Effects of low-flux and high-flux hemodialysis on the survival of elderly maintenance hemodialysis patients

BACKGROUND

Elderly hemodialysis (HD) patients have a high risk of death. The effect of different types of HD membranes on survival is still controversial. The purpose of this study was to determine the relationship between the use of low-flux or high-flux membranes and all-cause and cardiovascular mortality in elderly hemodialysis patients.

METHODS

This was a retrospective clinical study involving maintenance hemodialysis patients which were categorized into low-flux and high-flux groups according to the dialyzer they were using. Propensity score matching was used to balance the baseline data of the two groups. Survival rates were compared between the two groups, and the risk factors for death were analyzed by multivariate Cox regression.

RESULTS

Kaplan-Meier survival analysis revealed no significant difference in all-cause mortality between the low-flux group and the high-flux group (log-rank test, p = 0.559). Cardiovascular mortality was significantly greater in the low-flux group than in the high-flux group (log-rank test, p = 0.049). After adjustment through three different multivariate models, we detected no significant difference in all-cause mortality. Patients in the high-flux group had a lower risk of cardiovascular death than did those in the low-flux group (HR = 0.79, 95% CI, 0.54-1.16, p = 0.222; HR = 0.58, 95% CI, 0.37-0.91, p = 0.019).

CONCLUSIONS

High-flux hemodialysis was associated with a lower relative risk of cardiovascular mortality in elderly MHD patients. High-flux hemodialysis did not improve all-cause mortality rate. Differences in urea distribution volume, blood flow, and systemic differences in solute clearance by dialyzers were not further analyzed, which are the limitations of this study.

Dialysis for older adults: why should the targets be different?

The number of patients aged > 75-years treated by dialysis continues to increase, particularly in developed countries. Haemodialysis is a well-established treatment with national and international clinical guidelines designed to provide patients with optimal treatment. However, these were developed when the dialysis population was younger, and less co-morbid. This change in patient demographics questions whether these guideline targets still apply to older patients. More patients now start dialysis with residual kidney function and could benefit from a less frequent dialysis schedule. Older patients have a lower thirst drive, so lower interdialytic gains, reduced appetite, muscle mass and physical activity would potentially allow starting dialysis with less frequent sessions a practical option. Similarly, patients with residual kidney function and lower metabolic activity may not need to meet current dialyser Kt/Vurea clearance targets to remain healthy. Instead, some elderly patients may be at risk of malnutrition and might need liberalisation of the low salt, potassium and phosphate dietary restrictions, or even additional supplements to ensure adequate protein intake. Although a fistula is the preferred vascular access, a forearm fistula may not be an option due to vascular disease, while a brachial fistula can potentially compromise cardiovascular reserve, so a dialysis catheter becomes the de facto access, especially in patients with limited life expectancy. Thus, clinical guideline targets designed for a younger less co-morbid dialysis population may not be equally applicable to the older patient initiating dialysis, and so a more individualised approach to dialysis prescription and vascular access is required.

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

INTRODUCTION

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

RESULTS

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

CONCLUSION

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

Incremental and Personalized Hemodialysis Start: A New Standard of Care

Introduction

Incremental hemodialysis (iHD) may attenuate “dialysis shock” and reduce costs, preserving quality of life. It is considered difficult to reconcile with HD wards’ routine; fear of underdialysis and increasing mortality are additional concerns. The aim of this study was to evaluate mortality, morbidity, and costs in a large HD ward where iHD is the standard of HD start.

Methods

This observational study included all incident HD patients in 2017 to 2021, stratified according to HD start: iHD (1–2 sessions/wk), decremental HD (dHD, 3 sessions/wk at start, later reduced), or standard (3 sessions/wk). Results were compared with data recorded in the same unit before the incremental program (2015–2017) and with a propensity score-matched cohort from the French Renal Epidemiology and Information Network (REIN) registry.

