Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study

Efficacy of drug-coated balloon versus uncoated balloon for dysfunctional dialysis access: a systematic review and meta-analysis

BACKGROUND

Dysfunctional vascular access is a major cause of morbidity and mortality in patients undergoing hemodialysis, affecting both arteriovenous fistulas and grafts. The most optimal strategy to restore long-term patency has not been established. This meta-analysis compares drug-coated balloon (DCB) versus uncoated balloon (UCB) angioplasty for dysfunctional vascular access.

METHODS

We performed a systematic literature search across multiple databases from inception to June 2024. Randomized-controlled trials (RCTs) comparing DCB and UCB in dialysis patients with dysfunctional vascular access were included. Risk ratios were pooled using a random-effects model.

RESULTS

Twenty-seven RCTs (2645 patients) were included. Target lesion patency (TLP) at 6 months was significantly superior in the DCB group (RR 1.22, 95% CI 1.07-1.39, p = 0.003). The two regimens were comparable for TLP at 3 months (RR 1.14, p = 0.24) and 12 months (RR 1.14, p = 0.10). The two regimens were comparable in terms of circuit patency rate, target-lesion revascularization, and all-cause mortality.

CONCLUSION

DCB has significantly superior TLP and a comparable risk of mortality to UCB. Further research is warranted to identify factors affecting outcomes following DCB angioplasty for dysfunctional dialysis access.

Patients, healthcare providers, and general population preferences for hemodialysis vascular access: a discrete choice experiment

Background

A patient-centered dialysis treatment option requires an understanding of patient preferences for alternative vascular accesses and nephrologists often face difficulties when recommending vascular access to end-stage kidney disease (ESKD) patients. We aimed to quantify the relative importance of various vascular access characteristics to patients, healthcare providers and general population, and how they affect acceptability for patients and healthcare providers.

Methods

In a discrete choice experiment, patients with maintenance hemodialysis (MHD), healthcare providers, and individuals from the general population were invited to respond to a series of hypothetical vascular access scenarios that differed in five attributes: cumulative patency, infection rate, thrombosis rate, cost, and time to maturation. We estimated the respondents' preference heterogeneity and relative importance of the attributes with a mixed logit model (MXL) and predicted the willingness to pay (WTP) of respondents via a multinomial logit model (MNL).

Results

Healthcare providers (n = 316) and the general population (n = 268) exhibited a favorable inclination toward longer cumulative patency, lower access infection rate and lower access thrombosis rate. In contrast, the patients (n = 253) showed a preference for a 3-year cumulative patency, 8% access infection rate, 35% access thrombosis rate and 1.5 access maturity time, with only the 3-year cumulative patency reaching statistical significance. Among the three respondent groups, the general population found cumulative patency less important than healthcare providers and patients did. Patients demonstrated the highest WTP for cumulative patency, indicating a willingness to pay an extra RMB$24,720(US$3,708) for each additional year of patency time.

Conclusion

Patients and healthcare providers had a strong preference for vascular access with superior patency. While the general population preferred vascular access with lower thrombosis rates. These results indicate that most patients prefer autogenous arteriovenous fistula (AVF) as an appropriate choice for vascular access due to its superior patency and lower complications than other vascular access types.

Towards a better uptake of home dialysis in Europe: understanding the present and looking to the future

Use of peritoneal dialysis and home haemodialysis remains low in Europe, with the highest use in Scandinavian countries and the lowest in Eastern and Central Europe despite the advantages for people on dialysis and economic advantages for healthcare systems. This is partly due to the impact of the haemodialysis industry resulting in proliferation of haemodialysis units and nephrologist reimbursement related to use of haemodialysis. Equally important is the bias against home dialysis at both clinician and healthcare system levels. The underlying causes of this bias are discussed in relation to a mechanistic view of the human body, lack of compassion, failure to adjust dialysis provision for older age and frailty, proliferation of small dialysis centres, and complexity of decision-making and clinical care. For home dialysis to flourish, we need to foster a change in attitude to and vision of the aims of healthcare so that enabling meaningful activities of people requiring dialysis, as explored in the Standardized Outcomes in Nephrology initiative, rather than achieving biological numbers become the focus of care delivery.

Outcomes of elderly peritoneal dialysis patients: 65-74 years old versus ≥ 75 years old

OBJECTIVE

To analyze the clinical data of elderly patients with peritoneal dialysis (PD) and compare patient and technique survival rates between Group 1 (65-74 years old) and Group 2 (≥75 years old).

METHODS

This retrospective study enrolled 296 elderly patients (≥65 years old) on maintenance PD who were admitted to the Peritoneal Dialysis Center of the Second Hospital of Soochow University. The patients were categorized by outcome into ongoing PD, changed to hemodialysis, renal recovery dialysis stopped, or death groups. The patients were divided into Group 1 (65-74 years old) and Group 2 (≥75 years old). Patient survival and technique survival rates were calculated by the Kaplan-Meier method. Factors associated with patient survival were analyzed using the Cox regression model.

RESULTS

There were 176 (59.5%) subjects in Group 1 and 120 (40.5%) subjects in Group 2. The primary causes of death were cardiovascular events, peritonitis, and other infections. The patient survival rates at 1, 3, and 5 years were 91.2%, 68.0%, and 51.3% in Group 1 and 76.8%, 37.5%, and 17.6% in Group 2 (p < 0.001, HR 0.387, 95% CI 0.282-0.530). There was no statistically significant difference in the technique survival rate between the two groups (p = 0.54).

CONCLUSION

The elderly PD patients in this cohort mostly died from cardiovascular events, with a higher patient survival rate in Group 1 and similar technique survival in both groups. Older age, lower prealbumin, higher creatinine, not being on activated vitamin D, and high Charlson's comorbidity index (CCI) score were independent risk factors for death.

Renal Replacement Therapy For Elderly Patients with ESKD Through Shared Decision-Making

The incidence and prevalence of end-stage kidney disease (ESKD) in Korea are increasing, and ESKD constitutes a very important medical and social issue. Elderly dialysis patients have the highest risk of early mortality within 3 months after initiating dialysis, and geriatric syndromes such as aging, frailty, functional impairment, and cognitive impairment are crucial for the prognosis of elderly patients. Shared decision-making (SDM) is an approach through which clinicians and patients can achieve informed preferences, thereby yielding better clinical outcomes and quality of life. Through SDM-based, close consultation among patients, families, and healthcare providers, an ESKD Life-Plan for elderly patients should be established. A multidisciplinary approach led by nephrologists can help them to provide proper vascular access for dialysis at the right time, with the right evidence, and to the right patient. Strategies that can improve peritoneal dialysis in elderly patients include assisted peritoneal dialysis, homecare support programs, and automated peritoneal dialysis. In order to enhance the role of kidney transplantation in elderly patients with ESKD, it is necessary to accurately identify patients' clinical conditions before transplantation and to perform active rehabilitation activities and postoperative management to promote recovery after transplantation. With the aging population and the increase in ESKD in the elderly, clinicians must identify factors affecting the mortality and quality of life of elderly dialysis patients.

Mortality and Risk Factors in Very Elderly Patients Who Start Hemodialysis: Korean Renal Data System, 2016-2020

INTRODUCTION

The number of elderly patients with end-stage renal disease (ESRD) is increasing worldwide. However, decision-making about elderly patients with ESRD remains complex because of the lack of studies, especially in very elderly patients (≥75 years). We examined the characteristics of very elderly patients starting hemodialysis (HD) and the associated mortality and prognostic factors.

METHODS

Data were analyzed retrospectively using a nationwide cohort registry, the Korean Renal Data System. Patients who started HD between January 2016 and December 2020 were included and divided into three groups according to age at HD initiation (<65, 65-74, and ≥75 years). The primary outcome was all-cause mortality during the study period. Risk factors for mortality were analyzed using Cox proportional hazard models.

RESULTS

In total, 22,024 incident patients were included with 10,006, 5,668, and 6,350 in each group (<65, 65-74, and ≥75 years, respectively). Among the very elderly group, women had a higher cumulative survival rate than men. The survival rate was lower in patients with vascular access via a catheter than in those with an arteriovenous fistula or graft. Very elderly patients with more comorbid diseases had a significantly lower survival rate than those with fewer comorbidities. In the multivariate Cox models, old age, cancer presence, catheter use, low body mass index, low Kt/V, low albumin concentration, and capable status of partial self-care were associated with high risk of mortality.

CONCLUSION

Preparation of an arteriovenous fistula or graft when starting HD should be considered in very elderly patients with fewer comorbid diseases.

Quality of life in advanced renal disease managed either by haemodialysis or conservative care in older patients

OBJECTIVE

Consideration of quality of life (QoL) in people with end-stage renal disease has become an important part of treatment decision-making. The aim of this study was to report on QoL and other functional outcomes in patients with advanced chronic kidney disease (CKD).

METHOD

This was a cross-sectional study. Two samples of older patients (>60 years old) either conservatively managed (CM) or receiving hospital-based haemodialysis (HD), compared Kidney Disease Quality of Life (KDQoL-36) outcomes.

