NKF-DOQI clinical practice guidelines for hemodialysis adequacy. National Kidney Foundation

Interferon-gamma release assays for diagnosis of latent TB infection in chronic kidney diseases and dialysis patients

Introduction

Patients with chronic kidney disease (CKD), especially end-stage kidney disease (ESKD), are at risk of developing tuberculosis (TB). The prevalence and predictors of LTBI assessed by a high-sensitivity, high-specificity test such as an interferon-gamma release assay (IGRA) has not been thoroughly explored.

Methods

All patients with CKD were prospectively recruited from September 2020 to November 2021 and retrospectively reviewed from December 2020 to November 2021. The prevalence of LTBI was determined using IGRA by CKD stage and dialysis type. Predictors of LTBI were assessed by logistic regression analysis.

Results

In total, 199 patients with CKD were enrolled (102 prospectively, 97 retrospectively). Of these, 173 patients were evaluable (mean age, 53 ± 16 years; 44% male). Ninety-five (55%) patients had ESKD and were maintained on renal replacement therapy. Overall, 39 (22.5%) patients had LTBI with a prevalence of 25.0%, 12.5%, 25.0%, 25.0%, and 24.2% among patients with CKD stage 1, 2, 3a, 3b, and ESKD, respectively (p=0.89). Among patients with ESKD, the prevalence of LTBI was higher in those on hemodialysis than in those on peritoneal dialysis (28.9% vs. 5.3%, p=0.03). In the multivariable analysis of patients with ESKD, drinking alcohol was significantly associated with LTBI (odds ratio, 8.51; 95% confidence interval, 1.24–58.38; p=0.029), and hemodialysis was marginally associated with LTBI (odds ratio, 8.14; 95% confidence interval, 0.95–69.91; p=0.056).

Conclusion

In TB-endemic settings, 20% of patients with CKD and 25% of patients with ESKD may have LTBI. Alcohol consumption and hemodialysis can help to identify high-risk patients with ESKD and potentially screen for LBTI.

Ensuring hemodialysis adequacy by dialysis dose monitoring with UV spectroscopy analysis of spent dialyzate

Introduction:

Patients’ session-to-session variation has been shown to influence outcomes, making critical the monitoring of dialysis dose in each session. The aim of this study was to detect the intra-patient variability of blood single pool Kt/V as measured from pre-post dialysis blood urea and from the online tool Adimea^®, which measures the ultraviolet absorbance of spent dialyzate.

Methods:

This open, one-armed, prospective non-interventional study, evaluates patients on bicarbonate hemodialysis or/and on hemodiafiltration. Dialysis was performed with B. Braun Dialog+ machines equipped with Adimea^®. In the course of the prospective observation, online monitoring with Adimea^® in each session was established without the target warning function being activated. A sample size of 97 patients was estimated.

Results:

A total of 120 patients were enrolled in six centers in China (mean age 51.5 ± 12.2 years, 86.7% males, 24.2% diabetics). All had an AV-fistula. The proportion of patients with blood Kt/V < 1.20 at baseline was 48.3%. During follow-up with Adimea^®, the subgroup with Kt/V > 1.20 at baseline remains at the same adequacy level for more than 90% of the patients. Those with a Kt/V < 1.20 at baseline, showed a significant increase of Kt/V to 60% of the patients reaching the adequacy level >1.20. The coefficient of variation for spKt/V as evaluated by Adimea^® was 9.6 ± 3.4%, not significantly different from the 9.6 ± 8.6% as blood Kt/V taken at the same time.

Conclusion:

Online monitoring of dialysis dose by Adimea^® improves and maintains dialysis adequacy. Implementing online monitoring by Adimea into daily practice moves the quality of dialysis patient care a significant step forward.

Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis

INTRODUCTION

The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis.

AREAS COVERED

In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis.

EXPERT OPINION

In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.

Brachial Vein Transposition with Consecutive Skin Incisions in a Hemodialysis Patient with Absence of Adequate Superficial Veins: A Case Report

The creation of an arteriovenous fistula instead of a synthetic vascular graft is a smart decision in hemodialysis patients who do not have a suitable superficial vein. Basilic vein transposition (BVT) is a viable option in most cases, except in patients who do not have a proper basilic vein. In patients with inadequate superficial veins, another source of the autogenous vein is the brachial vein, a deep vein of the upper arm. Most surgeons choose a full medial arm incision to perform brachial vein exploration. We describe a patient in whom BVT was not possible and so brachial vein transposition using skip incisions was performed, with good results.

Adequacy of Hemodialysis and Its Associated Factors among Patients Undergoing Chronic Hemodialysis in Dar es Salaam, Tanzania

The worldwide prevalence of maintenance hemodialysis continues to rise. An adequate delivery of hemodialysis dose as measured by Kt/V or urea reduction ratio is a crucial determinant of clinical outcome for chronic hemodialysis patients. The aim of this study was to assess the adequacy of hemodialysis and its associated factors among patients undergoing chronic hemodialysis in Dar es Salaam. This was a cross-sectional study done on patients undergoing chronic hemodialysis in four dialysis centers in Dar es Salaam. Sociodemographic information and treatment characteristics were collected. Urea reduction rate and single-pool Kt/V were calculated to determine the adequacy of hemodialysis. The data were analyzed and any associated factors for inadequate hemodialysis were determined using a chi-square test and a logistic regression analysis. A total of 143 patients participated in the study. Males represented 65.7% of the study population. The mean age (±SD) was 51.7 ± 1.2 years. Only 34.3% (based on urea reduction ratio (URR)) and 40.6% (based on Kt/V) of patients received adequate hemodialysis. The univariate analysis showed that males were more likely to have inadequate dialysis (65.6% versus 48.0%, p=0.048 based on Kt/V). Patients using hemodialyzers with dialyzer surface area less than 1.4 m² received significantly less hemodialysis dose than those with more than 1.4 m² (69.0% versus 41.2%, p=0.02, by URR) (62.7% versus 35.3%, p=0.03, by Kt/V criteria). Patients who had hemoglobin <10 g/dl received significantly inadequate hemodialysis dose as compared to patients with hemoglobin ≥10 g/dl by Kt/V criteria (69.8% versus 51.3%, p=0.03). None of the factors acquired significance in the multivariate analysis. The proportion of patients receiving an adequate hemodialysis dose is low (34.3% based on URR and 40.6% based on Kt/V). Male gender, dialyzer surface area of <1.4 m², and hemoglobin level of <10 g/dl were associated with an inadequate delivered dose of hemodialysis in the univariate analysis but not in the multivariate analysis. This study can increase awareness about the importance of measuring hemodialysis adequacy and giving the correct hemodialysis dose to achieve the intended benefit.

Impact of residual kidney function on hemodialysis adequacy and patient survival

Background

Both dialysis dose and residual kidney function (RKF) contribute to solute clearance and are associated with outcomes in hemodialysis patients. We hypothesized that the association between dialysis dose and mortality is attenuated with greater RKF.

