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Bakari AI, Yahaya JJ, Matobogolo BM, Abraham ZS, Mpondo B. Adequacy of haemodialysis and associated factors among patients with end-stage kidney disease in Tanzania. J Taibah Univ Med Sci 2024; 19:287-295. [PMID: 38283378 PMCID: PMC10821596 DOI: 10.1016/j.jtumed.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 12/07/2023] [Accepted: 12/25/2023] [Indexed: 01/30/2024] Open
Abstract
Objectives Adequate haemodialysis helps maintain normal renal function by removing toxins and other waste products in patients with end-stage kidney disease. This study was aimed at determining the prevalence and predictors of adequacy of haemodialysis and outcomes in patients with end-stage kidney disease. Methods This longitudinal analytical hospital-based study was conducted at two dialysis centres in Dodoma city, Tanzania, between February and July of 2020. Adequacy of haemodialysis was measured with single-pool (sp) Kt/V and urea reduction rate (URR) formulae. Binary logistic regression and multivariable analysis were used to assess the independent predictors of adequacy of haemodialysis. Results The analysis included 100 patients with a mean age of 50.6 ± 15.0 years. The prevalence of adequacy of haemodialysis according to URR and sp-Kt/V was 72 % and 75 %, respectively. Having <12 months since dialysis initiation (AOR = 7.3, 95 % CI = 0.11-0.90, p = 0.032), fewer than three dialysis sessions per week (AOR = 6.9, 95 % CI = 1.52-31.49, p = 0.013) and severe anaemia (AOR = 2.2, 95 % CI = 0.26-0.93, p = 0.033) were predictors of inadequate haemodialysis, according to the URR formula. Having fewer than three dialysis sessions per week was significantly associated with inadequate haemodialysis (AOR = 5.6, 95 % CI = 1.47-19.66, p = 0.011), according to the sp-Kt/V formula. The mortality rate was 11.2 %, and cardiovascular disease and uremic syndrome were responsible for most deaths. Conclusion This study indicated a high percentage of adequacy of haemodialysis among patients with end-stage kidney disease. Having fewer than three dialysis sessions per week, late initiation of dialysis after diagnosis of end-stage kidney disease and severe anaemia were predictors of inadequate haemodialysis among patients.
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Affiliation(s)
- Abilah I. Bakari
- Department of Internal Medicine, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - James J. Yahaya
- Department of Pathology, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Boaz M. Matobogolo
- Department of Internal Medicine, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - Zephania S. Abraham
- Department of Surgery, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - Bonaventura Mpondo
- Department of Internal Medicine, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
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Karimi Z, Raeisi Shahraki H, Mohammadian-Hafshejani A. Investigating the relationship between erythropoiesis-stimulating agents and mortality in hemodialysis patients: A systematic review and meta-analysis. PLoS One 2023; 18:e0293980. [PMID: 37943776 PMCID: PMC10635442 DOI: 10.1371/journal.pone.0293980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND In recent years, various studies have been conducted to investigate the relationship between erythropoiesis-stimulating agents (ESAs) and mortality in hemodialysis patients, who showed contradictory results. Therefore, this study aimed to investigate the relationship between ESAs and mortality in hemodialysis patients. METHODS The current study is a systematic review and meta-analysis based on observational and interventional studies published in the Web of Science, Cochrane Library, Science Direct, PubMed, Scopus, and Google Scholar databases between 1980 and the end of 2022. Jadad scale checklist and Newcastle Ottawa scale were used to evaluate the quality of articles. The study data were analyzed using Stata 15 software. RESULTS In the initial search, 3933 articles were extracted, and by screening and considering the research criteria, 68 studies were finally included in the meta-analysis. According to the meta-analysis results, the risk ratio (RR) of overall mortality in hemodialysis patients receiving ESAs was equal to 1.19 (95% CI: 1.16-1.23, P ≤ 0.001). The RR of mortality in patients aged 60 years and under was equal to 1.33 (1.15-1.55, P ≤ 0.001), in the age group over 60 years was equal to 1.13 (1.10-1.16, P ≤ 0.001), in randomized clinical trial studies was equal to 1.06 (0.80-1.40, P = 0.701), in cohort studies was equal to 1.20 (1.16-1.25, P ≤ 0.001), in American countries was equal to 1.19 (1.10-1.29, P ≤ 0.001), in Asian countries was equal to 1.15 (1.10-1.19, P ≤ 0.001), and in European countries was equal to 1.18 (1.05-1.34, P = 0.007). CONCLUSION The results of the study show that receiving ESAs is associated with a 19% increase in the risk of overall mortality in hemodialysis patients.