RESULTS

Data from 263 CM patients (CKD 4 n=188, mean age 73.6 years, 48 women; CKD 5 n=75, mean age 74.4 years, 26 women) and 74 patients on HD (mean age 73.8 years, 24 women) were analysed. Significant group differences were identified for two subscales of KDQoL-36. Symptoms/Problems List subscale was significantly better for those receiving HD compared with those CM with CKD 5 (p=<0.001). Symptom/Problem List scores of CM CKD stage 4 patients were not significantly different compared with HD patients but were significantly better than CM CKD stage 5 patients (p<0.001). Burden of Kidney Disease subscale was significantly better for both CKD 4 (p<0.001) and CKD 5 (p<0.001) CM patients when compared with those receiving HD.

CONCLUSION

Symptoms of advanced CKD significantly impact QoL for patients CM with CKD stage 5. Conversely, QoL is significantly impacted for those in receipt of HD due to the burden of treatment. These findings provide evidence for the use of QoL tools to help with clinical prognostication in advanced CKD. Using QoL tools will ensure specialist support is available for appropriate management of patients with CKD.

A novel programme of supportive two-exchange assisted continuous ambulatory peritoneal dialysis for frail patients with end-stage kidney disease

We have developed a supportive two-exchange assisted continuous ambulatory peritoneal dialysis (asCAPD) programme for the older frail person who cannot do autonomous PD and do not want or are considered to be too high risk for haemodialysis (HD). Evaluation of the programme was determined by data collected retrospectively from patient records. Primary outcome was comparison of symptoms at start of dialysis and 3 months following dialysis start. Secondary outcomes were survival and peritonitis rate. Over a 4-year period (2016-2020), 49 patients with mean age 79.6 years (range 47-90) enrolled in the programme with eGFR 7.7 ± 2.6 ml/min (mean ± SD) at dialysis start. Forty-one patients had been on asCAPD for >3 months. There was an improvement in all symptoms at 3 months compared to baseline: anorexia (46% to 15%), fatigue (46% to 15%), shortness of breath (27% to 2%) and oedema (51% to 32%). One-year survival was 55%. Peritonitis rate was 0.52 episodes per patient year. The novel supportive two-exchange asCAPD programme shows potential improvement of symptoms after 3 months and may provide an acceptable dialysis modality for the frail co-morbid person with established kidney failure. More detailed study and evaluation are needed.

Clinical significance of hemodialysis quality of care indicators in very elderly patients with end stage kidney disease

INTRODUCTION

Improvement in life expectancy has increased the number of very elderly patients undergoing hemodialysis. However, it is not clear which quality measures for hemodialysis should be employed in this population. Therefore, in this paper we investigated the association between major adverse cardiovascular and cerebrovascular events (MACCE) indicators of hemodialysis quality in very elderly patients. PATIENTS AND METHODS: Data regarding a total of 29,692 patients undergoing maintenance hemodialysis (median age 61 years, 41.5% females) who participated in a national hemodialysis quality assessment program were analyzed. They were divided into < 80 years and ≥ 80 years age groups. The primary and secondary outcomes were MACCE and all-cause mortality, respectively. The association between the outcomes and some of the most widely used standard hemodialysis quality-of-care indicators, including spKt/V, hemoglobin, serum calcium, serum phosphate, and albumin levels, was evaluated. To explore the association between Cox proportional hazard models were constructed. Model 1 was adjusted for age and sex. Model 2 included additional demographic characteristics, such as Charlson Comorbidity Index (excluding diabetes), diabetes, cause of ESKD, dialysis vintage, BMI, and pre-dialysis systolic blood pressure. Model 3 was further adjusted for the main medications. To evaluate the relationship between MACCE risk and quality assessment indicators as a continuous variable, cubic spline analyses were conducted.

RESULTS

During a median follow-up of 3.7 years, MACCE occurred at a higher rate in the ≥ 80-years group than in the < 80-years group (282.0 vs. 110.1 events/1000 person-years). Multivariate Cox regression analysis revealed that spKt/V, serum calcium and phosphate, and hemoglobin levels were associated with MACCE and all-cause mortality risk in patients aged < 80 years. However, these indicators showed no significant relationship with MACCE and all-cause mortality in patients aged ≥ 80 years. Low serum albumin levels were significantly associated with increased MACCE and all-cause mortality risks, regardless of age.

CONCLUSION

In conclusion, hemodialysis quality-of-care indicators including spKt/V, serum calcium and phosphate levels, and hemoglobin were not related to MACCE or all-cause mortality in very elderly hemodialysis patients. However, lower serum albumin levels were associated with poor outcomes, regardless of patient age. Assuring nutritional status rather than improving hemodialysis management adequacy may be more beneficial for improving outcomes in very elderly hemodialysis patients. Further prospective evaluations are needed to confirm these findings.

Outcome Analysis of Transition From Peritoneal Dialysis to Hemodialysis: A Population-Based Study

If a technical failure occurs during peritoneal dialysis (PD), the patients undergoing PD may be transitioned to hemodialysis (HD). However, the clinical outcomes of patients who have undergone such a transition are under studied. This study assessed whether patients undergoing HD who have transitioned from PD have the same clinical outcomes as HD-only patients. This research was a retrospective cohort study by searching a National Health Insurance research database for data on patients in Taiwan who had undergone HD between January 2006 and December 2013. The patients were divided into two groups, namely a case group in which the patients were transitioned from PD to HD and a HD-only control group, through propensity score matching at a ratio of 1:4 (n = 1,100 vs. 4,400, respectively). We used the Cox regression model to estimate the hazard ratios (HRs) for all-cause death, all-cause hospitalization, infection-related admission, and major adverse cardiac events (MACE). Those selected patients will be followed until death or the end of the study period (December, 2017), whichever occurs first. Over a mean follow-up of 3.2 years, 1,695 patients (30.8%) died, 3,825 (69.5%) required hospitalization, and 1,142 (20.8%) experienced MACE. Patients transitioning from PD had a higher risk of all-cause death (HR: 1.36; 95% CI: 1.21–1.53) than HD-only patients. However, no significant difference was noted in terms of MACE (HR: 0.91; 95% CI: 0.73–1.12), all-cause hospitalization (HR: 1.07; 95% CI: 0.96–1.18), or infection-related admission (HR: 0.97, 95% CI: 0.80–1.18) between groups. Because of the violation of the proportional hazard assumption, the piecewise-HRs showed that the risk of mortality in the case group was significant within 5 months of the transition (HR: 2.61; 95% CI: 2.04–3.35) not in other partitions of the time axis. In conclusion, patients undergoing HD who transitioned from PD had a higher risk of death than the HD-only patients, especially in the first 5 months after transition (a 161% higher risk). Therefore, more caution and monitoring may be required for patients undergoing HD who transitioned from PD.

Survival of Older Patients With Advanced CKD Managed Without Dialysis: A Narrative Review

Shared decision making is important when deciding the appropriateness of dialysis for any individual, particularly for older patients with advanced chronic kidney disease who have high mortality. Emerging evidence suggests that patients with advanced age, high comorbidity burden, and poor functional status may not have any survival advantage on dialysis compared with those on a conservative kidney management pathway. The purpose of this narrative review is to summarize the existing studies on the survival of older patients with stage 4 or 5 chronic kidney disease managed with or without dialysis and to evaluate the factors that may influence mortality in an effort to assist clinicians with shared decision making. Median survival estimates of conservative kidney management patients are widely varied, ranging from 1-45 months with 1-year survival rates of 29%-82%, making it challenging to provide consistent advice to patients. In existing cohort studies, the selected group of patients on dialysis generally survives longer than the conservative kidney management cohort. However, in patients with advanced age (aged ≥80 years), high comorbidity burden, and poor functional status, the survival benefit conferred by dialysis is no longer present. There is an overall paucity of data, and the variability in outcomes reflect the heterogeneity of the existing studies; further prospective studies are urgently needed.

Outcomes of peritoneal dialysis in elderly vs non-elderly patients: A systemic review and meta-analysis

OBJECTIVES

Several studies have compared outcomes of peritoneal dialysis (PD) between elderly and non-elderly patients but with variable results. We hereby designed this review to compare mortality, peritonitis, and technique survival between elderly and non-elderly patients on PD.

METHODS

PubMed, Embase, and Google Scholar were searched for studies comparing outcomes of PD between elderly and non-elderly patients. The last search date was 14th July 2021.

RESULTS

Fourteen studies were included. 12 studies defined the elderly as ≥65 years of age and these were included in the meta-analysis. Pooled analysis of crude (RR: 2.45 95% CI: 1.36, 4.40 I2 = 97% p = 0.003) and adjusted data (HR: 2.80 95% CI: 2.45, 3.09 I2 = 0% p<0.00001) indicated a statistically significant increased risk of mortality amongst elderly patients as compared to non-elderly patients. Meta-analysis of four studies demonstrated a statistically significant increased risk of peritonitis in the elderly (RR: 1.56 95% CI: 1.18, 2.07 I2 = 76% p = 0.002). Pooled analysis demonstrated no statistically significant difference in technique survival between the two groups (RR: 0.95 95% CI: 0.86, 1.05 I2 = 86% p = 0.32).

CONCLUSION

Elderly patients on PD have a significantly increased risk of mortality as compared to non-elderly patients. The risk of peritonitis is also significantly increased in older adults but the increased age has no impact on technique survival. Further studies are needed to strengthen our conclusions.