Methods

Among 32 251 incident hemodialysis patients in a large US dialysis organization (2007-11), we examined the interaction between single-pool Kt/V (spKt/V) and renal urea clearance (rCLurea) levels in survival analyses using multivariable Cox proportional hazards regression model.

Results

The median rCLurea and mean baseline spKt/V were 3.06 [interquartile range (IQR) 1.74-4.85] mL/min/1.73 m2 and 1.32 ± 0.28, respectively. A total of 7444 (23%) patients died during the median follow-up of 1.2 years (IQR 0.5-2.2 years) with an incidence of 15.4 deaths per 100 patient-years. The Cox model with adjustment for case-mix and laboratory variables showed that rCLurea modified the association between spKt/V and mortality (Pinteraction = 0.03); lower spKt/V was associated with higher mortality among patients with low rCLurea (i.e. <3  mL/min/1.73 m2) but not among those with higher rCLurea. The adjusted mortality hazard ratios (aHRs) and 95% confidence intervals of the low (<1.2) versus high (≥1.2) spKt/V were 1.40 (1.12-1.74), 1.21 (1.10-1.33), 1.06 (0.98-1.14), and 1.00 (0.93-1.08) for patients with rCLurea of 0.0, 1.0, 3.0 and 6.0 mL/min/1.73 m2, respectively.

Conclusions

Incident hemodialysis patients with substantial RKF do not exhibit the expected better survival at higher hemodialysis doses. RKF levels should be taken into account when deciding on the dose of dialysis treatment among incident hemodialysis patients.

Renal Association Clinical Practice Guideline on Haemodialysis

This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.

Long Term Exposure to Tenofovir Disoproxil Fumarate-Containing Antiretroviral Therapy Is Associated with Renal Impairment in an African Cohort of HIV-Infected Adults

OBJECTIVES AND METHOD

There are growing concerns of tenofovir disoproxil fumarate (TDF)-associated renal toxicity. We evaluated the effect of long-term TDF exposure on renal function in a cohort of HIV-1-infected Nigerians between 2006 and 2015. Multivariate logistic regression was used to identify predictors of renal impairment at different time over 144 weeks of antiretroviral therapy (ART).

RESULTS

Data of 4897 patients, median age 42 years (interquartile range: 36-49), and 61% females were analyzed. The prevalence of renal impairment increased from 10% at week 24 to 45% at 144 weeks in TDF-exposed participants compared to an increase from 8% at 24 weeks to 14% at 144 weeks in TDF-unexposed participants. Tenofovir disoproxil fumarate exposure predicted the risk of renal impairment at 144 weeks of ART (odds ratio: 2.36; 95% confidence interval: 1.28-4.34).

CONCLUSION

Long-term exposure to TDF-based ART significantly increases the likelihood of renal impairment. The continued use of TDF-based regimen in our setting should be reviewed. We recommend the urgent introduction of tenofovir alafenamide-based regimen in the HIV treatment guidelines of Nigeria and other resource-limited countries.

Gastrointestinal lesions in chronic kidney disease patients with anaemia

INTRODUCTION

Despite the frequency with which anaemia is present in patients with chronic kidney disease (CKD), its relationship with gastrointestinal lesions has not been studied.

METHOD

A cross-sectional, analytical, observational study involving one year of recruitment was carried out to determine the prevalence of endoscopic gastrointestinal lesions and associated risk factors in asymptomatic patients with chronic kidney disease stages 1-5 and anaemia who had a positive qualitative immunochemical faecal occult blood test.

RESULTS

A total of 9,658 patients with CKD were analysed, of which 286 (2.9%) had anaemia; 198 had a positive faecal occult blood test (47% male, 71.1±11.8 years). The endoscopic study revealed 255 lesions, with at least one lesion in 68.2% of patients, with the most prevalent being: adenomatous colorectal polyps (39.6%), acute lesions of the gastric mucosa (22.6%), neoplastic lesions 15.1%), angiodysplasia (14.4%), oesophagitis (8.4%), inflammatory bowel disease (4.8%) and ischaemic colitis (3.1%). Uraemia and acetylsalicylic acid were identified as risk factors for acute gastric mucosal lesions. Angiodysplasia was associated with alcoholism, a more advanced stage of chronic kidney disease, anaemia, and lack of response to erythropoiesis-stimulating agents. Age and refractory anaemia were risk factors for adenomatous polyps and colorectal cancer.

CONCLUSION

Renal patients with anaemia could benefit from an endoscopic study due to their high prevalence of gastrointestinal lesions, particularly adenomatous polyps and colorectal cancer, which are more common in those over 50 years of age with CKD stages 3-5.

Endoscopic Saphenous Vein Harvesting for Hemodialysis Vascular Access Creation in the Forearm: A New Approach for Arteriovenous Bridge Graft

When superficial arm veins are not suitable to create a native arteriovenous (AV) fistula, an arteriovenous bridge graft by native and/or prosthetic graft is the next best alternative. However, harvesting a native vein, such as the saphenous vein (SV), is invasive and requires a large incision. We report an endoscopic saphenous vein harvesting (ESVH) technique combined with forearm bridge grafting as a new approach for vascular access (VA).

Methods

We used the Clearglide, Endoscopic Vessel Harvesting System (Eticon, Inc.) for a less invasive SV harvesting technique. Five patients had a SV graft implant and 10 patients had a polytetrafluoroethylene (PTFE) graft implant in the forearm.

Results

The SV was harvested easily in all patients in 46 ± 2 min. There were no wound complications. All SV and PTFE grafts provided satisfactory access within 1 month; however, two declotting procedures in the SV group and five in the PTFE group were required. The PTFE group had two graft infections.

Conclusions

It is possible that a combination of ESVH and SV forearm grafting will be one of the new approaches for hemodialysis (HD) access.

Indication for the use of Central Venous Catheters as Vascular Access for Hemodialysis

Adequate treatment for uremic patients on hemodialysis requires valid and lasting access to central vessels.

The Central Venous Catheter (CVC) as a mean of immediate access is indispensable in all acute cases where it has not been possible to prepare an AVF in time and when the peripheral vascularization is highly compromised. We present our investigation on the best access route to central vessels and the selection of the type of catheters to adopt in different conditions.

On the basis of complications arising during the catheter life especially as permanent access, it seems to us that the right internal jugular catheterization with the 2 Tesio catheters Kit is the more useful and less dangerous catheterization.

Improved Measurement of Vascular Access Pressure

Vascular access stenosis and thrombosis is one of the key problems for hemodialysis patients. Prospective monitoring of static venous dialysis pressures can be applied to detect outflow stenoses in a vascular access. However, the location of stenoses within the access may influence the diagnostic value of venous pressure measurements. Whereas a decrease in access flow occurs with all types of stenosis, strictures within the arterial anastomosis or between arterial and venous dialysis needle cannot be detected with venous pressure measurements alone.

