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Montez-Rath ME, Thomas IC, Charu V, Odden MC, Seib CD, Arya S, Fung E, O'Hare AM, Wong SPY, Kurella Tamura M. Effect of Starting Dialysis Versus Continuing Medical Management on Survival and Home Time in Older Adults With Kidney Failure : A Target Trial Emulation Study. Ann Intern Med 2024; 177:1233-1243. [PMID: 39159459 DOI: 10.7326/m23-3028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND For older adults with kidney failure who are not referred for transplant, medical management is an alternative to dialysis. OBJECTIVE To compare survival and home time between older adults who started dialysis at an estimated glomerular filtration rate (eGFR) less than 12 mL/min/1.73 m2 and those who continued medical management. DESIGN Observational cohort study using target trial emulation. SETTING U.S. Department of Veterans Affairs, 2010 to 2018. PARTICIPANTS Adults aged 65 years or older with chronic kidney failure and eGFR below 12 mL/min/1.73 m2 who were not referred for transplant. INTERVENTION Starting dialysis within 30 days versus continuing medical management. MEASUREMENTS Mean survival and number of days at home. RESULTS Among 20 440 adults (mean age, 77.9 years [SD, 8.8]), the median time to dialysis start was 8.0 days in the group starting dialysis and 3.0 years in the group continuing medical management. Over a 3-year horizon, the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days [95% CI, -17.4 to 30.1 days]). Compared with the group continuing medical management, the group starting dialysis had 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days at home). Compared with the group continuing medical management and forgoing dialysis completely, the group starting dialysis had longer survival by 77.6 days (CI, 62.8 to 91.1 days) and 14.7 fewer days at home (CI, 11.2 to 16.5 fewer days at home). LIMITATION Potential for unmeasured confounding due to lack of symptom assessments at eligibility; limited generalizability to women and nonveterans. CONCLUSION Older adults starting dialysis when their eGFR fell below 12 mL/min/1.73 m2 who were not referred for transplant had modest gains in life expectancy and less time at home. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs and National Institutes of Health.
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Affiliation(s)
- Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (M.E.M., E.F.)
| | - I-Chun Thomas
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (I.-C.T.)
| | - Vivek Charu
- Quantitative Sciences Unit, Department of Medicine, and Department of Pathology, Stanford University School of Medicine, Stanford, California (V.C.)
| | - Michelle C Odden
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California, and Geriatric, Research, Education, and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (M.C.O.)
| | - Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, and Division of General Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California (C.D.S.)
| | - Shipra Arya
- Department of Surgery, Stanford University School of Medicine, and Division of Vascular Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California (S.A.)
| | - Enrica Fung
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (M.E.M., E.F.)
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine, University of Washington, and Hospital and Specialty Medicine Service and Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (A.M.O., S.P.Y.W.)
| | - Susan P Y Wong
- Division of Nephrology, Department of Medicine, University of Washington, and Hospital and Specialty Medicine Service and Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (A.M.O., S.P.Y.W.)
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, and Geriatric Research, Education, and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (M.K.T.)
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Okada H, Ono A, Tomori K, Inoue T, Hanafusa N, Sakai K, Narita I, Moriyama T, Isaka Y, Fukami K, Itano S, Kanda E, Kashihara N. Development of a prognostic risk score to predict early mortality in incident elderly Japanese hemodialysis patients. PLoS One 2024; 19:e0302101. [PMID: 38603695 PMCID: PMC11008820 DOI: 10.1371/journal.pone.0302101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Information of short-term prognosis after hemodialysis (HD) introduction is important for elderly patients with chronic kidney disease (CKD) and their families choosing a modality of renal replacement therapy. Therefore, we developed a risk score to predict early mortality in incident elderly Japanese hemodialysis patients. MATERIALS AND METHODS We analyzed data of incident elderly HD patients from a nationwide cohort study of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) to develop a prognostic risk score. Candidate risk factors for early death within 1 year was evaluated using multivariate logistic regression analysis. The risk score was developed by summing up points derived from parameter estimate values of independent risk factors. The association between risk score and early death was tested using Cox proportional hazards models. This risk score was validated twice by using an internal validation cohort derived from the JRDR and an external validation cohort collected for this study. RESULTS Using the development cohort (n = 2,000), nine risk factors were retained in the risk score: older age (>85), yes = 2, no = 0; sex, male = 2, female = 0; lower body mass index (<20), yes = 2, no = 0; cancer, yes = 1, no = 0; dementia, yes = 3, no = 0; lower creatinine (<6.5 mg/dL), yes = 1, no = 0; lower albumin (<3.0 g/dL), yes = 3, no = 0; normal or high calcium (≥8.5 mg/dL), yes = 1, no = 0; and higher C reactive protein (>2.0 mg/dL), yes = 2, no = 0. In the internal and external validation cohorts (n = 739, 140, respectively), the medium- and high-risk groups (total score, 6 to 10 and 11 or more, respectively) showed significantly higher risk of early death than the low-risk group (total score, 0 to 5) (p<0.001). CONCLUSION We developed a prognostic risk score predicting early death within 1 year in incident elderly Japanese HD patients, which may help detect elderly patients with a high-risk of early death after HD introduction.