Results

A total of 158 patients started HD in 2017 to 2021, 57.6% on iHD, 8.9% dHD, and 33.5% standard HD schedule. Patients on the standard schedule had lower initial estimated glomerular filtration rate (eGFR) (5 vs. 7 ml/min per 1.72 m², P = 0.003). We found no survival differences according to period of start (same center) and propensity score matching (REIN). Patients intensively followed in the pre-HD period were more likely to start on iHD-dHD. Persistence on iHD-dHD was about 50% at 1 year and 35% at 2 years. Hospitalization rates and time to first hospitalization or death did not differ between the schedules. The iHD-dHD policy allowed a 16% cost saving, even accounting for supplemental biochemical tests.

Conclusion

Our study reveals that iHD can be a new standard of care, as it is safe and feasible in up to two-thirds of patients on incident HD.

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.

Chronic kidney disease-associated pruritus significantly impacts on quality of life of patients on haemodialysis and associates with increased levels of serum calcium and phosphorus

PURPOSE OF THE STUDY

Chronic kidney disease-associated pruritus (CKD-aP) is common among patients on maintenance haemodialysis (HD). We performed a study to explore the clinical features of patients with CKD-aP and evaluate the impact of CKD-aP on the quality of life of HD patients.

STUDY DESIGN

Patients who were receiving regular HD over 3 months were recruited. Quality of life was quantified by the Short Form-12 (SF-12) questionnaire. Pruritus was evaluated by the 5D-Itch Scale. Demographic characteristics and biochemical indicators were obtained from the medical record system. Multiple linear regression was used to assess the association between pruritus and targeting factors. The relationship between the scores on the 5D-Itch Scale and SF-12 was analysed using multiple linear regression, adjusted for other factors, to demonstrate the impact of CKD-aP on the quality of life of HD patients.

RESULTS

In total, 269 out of 301 (89.4%) patients accomplished all investigations. The prevalence of CKD-aP in our cohort was 40.9%. Age (B=0.339, p=0.042), treatment with haemoperfusion (B=1.853, p=0.018), and serum level of calcium (B=3.566, p=0.008) and phosphorus (B=1.543, p=0.002) were independently associated with pruritus. Score on the 5D-Itch Scale negatively impacted on physical component summary (B=-0.778, p<0.001) and mental component summary (B=-0.675, p<0.001).

CONCLUSIONS

Pruritus significantly aggravates the quality of life of HD patients. Irregularity in the metabolism of calcium and phosphorus may partially explain the mechanism of CKD-aP. More effective treatment of CKD-MBD may help to prevent pruritus and improve patients' mental and physical health conditions.

Optimizing dialysis dose in the context of frailty: an exploratory study

INTRODUCTION

Frailty is a multicausal syndrome characterized by a decrease in strength, resistance and physiological function, which makes the individual vulnerable and dependent, and increases his/her mortality. This syndrome is more prevalent among older individuals, and chronic kidney disease patients, particularly those on dialysis. Dialysis dose is currently standardized for hemodialysis (HD) patients regardless of their age and functional status. However, it has been postulated that the dialysis dose required in older patients, especially frail ones, should be lower, since it could increase their degree of frailty. Then, the purpose of this study was to evaluate if there would be a correlation between the dose of Kt/V and the degree of frailty in a population of adult patients on HD.

MATERIALS AND METHODS

A cross-sectional study with 82 patients on HD in Barranquilla (Colombia) and Lobos (Argentina) was conducted. Socio-demographic and laboratory data, as well as dialysis doses (Kt/V) were recorded and scales of fragility, physical activity, gait and grip strength were applied. Then these data were correlated by a Spearman's correlation and a logistic regression.

RESULTS

CFS, social isolation, physical activity, gait speed, and prehensile strength tests were outside the reference ranges in the studied group. No significant correlation was found between dialysis dose and all the above mentioned functional tests. However, a significant and inverse correlation between physical activity and CFS was documented (score - 1.41 (CI - 2.1 to - 0.7).