A new approach is discussed, which bases on the improved measurement of static venous and arterial extracorporeal pressures. Extracorporeal pressure at zero blood flow depends on both the position of the heart relative to the extracorporeal blood circuit and the vertical offset between access site and fluid level in the bloodline. After hydrostatic correction of each pressure signal the normalized arterial and venous intra-access pressure ratio AP/MAP can be calculated. A venous stenosis leads to an increase in both arterial and venous pressure ratio. In case of access stenosis between arterial and venous needle the ratio of venous pressure to mean arterial pressure is normal, and only the arterial pressure ratio is elevated. In summary, a combination of arterial and venous pressure measurement is more sensitive and allows differentiation between mid-access and venous stenosis. Hydrostatic correction of the dialysis pressure signal is inevitable. To minimize the rate of access thrombosis, venous and arterial intra-access pressure should be considered when evaluating dialysis pressures as part of any access monitoring program.

On-line hemodiafiltration did not induce an overproduction of oxidative stress and inflammatory cytokines in intensive care unit-acute kidney injury

Background

Though on-line intermittent hemodiafiltration (OL-IHDF) is a routine therapy for chronic dialysis patients, it is not yet widespread used in critically ill patients. This study was undergone to evaluate efficiency and tolerance of OL-IHDF and to appreciate inflammatory consequences of its use in intensive care unit (ICU)-acute kidney injury (AKI) patients.

Methods

In this prospective cohort study conducted in a medical academic ICU in France, 30 AKI patients who underwent OL-IHDF were included. OL-HDF used an ultrapure water production: AQ 1250 line with double reverse osmosis, a generator 5008 with a 1.8m² dialyzer with Polysulfone membrane (Fresenius Medical Care). Tolerance and efficiency of OL-IHDF were evaluated as well as its inflammatory risk by the measurement of plasma concentrations of proinflammatory (Interleukin 6, IL1β, IL8, Interferon γ) and anti-inflammatory (IL4, IL10) cytokines, Epidermal growth factor (EGF), Vascular Endothelial growth factor (VEGF) and Macrophage Chemoattractive Protein-1 (MCP-1) before and after sessions.

Results

Intradialytic hypotensive events were observed during 27/203 OL-IHDF sessions accounting for a mal-tolerated session’s rate at 13.3%. Mean delivered urea Kt/V per session was 1.12 ± 0.27 with a percentage of reduction for urea, creatinine, β2-microglobulin and cystatine C at 61.6 ± 8.8%, 55.3 ± 6.7%, 51.5 ± 8.7% and 44.5 ± 9.8% respectively. Production of superoxide anion by leukocytes, mean levels of pro- and anti-inflammatory cytokines and plasmatic concentrations of EGF, VEGF and MCP-1 did not differ before and after OL-IHDF sessions. We observed however a significant decrease of mean TNFα plasmatic concentrations from 8.2 ± 5.8 to 4.8 ± 3.5 pg/ml at the end of OL-IHDF.

Conclusions

OL-IHDF was not associated with an increase in pro and anti-inflammatory cytokines, oxidative stress or EGF, VEGF and MCP-1 in AKI patients and seems therefore a secure and feasible modality in ICUs.

Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society

End-stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non-Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre-ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.

Incremental and infrequent hemodialysis: a new paradigm for both dialysis initiation and conservative management

Registry or national dialysis data show that a sizeable proportion of contemporary dialysis patients have substantial levels of residual kidney function especially upon transitioning to dialysis therapy. However, among incident hemodialysis patients, the prevailing paradigm has been to initiate "full-dose" triweekly treatment schedules irrespective of native kidney function in most developed countries. Recognizing the benefits of residual kidney function upon the health and survival of dialysis patients, there has been growing interest in incremental hemodialysis, in which dialysis frequency and dose are tailored according to the degree of patients' residual kidney function. Infrequent hemodialysis can also be used for those who prefer a more conservative approach in managing uremia. Clinical practice guidelines support the use of twice-weekly hemodialysis among patients with adequate residual kidney function (renal urea clearance >3 mL/min/1.73 m2), and a growing body of evidence indicates that incremental hemodialysis is associated with better preservation of residual kidney function without adversely impacting survival. Nonetheless, incremental hemodialysis remains an underutilized approach in this population. In this review, we will discuss the history of the twice- versus triweekly hemodialysis schedules; current clinical practice guidelines regarding infrequent hemodialysis; emerging data on incremental treatment regimens and outcomes; and guidelines for the practical implementation of incremental and infrequent hemodialysis in the clinical setting.

Antecubital Jump Revisions for Salvaging Hemodialysis Grafts

When expanded polytetrafluoroethylene (PTFE) is used for hemodialysis access, the authors' initial preference is a forearm loop arteriovenous (AV) graft below the antecubital fossa. However, AV graft thrombosis remains a significant problem caused mainly by venous outflow hyperplasia and managed often by either surgical or radiologic thrombectomy and angioplasty. At the time of surgical revision, the lack of an adequate superficial or deep forearm outflow vein below the elbow would require an antecubital (across the elbow) jump bypass revision to a more proximal upper arm vein to salvage the original forearm AV graft. With an increasing interest in monitoring the specific outcomes of the different surgical interventions used to salvage thrombosed hemoaccess, the authors reviewed their most recent 24--month experience of 32 antecubital jump revisions using ring reinforced PTFE. The mean primary patency of these antecubital jump revisions was 8.2 months with 18 presently patent. AV grafts revisions using antecubital jump grafts confer additional patency; they are another important method for salvaging thrombosed AV hemodialysis grafts.

Coronary artery calcifications predict long term cardiovascular events in non diabetic Caucasian hemodialysis patients

Vascular calcifications are frequent in chronic renal disease and are associated to significant cardiovascular morbidity and mortality. The long term predictive value of coronary artery calcifications detected by multi-layer spiral computed tomography for major cardiovascular events was evaluated in non-diabetic Caucasian patients on maintenance hemodialysis free of clinical cardiovascular disease. Two-hundred and five patients on maintenance hemodialysis were enrolled into this observational, prospective cohort study. Patients underwent a single cardiac multi-layer spiral computed tomography. Calcium load was quantified and patients grouped according to the Agatston score: group 1 (Agatston score: 0), group 2 (Agatston score 1-400), group 3 (Agatston score 401-1000) and group 4 (Agatston score >1000). Follow-up was longer than seven years. Primary endpoint was death from a major cardiovascular event. Actuarial survival was calculated separately in the four groups with Kaplan-Meier method. Patients who died from causes other than cardiovascular disease and transplanted patients were censored. The “log rank” test was employed to compare survival curves. One-hundred two patients (49.7%) died for a major cardiovascular event during the follow-up period. Seven-year actuarial survival was more than 90% for groups 1 and 2, but failed to about 50% for group 3 and to <10% for group 4. Hence, Agatston score >400 predicts a significantly higher cardiovascular mortality compared with Agatston score <400 (p<0.0001); furthermore, serum Parathyroid hormone levels > 300 pg/l were associated to a lower survival (p < 0.05). Extended coronary artery calcifications detected by cardiac multi-layer spiral computed tomography, strongly predicted long term cardiovascular mortality in non-diabetic Caucasian patients on maintenance hemodialysis. Moreover, it was not related to conventional indices of atherosclerosis, but to other non-traditional risk factors, as serum Parathyroid hormone levels. A full cost-benefit analysis is however necessary to justify a widespread use of cardiac multi-layer spiral computed tomography in clinical practice.