Assisted peritoneal dialysis: a feasible KRT modality for frail older patients with end-stage kidney disease (ESKD)

Assisted PD is used as an alternative option for the growing group of frail, older ESKD patients unable to perform their own PD. This study was undertaken to investigate the outcomes of assisted PD in older patients by comparing assisted PD patients with self-care PD patients. This study included all patients aged 70 and above who started on PD in our hospital from 2009 to 2018. Patients were followed up until death, PD cessation or to the end of the study (December 31, 2019). Risk factors associated with mortality, peritonitis and technique failure were evaluated using both cause-specific hazards and subdistribution hazards models. 180 patients were enrolled, including 106 (58.9%) males with a median age of 77.5 (77.2-81.2) years. Among the 180 patients, 62 patients (34.4%) were assisted. Patients on assisted PD group were older, more likely to be female, more prevalent in DM and CVD, with a higher Charlson score than patients undergoing self-care PD (P all < 0.05). In the multivariable analysis, assisted patients had a comparable patient survival and peritonitis-free survival compared to self-care PD patients either in the Cox or in the FG models. According to a Cox model, the use of assisted PD was associated with a lower risk of technique failure (cs-HR 0.20, 95% CI 0.04-0.76), but the association lost its statistical significance in the Fine and Gray model. Our results suggest that assisted PD could be a safe and effective KRT modality for older ESKD patients who need assistance.

Decision-making around Commencing Dialysis

The decision regarding dialysis initiation is complex. Awareness that renal replacement therapy should not be regarded as default therapy for every patient with advanced renal failure is necessary. Decision to initiate dialysis and modality should be individualized in a shared decision-making process involving the treating nephrologist and the patient. Patients should receive predialysis education early in the course of chronic kidney disease so as to help prepare them well in advance for this eventuality. Withholding dialysis may be a reasonable option in a certain subset of patients, especially elderly patient with multiple co-morbid illnesses. Comprehensive conservation care should be offered in all patients where the decision to not dialyze is taken.

Emergent initiation of dialysis is related to an increase in both mortality and medical costs

The number of patients with end-stage renal disease (ESRD) has been increasing, with dialysis treatment being a serious economic problem. To date, no report in Japan considered medical costs spent at the initiation of dialysis treatment, although some reports in other countries described high medical costs in the first year. This study focused on patient status at the time of initiation of dialysis and examined how it affects prognosis and the medical costs. As a result, all patients dying within 4 months experienced emergent dialysis initiation. Emergent dialysis initiation and high medical costs were risk factors for death within 2 years. High C-reactive protein levels and emergent dialysis initiation were associated with increasing medical costs. Acute kidney injury (AKI) contributed most to emergent dialysis initiation followed by stroke, diabetes, heart failure, and short-term care by nephrologists. Therefore, emergent dialysis initiation was a contributing factor to both death and increasing medical costs. To avoid the requirement for emergent dialysis initiation, patients with ESRD should be referred to nephrologists earlier. Furthermore, ESRD patients with clinical histories of AKI, stroke, diabetes, or heart failure should be observed carefully and provided pre-planned initiation of dialysis.

Good Patient and Technique Survival in Elderly Patients on Continuous Ambulatory Peritoneal Dialysis

The aging population has significant implications for the community. The increasing number of elderly end-stage renal disease (ESRD) patients presses the renal team to find an appropriate management plan. We used a retrospective analysis to study the effectiveness of continuous ambulatory peritoneal dialysis (CAPD) in elderly ESRD patients. Of the 328 CAPD patients recruited for the study, 121 were in the elderly group (≥ 65 years of age), and 207 were in the control group (under 65 years of age). Median age in the elderly group was 71 years, and in the control group, 51 years. The elderly group had a higher prevalence (54.5%) of diabetes mellitus. The 2-year and 5-year rates of patient survival were 89.3% and 54.8% respectively in the elderly group and 92.2% and 62.9% in the control group ( p = 0.19). The 2-year and 5-year rates of technique survival were 84.0% and 45.7% respectively in the elderly group and 80.9% and 49.1% in the control group ( p = 0.75). The probability of a 12-month peritonitis-free period was 76.6% in the elderly group and 76.5% in the control group ( p = 0.75).

One hundred elderly patients (82.6% of the group) performed their CAPD exchanges by themselves. We observed no significant difference in clinical outcome—including patient survival, technique survival, and peritonitis-free period—between the elderly self-care CAPD and the elderly assisted CAPD groups.

In elderly ESRD patients, CAPD is an effective dialysis modality. A slightly longer training time is to be expected for elderly patients. Self-care CAPD for elderly patients who are capable of performing their own exchanges provides them with an independent home life.

Survival Analysis: Comparing Peritoneal Dialysis and Hemodialysis in Taiwan

⋄ Objectives

Comparisons of survival in patients on peritoneal dialysis (PD) and on hemodialysis (HD) have been conducted in many Western countries, but publications on this subject in Asian populations are scarce. The present study estimated the survival and the relative mortality hazard for HD and PD patients in Taiwan.

⋄ Methods

Incident end-stage renal disease patients reported to the Taiwan Renal Registry during 1995 – 2002 were included in the study. Patients had to be 20 years of age or older and had to have survived for the first 90 days on dialysis. A total of 45 820 incident HD and 2809 incident PD patients formed the study population. Patients on PD were treated mainly with traditional glucose-based solutions. Using an intent-to-treat analysis, the Cox proportional hazards (CPH) model was applied to identify the factors that predict survival by treatment modality. Subgroup analyses were conducted by stratifying patients according to sex, comorbidity, age, and diabetes status. Kaplan–Meier estimates were used to explore the survival of HD and PD patients. Adjustments were implemented using the CPH model.

⋄ Results

The overall 1-year, 2-year, 3-year, 5-year and 10-year survival rates for PD patients were 89.8%, 77.6%, 67.6%, 55.5%, and 35% respectively. The equivalent survival rates for HD patients were 87.5%, 76.6%, 68.1%, 54.3%, and 33.8%. The differences were not statistically significant ( p = 0.125). The CPH analysis stratified by diabetes status and age revealed that PD patients 55 years of age or younger and nondiabetic had a lower mortality ratio (MR) of 0.94. But the MR increased to 1.31 for nondiabetic patients older than 55. The MR for PD versus HD further increased to 1.72 for diabetic patients 55 years of age or younger, and to 1.99 for diabetic patients older than 55.

⋄ Conclusions

After adjusting for both demographic and clinical case-mix differences, PD and HD patients were observed to have similar long-term survival. Subgroup analyses revealed that, among diabetic patients and patients older than 55, those on HD experienced better survival than did those on PD.

How to Improve Survival in Geriatric Peritoneal Dialysis Patients

♦ Background

Recently, more elderly patients who are independent or able to live at home with the support of family are opting for continuous ambulatory peritoneal dialysis (CAPD). At the end of 2005, the annual statistical survey conducted by the Japanese Society for Dialysis Therapy indicated that the mean age of patients at initiation of dialysis treatment is 66.2 years. Only 3.6% of the overall end-stage renal disease population were treated with CAPD, and this small number of elderly patients was treated with CAPD despite the many merits of peritoneal dialysis (PD) for the elderly. In the present study, we reviewed our experience with patients 65 years of age and older at the start of PD and the results from two multicenter studies on PD treatment in elderly patients in Japan.

♦ Patients and Methods

Study 1: Of 313 PD patients at Okayama Saiseikai General Hospital between January 1991 and June 2006, 166 patients 65 years of age and older were studied. The characteristics of these elderly PD patients were reviewed to determine which elderly patients can continue PD for more than 5 years, and what the causes of death and the effects of icodextrin were in elderly PD patients. Study 2: A multicenter study of 421 patients introduced to PD from April 2000 to December 2004 in Japan was carried out by the Japanese Society for Elderly Patients on Peritoneal Dialysis to retrospectively analyze patient survival and technique survival and to find factors that have the potential to influence prognosis in these patients. Study 3: A review of the PD management and nursing-care insurance system (long-term care insurance) targeted patients 65 years of age and older who were initiated onto PD from January 2000 to June 2002 at 82 centers in Japan. The review found 765 patients under the age of 65 years (62.6%), and 458 patients 65 years of age and over (37.4%). Data on 409 elderly PD patients from 73 centers were analyzed.

♦ Results

Study 1: In 166 elderly patients, 27 (16.3%; 18 women, 9 men) continued PD for more than 5 years at our hospital. The original disease was chronic glomerulonephritis in 21 patients, diabetic nephropathy in 2 patients, nephrosclerosis in 2 patients, and polycystic kidney disease in 2 patients. The causes of death in the elderly PD patients at our hospital were heart failure (20.3%), cerebrovascular disease (17.7%), myocardial infarction (15.2%), debilitation (12.7%), peritonitis (7.6%), and pneumonia (3.8%). We observed significant differences in ultrafiltration, body weight, sodium, chloride, red blood cells, and hematocrit after using icodextrin in 14 elderly PD patients. Also, use of icodextrin in the daytime helps the family supporting an elderly member on PD by reducing the number of exchanges. Study 2: The average age of 421 patients in 37 hospitals throughout Japan was 76.4 years. Women accounted for 41% of all patients. The average modified (exclusive of factors of aging) Charlson comorbidity index (CCI) was 3.7. The modified CCI was an important factor not only in patient survival but also in technique survival. Patient survival was significantly different for the three modified CCI groups (CCI < 3, 3 ≤ CCI < 5, 5 ≤ CCI). Factors that influenced patient survival included patient choice of modality, modified CCI, exchanges performed by family members, and age at the start of PD. Factors that influenced technique survival included patient choice of modality, modified CCI, and exchanges performed by family members. Age at the start of PD was not a significant factor influencing technique survival. Study 3: Most elderly PD patients were living with family; 7% were living alone. At the start of PD, 24% of elderly PD patients were covered by nursing-care insurance, including 11% of young elderly patients (65 – 74 years of age), 35% of old elderly patients (75 – 84 years of age), and 29% of very old elderly patients (85 years of age or older). Patients 75 years of age or older were covered by nursing-care insurance more frequently than were patients under 75 years of age. Nevertheless, at the start of dialysis, fewer than 10% of elderly patients were using nursing-care insurance for PD.