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Affiliation(s)
- Zahra Karimi
- M.Sc. of Epidemiology, Student Research Committee, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Hadi Raeisi Shahraki
- Assistant Professor of Biostatistics, Department of Epidemiology and Biostatistics, School of Health, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Abdollah Mohammadian-Hafshejani
- Assistant Professor of Epidemiology, Modeling in Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran
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Kotb E, El Mancy IM, Mohamed IGR, Ayoub HSA, Rashed ASM, El-Nasser WS, Hamed HI, Aladl HA, Sabrh M, Eliwa A, Ghamry EM, Elmonier R, Abd El Fattah MOA, El Sheref SEDM, Mahmoud TM. Relation between erythropoietin resistance and metabolic syndrome in hemodialysis patients: A multicentric propensity score matched analysis. J Investig Med 2023; 71:753-759. [PMID: 37199290 DOI: 10.1177/10815589231171405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Erythropoietin (EPO) resistance is frequently reported in hemodialysis (HD) patients. Metabolic syndrome (MetS) is a common biochemical condition that comprises central obesity, dyslipidemia, hypertension, and hyperglycemia. The present study aimed to assess the relation between MetS and EPO resistance in HD patients. The present multicentric study included 150 patients with EPO resistance and 150 patients without EPO resistance. Short-acting EPO resistance was diagnosed if the erythropoietin resistance index is ≥1.0 IU/kg/gHb. Comparison between patients with EPO resistance and patients without resistance revealed that the former group had significantly higher body mass index, lower hemoglobin levels, lower albumin levels, higher ferritin levels, and higher high-sensitivity C-reactive protein (hsCRP) levels. In addition, patients in the EPO resistance group had significantly higher frequency of MetS (75.3% vs 38.0%, p < 0.001) and higher number of MetS components (2.7 ± 1.3 vs 1.8 ± 1.6, p < 0.001). Multivariate logistic regression analysis identified lower albumin levels (OR (95% CI): 0.072 (0.016-0.313), p < 0.001), higher ferritin levels (OR (95% CI): 1.05 (1.033-1.066), p< 0.001), higher hsCRP levels (OR (95% CI): 1.041 (1.007-1.077), p = 0.018), and MetS (OR (95% CI): 36.68 (2.893-465.05), p = 0.005) as predictors of EPO resistance in the studied patients. The present study identified MetS as a predictor of EPO resistance in HD patients. Other predictors include serum ferritin, hsCRP, and albumin levels.
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Affiliation(s)
- Essam Kotb
- Internal Medicine Department, October 6 University, Giza, Egypt
| | | | | | | | | | | | | | | | - Mostafa Sabrh
- Internal Medicine Department, Al-Azhar University, Cairo, Egypt
| | - Ahmed Eliwa
- Internal Medicine Department, Al-Azhar University, Cairo, Egypt
| | - Esam M Ghamry
- Internal Medicine Department, Al-Azhar University, Cairo, Egypt
| | - Rady Elmonier
- Internal Medicine Department, Al-Azhar University, Cairo, Egypt
| | | | | | - Tamer M Mahmoud
- Internal Medicine Department, Beni-Suef University, Beni-Suef, Egypt
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Ellis P. An overview of haemodialysis. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:356-360. [PMID: 37083382 DOI: 10.12968/bjon.2023.32.8.356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Affiliation(s)
- Peter Ellis
- Independent nursing and health and social care consultant, educator and writer
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5
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Liu T, Dogan I, Rothe M, Kunz JV, Knauf F, Gollasch M, Luft FC, Gollasch B. Hemodialysis and biotransformation of erythrocyte epoxy fatty acids in peripheral tissue. Prostaglandins Leukot Essent Fatty Acids 2022; 181:102453. [PMID: 35633593 DOI: 10.1016/j.plefa.2022.102453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/05/2022] [Accepted: 05/19/2022] [Indexed: 11/28/2022]
Abstract