Adequacy of twice weekly hemodialysis in end stage renal disease patients at a tertiary care dialysis centre

Hemodialysis has improved the morbidity and mortality associated with end stage renal disease. In India, hemodialysis prescription is empiric, which leads to complications related to under-dialysis. Hence, adequacy of hemodialysis in Indian setting was analyzed in this study. A total of 50 patients on twice per week hemodialysis were assessed for 1 month. The number of sessions meeting standards laid out by Kidney Diseases Outcome Quality Initiatives (KDOQI) guidelines were calculated. They were divided into two groups: one in whom dialysis was monitored and session length enhanced to meet the minimum standard Kt/V of 2 and second control group; where Kt/V was not monitored. Hemoglobin (Hb) levels, albumin levels, mean arterial pressure and World Health Organization (WHO) quality of life (QoL) score were compared in the two groups after 6 months. Only 28% of hemodialysis sessions were adequate as per KDOQI guidelines. There was significant improvement in Hb levels (1.47 vs. 0.15 g/dl), mean arterial pressure levels (15.2 vs. 3.16 mm Hg), serum albumin levels (0.82 vs. 0.11 g/dl) and WHO QoL score (17.2 vs. 2.24) in study group as compared to control group. Standard Kt/V can be used as an important tool to modify twice weekly dialysis sessions to provide better QoL to the patients. However, studies with larger sample size are required to conclusively prove our results.

Chronic Hemodialysis Therapy in the West

BACKGROUND

Chronic hemodialysis (HD) in the 1960s encompassed a wide variety of prescriptions from twice weekly to five times per week HD. Over time, HD prescriptions in the West became standardized at three times per week, 2.5-4 h per session, with occasional additional treatments for volume overload.

SUMMARY

When clinical trials of dialysis dose failed to show significant benefit of extending time compared with the traditional dialysis prescription, interest in more frequent HD was renewed. Consequently, there has been growth in home HD therapies as well as alternative dialysis prescriptions. Data from recent randomized clinical trials have demonstrated the benefits and risks of these more frequent therapies, with surprising differences in outcomes between short daily HD and long nocturnal HD. More frequent therapies improve control of both hypertension and hyperphosphatemia, but at the expense of increased vascular access complications and, at least for nocturnal HD, a faster loss of residual renal function.

KEY MESSAGES

In the West, the standard HD prescription is three treatments per week with a minimal time of 3.0 h and dialysis is performed in an outpatient dialysis center. A minority of patients will have a fourth treatment per week for volume issues. Alternative HD prescriptions, although rare, are more available compared to the recent past.

FACTS FROM EAST AND WEST

(1) While developed Western and Asian countries provide end-stage renal disease patients full access to HD, healthcare systems from South and South-East Asia can offer access to HD only to a limited fraction of the patients in need. Even though the annual costs of HD are much lower in less developed countries (for instance 30 times lower in India compared to the US), patients often cannot afford costs not covered by health insurance. (2) The recommended dialysis pattern in the West is at least three sessions weekly with high-flux dialyzers. Studies from Shanghai and Taiwan might however indicate a benefit of twice versus thrice weekly sessions. In less developed Asian countries, a twice weekly pattern is common, sometimes with dialyzer reuse and inadequate water treatment. A majority of patients decrease session frequency or discontinue the program due to financial constraint. (3) As convective therapies are gaining popularity in Europe, penetration in Asia is low and limited by costs. (4) In Asian countries, in particular in the South and South-East, hepatitis and tuberculosis infections in HD patients are higher than in the West and substantially increase mortality. (5) Progress has recently been made in countries like Thailand and Brunei to provide universal HD access to all patients in need. Nevertheless, well-trained personnel, reliable registries and better patient follow-up would improve outcomes in low-income Asian countries.

Comparing Changes in Plasma and Skin Autofluorescence in Low-Flux versus High-Flux Hemodialysis

Background

Tissue advanced glycation end products (AGE) are increased in hemodialysis (HD) patients, especially those with cardiovascular complications. Skin autofluorescence (skin-AF) can noninvasively estimate the accumulation of AGE in tissue. The aim was to clarify whether HD using a high-flux (HF) dialyzer favors plasma- or skin-AF removal compared to low-flux (LF) dialysis.

Material and methods

28 patients were treated with either an HF-HD or LF-HD but otherwise unchanged conditions in a cross-over design. A glucose containing dialysate was used. Skin-AF was measured noninvasively with an AGE reader before and after HD. Fluorescence (370 nm/465 nm) of plasma (p-AF) was determined as total and nonprotein-bound fractions. Correction for hemoconcentrations were made using the change in serum albumin. Paired and nonpaired statistical analyses were used.

Results

Skin-AF was unchanged after LF- and HF-dialysis. Total, free, and protein- bound p-AF was reduced after a single LF-HD by 21%, 28%, and 17%, respectively ( P<.001). After HF HD total and free p-AF was reduced by 5% and 15%, respectively ( P<.001), while protein bound values were unchanged. The LF-HD resulted in a more pronounced reduction of p-AF than did HF HD ( P<.001). Serum albumin correlated inversely with p-AF in HF-HD.

Conclusions

In the dialysis settings used there was no significant change in skin AF after dialysis, with LF or with HF dialysis. Although only limited reduction in plasma fluorescence was observed, this was more pronounced when performing LF dialysis. These data are not in overwhelming support of the use of HF dialysis in the setting used in this study.

Comparison of the Prevalence of Latent Tuberculosis Infection among Non-Dialysis Patients with Severe Chronic Kidney Disease, Patients Receiving Dialysis, and the Dialysis-Unit Staff: A Cross-Sectional Study

Background

Patients with renal failure are vulnerable to tuberculosis, a common worldwide infectious disease. In the growing dialysis population, the risk for tuberculosis among the associated sub-groups is important but unclear. This study investigated latent tuberculosis infection (LTBI) in patients with severe chronic kidney disease (CKD) and among dialysis-unit staff caring for patients on dialysis.

Methods

From January 2012 to June 2013, patients undergoing dialysis, those with severe CKD (estimated glomerular filtration rate <30ml/min/1.73 m²), and the dialysis-unit staff (nursing staff and doctors in hemodialysis units) in several Taiwan hospitals were prospectively enrolled. Interferon-gamma release assay (IGRA) through QuantiFERON-TB Gold In-tube was used to determine LTBI. Predictors for LTBI were analyzed.