♦ Conclusions

In elderly patients, PD has good outcomes, especially in nondiabetic patients, in patients with few comorbidities, and in patients managing PD by themselves. In introducing dialysis in elderly patients, PD should be the treatment of choice. A more secure support system should be established to allow the elderly to choose PD treatment.

Semaglutide: Charting New Horizons in GLP-1 Analogue Outcome Studies

The growing epidemic of obesity and diabetes represents a growing health emergency, exemplified by a marked increase in cardiovascular and renal disease. As such, healthcare systems are increasingly focussing on therapeutic approaches to address these challenges. Cardiovascular outcome trials (CVOTs) evaluating glucagon-like peptide-1 (GLP-1) analogues have previously observed significant improvements in major adverse cardiac events in people with type 2 diabetes (T2D). However, their impact in obese people without T2D is unknown. The SELECT study is the first pharmacotherapy study in obesity powered for cardiovascular superiority and investigates the impact of semaglutide on cardiovascular disease outcomes in overweight and obese people without T2D. The results of this study will potentially redefine obesity management, especially as secondary outcomes of the study will include evaluation of health-related quality of life and incident diabetes rates. In another potentially evolutionary therapeutic step for the incretin class of therapeutic agents, the FLOW study is the first dedicated study to investigate the effects of GLP-1 receptor analogues on renal and cardiovascular outcomes in people with renal impairment and T2D. Post-hoc analyses of GLP-1 analogue CVOTs have demonstrated reduced adverse renal outcomes associated with their use. In this review we discuss the known impact of GLP-1 analogues on cardiovascular, weight and renal outcomes in previous CVOTs. We further discuss the importance of the ongoing SELECT and FLOW studies on shifting the paradigm of obesity pharmacotherapy and in adding to our understanding of renal disease management in people with T2D.

Análisis de fragilidad y riesgo de peritonitis en pacientes ancianos en diálisis peritoneal

Introducción: Los pacientes ancianos en diálisis peritoneal tienen mayor riesgo de presentar fragilidad, pérdida de autonomía, comorbilidad y disminución de calidad de vida. Objetivo: evaluar la fragilidad, dependencia, depresión y calidad de vida, analizando la repercusión de la fragilidad sobre el tiempo de aprendizaje de la técnica y la aparición del primer episodio de peritonitis. Material y Método: estudio descriptivo retrospectivo. Se incluyeron pacientes mayores de 70 años, desde septiembre 2016 a 2017, las peritonitis hasta final de 2018. Se estudiaron variables demográficas, modalidad dialítica, índices de Charlson, Barthel y escala de depresión de Yesavage Escala de fragilidad clínica, calidad de vida, tiempo de entrenamiento y primera peritonitis. Resultados: Se incluyeron 25 pacientes, 56% hombres, edad media 76,77±5,34 años, el 72% estaban en diálisis peritoneal manual. La media del Charlson 7,88±2,06, del Barthel 88,27±24,66 y del Short form 12 health survey 32,96±8,61. El 40% tenían algún grado de fragilidad, 24% depresión, el 28% precisaban ayuda o estaban institucionalizados. Tiempo medio de entrenamiento en pacientes frágiles fue 16,77±7,93 horas vs no frágiles 15,20±5,06 (p=0,42). Se recogieron 16 episodios de peritonitis, repartidos al 50%, tiempo medio de aparición frágiles 315,13±212,73 días vs no frágiles 320,25±224,91 (p=0,44). Conclusiones: La mayoría de los pacientes realizan diálisis peritoneal manual de forma autónoma. Tienen un nivel de fragilidad bajo, no presentan depresión y gozan de buena calidad de vida para su edad. No existe diferencia en el tiempo de aprendizaje entre los dos grupos. Las peritonitis se reparten al 50% en frágiles y no frágiles.

[Impact of renal replacement therapy on frail older adults]

INTRODUCTION

End-stage renal disease prevalence is increasing in older adults. Frailty is highly prevalent in older adults with end-stage renal disease. However, there are no prospective studies comparing the performance of the different modalities of renal replacement therapy (RRT) in frail older adults.

OBJECTIVE

To compare clinically relevant outcomes (hospital admission, falls, hip fractures, and mortality) in prefrail and frail older adults according to the modality of RRT: peritoneal dialysis or haemodialysis.

METHODS

A prospective observational study in prefrail and frail older adults (according to FRAIL scale) on peritoneal dialysis and haemodialysis was carried out. An evaluation was made using baseline characteristics (age, Charlson, body mass index, time on RRT, compliance with Kt/V dose, haemoglobin, and albumin). The patients were followed-up over 12 months, recording mortality, days and number of hospital admissions, falls, and hip fractures.

RESULTS

A total of 54/65 (83%) older adults on RRT met criteria for prefrailty or frailty, and signed informed consent (27 in each modality). Baseline characteristics were similar, except for serum albumin and time on RRT, both of which were significantly lower in the peritoneal dialysis group. The FRAIL score was similar in both groups. Baseline FRAIL correlated with higher comorbidity, lower albumin levels, and non-compliance of Kt/V dose, while it was independent of age, body mass index, and time on RRT. Days and number of hospital admissions at 12 months were similar in patients on peritoneal dialysis and haemodialysis. Survival on peritoneal dialysis and haemodialysis was similar. There were no differences in falls or hip fractures.

CONCLUSIONS

Pre-frail and frail older adults on peritoneal dialysis and haemodialysis have similar clinical outcomes.

Patients’ Descriptions of Specific Factors Leading to Modality Selection of Chronic Peritoneal Dialysis Or Hemodialysis

♦ Objectives

There has been increasing interest in understanding how patients with chronic renal failure choose between chronic peritoneal dialysis (CPD) and hemodialysis (HD) for renal replacement therapy. The purpose of the present study was to examine the influences and specific factors that patients identify as significant in choosing a specific dialysis modality for treatment of their end-stage renal disease (ESRD).

♦ Patients and Design

40 patients (20 CPD, 20 HD) who had started dialysis within the preceding 6 months were randomly selected to participate in the study. A structured interview was conducted with the patients, discussing and exploring what factors patients thought were important in helping them decide their treatment modality. The format of the interview was open-ended. Based on patients’ comments, a taxonomy of the specific factors that influenced the patients’ decisions was developed.

♦ Setting

The study was conducted in a freestanding CPD unit and two freestanding HD units.

♦ Results

All 20 CPD patients reported choosing their treatment modality; only 8 of the 20 HD patients reported having a choice of treatment modality. 18 of the 22 patients who participated in predialysis educational programs opted for CPD. 83% of the patients reported that their physician was important in influencing their treatment choice; however, the CPD patients relied more on written material and the opinions of their spouse/significant other or other family members in making their decisions. Issues of autonomy and control were important for 95% of patients choosing CPD. Both CPD and HD patients cited a variety of treatment-specific factors. The three most frequently cited reasons for choosing CPD were ( 1 ) flexibility of schedule (19 patients), ( 2 ) convenience of performing CPD in their own home (19 patients), and ( 3 ) the option of doing dialysis at night while sleeping (8 patients). The 8 HD patients who selected their treatment modality cited the desirability of having a planned schedule (7 patients) and letting nurses or other take care of them (5 patients).

♦ Conclusions

The present study explored factors perceived by patients as being important in determining their choice of renal replacement therapy. A taxonomy of patient influences and concerns has been developed to provide caregivers with a framework to structure their educational strategies and assist patients with progressive renal failure in making an informed choice of therapeutic modality for their ESRD treatment.

Peritoneal Dialysis in Elderly Patients: Clinical Experience

Many older patients do not cope well with hemodialysis, yet the proportion of older patients on peritoneal dialysis (PD) is considerably lower than for younger patients. This is despite the fact that clinical outcome studies show that older patients cope as well as, if not better than, younger patients on PD. Furthermore, the North Thames Dialysis Study, a prospective study of patients ≥70 years old, has shown that survival, hospitalization, and quality of life were identical for patients on hemodialysis and patients on PD.

Harris SA, Lamping DL, Brown EA, Constantinovici N. Clinical outcomes and Quality of Life in Elderly Patients on Peritoneal Dialysis versus Hemodialysis

♦ Objective

To compare clinical outcomes and quality of life (QOL) in elderly patients on peritoneal dialysis (PD) and hemodialysis (HD) in the North Thames Dialysis Study.

♦ Design

A 12-month prospective cohort study.

♦ Setting

Four hospital-based renal units in London, UK.

♦ Patients

174 patients that were 70 years or older at the start of dialysis, separated into two cohorts: 78 new patients (36 PD, 42 HD) that were recruited after 90 days of chronic dialysis; and 96 stock patients (42 PD, 54 HD) that were already on dialysis during the recruitment period.