Cardiovascular disease is the leading cause of mortality in patients with renal failure. Red blood cells (RBCs) are potential reservoirs for epoxy fatty acids (oxylipins) that regulate cardiovascular function. Hemoglobin exhibits pseudo-lipoxygenase activity in vitro. We previously assessed the impact of single hemodialysis (HD) treatment on RBC epoxy fatty acids status in circulating arterial blood and found that eicosanoids in oxygenated RBCs could be particularly vulnerable in chronic kidney disease and hemodialysis. The purpose of the present study was to evaluate the differences of RBC epoxy fatty acids profiles in arterial and venous blood in vivo (AV differences) from patients treated by HD treatment. We collected arterial and venous blood samples in upper limbs from 12 end-stage renal disease (ESRD) patients (age 72±12 years) before and after HD treatment. We measured oxylipins derived from cytochrome P450 (CYP) monooxygenase and lipoxygenase (LOX)/CYP ω/(ω-1)-hydroxylase pathways in RBCs by LC-MS/MS tandem mass spectrometry. Our data demonstrate arteriovenous differences in LOX pathway metabolites in RBCs after dialysis, including numerous hydroxyeicosatetraenoic acids (HETEs), hydroxydocosahexaenoic acids (HDHAs) and hydroxyeicosapentaenoic acids (HEPEs). We detected more pronounced changes in free metabolites in RBCs after HD, as compared with the total RBC compartment. Hemodialysis treatment did not affect the majority of CYP and CYP ω/(ω-1)-hydroxylase products in RBCs. Our data indicate that erythro-metabolites of the LOX pathway are influenced by renal-replacement therapies, which could have deleterious effects in the circulation.
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Affiliation(s)
- Tong Liu
- Experimental and Clinical Research Center (ECRC), a joint institution of the Charité Medical Faculty and Max Delbrück Center (MDC) for Molecular Medicine, Berlin 13125, Germany
| | - Inci Dogan
- LIPIDOMIX GmbH, Robert-Rössle-Str. 10, Berlin 13125, Germany
| | - Michael Rothe
- LIPIDOMIX GmbH, Robert-Rössle-Str. 10, Berlin 13125, Germany
| | - Julius V Kunz
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353
| | - Maik Gollasch
- Department of Internal Medicine and Geriatrics, University Medicine Greifswald, Greifswald 17475, Germany
| | - Friedrich C Luft
- Experimental and Clinical Research Center (ECRC), a joint institution of the Charité Medical Faculty and Max Delbrück Center (MDC) for Molecular Medicine, Berlin 13125, Germany
| | - Benjamin Gollasch
- Experimental and Clinical Research Center (ECRC), a joint institution of the Charité Medical Faculty and Max Delbrück Center (MDC) for Molecular Medicine, Berlin 13125, Germany; Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353; HELIOS Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin 13125, Germany.
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Carrilho P, Fidalgo P, Lima A, Bastos L, Soares E, Manso R, Santos A, Nobrega L. Post-mortem liver and bone marrow iron quantification in haemodialysis patients: A prospective cohort study. EBioMedicine 2022; 77:103921. [PMID: 35272260 PMCID: PMC8907683 DOI: 10.1016/j.ebiom.2022.103921] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/19/2022] [Accepted: 02/22/2022] [Indexed: 11/23/2022] Open
Abstract
Background Magnetic resonance liver scans indicate that iron overload is common in haemodialysis (HD) patients. However, histological evidence is scarce. Methods Liver biopsy and bone marrow aspirate were obtained in the first 24h post mortem from 21 adult HD patients. Biochemical liver iron content (LIC) was quantified by electrothermal atomization atomic absorption spectrophotometry. Tissue iron deposition was graded in the liver and bone marrow using Scheuer and Gale's criteria, respectively. Findings Median LIC was 42.5 (22.9-69.7) μmol/g and the majority (n=11; 57%) had mild to moderate liver iron overload (LIC >36 μmol/g). Scheuer grade was 2 (1-3) and 13 (62%) of liver biopsies had increased (> 1) iron deposition. In the bone marrow, median Gale's grade was 3 (3-4) and 9 (45%) patients had increased (>3) iron content. Contrary to old autopsy studies, done in the pre-erythropoiesis-stimulating agents (ESAs) era, both liver and bone marrow were iron replete and showed a positive correlation (r=0.71, p<0.001). Ferritin proved to have a good diagnostic accuracy for liver iron overload (0.87 95% CI 0.71-1.00) with an optimal cut-off value of 422 ng/ml. Haemoglobin was negatively associated with both LIC (r= -0.46, p=0.04) and iron content in the bone marrow (p=0.04). Patients with increased LIC had higher resistance to ESAs (p=0.02), yet no association with previous IV iron therapy. Interpretation In the majority of HD patients there was iron accumulation in both the liver and bone marrow that associated with anaemia severity and resistance to ESAs, suggesting a blocking mechanism of iron's utilization. Funding None.