Results

Of the 599 participants enrolled, 106 (25%) in the dialysis group were IGRA positive. This was higher than the seven (11%) among severe CKD patients and 12 (11%) in the dialysis-unit staff. Independent predictors of LTBI in patient with renal dysfunction were old age (odds ratio [OR]: 1.03 [1.01–1.04] per year increment), prior TB lesion on chest radiograph (OR: 2.90 [1.45–5.83]), serum albumin (OR: 2.59 [1.63–4.11] per 1 g/dl increment), and need for dialysis (OR: 2.47, [1.02–5.95]). The QFT-GIT response was similar among the three groups. Malignancy (OR: 4.91 [1.84–13.10]) and low serum albumin level (OR: 0.22 [0.10–0.51], per 1 g/dl decrease) were associated with indeterminate IGRA results.

Conclusions

More patients on dialysis have LTBI compared to those with severe CKD and the dialysis-unit staff. Old age, prior radiographic TB lesion, high serum albumin, and need for dialysis are predictors of LTBI in patients with renal failure. Patients with severe CKD are a lower priority for LTBI screening. The hemodialysis environment is not a risk for LTBI and dialysis-unit staff may be treated as general healthcare workers.

Renal replacement therapy due to type 1 diabetes; time trends during 1995-2010--a Swedish population based register study

BACKGROUND

End stage renal disease (ESRD), is the most severe complication of diabetes mellitus. This population-based study analysed time trends for start of renal replacement therapy (RRT) due to type 1 diabetes compared to type 2 diabetes and other diagnoses.

MATERIAL AND METHODS

We used data on patients who were registered 1995-2010 in the Swedish Renal Registry, a nationwide register covering 95 % of all patients with uraemia. The patients were analysed according to their original kidney disease. The incidence was analysed by calendar year, age at start of RRT and gender.

RESULTS

Of 17389 patients who were registered, 1833 had type 1 diabetes; 65% were men. The mean age at onset of RRT for patients with type 1 diabetes was 52.8 years which increased by more than 3 years over the studied period. The number of patients in need of RRT due to type 1 diabetes decreased, while RRT due to type 2 diabetes increased during the period studied.

CONCLUSIONS

The overall incidence of RRT in Sweden is rather constant over the years but the need for RRT in type 1 diabetes patients decreased and patients with type 1 diabetes tend to become older at onset of RRT.

Association of serum alkaline phosphatase with mortality in non-selected European patients with CKD5D: an observational, three-centre survival analysis

OBJECTIVES

For characterisation of mineral bone disease in chronic kidney disease (CKD), laboratory surrogates have been suggested. This observational should investigate the association of total and skeletal alkaline phosphatase (AP) with mortality of patients undergoing maintenance renal replacement therapy.

SETTING

Three renal outpatient centers in eastern-central Germany (secondary and tertiary care).

PARTICIPANTS

Complete survival and laboratory datasets were available in 407 of 493 patients. Age and gender distribution was equivalent to a general population with end-stage CKD (CKD5D). Patients were included between 2008 and 2010 if at least 2 weeks of maintenance treatment were documented.

PRIMARY OUTCOME MEASURES

Mortality was estimated by setting the end of dialysis date as event date. Events other than death (change to another centre, life-sustaining renal function or transplantation) were censored.

RESULTS

The OR to die within follow-up for patients in the higher of two total AP strata was 2.70 (95% CI 1.76 to 4.15). In univariate Kaplan-Meier analysis, total AP had a strong association with all-cause mortality (LogRank=24.1, p<0.001). Mean total AP and individual lowest skeletal AP, but not mean skeletal AP entered step-wise Cox models for survival from dialysis start (χ(2)=22.4; p<0.001) after adjusting for age, Kt/V, diabetes and vintage. Mean values of skeletal, total AP and parathyroid hormone were 14.8±8.9 µg/L, 91.9±55.3 U/L and 188±164 ng/L, respectively. Skeletal and total AP were highly correlated (R=0.86; p<0.001).

CONCLUSIONS

This unselected CKD5D population exhibited a clinical significant association of total AP with crude mortality and a stronger death risk association of total AP and individual lowest skeletal AP with crude mortality.

Why multidisciplinary clinics should be the standard for treating chronic kidney disease

In adults, strong evidence indicates that slowing progression of chronic kidney disease (CKD) requires an integrated, multidisciplinary approach. In children, however, this approach has not been studied. This editorial commentary to the study by Ajarmeh et al in this volume of Pediatric Nephrology highlights how a dedicated, multidisciplinary team of physicians, nurses, pharmacists, dieticians, social workders and clinic data managers slowed the progression of CKD in children to a remarkable degree. We discuss the strengths and limitations of the study and its cost implications, as well as the issue of determining the optional complement of physicians and allied health care professionals in such clinics. Our calculations indicate that the additional costs of such clinics would be recovered in one year, even if the progession of CKD were to be delayed by 1 year in only 2% of affected children. Here, we call on the international pediatric nephrology community to establish guidelines for forming multidisciplinary clinics throughout the world.

Erythrocyte glutathione transferase: a new biomarker for hemodialysis adequacy, overcoming the Kt/V(urea) dogma?

Kt/V_urea ratio is commonly used to assess the delivered dose of dialysis in maintenance hemodialysis (MHD) patients. This parameter only reflects the efficacy of dialytic treatments in removing small toxins, but not middle and protein-bound toxins. Erythrocyte glutathione transferase (e-GST), an enzyme devoted to cell depuration against a lot of large and small toxins, is overexpressed in uremic patients. Aim of the present study is to verify whether e-GST may represent a novel biomarker to assess the adequacy of different dialytic techniques complementary to Kt/V_urea parameter. Furthermore, it will be investigated whether e-GST could reflect the ‘average' adequacy of multiple dialytic sessions and not of a single one treatment as it occurs for Kt/V_urea. One hundred and three MHD patients and 82 healthy subjects were tested. Fourty four patients were treated with standard bicarbonate hemodialysis (HD) and 59 patients were on online hemodiafiltration (HDF). In all MHD patients e-GST activity was 60% higher than in healthy controls. In HDF, e-GST activity was lower than in HD subgroup (8.2±0.4 versus 10.0±0.4 U/g_Hb, respectively). Single-pool Kt/V_urea and total weekly Kt/V_urea were higher in HDF than in HD, but no correlation was found between e-GST activity and Kt/V_urea data. e-GST, whose level is stable during the erythrocyte life-span, provides information on the long-term depurative efficacy of dialysis treatments.

Predictors and prevalence of latent tuberculosis infection in patients receiving long-term hemodialysis and peritoneal dialysis

Background

Tuberculosis is a common infectious disease in long-term dialysis patients. The prevalence of latent tuberculosis infection (LTBI) in this population is unclear, particularly in those receiving peritoneal dialysis (PD). This study investigated the prevalence of LTBI in patients receiving either hemodialysis (HD) or PD to determine predictors of LTBI and indeterminate results of interferon-gamma release assay.