♦ Main Outcome Measures

12-month survival and hospitalization rate, and QOL assessed at baseline and at 6 and 12 months by the SF-36 and the Symptoms/Problems scale of the Kidney Disease Quality of Life Questionnaire (KDQOL).

♦ Results

Peritoneal dialysis and HD patients were similar for sociodemographic and clinical characteristics. Annual mortality and hospitalization rates in PD versus HD patients were 26.1 versus 26.4 deaths/100 person–years and 1.9 versus 2.0 admissions/person–year, respectively. Adjusted relative risks showed no effect of modality on clinical outcomes. Multiple linear regression analyses of QOL at baseline showed similar SF-36 scores between PD and HD patients, but higher KDQOL scores in PD patients (3.5 points higher, 95% confidence interval 0.3 – 6.6). There was, however, no effect of dialysis modality on QOL at 6 or 12 months.

♦ Conclusions

Clinical outcomes and QOL are similar in elderly people on PD and HD. Peritoneal dialysis is a viable option for more than a carefully selected minority of elderly people requiring dialysis.

Should Older Patients be Offered Peritoneal Dialysis?

On haemodialysis, my life was not my own — handing control to nursing staff for 4 hours, 3 days a week, surrounded by noisy machines and unhappy patients, returning home after 11 hours, too exhausted to eat and falling into bed. However, peritoneal dialysis has given me back my life. I am in control of me and am treated like a human being, not just a patient. There are minor drawbacks, such as storage for the fluids and being unable to have a bath, but it is a small price to pay.

In-Center Intermittent Peritoneal Dialysis: Retrospective Ten-Year Single-Center Experience with Thirty Consecutive Patients

Background

In-center intermittent peritoneal dialysis (IPD) is sometimes performed in elderly and multimorbid patients that have failed hemodialysis and that are unable to perform peritoneal dialysis (PD) at home. Complications, frequency of hospital admission, and survival are often claimed to be dismal although current data are lacking.

Methods

We performed a retrospective cohort study of patients that underwent IPD at Hannover Medical School, Germany, between 1997 and 2007. Underlying renal disorders, comorbidity, and circumstances that precluded hemodialysis and home PD were recorded. Survival, cause of death, episodes of hospitalization, and episodes of peritonitis were calculated. Laboratory values at baseline and after 3 months of IPD were also retrieved.

Results

We identified 30 patients with severe comorbidity (median Charlson Comorbidity Index of 6; n = 30) who underwent IPD for 439 months in total. The majority of patients had vascular/hypertensive nephropathy ( n = 12; 40%); congestive heart failure was the leading cause for choosing PD ( n = 13; 43.3%); 73.3% of our patients had either no partner or at least one disease that precluded home therapy. Hospitalization rate was 1.39 admissions per patient-year and there was 1 episode of peritonitis per 48.8 IPD-months. Mean survival was 26.6 months (median 17 months; n = 30); sepsis was the leading cause of death ( n = 13; 59.1%).

Conclusions

IPD is associated with fewer episodes of peritonitis, fewer admissions, and longer survival than is often believed. Suitable patients in whom palliative care alone seems inappropriate should not be denied a trial of IPD if they so choose.

Quality of life may be a more valuable prognostic factor than depression in older hemodialysis patients

PURPOSE

Depression and impairment of quality of life (QoL) reduce the survival of individual on hemodialysis (HD). However, few studies evaluated the impact of these conditions on the survival of older patients undergoing HD.

METHODS

A retrospective cohort study was performed including patients aged ≥ 60 years on HD in Recife, Brazil, assessed in 2013 and monitored until 2017. Depression was evaluated with the Mini-International Neuropsychiatric Interview and QoL with the Control, Autonomy, Self-realization, and Pleasure Questionnaire (CASP-16). Survival differences according to the depression and QoL status were measured by Kaplan-Meier analysis and Cox regression. Death Certificates were analyzed to assess the cause of death.

RESULTS

A total of 171 patients were included (mean age 68.7 ± 6.9 years). The mean follow-up time was 3 years (maximum 4.5 years) and there were 98 deaths (57.3% of the sample). In a multivariate model that included depression and QoL, only QoL impairment was associated with a higher risk of death (HR 1.62, p = 0.035). Among CASP domains, only "Control" was associated with survival (HR 0.90, p = 0.014). Depression was unrelated to the cause of death, but there was a trend for death by endocrine diseases if QoL was impaired (p = 0.057).

CONCLUSION

QoL impairment is a key predictor of prognosis in older patients on HD and may be more important than depression. It is important that teams dealing with this population include in protocols an assessment of QoL, in order to offer a range of care according to the needs of these patients.

[A case of oldest-old patient with chronic renal failure successfully treated with peritoneal dialysis]

He was a 92-year-old male patient with mild cognitive impairment while preserved activity of daily life. His renal dysfunction gradually increased due to the nephrosclerosis accompanied by systemic edema and water retention. We eventually decided to initiate peritoneal dialysis instead of standard hemodialysis for his end-stage renal dysfunction refractory to optimal medical therapy, given his preserved cognitive function and family support. He underwent an established therapeutic program for the peritoneal dialysis at home with an Information and Communication Technology (ICT).Given the increase in age of the patients with renal dysfunction, peritoneal dialysis has been receiving great attention as a home care strategy. The recent improvement in the device technology and ICT that enables us remote monitoring would reduce patients' effort in the management of peritoneal dialysis. Collaboration with home nursing and care workers would also be warranted for successful home care.

Quality of life, symptoms, and sleep quality of elderly with end-stage renal disease receiving conservative management: a systematic review

BACKGROUND

Older patients with end-stage renal disease (ESRD) have experienced diminished quality of life and debilitating symptoms. Conservative management may be a potential treatment option. Currently, limited studies have been conducted about the main outcome of conservative management, including quality of life, symptoms and sleep quality. The aim of this systematic review was to examine the quality of life, symptoms and sleep quality of elderly patients with ESRD undergoing conservative management.

METHODS

Evidence-based medicine database (JBI and Cochrane) and original literature database (PubMed, Medline, EMbase, Web of Science) were searched up to March 12, 2018. The quality of included papers was evaluated with the Newcastle-Ottawa Scale.

RESULTS

Eight studies met the inclusion criteria. The total of 1229 patients were involved with an average age of 60.6 ~ 82 years. Patients choosing conservative management were older and more functionally impaired compared to those opting for dialysis. 55% patients undergoing conservative management had stable or improved quality of life and symptoms in prospective cohort study. However, the results revealed that there were no significant differences in quality of life and symptom between conservative management and renal replacement therapy. Only one study assessed quality of life of older patients using SF-36, with a lower score in physical health subscale of conservative management patients than those of renal replacement therapy. Although more than 40% of the patients had poor sleep quality, no significant difference was found between conservative management and renal replacement therapy. Sleep disorders were associated with fatigue and other symptoms.

CONCLUSIONS

Although there is a limited literature, conservative management is likely to improve quality of life and alleviate symptoms of end-stage renal disease patients with considerable clinical implications mainly in elderly patients. Future study should pay more attention to the various treatment outcomes of conservative management, providing abundant evidence.

Relative prognostic impact of nutrition, anaemia, bone metabolism and cardiovascular comorbidities in elderly haemodialysis patients

BACKGROUND

The prognostic impact of nutrition and chronic kidney disease (CKD) complications has already been described in elderly haemodialysis patients but their relative weights on risk of death remain uncertain. Using structural equation models (SEMs), we aimed to model a single variable for nutrition, each CKD complication and cardiovascular comorbidities to compare their relative impact on elderly haemodialysis patients' survival.

METHODS

This prospective study recruited 3165 incident haemodialysis patients ≥75 years of age from 178 French dialysis units. Using SEMs, the following variables were computed: nutritional status, anaemia, mineral and bone disorder and cardiovascular comorbidities. Systolic blood pressure was also used in the analysis. Survival analyses used Poisson models.

RESULTS

The population average age was 81.9 years (median follow-up 1.51 years, 35.5% deaths). All variables were significantly associated with mortality by univariate analysis. Nutritional status was the variable most strongly associated with mortality in the multivariate analysis, with a negative prognostic impact of low nutritional markers {incidence rate ratio [IRR] 1.42 per 1 standard deviation [SD] decrement [95% confidence interval (CI) 1.32-1.53]}. The 'cardiovascular comorbidities' variable was the second variable associated with mortality [IRR 1.19 per 1 SD increment (95% CI 1.11-1.27)]. A trend towards low intact parathyroid hormone and high serum calcium and low values of systolic blood pressure were also associated with poor survival. The variable 'anaemia' was not associated with survival.

CONCLUSIONS

These findings should help physicians prioritize care in elderly haemodialysis patients with CKD complications, with special focus on nutritional status.

Conservative management for patients with chronic kidney disease refusing dialysis

Estimates suggest that 20-30% of the deaths of patients with chronic kidney disease with indication to undergo dialysis occur after refusal to continue dialysis, discontinuation of dialysis or inability to offer dialysis on account of local conditions. Contributing factors include aging, increased comorbidity associated with chronic kidney disease, and socioeconomic status. In several occasions nephrologists will intervene, but at times general practitioners or family physicians are on their own. Knowledge of the main etiologies of chronic kidney disease and the metabolic alterations and symptoms associated to end-stage renal disease is an important element in providing patients with good palliative care. This review aimed to familiarize members of multidisciplinary care teams with the metabolic alterations and symptoms arising from chronic kidney disease treated clinically without the aid of dialysis.