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Affiliation(s)
- Hirokazu Okada
- Department of Nephrology, Saitama Medical University, Irumagun, Japan
| | - Atsushi Ono
- Department of Nephrology, Saitama Medical University, Irumagun, Japan
- Department of Nephrology, SUBARU Health Insurance Association Ota Memorial Hospital, Ota, Japan
| | - Koji Tomori
- Department of Nephrology, Saitama Medical University, Irumagun, Japan
| | - Tsutomu Inoue
- Department of Nephrology, Saitama Medical University, Irumagun, Japan
| | - Norio Hanafusa
- Department of Medicine, Blood Purification, Tokyo Women’s Medical University, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Toho University, Tokyo, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | | | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kei Fukami
- Department Medicine, Division of Nephrology, Kurume University School of Medicine, Fukuoka, Japan
| | - Seiji Itano
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Eiichiro Kanda
- Department of Medical Science, Kawasaki Medical School, Kurashiki, Japan
| | - Naoki Kashihara
- Department of Medical Science, Kawasaki Medical School, Kurashiki, Japan
- Geriatric Medical Center, Kawasaki Medical School, Okayama, Japan
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Martino FK, Novara G, Nalesso F, Calò LA. Conservative Management in End-Stage Kidney Disease between the Dialysis Myth and Neglected Evidence-Based Medicine. J Clin Med 2023; 13:41. [PMID: 38202048 PMCID: PMC10779521 DOI: 10.3390/jcm13010041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
In the last few decades, the aging of the general population has significantly increased the number of elderly patients with end-stage kidney disease (ESKD) who require renal replacement therapy. ESKD elders are often frail and highly comorbid with social issues and seem to not benefit from dialysis in terms of survival and quality of life. Conservative management (CM) could represent a valid treatment option, allowing them to live for months to years with a modest impact on their habits. Despite these possible advantages, CM remains underused due to the myth of dialysis as the only effective treatment option for all ESKD patients regardless of its impact on quality of life and survival. Both CM and dialysis remain valid alternatives in the management of ESKD. However, assessing comorbidities, disabilities, and social context should drive the choice of the best possible treatment for ESKD, while in elderly patients with short life expectancies, referring them to palliative care seems the most reasonable choice.
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Affiliation(s)
- Francesca K. Martino
- Nephrology, Dialysis, Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35124 Padua, Italy; (F.K.M.); (F.N.)
| | - Giacomo Novara
- Department of Surgery, Oncology and Gastroenterology, Urology Clinic University of Padua, 35124 Padua, Italy
| | - Federico Nalesso
- Nephrology, Dialysis, Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35124 Padua, Italy; (F.K.M.); (F.N.)
| | - Lorenzo A. Calò
- Nephrology, Dialysis, Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35124 Padua, Italy; (F.K.M.); (F.N.)