Methods

Patients receiving long-term (≥3 months) HD or PD from March 2011 to February 2012 in two medical centers were prospectively enrolled. QuantiFERON-Gold in tube (QFT) test was used to determine the status of LTBI after excluding active tuberculosis. The LTBI prevalence was determined in patients receiving different dialysis modes to obtain predictors of LTBI and QFT-indeterminate results.

Results

Of 427 patients enrolled (124 PD and 303 HD), 91 (21.3%) were QFT-positive, 316 (74.0%) QFT-negative, and 20 (4.7%) QFT-indeterminate. The prevalence of LTBI was similar in the PD and HD groups. Independent predictors of LTBI were old age (OR: 1.034 [1.013–1.056] per year increment), TB history (OR: 6.467 [1.985–21.066]), and current smoker (OR: 2.675 [1.061–6.747]). Factors associated with indeterminate QFT results were HD (OR: 10.535 [1.336–83.093]), dialysis duration (OR: 1.113 [1.015–1.221] per year increment), anemia (OR: 8.760 [1.014–75.651]), and serum albumin level (OR: 0.244 [0.086–0.693] per 1 g/dL increment).

Conclusion

More than one-fifth of dialysis patients have LTBI. The LTBI prevalence is similar in PD and HD patients but is higher in the elderly, current smokers, and those with prior TB history. Such patients require closer follow-up. Repeated or alternative test may be required for malnutrition patients who received long length of HD.

The prevalence of metabolic syndrome and factors associated with quality of dialysis among hemodialysis patients in Southern Taiwan

OBJECTIVES

The purpose of this study was to evaluate the prevalence of metabolic syndrome (MetS) among hemodialysis patients and factors associated with quality of dialysis.

METHODS

Data were collected from 377 long-term hemodialysis patients who received hemodialysis treatment from clinics in Tainan and Kaohsiung between November 2009 and February 2010. MetS was defined using the criteria set in 2007 by the Bureau of Health Promotion, Department of Health, Taiwan. The measurement of Kt/V was used as an indicator of the quality of dialysis. A below 1.4 Kt/V was considered poor dialysis quality.

RESULTS

Results showed that the prevalence of MetS among the chronic hemodialysis patients in this sample was 63.1%. Logistic regression results identified that the quality of dialysis in females was better than that in males (odds ratio (OR)=7.98, 95% confidence interval (CI): 2.52-25.31). Better quality dialysis was associated with older age, longer treatment time, and increased blood flow rate (OR=1.49, 13.63, and 1.35, respectively). However, for every one kilogram increase in weight, the quality of dialysis decreased by 13 percents (OR=0.87, 95% CI: 0.83-0.92).

CONCLUSIONS

MetS is common among hemodialysis patients. The prevalence of hypertension, hyperlipidemia, and hyperglycaemia were significantly higher among hemodialysis patients. Quality of dialysis related to gender, age, weight, and the dialysis prescription (treatment time and blood flow rate).

Surgical removal of endovascular stent after migration to the right ventricle following right subclavian vein deployment for treatment of central venous stenosis

Central venous stenosis or occlusion occurs in 11-50% of hemodialysis patients with prior subclavian vein cannulation and ipsilateral fistula or shunt. Most patients are asymptomatic but some require treatment to reduce the risk of thrombosis and improve inadequate hemodialysis pressure. In these cases, endovascular intervention, including ballooning and stenting, is a feasible strategy for selected patents. We report an unusual case of a 40-year-old man on hemodialysis that underwent endovascular stenting to treat right subclavian vein stenosis and experienced stent migration to the right ventricle, requiring surgical removal.

Ideal timing and predialysis nephrology care duration for dialysis initiation: from analysis of Japanese dialysis initiation survey

Previous studies have suggested that early initiation of dialysis therapy was not superior in terms of patient survival. In this study, we analyzed the effects of renal function at the start of renal replacement therapy (RRT), duration of nephrology care, and comorbidity on 12-month survival of end-stage renal disease (ESRD) patients. The subjects in this study were 9695 new ESRD patients who started RRT in 2007. The average age of the subjects was 67.5 years, 64.1% of the subjects were male, and 42.9% had diabetes. During the 12-month period after the start of RRT, 1546 patients died, and 35 patients received renal transplantation. Average estimated glomerular filtration rate (eGFR) at the initiation of dialysis was 6.52 ± 4.20 mL/min/1.73 m(2) . By unadjusted logistic analysis, one-year Odds Ratio (OR) of mortality in patients with eGFR more than 4-6 mL/min/1.73 m(2) was increased with increased eGFR at dialysis initiation, but the OR was identical among the groups with eGFR less than 4 mL/min/1.73 m(2) . After adjustment for age, gender, underlying renal diseases, and other clinical characteristics at dialysis initiation, OR was identical among the groups with eGFR less than 8 mL/min/1.73 m(2) . Furthermore, an OR increment was observed in eGFR less than 4 mL/min/1.73 m(2) group. In terms of the duration of nephrology care before dialysis initiation, 6 months or longer of nephrology care significantly decreased the OR of mortality after adjustment of covariance. Not only patients with sufficient residual renal function at the initiation of dialysis, but also patients with very low eGFR at the initiation of dialysis showed poor survival.

Hotline update of clinical trials and registries presented at the at the European Society of Cardiology Congress in Paris 2011

This article provides information and commentaries on trials which were presented at the Hotline and Clinical Trial Update Sessions during the Late Breaking Clinical Trial Sessions European Society of Cardiology Congress, held in Paris, France, from 27th to 31st August 2011. This article gives an overview on a number of novel clinical trials in the field of cardiovascular medicine, which were presented. The data have been presented by leading experts in the accordant field with relevant positions in the trials. Unpublished reports should be considered as preliminary data as the analysis may change in the final publications. The comprehensive summaries have been generated from the oral presentation and the webcasts of the European Society of Cardiology, similar as previously reported (Lenski et al. in Clin Res Cardiol Off J Ger Card Soc 99: 679-692, 2010) and should provide the readers with the most comprehensive information of relevant publications. The data were presented by leading experts in the field with relevant positions in the trials.

How public and private reforms dramatically improved access to dialysis therapy in Malaysia

Between 1990 and 2005, dialysis treatment rates in Malaysia increased more than eightfold. Dialysis treatment reached a level comparable to rates in developed countries. This remarkable transformation was brought about in large part by the Malaysian government's large-scale purchase of dialysis services from the highly competitive private sector. This paper traces a series of public- and private-sector reforms that dramatically increased access to dialysis for patients with kidney failure from 13 per million people in the population in 1990 to 119 per million in 2005. Not all developing countries have had uniformly positive experiences with private-sector participation in health care. However, our data suggest that strong participation by the private sector in Malaysia has helped make for a stronger health care system as well as healthier patients. Yet the policy decisions that enabled the private sector to participate fully in providing dialysis have not been repeated with other medical services.