Peritoneal Dialysis in Adult Patients with Permanent Suprapubic Catheter: A Single-Center Experience and Literature Review

Background

The aim of this paper was to review the feasibility of peritoneal dialysis (PD) in the presence of a permanent supra-pubic catheter over a long follow-up period.

Methods

Twelve patients with automated PD and permanent suprapubic catheters were studied for complications over a period of 10 years.

Results

In all 12 patients, PD went smoothly. Two of our patients required removal of the PD catheter due to peritonitis. The overall rate of exit-site infection throughout the study was 41.7/patient-month and the difference between patients 60 years or older and those 25 years or younger was not significant ( p = 0.3673). The overall peritonitis rate for all patients was 38.3 episode/patient-month, and none of the patients with ventriculoperitoneal shunt (VPS) had peritonitis. All patients with episodes of infection responded well to the proper antibiotics.

Conclusions

The available data supported the feasibility of PD in patients with permanent suprapubic catheters; however, a greater number of patients with a longer follow-up period need to be studied to support our results.

Outcomes in dialysis versus conservative care for older patients: A prospective cohort analysis of stage 5 Chronic Kidney Disease

Background

The benefits of dialysis in older people with ESKD are not clear. We prospectively evaluated whether dialysis has survival advantage compared to conservative care (CC) in older people who were medically suitable for dialysis therapy.

Methods

This was a prospective observational study of CKD patients aged ≥75 years when eGFR first reached ≤15ml/min/1.73m². Hazard ratios (HR) for death were compared between patients who chose dialysis versus conservative care (CC) from when first seen in pre-dialysis clinic (eGFR ≤15ml/min/1.73m²), and when initiation of dialysis was first considered (eGFR ≤10ml/min/1.73m²). Patients with co-morbidities likely to significantly reduce life expectancy such as advanced heart failure, advanced dementia, and malignancy, were excluded.

Results

There were 204 patients (123 dialysis, 81 CC). 115 went on to record eGFR of ≤10ml/min/1.73m² (73 dialysis, 42 CC). The median survival from eGFR first ≤15ml/min/1.73m² for the dialysis and CC groups were 42 (33–50) months and 31 (21–41) months. The adjusted hazard ratio (HR) for death in the dialysis group compared to CC was 0.61 (0.41–0.61, p = 0.01). The median survival from eGFR first ≤10ml/min/1.73m² for dialysis and CC group were 36 (25–47) months and 12 (0–5) months. The adjusted HR for death in the dialysis group compared to CC was 0.36 (0.21–0.62, p <0.001).

Conclusion

Dialysis confers a survival benefit in older patients medically suitable for dialysis. This study is novel in being both prospective and in excluding patients with co-morbidities which may limit suitability for dialysis and life expectancy. A future focus on quality of life is needed to establish the true benefits of dialysis in older people.

The Factors Affecting Survival in Geriatric Hemodialysis Patients

Introduction

The number of geriatric patients is increasing in hemodialysis population over the years and mortality is higher in this group of patients. This study evaluated the factors affecting geriatric hemodialysis patient survival.

Materials and Methods

This retrospective cohort study enrolled patients discharged from our nephrology clinic from 2009 to 2014. Data collected included demographics, Eastern Cooperative Oncology Group-Performance Status, vascular access type, and metabolic parameters. Comorbidity was quantified using the modified Liu comorbidity index. The outcome measure was mortality.

Results

The study enrolled 99 elderly dialysis patients (42.4% women (n = 42); mean age 75 ± 7 years). The mean follow-up duration was 19.7 ± 11 months. The mortality rate over the four years was 47.5% (n = 46). The modified Liu comorbidity index score, patient age, and Eastern Cooperative Oncology Group-Performance Status were significantly related to mortality in univariate and multivariate analyses.

Conclusion

The present study revealed that comorbidities and low performance status at the onset of dialysis had shortened the survival time in the geriatric hemodialysis patient group.

Current Practice and Outcomes of Peritoneal Dialysis in the Nippon Medical School Musashi Kosugi Hospital

INTRODUCTION

Various innovations for preventing complications and improving a patient's quality of life have been implemented for peritoneal dialysis (PD), which was established in Japan approximately 35 years ago and introduced at our hospital in 1999. Herein, we investigate the outcomes of patients undergoing PD to identify approaches for improving their long-term prognosis.

METHODS

This retrospective study included 114 patients who underwent PD between September 1999 and August 2017 and included various parameters such as patient survival rate, technical survival rate, cause (s) of PD withdrawal, incidence of peritonitis, dialysis duration, and change in residual renal function (RRF). Furthermore, factors associated with PD withdrawal and duration, as well as risk factors for peritonitis, were examined.

RESULTS

Mean (± standard deviation) PD duration was 35.62 (±29.88) months in all patients and 37.16 (±34.09) months in 58 patients who withdrew from treatment. Five-year continuance and survival rates were 40.41% and 55.74%, respectively (p=0.0061). However, in patients aged ≥65 years, the continuance and survival rates were not significantly different (p=0.1250). Furthermore, the continuance and survival rates in diabetic patients were not significantly different from those of non-diabetic patients (p=0.1334 and 0.7140, respectively). Comparison of changes in RRF in young and elderly patients revealed that it was not significantly sustained in elderly patients (p=0.0259). The Cox proportional hazards model revealed that age (p=0.0455) and total cholesterol levels (p=0.0494) were independent risk factors for PD withdrawal, and multiple regression analysis showed that the presence of peritonitis (p=0.0063) and low-density lipoprotein cholesterol (LDL-C) levels (p=0.0087) were significant factors for PD duration. Peritonitis incidence was 0.077 times per patient per year, and multivariate analysis identified PD duration (p=0.0009) and LDL-C levels (p=0.0054) as independent risk factors for peritonitis.

CONCLUSION

The findings of this study revealed that assessment of the nutritional status of the patient and prevention of peritonitis are important for continuation of PD. PD is a safe treatment option that can maintain the quality of life in elderly patients. In a rapidly aging society, the need for PD-based medical care is expected to increase.

Peritoneal dialysis in older adults: Evaluation of clinical, nutritional, metabolic outcomes, and quality of life

The number of older adults requiring dialysis is increasing worldwide, whereas the use of peritoneal dialysis (PD) in this population is lower with respect to younger patients, despite the theoretical advantages of PD respect to hemodialysis. This is most likely due to the concern that older patients may not be able to correctly and safely manage PD.We aimed to prospectively compare clinical, nutritional and metabolic outcomes and measures of quality of life between younger (<65 years old) and older (≥65 years old) patients on PD.PD patients were enrolled and divided into 2 groups according to age (Group A < 65 years, Group B ≥ 65 years). Clinical and instrumental parameters, and quality of life were evaluated at baseline (start of PD) (T0) and at 24 months (T1). Technique survival, mortality, total number of hospitalizations, and the index of peritonitis (episodes of peritonitis/month) were also evaluated.Fifty-one patients starting PD were enrolled. Group A included 22 patients (48.7 ± 8.3 years), and Group B consisted of 29 patients (74.1 ± 6.4 years). At baseline, the 2 groups showed no differences in cognitive status, whereas Group A showed higher total cholesterol (P = .03), LDL (P = .03), and triglycerides (P = .03) levels and lower body mass index (P = .02) and carotid intima media thickness (P < .0001) with respect to Group B. At T1 Group B showed, compared to baseline, a significant reduction in albumin (P < .0001) and phosphorus (P = .045) levels, while no significant differences on body composition, technique survival, total number of hospitalizations, index of peritonitis, and quality of life indices were observed.Our data do not show clinically relevant barriers to use PD in older adult patients, supporting its use in this population. Nutritional and metabolic parameters should be carefully monitored in older PD patients.

Functional status, pre-dialysis health and clinical outcomes among elderly dialysis patients

Background

Elderly patients comprise the fastest growing population initiating dialysis in United States. The impact of poor functional status and pre-dialysis health status on clinical outcomes in elderly dialysis patients is not well studied.

Methods

We studied a retrospective cohort of 49,645 incident end stage renal disease patients that initiated dialysis between January 1, 2008 and December 31, 2008 from the United States Renal Data System with linked Medicare data covering at least 2 years prior to dialysis initiation. Using logistic regression models adjusted for pre-dialysis health status and other cofounders, we examined the impact of poor functional status as defined from form 2728 on 1-year all-cause mortality as primary outcome, type of dialysis modality (hemodialysis vs. peritoneal dialysis), and type of initial vascular access (arteriovenous access vs. central venous catheter) among hemodialysis patients as secondary outcomes.

Results

Mean age was 72 ± 11 years. At dialysis initiation, 18.7% reported poor functional status, 88.9% had at least 1 pre-dialysis hospitalization, and 27.8% did not receive pre-dialysis nephrology care. In adjusted analyses, 1-year mortality was higher in patients with poor functional status (OR, 1.48; 95% CI, 1.40–1.57). Adjusted odds of being initiated on hemodialysis than peritoneal dialysis (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.16–1.66) were higher in patients with poor functional status. Poor functional status decreased the adjusted odds of starting hemodialysis with arteriovenous access as compared to central venous catheter (OR, 0.79; 95% CI, 0.72–0.86).

