential of docosahexaenoic acid (DHA)-derived pro-resolving lipid mediators, 17-hydroxy-DHA (17-HDHA) and Protectin DX (PDX), to reverse established ESRD damage. HFHS-fed vehicle-treated LRKOB100/IGFII mice developed severe kidney dysfunction leading to ESRD, as revealed by advanced glomerular fibrosis and mesangial expansion along with reduced percent survival. The kidney failure outcome was associated with cardiac dysfunction, revealed by reduced heart rate and prolonged diastolic and systolic time. Dietary FO prevented kidney damage, lean mass loss, cardiac dysfunction, and death. 17-HDHA reduced podocyte foot process effacement while PDX treatment alleviated kidney fibrosis and mesangial expansion as compared to vehicle treatment. Only PDX therapy was effective at preserving the heart function and survival rate. These results show that dietary LCω3FA intake can prevent ESRD and cardiac dysfunction in LRKOB100/IGFII diabetic mice. Our data further reveals that PDX can protect against renal failure and cardiac dysfunction, offering a potential new therapeutic strategy against ESRD.

Effects of Home-Based Exercise on Frailty in Patients With End-Stage Renal Disease: Systematic Review

BACKGROUND

New or worsening frailty is a common problem in patients with end-stage renal disease (ESRD) during the prolonged time awaiting kidney transplantation. Structured physical activity in the dialysis setting has been shown to mitigate frailty, but little is known about the benefits of home-based exercise. The purpose of this systematic review was to summarize the effects of home-based exercise interventions on indicators of frailty (weakness, slowness, low physical activity, perceived exhaustion, and shrinking) among patients diagnosed with ESRD.

METHODS

We searched PubMed, MEDLINE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar using Medical Subject Heading terms and free text keywords including kidney failure, exercise, and frailty. We identified 13 relevant articles (eight randomized controlled trials, five quasi-experimental studies).

RESULTS

Our review found potential effectiveness of home-based exercise interventions on mitigating or preventing selected indicators of frailty (e.g., weakness, slowness, low physical activity, perceived exhaustion), particularly when the interventions combined aerobic walking, resistance exercise, and behavioral components and were delivered for at least 6 months. However, no published studies measured the effect of home-based exercise interventions on frailty as a whole.

CONCLUSIONS

While existing studies suggest likely benefits of home-based exercise interventions among patients with ESRD, future research is warranted to develop and test home-based physical activity interventions that address all indicators of frailty.

Exome sequencing as a diagnostic tool in chronic kidney disease: ready for clinical application?

PURPOSE OF REVIEW

Patients who develop chronic kidney disease at an early age, or from an uncertain cause, may benefit from genomic sequencing approaches to define causative mutations and inform subsequent management.

RECENT FINDINGS

Whole-exome sequencing has been used to investigate the molecular genetic variants associated with chronic kidney disease in both specific phenotypes such as steroid-resistant nephrotic syndrome, and in large cohorts of patients not selected for a certain diagnosis. These studies have shown that whole-exome sequencing is able to find a genetic variant in a significant number of patients. Often these variants may reclassify the diagnosis, the variants may have ramifications for the patient's management, and some variants may be previously undescribed in the literature.

SUMMARY

Whole-exome sequencing is likely to become widely used in the investigation of chronic kidney disease, especially in certain phenotypes.

Association of blood pressure and renal outcome in patients with chronic kidney disease; a post hoc analysis of FROM-J study

It is well-known that hypertension exacerbates chronic kidney disease (CKD) progression, however, the optimal target blood pressure (BP) level in patients with CKD remains unclear. This study aimed to assess the optimal BP level for preventing CKD progression. The risk of renal outcome among different BP categories at baseline as well as 1 year after, were evaluated using individual CKD patient data aged between 40 and 74 years from FROM-J [Frontier of Renal Outcome Modifications in Japan] study. The renal outcome was defined as ≥ 40% reduction in estimated glomerular filtration rate to < 60 mL/min/1.73 m², or a diagnosis of end stage renal disease. Regarding baseline BP, the group of systolic BP (SBP) 120-129 mmHg had the lowest risk of the renal outcome, which increased more than 60% in SBP ≥ 130 mmHg group. A significant increase in the renal outcome was found only in the group of diastolic BP ≥ 90 mmHg. The group of BP < 130/80 mmHg had a benefit for lowering the risk regardless of the presence of proteinuria, and it significantly reduced the risk in patients with proteinuria. Achieving SBP level < 130 mmHg after one year resulted in a 42% risk reduction in patients with SBP level ≥ 130 mmHg at baseline. Targeting SBP level < 130 mmHg would be associated with the preferable renal outcome.Clinical Trial Registration-URL: https://www.umin.ac.jp/ctr/ . Unique identifier: UMIN000001159 (16/05/2008).