Hospitalization rates and clinical performance measures in U.S. adolescent hemodialysis patients

The Centers for Medicare and Medicaid Services' End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project monitors clinical measure attainment in pediatric hemodialysis (HD) patients. Targets include hemoglobin ≥ 11 g/dL, albumin ≥ 3.5/3.2 g/dL (bromcresol green/purple), single-pooled Kt/V ≥ 1.2, and the use of subcutaneous access. We hypothesized that the achievement of multiple targets by adolescent HD patients is associated with decreased morbidity. Data on patients aged 12-18 years included in the ESRD CPM Project from 2000 to 2004 with Medicare as primary payer were linked to the U.S. Renal Data System data from October 1, 1999 to December 31, 2004. Hospitalization rates by number of targets achieved were determined with Poisson regression analysis adjusted for dialysis vintage, short stature, and race. A total of 1534 patients with 1774 patient-years of follow-up, with 580 hospitalizations, were included in the analysis. In their first year in the ESRD CPM Project, 22% of the patients achieved four targets, with 34 and 28% achieving three and two targets, respectively. Subcutaneous access was least frequently attained target; spKt/V ≥ 1.2 was the most frequently attained target. After adjustment, there was decreased hospitalization risk with increasing target attainment (incidence rate ratio 0.74, 95% confidence interval 0.67-0.80, p < 0.001). Based on this analysis, meeting adult-defined targets is associated with decreases in the hospitalization rate of adolescent HD patients. Tracking adult-defined HD measures is appropriate for assessing hospitalization risk in adolescent patients, although no evidence for a cause-and-effect relationship exists.

Associations between nutritional markers and inflammation in hemodialysis patients

The purpose of this study is to evaluate associations between clinical, laboratory, demographic, and nutritional markers with inflammatory state and malnutrition in hemodialysis (HD) patients. Fifty-two patients on regular HD were evaluated by clinical, demographic, laboratory, and nutritional parameters (food intake, anthropometric measurements, bioelectric impedance, subjective global assessment--SGA and appetite characteristics). Inflammation (serum C-reactive protein >or= 0.9 mg/dl) was present in 13 (25%) and malnutrition (SGA) in 16 (30.7%) patients. Body mass index (BMI), total lymphocytes count, and phase angle were negative and independently associated with malnutrition. Values of BMI >or= 25 kg/m2 were associated with diabetes, positively associated with adipose tissue percentage (BIA) and negatively associated with diastolic blood pressure. Phase angle was positively associated with hematocrit, total lymphocytes count and serum creatinine, and was negatively associated with age. A negative and independent association between muscle mass percentage (BIA) and inflammation was observed. These results suggested that inflammatory state induces muscle mass depletion, while high BMI is associated with diabetes and with lower diastolic blood pressure, a recognized cardiovascular risk factor in uremic patients. Phase angle and SGA were associated with traditional nutritional markers, reinforcing their validity for HD patients.

An Official ATS/ERS/ESICM/SCCM/SRLF Statement: Prevention and Management of Acute Renal Failure in the ICU Patient: an international consensus conference in intensive care medicine

OBJECTIVES

To address the issues of Prevention and Management of Acute Renal Failure in the ICU Patient, using the format of an International Consensus Conference.

METHODS AND QUESTIONS

Five main questions formulated by scientific advisors were addressed by experts during a 2-day symposium and a Jury summarized the available evidence: (1) Identification and definition of acute kidney insufficiency (AKI), this terminology being selected by the Jury; (2) Prevention of AKI during routine ICU Care; (3) Prevention in specific diseases, including liver failure, lung Injury, cardiac surgery, tumor lysis syndrome, rhabdomyolysis and elevated intraabdominal pressure; (4) Management of AKI, including nutrition, anticoagulation, and dialysate composition; (5) Impact of renal replacement therapy on mortality and recovery.

RESULTS AND CONCLUSIONS

The Jury recommended the use of newly described definitions. AKI significantly contributes to the morbidity and mortality of critically ill patients, and adequate volume repletion is of major importance for its prevention, though correction of fluid deficit will not always prevent renal failure. Fluid resuscitation with crystalloids is effective and safe, and hyperoncotic solutions are not recommended because of their renal risk. Renal replacement therapy is a life-sustaining intervention that can provide a bridge to renal recovery; no method has proven to be superior, but careful management is essential for improving outcome.

The state of chronic kidney disease, ESRD, and morbidity and mortality in the first year of dialysis

This review examines trends in the ESRD program, assessing progress in preventive care, hospitalizations, and mortality since 1989, the year of the Dallas Morbidity and Mortality Conference. The number of prevalent dialysis patients nearly tripled, to 366,000 in 2007 from 123,000 in 1989. Prevalent population mortality rates declined in the mid-1980s but did not change overall through the 1990s; rates declined for patients on dialysis for less than 5 yr but increased for patients on dialysis for longer than 5 yr. Death rates throughout the prevalent population have subsequently declined since 2000. In the incident dialysis population, death rates after the first year have declined, but first-year rates have remained flat since 1996; rates peak in months 2 and 3, then decline to the level of the first month by 12 mo. Infectious hospitalization rates in the prevalent population increased 40% in the last 10 yr. For incident patients, infectious hospitalizations increased almost 100% over 10 yr, vascular access hospitalizations by 200%, and cardiovascular hospitalizations by 30%. Use of dialysis catheters is high; 82% of patients start dialysis with a catheter. Poor planning for dialysis initiation may contribute to catheter use and the associated high infectious hospitalization rate, limiting potential for improved patient survival during the first year. Public health programs, including the new Medicare chronic kidney disease education benefit, are needed to promote better care of patients who may need dialysis to reduce the high morbidity and mortality in the first year.

Profile of Hospitalisation and Death in the First Year after Diagnosis of End-stage Renal Disease in a Multi-ethnic Asian Population

Introduction: The increasing prevalence of end-stage renal disease (ESRD) is an important public health issue due to the high costs of kidney replacement therapies. We examined the impact of ethnicity and other factors in ESRD management and hospitalisation in a multiracial Asian population in the first year after diagnosis. Materials and Methods: We analysed a prospectively collected database of 168 new ESRD patients from the National University Hospital, Singapore (NUH) in 2005. Univariate and multivariate analyses were performed to assess factors for mortality and hospitalisation. Results: Sixteen patients eventually chose conservative treatment, 102 haemodialysis, 41 peritoneal dialysis and 9 patients underwent kidney transplantation for their long-term treatment. Although more Chinese patients had dialysis plans (56.7% vs 36.8%, P = 0.022), many still required urgent dialysis initiation via catheters (61.3%). These dialysed patients who required urgent treatment had more admissions (3.6 vs 2.6, P = 0.023) and longer length of stay (9.3 days, P = 0.014). Approximately 40 (7.4%) admissions were related to vascular access complications (thromboses, dislodgements and infections), and 15 (2.8%) were for new tunnelled catheter insertions. Deaths were 23.8% in the first year after diagnosis and median survival was 125 days. Age, final treatment modality, type of therapy centre, history of coronary artery disease, left ventricular ejection fraction (LVEF) <50%, and having no plans for dialysis were associated with mortality. Conclusions: The care of ESRD patients requires substantial commitment of healthcare resources particularly in the first year after diagnosis. Steps to reduce urgent initiation of dialysis will help reduce resource utilisation and improve patient outcomes. Key words: Dialysis, Kidney failure, Palliation

On Small Solute Clearance and Patient Outcomes: Evidential Practice or Observational Trepidation?