CONCLUSION

No significant correlation was documented between Kt/V value and different parameters of the frailty status, but this status correlated significantly and inversely with physical activity in this group. Frailty status in hemodialysis patients was significantly higher in older individuals, although young individuals were not exempt from it.

Can incremental haemodialysis reduce early mortality rates in patients starting maintenance haemodialysis?

PURPOSE OF REVIEW

Early mortality rates after the start of maintenance haemodialysis therapy are high. Compared with three-times weekly haemodialysis, incremental haemodialysis is associated with better preservation of residual renal function (RRF) and at least equivalent mid-term to long-term survival. However, there is paucity of data in relation to its use as a means of helping patients through the transitional period, when they first become dialysis dependent.

RECENT FINDINGS

Studies of incremental haemodialysis have overlooked early mortality as an outcome measure. This is primarily due to their retrospective design which makes it difficult to link early deaths to the frequency of haemodialysis. New data confirm previous observations associating incremental haemodialysis with favourable outcomes. They also raise the possibility that in selected groups and for short periods, the pursuit of set clearance targets during the early days of dialysis may not necessarily bring additional short-term gains.

SUMMARY

We argue that, while simpler ways of estimating RRF are being explored, future trials must consider implementing incremental haemodialysis focusing on practical aspects of care in the transitional period; safety monitoring in such regimes should be undertaken using conventional methods. Such an approach is likely to benefit a larger subset of haemodialysis population.

[Impact of renal replacement therapy on frail older adults]

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Análisis de la calidad de vida en pacientes con tratamiento renal sustitutivo: influencia de los parámetros analíticos y socio-clínicos

Introducción: La enfermedad renal crónica es una enfermedad en crecimiento y un reto para los países desarrollados ya que produce un importante impacto en la calidad de vida de los pacientes, alterando las actividades cotidianas y provocando cambios en los aspectos físicos, emocionales y sociales. Objetivos: Evaluar la calidad de vida percibida por los pacientes con enfermedad renal crónica sometidos a tratamiento renal sustitutivo con hemodiálisis o con diálisis peritoneal, y en qué medida son influenciados por los parámetros analíticos y socioclínicos. Material y Método: Estudio transversal en un grupo de pacientes con enfermedad renal crónica en tratamiento con diálisis peritoneal y hemodiálisis, mediante la cumplimentación del cuestionario de Calidad de Vida en las Enfermedades Renales KDQOL-SF 36. Además se añadieron una serie de variables socioclínicas y parámetros de laboratorio para analizar su posible influencia en la calidad de vida. El análisis estadístico fue realizado con el software estadístico SPSS versión 22.0 para Windows. Resultados: En nuestra muestra observamos que los dominios de la calidad de vida peor valorados por los pacientes son la salud general, estrés por la enfermedad y rol físico; en cambio, los mejor valorados son el dolor corporal y la salud mental. También se halló mayor repercusión sobre algunos dominios de la calidad de vida si el paciente está en tratamiento con hemodiálisis, si dispone de fístula arteriovenosa como acceso, y cuanto más tiempo lleve en tratamiento renal sustitutivo, e incluso, si están alterados ciertos parámetros analíticos como el Ky/V, urea, potasio o hemoglobina. Conclusiones: El tratamiento renal sustitutivo con hemodiálisis o diálisis peritoneal genera un impacto enorme en la calidad de vida percibida por el paciente y se debe prestar especial atención a la idoneidad de la técnica elegida en cada momento, a la adecuación del acceso para diálisis, sin descuidar a los pacientes “veteranos” por el hecho de llevar mucho tiempo en tratamiento.