Conclusion

Poor functional status in elderly patients with end stage renal disease is associated with higher odds of initiating hemodialysis; increases the risk of central venous catheter use, and is an independent predictor of 1-year mortality.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-0898-1) contains supplementary material, which is available to authorized users.

Canagliflozin, dapagliflozin and empagliflozin monotherapy for treating type 2 diabetes: systematic review and economic evaluation

BACKGROUND

Most people with type 2 diabetes are overweight, so initial treatment is aimed at reducing weight and increasing physical activity. Even modest weight loss can improve control of blood glucose. If drug treatment is necessary, the drug of first choice is metformin. However, some people cannot tolerate metformin, which causes diarrhoea in about 10%, and it cannot be used in people with renal impairment. This review appraises three of the newest class of drugs for monotherapy when metformin cannot be used, the sodium-glucose co-transporter 2 (SGLT2) inhibitors.

OBJECTIVE

To review the clinical effectiveness and cost-effectiveness of dapagliflozin (Farxiga, Bristol-Myers Squibb, Luton, UK), canagliflozin (Invokana, Janssen, High Wycombe, UK) and empagliflozin (Jardiance, Merck & Co., Darmstadt, Germany), in monotherapy in people who cannot take metformin.

SOURCES

MEDLINE (1946 to February 2015) and EMBASE (1974 to February 2015) for randomised controlled trials lasting 24 weeks or more. For adverse events, a wider range of studies was used. Three manufacturers provided submissions.

METHODS

Systematic review and economic evaluation. A network meta-analysis was carried out involving the three SGLT2 inhibitors and key comparators. Critical appraisal of submissions from three manufacturers.

RESULTS

We included three trials of dapagliflozin and two each for canagliflozin and empagliflozin. The trials were of good quality. The canagliflozin and dapagliflozin trials compared them with placebo, but the two empagliflozin trials included active comparators. All three drugs were shown to be effective in improving glycaemic control, promoting weight loss and lowering blood pressure (BP).

LIMITATIONS

There were no head-to-head trials of the different flozins, and no long-term data on cardiovascular outcomes in this group of patients. Most trials were against placebo. The trials were done in patient groups that were not always comparable, for example in baseline glycated haemoglobin or body mass index. Data on elderly patients were lacking.

CONCLUSIONS

Dapagliflozin, canagliflozin and empagliflozin are effective in improving glycaemic control, with added benefits of some reductions in BP and weight. Adverse effects are urinary and genital tract infections in a small proportion of users. In monotherapy, the three drugs do not appear cost-effective compared with gliclazide or pioglitazone, but may be competitive against sitagliptin (Januvia, Boehringer Ingelheim, Bracknell, UK).

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model

BACKGROUND

End-stage renal disease is a long-term irreversible decline in kidney function requiring renal replacement therapy: kidney transplantation, haemodialysis or peritoneal dialysis. The preferred option is kidney transplantation, followed by immunosuppressive therapy (induction and maintenance therapy) to reduce the risk of kidney rejection and prolong graft survival.

OBJECTIVES

To review and update the evidence for the clinical effectiveness and cost-effectiveness of basiliximab (BAS) (Simulect(®), Novartis Pharmaceuticals UK Ltd) and rabbit anti-human thymocyte immunoglobulin (rATG) (Thymoglobulin(®), Sanofi) as induction therapy, and immediate-release tacrolimus (TAC) (Adoport(®), Sandoz; Capexion(®), Mylan; Modigraf(®), Astellas Pharma; Perixis(®), Accord Healthcare; Prograf(®), Astellas Pharma; Tacni(®), Teva; Vivadex(®), Dexcel Pharma), prolonged-release tacrolimus (Advagraf(®) Astellas Pharma), belatacept (BEL) (Nulojix(®), Bristol-Myers Squibb), mycophenolate mofetil (MMF) (Arzip(®), Zentiva; CellCept(®), Roche Products; Myfenax(®), Teva), mycophenolate sodium (MPS) (Myfortic(®), Novartis Pharmaceuticals UK Ltd), sirolimus (SRL) (Rapamune(®), Pfizer) and everolimus (EVL) (Certican(®), Novartis) as maintenance therapy in adult renal transplantation.

METHODS

Clinical effectiveness searches were conducted until 18 November 2014 in MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Wiley Online Library) and Web of Science (via ISI), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment (The Cochrane Library via Wiley Online Library) and Health Management Information Consortium (via Ovid). Cost-effectiveness searches were conducted until 18 November 2014 using a costs or economic literature search filter in MEDLINE (via Ovid), EMBASE (via Ovid), NHS Economic Evaluation Database (via Wiley Online Library), Web of Science (via ISI), Health Economic Evaluations Database (via Wiley Online Library) and the American Economic Association's electronic bibliography (via EconLit, EBSCOhost). Included studies were selected according to predefined methods and criteria. A random-effects model was used to analyse clinical effectiveness data (odds ratios for binary data and mean differences for continuous data). Network meta-analyses were undertaken within a Bayesian framework. A new discrete time-state transition economic model (semi-Markov) was developed, with acute rejection, graft function (GRF) and new-onset diabetes mellitus used to extrapolate graft survival. Recipients were assumed to be in one of three health states: functioning graft, graft loss or death.

RESULTS

Eighty-nine randomised controlled trials (RCTs), of variable quality, were included. For induction therapy, no treatment appeared more effective than another in reducing graft loss or mortality. Compared with placebo/no induction, rATG and BAS appeared more effective in reducing biopsy-proven acute rejection (BPAR) and BAS appeared more effective at improving GRF. For maintenance therapy, no treatment was better for all outcomes and no treatment appeared most effective at reducing graft loss. BEL + MMF appeared more effective than TAC + MMF and SRL + MMF at reducing mortality. MMF + CSA (ciclosporin), TAC + MMF, SRL + TAC, TAC + AZA (azathioprine) and EVL + CSA appeared more effective than CSA + AZA and EVL + MPS at reducing BPAR. SRL + AZA, TAC + AZA, TAC + MMF and BEL + MMF appeared to improve GRF compared with CSA + AZA and MMF + CSA. In the base-case deterministic and probabilistic analyses, BAS, MMF and TAC were predicted to be cost-effective at £20,000 and £30,000 per quality-adjusted life-year (QALY). When comparing all regimens, only BAS + TAC + MMF was cost-effective at £20,000 and £30,000 per QALY.

LIMITATIONS

For included trials, there was substantial methodological heterogeneity, few trials reported follow-up beyond 1 year, and there were insufficient data to perform subgroup analysis. Treatment discontinuation and switching were not modelled.

FUTURE WORK

High-quality, better-reported, longer-term RCTs are needed. Ideally, these would be sufficiently powered for subgroup analysis and include health-related quality of life as an outcome.

CONCLUSION

Only a regimen of BAS induction followed by maintenance with TAC and MMF is likely to be cost-effective at £20,000-30,000 per QALY.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014013189.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Evaluation of unplanned dialysis as a predictor of mortality in elderly dialysis patients: a retrospective data analysis

Background

Increasing numbers of elderly patients are undergoing long-term dialysis. However, the role of dialysis in survival and quality of life is unclear, and poor outcomes may be associated with comorbidities rather than with age only. The initiation of unplanned dialysis in elderly patients with chronic kidney disease (CKD) has been reported to be associated with poor survival. We evaluated patient and practice factors associated with poor survival.

Methods

We performed a retrospective analysis of 90 consecutive elderly patients (≥75 years) with CKD initiated on long-term dialysis at our renal unit between October 2010 and February 2014. Six patients were excluded; data from 84 remaining patients (≥75 years) with end-stage renal disease undergoing planned or unplanned dialysis were analyzed. Patients were followed up until death or January 2015. Patient factors such as age at initiation of dialysis and comorbidities (i.e., diabetes mellitus, ischemic heart disease [IHD], peripheral vascular disease, cancer, chronic obstructive pulmonary disease, and cognitive dysfunction) were analyzed. Practice factors such as planned or unplanned initiation of dialysis were compared in relation to survival outcomes. “Unplanned dialysis” was defined as a patient with known CKD stage 4 or 5 who had not been evaluated by a nephrologist in the 3 months before dialysis initiation.

Results

The average age at dialysis initiation was 81.5 ± 4.5 years), serum albumin level was 24.8 ± 6 g/L, body mass index was 22.5 ± 4.8 kg/m², and glycated hemoglobin A1c level was 6.3 ± 1.3. Overall, 51 (61%) and 33 (39%) patients underwent unplanned and planned dialysis, respectively. On univariate analysis, the presence of IHD, peripheral vascular disease, ≥3 comorbidities, and unplanned initiation of dialysis were significantly related to death. On multivariate analysis, unplanned start of dialysis, ischemic heart diseases and peripheral vascular disease remained significant. Survival rates at 3 and 12 months were 38.6% vs. 90.9% and 14.4% vs. 73.6% for unplanned vs. planned dialysis, respectively (p < 0.001). Unplanned dialysis was significantly associated with greater mortality.

Conclusions

In elderly dialysis patients, unplanned start of dialysis was associated with poor survival. Patient characteristics such as associated peripheral vascular disease and IHD were associated with poor survival.