Recent guidelines on peritoneal dialysis adequacy set a minimum target for small solute clearance at Kt/V urea 1.70. While evidence from both observational studies and randomized controlled trials (RCTs) supports such a minimum target, there continues to be debate over what role small solute clearance plays in determining patient outcome. Current ANZDATA Registry results from Australia and New Zealand add fuel to this debate by demonstrating a significant nonlinear U-shaped relationship between peritoneal small solute clearance and patient survival. The ANZDATA results indicate that patients with too low or too high peritoneal Kt/V urea may be at significant risk of death compared to those with a peritoneal Kt/V urea between 1.70 and 2.00. As these results are somewhat at odds with results from published RCTs, we will examine the level of evidence from the observational setting that is the ANZDATA Registry and contrast it against the level of evidence from RCTs, particularly the ADEMEX trial. New results from the ADEMEX study are presented as a possible explanation for the paradoxical U-shaped results seen in the ANZDATA study.

Increased type IIA secretory phospholipase A(2) expression contributes to oxidative stress in end-stage renal disease

End-stage renal disease (ESRD) patients exhibit increased in vivo oxidative stress conceivably contributing to cardiovascular mortality. The type IIA secretory phospholipase A(2) (sPLA(2)) has proatherogenic activity. We explored the hypothesis that sPLA(2) contributes to oxidative stress generation and endothelial dysfunction in ESRD patients and transgenic (tg) mice. Patients with ESRD had increased in vivo oxidative stress as assessed by plasma isoprostane levels (p < 0.001). Active sPLA(2) in plasma was substantially increased compared with healthy controls (1,156 +/- 65 versus 184 +/- 5 ng/dL, p < 0.001) and correlated with plasma isoprostanes (r = 0.61, p < 0.001). Correspondingly, human sPLA(2) tg mice display increased generation of reactive oxygen species within aortic vascular smooth muscle cells, leading to severe endothelial dysfunction (maximal vasodilation in response to 10 micromol/L acetylcholine, sPLA(2) 36 +/- 8%, controls 80 +/- 2% of phenylephrine-induced vasoconstriction). Increased vascular oxidative stress in sPLA(2) tg mice is dependent on the induction of vascular cyclooxygenase (COX)2 expression. Conversely, ESRD patients show increased formation of COX2-derived prostaglandins (p < 0.05) correlated with plasma sPLA(2) (r = 0.71, p < 0.05). Our data indicate that increased expression of sPLA(2) might represent a novel causative risk factor contributing to the increased cardiovascular disease morbidity and mortality in ESRD.

Hypertension and hyperparathyroidism are associated with left ventricular hypertrophy in patients on hemodialysis

Conflicting data for association between left ventricular hypertrophy (LVH) and secondary hyperparathyroidism has been reported previously among dialysis patients. The present study was conducted to evaluate the association of hyperparathyroidism and hypertension with LVH. Charts of 130 patients on hemodialysis for at least six months were reviewed. All were subjected to M-mode echocardiography. Left ventricular mass (LVM) was calculated by Devereux's formula. LVM Index (LVMI) was calculated by dividing LVM by body surface area. Sera were analyzed for intact parathyroid hormone (iPTH). iPTH of > 32 pmol/l and a mean blood pressure (MAP) of > 107 mmHg were considered high. Patients were stratified into groups according to their MAP and iPTH. A total of (47.7%) patients were males and 68 (52.3%) were females. Their median age was 57 years. The median duration on dialysis was 26 months. Forty eight (36.9%) patients had high BP and 54 (41.5%) had high iPTH. Both high BP and high iPTH were present in 38 (29.2%) patients. Analysis of the relationship between LVM, LVMI, MAP and iPTH showed that LVM and LVMI were significantly (P < 0.001) higher in patients with concomitant high BP and high iPTH. LVMI was significantly higher in patients with high iPTH alone. Concomitant high iPTH and high MAP increase the risk of LVH in hemodialysis patients. High iPTH alone might contribute in escalating LVH. Adequate control of hypertension and hyperparathyroidism might reduce the risk of developing LVH.

Kidney disease: improving global outcomes

Kidney Disease: Improving Global Outcomes (KDIGO) is an independent organization with the mission to improve care and outcomes of patients with kidney disease worldwide through the development and coordination of clinical practice guidelines. KDIGO has established firm links with other organizations that have previously produced clinical practice guidelines in the field of kidney disease. The first three KDIGO guidelines--treatment of hepatitis C, management of bone and mineral disease, and care of kidney transplant recipients--have been finalized and the next three--acute kidney injury, management of glomerulonephritis, and management of blood pressure in chronic kidney disease--are under development. The ultimate goal is to cover most major aspects of care for patients with kidney disease. Corner stones of KDIGO's guideline development process are independent, multidisciplinary, international work groups, close collaboration with professional methodology experts who perform systematic evidence reviews, and open public review of each guideline. Grades of Recommendation Assessment, Development, and Evaluation (GRADE) methodology is applied for grading the quality of evidence and strength of recommendations. International conferences organized by KDIGO support the coordination of guideline development, assess the suitability of guideline topics and help to establish global consensus on definitions and policies.

Neurological complications of chronic kidney disease

Chronic kidney disease (CKD) is a critical and rapidly growing global health problem. Neurological complications occur in almost all patients with severe CKD, potentially affecting all levels of the nervous system, from the CNS through to the PNS. Cognitive impairment, manifesting typically as a vascular dementia, develops in a considerable proportion of patients on dialysis, and improves with renal transplantation. Patients on dialysis are generally weaker, less active and have reduced exercise capacity compared with healthy individuals. Peripheral neuropathy manifests in almost all such patients, leading to weakness and disability. Better dialysis strategies and dietary modification could improve outcomes of transplantation if implemented before surgery. For patients with autonomic neuropathy, specific treatments, including sildenafil for impotence and midodrine for intradialytic hypotension, are effective and well tolerated. Exercise training programs and carnitine supplementation might be beneficial for neuromuscular complications, and restless legs syndrome in CKD responds to dopaminergic agonists and levodopa treatment. The present Review dissects the pathophysiology of neurological complications related to CKD and highlights the spectrum of therapies currently available.