Palliative dialysis: Addressing the need for alternative dialysis delivery modes

For some patients with kidney failure, particularly those who have limited life expectancy or severe comorbidities, the "standard" dialysis treatment regimen may be perceived as excessively burdensome and may not align well with the patient's own priorities. For such patients, a palliative approach to the provision of dialysis-whereby treatment is tailored to the needs of the individual so as to optimize quality of life and minimize disease-related symptoms, but limit treatment burden-might offer a way to better align the delivery of care with the life goals of the patient. Here, we discuss the fundamental principles of palliative dialysis: the patients who might most benefit from this approach, treatment strategies and considerations for implementation, as well as potential barriers to its provision.

A swan song for Kt/Vurea

Dialyzer clearance of urea multiplied by dialysis time and normalized for urea distribution volume (Kt/V_urea or simply Kt/V) has been used as an index of dialysis adequacy since more than 30 years. This article reviews the flaws of Kt/V, starting with a lack of proof of concept in three randomized controlled hard outcome trials (RCTs), and continuing with a long list of conditions where the concept of Kt/V was shown to be flawed. This information leaves little room for any conclusion other than that Kt/V, as an indicator of dialysis adequacy, is obsolete. The dialysis patient might benefit more if, instead, the nephrology community concentrates in the future on pursuing the optimal dialysis dose that conforms with adequate quality of life and on factors that are likely to affect outcomes more than Kt/V. These include residual renal function, volume status, dialysis length, ultrafiltration rate, the number of intra-dialytic hypotensive episodes, interdialytic blood pressure, serum potassium and phosphate, serum albumin, and C reactive protein.

Incremental hemodialysis, a valuable option for the frail elderly patient

Management of older people on dialysis requires focus on the wider aspects of aging as well as dialysis. Recognition and assessment of frailty is vital in changing our approach in elderly patients. Current guidelines in dialysis have a limited evidence base across all age group, but particularly the elderly. We need to focus on new priorities of care when we design guidelines "for people not diseases". Patient-centered goal-directed therapy, arising from shared decision-making between physician and patient, should allow adaption of the dialysis regime. Hemodialysis (HD) in the older age group can be complicated by intradialytic hypotension, prolonged time to recovery, and access-related problems. There is increasing evidence relating to the harm associated with the delivery of standard thrice-weekly HD. Incremental HD has a lower burden of treatment. There appears to be no adverse clinical effects during the first years of dialysis in presence of a significant residual kidney function. The advantages of incremental HD might be particularly important for elderly patients with short life expectancy. There is a need for more research into specific topics such as the assessment of the course of frailty with progression of chronic kidney disease and after dialysis initiation, the choice of dialysis modality impacting on the trajectory of frailty, the timing of dialysis initiation impacting on frailty or on other outcomes. In conclusion, understanding each individual's goals of care in the context of his or her life experience is particularly important in the elderly, when overall life expectancy is relatively short, and life experience or quality of life may be the priority.

Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices?

Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.

Usefulness of frailty evaluation for handling chronic kidney disease elderly patients: a review and original proposal

There is interdependence between chronic kidney disease (CKD) and ageing whereby CKD makes ageing more accelerated and pronounced, whereas ageing accelerates chronic nephropathy's progression. Frailty status catalyzes this spiral, with renal and systemic negative consequences, and this condition can currently be documented by applying already validated clinical scores (frailty phenotype) or physical test (gate speed). Although, nephroprevention strategies are similar between young adult and senior CKD patients, standard targets should be adequate to very old and frail elderly individuals. For this purpose, an original algorithm is here proposed to adjust the conventional nephroprevention strategies to the condition of CKD frail patient (more relaxed targets and tighter control), as well as to prescribe anti-frailty interventions to slow patient's functional decline, hospitalization and mortality.

Prevalence of chronic kidney disease-associated pruritus, and association with sleep quality among hemodialysis patients in Pakistan

Background

The prevalence of chronic kidney disease-associated pruritus (CKD-aP) varies from 22% to 84% among patients receiving hemodialysis. It occurs more frequently at night, and often affects patient’s sleep quality. CKD-aP is often unreported by patients, and many do not receive effective treatment. There is, however, a paucity of available data on the prevalence and impact of CKD-aP on patients receiving hemodialysis in Pakistan.