Gene expression profiles of diabetic kidney disease and neuropathy in eNOS knockout mice: Predictors of pathology and RAS blockade effects

Diabetic kidney disease (DKD) and diabetic peripheral neuropathy (DPN) are two common diabetic complications. However, their pathogenesis remains elusive and current therapies are only modestly effective. We evaluated genome-wide expression to identify pathways involved in DKD and DPN progression in db/db eNOS-/- mice receiving renin-angiotensin-aldosterone system (RAS)-blocking drugs to mimic the current standard of care for DKD patients. Diabetes and eNOS deletion worsened DKD, which improved with RAS treatment. Diabetes also induced DPN, which was not affected by eNOS deletion or RAS blockade. Given the multiple factors affecting DKD and the graded differences in disease severity across mouse groups, an automatic data analysis method, SOM, or self-organizing map was used to elucidate glomerular transcriptional changes associated with DKD, whereas pairwise bioinformatic analysis was used for DPN. These analyses revealed that enhanced gene expression in several pro-inflammatory networks and reduced expression of development genes correlated with worsening DKD. Although RAS treatment ameliorated the nephropathy phenotype, it did not alter the more abnormal gene expression changes in kidney. Moreover, RAS exacerbated expression of genes related to inflammation and oxidant generation in peripheral nerves. The graded increase in inflammatory gene expression and decrease in development gene expression with DKD progression underline the potentially important role of these pathways in DKD pathogenesis. Since RAS blockers worsened this gene expression pattern in both DKD and DPN, it may partly explain the inadequate therapeutic efficacy of such blockers.

Mortality After Home Hemodialysis Treatment Failure and Return to In-Center Hemodialysis

RATIONALE OBJECTIVE

Patients on home hemodialysis (HHD) may eventually return to in-center hemodialysis (ICHD) for clinical, technical or psycho-social reasons. We studied the mortality of patients returning to ICHD after HHD comparing it to the mortality experience among patients receiving HHD and patients receiving ICHD without prior treatment with HHD.

STUDY DESIGN

Retrospective cohort study.

SETTING PARTICIPANTS

All patients represented in the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry who commenced HD during 2005-2015 and were treated for >90 days.

EXPOSURES

ICHD and/or HHD, and clinical characteristics at study entry.

OUTCOMES

Mortality and cause of death.

ANALYTICAL APPROACH

A time-varying multivariate Cox proportional hazards analysis with shared frailty was implemented to explore the association between patient treatment states and mortality. Patients were censored at the time of transplantation and change in treatment modality to peritoneal dialysis.

RESULTS

A total of 19,306 patients initiated HD and were treated for >90 days. The mean age of patients was 60.8y (SD=15.4y), 62% were male and 49% had diabetes. After HHD treatment failure, adjusted mortality was increased compared to continued HHD at 0-30 days (HR 3.93, 95% CI 2.09-7.40 p<0.001), 30-90 days (HR 3.34, 95% CI 1.98-5.62, p<0.001) and >90 days (HR 2.29, CI 1.84-2.85, p<0.001).

LIMITATIONS

Covariates recorded at dialysis initiation. Residual confounding underlying successful initiation of HHD treatment.Observational data lacking detail on cause of HHD treatment failure.

CONCLUSIONS

HHD treatment failure is associated with a significant increase in mortality compared to continued HHD. This risk was present in both the early (first 30 days and 30-90 days) and late (>90 days) periods after HHD treatment failure. Further investigation into the specific causes of treatment failure and death may highlight specific high-risk patients.

PAR2-Induced Tissue Factor Synthesis by Primary Cultures of Human Kidney Tubular Epithelial Cells Is Modified by Glucose Availability

Coagulopathies common to patients with diabetes and chronic kidney disease (CKD) are not fully understood. Fibrin deposits in the kidney suggest the local presence of clotting factors including tissue factor (TF). In this study, we investigated the effect of glucose availability on the synthesis of TF by cultured human kidney tubular epithelial cells (HTECs) in response to activation of protease-activated receptor 2 (PAR2). PAR2 activation by peptide 2f-LIGRLO-NH₂ (2F, 2 µM) enhanced the synthesis and secretion of active TF (~45 kDa) which was blocked by a PAR2 antagonist (I-191). Treatment with 2F also significantly increased the consumption of glucose from the cell medium and lactate secretion. Culturing HTECs in 25 mM glucose enhanced TF synthesis and secretion over 5 mM glucose, while addition of 5 mM 2-deoxyglucose (2DOG) significantly decreased TF synthesis and reduced its molecular weight (~40 kDa). Blocking glycosylation with tunicamycin also reduced 2F-induced TF synthesis while reducing its molecular weight (~36 kDa). In conclusion, PAR2-induced TF synthesis in HTECs is enhanced by culture in high concentrations of glucose and suppressed by inhibiting either PAR2 activation (I-191), glycolysis (2DOG) or glycosylation (tunicamycin). These results may help explain how elevated concentrations of glucose promote clotting abnormities in diabetic kidney disease. The application of PAR2 antagonists to treat CKD should be investigated further.