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Locatelli F, Del Vecchio L, Minutolo R, De Nicola L. Anemia: A Connection Between Heart Failure and Kidney Failure. Cardiol Clin 2021; 39:319-333. [PMID: 34247747 DOI: 10.1016/j.ccl.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Erythropoiesis-stimulating agents (ESAs) have improved the quality of life and reduced the need for transfusions in patients with chronic kidney disease. However, randomized trials showed no benefit but possible safety issues following high doses of ESAs given to reach normal hemoglobin levels. Iron therapy is used together with ESA; when given proactively, it may reduce the risk of mortality and cardiovascular events in hemodialysis patients. Recent trials also showed benefits of intravenous iron therapy in patients with heart failure. New drugs for correcting anemia may retain the present efficacy of ESAs as antianemic drugs and reduce cardiovascular risks.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology, Alessandro Manzoni Hospital, Via dell'eremo 9, Lecco 23900, Italy.
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Via Napoleona 60, Como 22100, Italy
| | - Roberto Minutolo
- Division of Nephrology, University of Campania Luigi Vanvitelli, Piazza Miraglia, Naples 22100, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania Luigi Vanvitelli, Piazza Miraglia, Naples 22100, Italy
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Cirillo L, Somma C, Allinovi M, Bagalà A, Ferro G, Di Marcantonio E, Bellelli S, Dallari LA, Ballo P, Dattolo PC. Ferric carboxymaltose vs. ferrous sulfate for the treatment of anemia in advanced chronic kidney disease: an observational retrospective study and cost analysis. Sci Rep 2021; 11:7463. [PMID: 33811227 PMCID: PMC8018957 DOI: 10.1038/s41598-021-86769-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 03/15/2021] [Indexed: 01/02/2023] Open
Abstract
In non-dialysis-dependent chronic kidney disease (NDD-CKD), erythropoiesis-stimulating agents (ESAs) and iron supplementation are essential for anemia management. Ferric carboxymaltose (FCM) is a relatively novel intravenous iron formulation used in different clinical settings, although scarce data exist in NDD-CKD patients. Primary objective of this study was to retrospectively evaluate the efficacy of FCM compared with oral ferrous sulfate for the treatment of iron-deficiency anemia in a cohort of NDD-CKD patients, considering also the treatment costs. This was a monocentric, retrospective observational study reviewing 349 NDD-CKD patients attending an outpatient clinic between June 2013 and December 2016. Patients were treated by either FCM intravenous infusion or oral ferrous sulfate. We collected serum values of hemoglobin, ferritin and transferrin saturation (TSAT) and ESAs doses at 12 and 18 months. The costs related to both treatments were also analysed. 239 patients were treated with FCM intravenous infusion and 110 patients with oral ferrous sulfate. The two groups were not statistically different for age, BMI and eGFR values. At 18 months, hemoglobin, serum ferritin and TSAT values increased significantly from baseline in the FCM group, compared with the ferrous sulfate group. ESAs dose and rate of infusion decreased only in the FCM group. At 18 months, the treatment costs, analysed per week, was higher in the ferrous sulfate group, compared with the FCM group, and this was mostly due to a reduction in ESAs prescription in the FCM group. Routine intravenous FCM treatment in an outpatient clinic of NDD-CKD patients results in better correction of iron-deficiency anemia when compared to ferrous sulfate. In addition to this, treating NDD-CKD patients with FCM leads to a significant reduction of the treatment costs by reducing ESAs use.
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Affiliation(s)
- Luigi Cirillo
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Chiara Somma
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplant Unit, Careggi University Hospital, Florence, Italy
| | - Alfredo Bagalà
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Giuseppe Ferro
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Elio Di Marcantonio
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Stefania Bellelli
- Health Technology Assessment and Management (HTAM) Research Area, IRES Piemonte, Torino, Italy
| | - Lorenzo Antonio Dallari
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Piercarlo Ballo
- Cardiology Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Claudio Dattolo
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy.