Methods

A multicenter cross-sectional study was undertaken from July 2016 to April 2017 at a tertiary care hospitals in Pakistan.

Results

354 patients undergoing hemodialysis were studied. 35.6% had CKD for 1–2 years, and 42.4% were receiving hemodialysis for 1–2 years. The prevalence of pruritus was 74%. The median [interquartile range] score for pruritus was 10.0 (out of possible 25) [8.0–12.0]; while the median [interquartile range] Pittsburgh Sleep Quality Index (PSQI) score was 8.0 (out of possible 21) [7.0–10.0]'. Pruritus was significantly correlated with the sleep score (r = 0.423, p<0.001). The results of the multivariate linear regression revealed a positive association between pruritus and age of patients (β = 0.031; 95% CI = 0.002–0.061; p = 0.038) and duration of CKD (β = -0.013; 95% CI = -0.023 –-0.003; p = 0.014). Similarly there was a positive association between sleep score and duration of CKD (β = 0.010; 95% CI = 0.002–0.019; p = 0.012) and pruritus (β = 0.143; 95% CI = 0.056–0.230; p = 0.001).

Conclusions

Chronic kidney disease-associated pruritus is very common in patients receiving hemodialysis in Pakistan. Pruritus is significantly associated with poor sleep quality.

No Survival Benefit in Octogenarians and Nonagenarians with Extended Hemodialysis Treatment Time

BACKGROUND

The population of elderly end-stage renal disease patients initiating dialysis is rapidly growing. Although longer treatment is supposed to benefit for hemodialysis (HD) patients through more solute clearance and slower fluid removal, it is not yet clear how treatment session length affects mortality risk in octogenarians and nonagenarians.

METHODS

In a cohort of 112,026 incident HD patients between 2007 and 2011, we examined the association of treatment session length with all-cause mortality, adjusting for demographics and comorbid conditions. We also used restricted spline functions for age to evaluate continuous changes in the association of short (< 210 min) and extended (≥240 min) HD treatment (vs. 210 to < 240 min) with all-cause mortality over continuous age.

RESULTS

During the first 91 days of dialysis, patients aged ≥80 years tended to have the lowest treatment session length (median [interquartile range] 211 [193-230] min, r > 0.5). Longer treatment was associated with better survival in patients < 65 and 65 to < 80 years but not in octogenarians/nonagenarians. The association of extended treatment (≥240 min) with better survival was attenuated across age and not significant among patients aged ≥80 years with a hazard ratio of 1.10 (95% CI 0.99-1.20). Shorter treatment sessions (< 210 min) was associated with higher mortality across all age groups.

CONCLUSION

Extended HD was not associated with lower mortality among octogenarians and nonagenarians, while it was associated with better survival among younger patients. Further studies are needed to determine the optimal treatment session length in elderly incident HD patients.

Conventional dialysis in the elderly: How lenient should our guidelines be?

There has been a dramatic, worldwide expansion in life expectancy across the last century. This has resulted in a progressively more elderly and comorbid population. It is increasingly recognized that healthcare in this group needs to move to the concept of "adding life to years". Recognition and assessment of frailty is vital in changing our approach in elderly patients. Current guidelines in dialysis have a limited evidence base across all age groups, but particularly the elderly and serve them poorly. Moreover, the burden of guidelines for each comorbidity of the multimorbid patient is increasing and can be conflicting. Finally, there is increasing evidence relating to the harm associated with the delivery of conventional dialysis. In dialysis patients, frailty is the overwhelming determinant in relation to patient-specific outcomes rather than modality of treatment; therefore, the focus should be on promoting quality of life. We need to focus on new priorities of care when we design guidelines "for people not diseases". Patient-centered goal-directed therapy, arising from shared decision making between physician and patient, should allow adaption of the dialysis regime to maximize opportunities while minimizing treatment-related morbidity and concentrating on alleviating symptoms.