Caring for critically ill oldest old patients: a clinical review

Despite technological advances, the mortality rate for critically ill oldest old patients remains high. The intensive caring should be able to combine technology and a deep humanity considering that the patients are living the last part of their lives. In addition to the traditional goals of ICU of reducing morbidity and mortality, of maintaining organ functions and restoring health, caring for seriously oldest old patients should take into account their end-of-life preferences, the advance or proxy directives if available, the prognosis, the communication, their life expectancy and the impact of multimorbidity. The aim of this review was to focus on all these aspects with an emphasis on some intensive procedures such as mechanical ventilation, noninvasive mechanical ventilation, cardiopulmonary resuscitation, renal replacement therapy, hemodynamic support, evaluation of delirium and malnutrition in this heterogeneous frail ICU population.

Predicting Quality of Life Changes in Hemodialysis Patients Using Machine Learning: Generation of an Early Warning System

Objective

To predict changes in the quality of life scores of hemodialysis patients for the coming month and the development of an early warning system using machine learning

Methods

It was a prospective cohort study (one-month duration) at the dialysis center of a tertiary care hospital in Pakistan. The study started on 1^st October 2016. About 78 patients have been enrolled till now. Bachelor of Medicine and Bachelor of Surgery (MBBS) qualified doctors administered a proforma with demographics and the validated Urdu version of World Health Organization Quality Of Life-BREF (WHOQOL-BREF). It was to be repeated after one month to the same patient by the same investigator. Simple statistics were computed using SPSS version 24 (IBM Corp., Armonk, NY) while machine learning was performed using R (version 3.0) and Orange (version 3.1).

Results

Using machine learning algorithms, two models (classification tree and Naïve Bayes) were generated to predict an increase or decrease of 5% in a patient’s WHOQOL-BREF score over one month. The classification tree was selected as the most accurate model with an area under curve (AUC) of 83.3% (accuracy: 81.9%) for the prediction of 5% increase in QOL and an AUC of 76.2% (accuracy: 81.8%) for the prediction of 5% decrease in QOL over the coming month. The factors associated with an increase of QOL by 5% or more over the next month included younger age (<19 years) and higher iron sucrose doses (>278mg/month). Drops in psychological, physical, and social domain scores lead to a decrease of 5% or more in QOL scores over the following month.

Conclusion

An early warning system, dialysis data interpretation for algorithmic-prediction on quality of life (DIAL) was built for the early detection of deteriorating QOL scores in the hemodialysis population using machine learning algorithms. The model pointed out that working on psychological and environmental domains, in particular, may prevent the drop in QOL scores from occurring. DIAL, if implemented on a larger scale, is expected to help patients in terms of ensuring a better QOL and in reducing the financial burden in the long term.

Survival analysis of conservative vs. dialysis treatment of elderly patients with CKD stage 5

Elderly patients represent a growing population among people suffering from ESRD. So far only limited data on actual survival benefits of elderly adults initiating dialysis have been published. Besides the high burden of preexisting comorbidities, dialysis treatment itself may be associated with a further deterioration in functional status in this population. We retrospectively analyzed the Austrian Dialysis and Transplant Registry and identified 8,622 patients who started maintenance hemodialysis after the age of 65 years between 2002 and 2009. We compared this data set to a cohort of 174 patients aged over 65 years with CKD stage 5 who progressed to an eGFR < 10ml/min/ and were managed conservatively in the same era. All patients who died of malignant disease were excluded from this analysis. The risk of mortality was analyzed using multivariable Cox proportional hazards models. Furthermore, a parametric model of time to event analysis was used for visualization of changing risk over time and precise calculation of time to equal risk assuming a Weibull distribution. Hemodialysis treatment was associated with a decreased risk for death with a HR of 0.23 (95% CI 0.18 to 0.29; p<0.001) compared to conservative treatment. The time to event analysis however showed, that although survival was initially superior in the hemodialysis group, hazards crossed thereafter. Time to equal risk was 2.9 months and 1.9 months for female and male patient aged 65, respectively, and decreased to one month in the very elderly aged 95. Elderly patients with ERSD did benefit from initiation of hemodialysis, as the conservative group showed a very high initial mortality rate. This survival benefit of dialysis treatment however did not persist beyond the first two months compared to survivors of the conservative group.

A Description of Advanced Chronic Kidney Disease Patients in a Major Urban Center Receiving Conservative Care

BACKGROUND

Conservative/palliative (nondialysis) management is an option for some individuals for treatment of stage 5 chronic kidney disease (CKD). Little is known about these individuals treated with conservative care in the Canadian setting.

OBJECTIVE

To describe the characteristics of patients treated with conservative care for category G5 non-dialysis CKD in a Canadian context.

DESIGN

Retrospective chart review.

SETTING

Urban nephrology center.

PATIENTS

Patients with G5 non-dialysis CKD (estimated glomerular filtration rate <15 mL/min/1.73 m²).

MEASUREMENTS

Baseline patient demographic and clinical characteristics of conservative care follow-up, advanced care planning, and death.

METHODS

We undertook a descriptive analysis of individuals enrolled in a conservative care program between January 1, 2009, and June 30, 2015.

RESULTS

One hundred fifty-four patients were enrolled in the conservative care program. The mean age and standard deviation was 81.4 ± 9.0 years. The mean modified Charlson Comorbidity Index score was 3.4 ± 2.8. The median duration of conservative care participation was 11.5 months (interquartile range: 4-25). Six (3.9%) patients changed their modality to dialysis. One hundred three (66.9%) patients died during the study period. Within the deceased cohort, most (88.2%) patients completed at least some advanced care planning before death, and most (81.7%) of them died at their preferred place. Twenty-seven (26.7%) individuals died in hospital.

LIMITATIONS

Single-center study with biases inherent to a retrospective study. Generalizability to non-Canadian settings may be limited.

CONCLUSIONS

We found that individuals who chose conservative care were very old and did not have high levels of comorbidity. Few individuals who chose conservative care changed modality and accepted dialysis. The proportions of engagement in advanced care planning and of death in place of choice were high in this population. Death in hospital was uncommon in this population.

Quality of life as indicator of poor outcome in hemodialysis: relation with mortality in different age groups

BACKGROUND

Physical, cognitive and psychosocial functioning are frequently impaired in dialysis patients and impairment in these domains relates to poor outcome. The aim of this analysis was to compare the prevalence of impairment as measured by the Kidney Disease Quality of Life- Short Form (KDQOL-SF) subscales between the different age categories and to assess whether the association of these subscales with mortality differs between younger and older dialysis patients.

METHODS

This study included data from 714 prevalent hemodialysis patients, from 26 centres, who were enrolled in the CONvective TRAnsport STudy (CONTRAST NCT00205556, 09-12-2005). Baseline HRQOL domains were evaluated for patients <65 years, 65-74 years and over 75 years. Multivariable Cox proportional hazards analyses were performed to assess the relation between the separate domains and 2-year mortality.

RESULTS

Emotional health was higher in patients over the age of 75 compared to younger patients (mean level 71, 73 and 77 for increasing age categories respectively, p = 0.02), whilst physical functioning was significantly lower in older patients (mean level 60, 48 and 40, p < 0.01). A low level of physical functioning (Hazard Ratio (HR) 1.72 [95%Confidence Interval (CI) 1.02-2.73]), emotional health (HR 1.85 [95% 1.30-2.63]), and social functioning (HR 1.59 [95% CI 1.12-2.26]), was individually associated with an increased 2-year mortality within the whole population. The absence of effect modification suggests no evidence for different relations within the older age groups.

CONCLUSIONS

In dialysis patients, older age is associated with lower levels of physical functioning, whilst the level of emotional health is not associated with age. KDQOL-SF domains physical functioning, emotional health and social functioning are independently associated with mortality in prevalent younger and older hemodialysis patients.

Quality of Life, Perceptions, and Health Satisfaction of Older Adults with End-Stage Renal Disease: A Systematic Review

OBJECTIVES

To explore the quality of life (QOL), perceptions, and health satisfaction of older adults with end-stage renal disease (ESRD) undergoing renal replacement therapy (RRT).

DESIGN

Systematic review of literature.

PARTICIPANTS

Individuals with ESRD undergoing RRT aged 65 and older.

MEASUREMENTS

Articles identified from PubMed database search from January 1994 to December 2014. The methodological quality of each of the selected articles was assessed using eight standards adapted from well-established research quality review criteria.

RESULTS

Of the initial 1,401 articles identified, 23 met the inclusion criteria. The age range of study participants examined was 65 to 90. Seventy-eight percent of the studies met six or more of the methodological standards; 47% found overall health-related and mental component summary QOL scores in elderly adults with ESRD to be similar to or higher than those of age-matched controls or younger individuals, although the physical component summary QOL scores tended to be lower in older adults. Only six studies addressed health satisfaction and perceptions of elderly adults with ESRD, with widely variable findings.

CONCLUSION

Few studies specifically examine QOL in elderly adults with ESRD undergoing RRT and even fewer address issues of perceptions and health satisfaction. However, the limited data from the QOL studies looks promising with a significant proportion showing similar or higher overall health-related and mental component summary QOL scores in elderly adults with ESRD. The very limited data on perceptions and health satisfaction of elderly adults with ESRD undergoing RRT makes it difficult to make any generalizable conclusions. Overall, more research is needed to examine these factors in elderly adults with ESRD.