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Zhu Y, Xue C, Ou J, Xie Z, Deng J. Effect of L-carnitine supplementation on renal anemia in patients on hemodialysis: a meta-analysis. Int Urol Nephrol 2021; 53:2149-2158. [PMID: 33713287 DOI: 10.1007/s11255-021-02835-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 03/06/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND L-carnitine is an amino acid derivative that is thought to be helpful for treating renal anemia in hemodialysis patients. However, the mechanism remains to be fully elucidated. METHODS A literature search was performed on PubMed, Embase, and Cochrane Central Register of Controlled Trials to identify randomized controlled trials (RCTs) and conduct a meta-analysis for investigating the effect of L-carnitine in the treatment of renal anemia in participants receiving hemodialysis. RESULTS A total of 18 eligible trials with 1090 participants were included in this study. L-carnitine can significantly increase plasma free L-carnitine levels (mean difference [MD]: 140.53, 95% confidence interval [CI] 102.22-178.85; P < 0.00001), decrease the erythropoietin responsiveness index (ERI; MD: -2.72, 95% CI -3.20 to -2.24; P < 0.00001) and the required erythropoiesis-stimulating agent (ESA) doses (MD: -1.70, 95% CI -2.04 to -1.36; P < 0.00001). However, the use of L-carnitine was not associated with a higher hemoglobin level (MD: 0.18, 95% CI -0.20 to 0.55; P = 0.35) and hematocrit level (MD: 1.07, 95% CI -0.73 to 2.87; P = 0.24). In subgroup analyses, the effects of L-carnitine supplementation on renal anemia in patients on hemodialysis were independent of the treatment duration and intervention routes. CONCLUSION The present meta-analysis indicated that L-carnitine therapy significantly increased plasma L-carnitine concentrations, improved the response to ESA, decreased the required ESA doses in patients receiving hemodialysis, and maintained hemoglobin and hematocrit levels. L-carnitine supplementation should be supported in hemodialysis patients. However, the relationship between L-carnitine treatment and long-term outcomes is still unclear. Further high-quality RCTs are needed to verify our findings.
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Affiliation(s)
- Yan Zhu
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China.
- Department of Nephrology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China.
| | - Chao Xue
- Department of Nephrology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jihong Ou
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Zhijuan Xie
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Jin Deng
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
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10
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A real-world longitudinal study of anemia management in non-dialysis-dependent chronic kidney disease patients: a multinational analysis of CKDopps. Sci Rep 2021; 11:1784. [PMID: 33469061 PMCID: PMC7815803 DOI: 10.1038/s41598-020-79254-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023] Open
Abstract
Previously lacking in the literature, we describe longitudinal patterns of anemia prescriptions for non-dialysis-dependent chronic kidney disease (NDD-CKD) patients under nephrologist care. We analyzed data from 2818 Stage 3-5 NDD-CKD patients from Brazil, Germany, and the US, naïve to anemia medications (oral iron, intravenous [IV] iron, or erythropoiesis stimulating agent [ESA]) at enrollment in the CKDopps. We report the cumulative incidence function (CIF) of medication initiation stratified by baseline characteristics. Even in patients with hemoglobin (Hb) < 10 g/dL, the CIF at 12 months for any anemia medication was 40%, and 28% for ESAs. Patients with TSAT < 20% had a CIF of 26% and 6% for oral and IV iron, respectively. Heart failure was associated with earlier initiation of anemia medications. IV iron was prescribed to < 10% of patients with iron deficiency. Only 40% of patients with Hb < 10 g/dL received any anemia medication within a year. Discontinuation of anemia treatment was very common. Anemia treatment is initiated in a limited number of NDD-CKD patients, even in those with guideline-based indications to treat. Hemoglobin trajectory and a history of heart failure appear to guide treatment start. These results support the concept that anemia is sub-optimally managed among NDD-CKD patients in the real-world setting.
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11
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Sheng K, Zhang P, Yao X, Li J, He Y, Chen J. Prognostic Machine Learning Models for First-Year Mortality in Incident Hemodialysis Patients: Development and Validation Study. JMIR Med Inform 2020; 8:e20578. [PMID: 33118948 PMCID: PMC7661257 DOI: 10.2196/20578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/15/2020] [Accepted: 08/16/2020] [Indexed: 12/26/2022] Open
Abstract
Background The first-year survival rate among patients undergoing hemodialysis remains poor. Current mortality risk scores for patients undergoing hemodialysis employ regression techniques and have limited applicability and robustness. Objective We aimed to develop a machine learning model utilizing clinical factors to predict first-year mortality in patients undergoing hemodialysis that could assist physicians in classifying high-risk patients. Methods Training and testing cohorts consisted of 5351 patients from a single center and 5828 patients from 97 renal centers undergoing hemodialysis (incident only). The outcome was all-cause mortality during the first year of dialysis. Extreme gradient boosting was used for algorithm training and validation. Two models were established based on the data obtained at dialysis initiation (model 1) and data 0-3 months after dialysis initiation (model 2), and 10-fold cross-validation was applied to each model. The area under the curve (AUC), sensitivity (recall), specificity, precision, balanced accuracy, and F1 score were used to assess the predictive ability of the models. Results In the training and testing cohorts, 585 (10.93%) and 764 (13.11%) patients, respectively, died during the first-year follow-up. Of 42 candidate features, the 15 most important features were selected. The performance of model 1 (AUC 0.83, 95% CI 0.78-0.84) was similar to that of model 2 (AUC 0.85, 95% CI 0.81-0.86). Conclusions We developed and validated 2 machine learning models to predict first-year mortality in patients undergoing hemodialysis. Both models could be used to stratify high-risk patients at the early stages of dialysis.
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Affiliation(s)
- Kaixiang Sheng
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ping Zhang
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xi Yao
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiawei Li
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yongchun He
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Nicholls SG, Carroll K, Weijer C, Goldstein CE, Brehaut J, Sood MM, Al-Jaishi A, Basile E, Grimshaw JM, Garg AX, Taljaard M. Ethical Issues in the Design and Conduct of Pragmatic Cluster Randomized Trials in Hemodialysis Care: An Interview Study With Key Stakeholders. Can J Kidney Health Dis 2020; 7:2054358120964119. [PMID: 33194212 PMCID: PMC7597560 DOI: 10.1177/2054358120964119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pragmatic cluster randomized trials (CRTs) offer an opportunity to improve health care by answering important questions about the comparative effectiveness of treatments using a trial design that can be embedded in routine care. There is a lack of empirical research that addresses ethical issues generated by pragmatic CRTs in hemodialysis. OBJECTIVE To identify stakeholder perceptions of ethical issues in pragmatic CRTs conducted in hemodialysis. DESIGN Qualitative study using semi-structured interviews. SETTING In-person or telephone interviews with an international group of stakeholders. PARTICIPANTS Stakeholders (clinical investigators, methodologists, ethicists and research ethics committee members, and other knowledge users) who had been involved in the design or conduct of a pragmatic individual patient or cluster randomized trial in hemodialysis, or their role would require them to review and evaluate pragmatic CRTs in hemodialysis. METHODS Interviews were conducted in-person or over the telephone and were audio-recorded with consent. Recorded interviews were transcribed verbatim prior to analysis. Transcripts and field notes were analyzed using a thematic analysis approach. RESULTS Sixteen interviews were conducted with 19 individuals. Interviewees were largely drawn from North America (84%) and were predominantly clinical investigators (42%). Six themes were identified in which pragmatic CRTs in hemodialysis raise ethical issues: (1) patients treated with hemodialysis as a vulnerable population, (2) appropriate approaches to informed consent, (3) research burdens, (4) roles and responsibilities of gatekeepers, (5) inequities in access to research, and (6) advocacy for patient-centered research and outcomes. LIMITATIONS Participants were largely from North America and did not include research staff, who may have differing perspectives. CONCLUSIONS The six themes reflect concerns relating to individual rights, but also the need to consider population-level issues. To date, concerns regarding inequity of access to research and the need for patient-centered research have received less coverage than other, well-known, issues such as consent. Pragmatic CRTs offer a potential approach to address equity concerns and we suggest future ethical analyses and guidance for pragmatic CRTs in hemodialysis embed equity considerations within them. We further note the potential for the co-creation of health data infrastructure with patients which would aid care but also facilitate patient-centered research. These present results will inform planned future guidance in relation to the ethical design and conduct of pragmatic CRTs in hemodialysis. TRIAL REGISTRATION Registration is not applicable as this is a qualitative study.
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Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, Canada
- Department of Medicine, Western University, London, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Canada
| | | | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Manish M. Sood
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Jindal Research Chair for the Prevention of Kidney Disease, The Ottawa Hospital, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | - Ahmed Al-Jaishi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Erika Basile
- Research Ethics and Compliance, Western University, London, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
- Division of Nephrology- Department of Medicine, Western University, London, Canada
- Nephrology, London Health Sciences Centre, London, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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