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Wallin JM, Jacobson SH, Axelsson L, Lindberg J, Persson CI, Stenberg J, Wennman-Larsen A. Discrepancy in responses to the surprise question between hemodialysis nurses and physicians, with focus on patient clinical characteristics: A comparative study. Hemodial Int 2023; 27:454-464. [PMID: 37318069 DOI: 10.1111/hdi.13103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 05/16/2023] [Accepted: 05/24/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The surprise question (SQ) "Would I be surprised if this patient died within the next xx months" can be used by different professions to foresee the need of serious illness conversations in patients approaching end of life. However, little is known about the different perspectives of nurses and physicians in responses to the SQ and factors influencing their appraisals. The aim was to explore nurses' and physicians' responses to the SQ regarding patients on hemodialysis, and to investigate how these answers were associated with patient clinical characteristics. METHODS This comparative cross-sectional study included 361 patients for whom 112 nurses and 15 physicians responded to the SQ regarding 6 and 12 months. Patient characteristics, performance status, and comorbidities were obtained. Cohen's kappa was used to analyze the interrater agreement between nurses and physicians in their responses to the SQ and multivariable logistic regression was applied to reveal the independent association to patient clinical characteristics. FINDINGS Proportions of nurses and physicians responding to the SQ with "no, not surprised" was similar regarding 6 and 12 months. However, there was a substantial difference concerning which specific patient the nurses and physicians responded "no, not surprised", within 6 (κ = 0.366, p < 0.001, 95% CI = 0.288-0.474) and 12 months (κ = 0.379, p < 0.001, 95% CI = 0.281-0.477). There were also differences in the patient clinical characteristics associated with nurses' and physicians' responses to the SQ. DISCUSSION Nurses and physicians have different perspectives in their appraisal when responding to the SQ for patients on hemodialysis. This may reinforce the need for communication and discussion between nurses and physicians to identify the need of serious illness conversations in patients approaching the end of life, in order to adapt hemodialysis care to patient preferences and needs.
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Affiliation(s)
- Jeanette M Wallin
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Lena Axelsson
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
| | - Jenny Lindberg
- Department of Clinical Sciences, Unit of Medical Ethics, Lund University, Lund, Sweden
| | - Carina I Persson
- Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden
| | - Jenny Stenberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Agneta Wennman-Larsen
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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5
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Miyauchi T, Nishiwaki H, Mizukami A, Yazawa M. Hyponatremia and mortality in patients undergoing maintenance hemodialysis: Systematic review and meta-analysis. Semin Dial 2023; 36:303-315. [PMID: 36929612 DOI: 10.1111/sdi.13140] [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: 04/17/2022] [Revised: 08/23/2022] [Accepted: 01/11/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION This systematic review and meta-analysis examined the relationship between hyponatremia and worse outcomes in patients undergoing maintenance hemodialysis. METHODS The MEDLINE, EMBASE, CENTRAL, and Web of Science databases were used to search for relevant articles. The target population was patients on maintenance hemodialysis (those undergoing hemodialysis for ≥60 days). The defined outcomes were death, cardiovascular disease, cognitive decline, and falls. Meta-analysis was performed with a random-effects model of pairwise comparisons of normonatremia and hyponatremia defined for each study, 1-mmol/L increment of sodium analysis, and dose-response analysis using the sodium concentration defined for each study. This study was registered with PROSPERO (registration number CRD42018087667). RESULTS Thirteen articles were included. The pairwise analysis revealed that the hazard ratio for all-cause mortality was 1.45 (95% confidence interval, 1.31-1.61). The analysis of 1-mmol/L increment of sodium included six studies with a hazard ratio for all-cause mortality of 0.94 (95% confidence interval, 0.91-0.97) for each 1-mmol/L increase in the serum sodium concentration. In the dose-response analysis, assuming a linear relationship, a sodium increment of 1 mmol/L revealed a hazard ratio for all-cause mortality of 0.97 (95% confidence interval, 0.96-0.98). Other outcomes could not be integrated. CONCLUSIONS Hyponatremia is associated with all-cause mortality in patients undergoing maintenance hemodialysis. Healthcare providers should pay special attention to even the slightest indication of hyponatremia.
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Affiliation(s)
- Takamasa Miyauchi
- Daini Hattori Clinic, Tokyo, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hiroki Nishiwaki
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
- Showa University Research Administration Center (SURAC), Tokyo, Japan
| | - Aya Mizukami
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Park JH, Park HC, Kim DH, Lee YK, Cho AJ. Mortality and Risk Factors in Very Elderly Patients Who Start Hemodialysis: Korean Renal Data System, 2016-2020. Am J Nephrol 2023; 54:175-183. [PMID: 37231807 DOI: 10.1159/000530933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/23/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION The number of elderly patients with end-stage renal disease (ESRD) is increasing worldwide. However, decision-making about elderly patients with ESRD remains complex because of the lack of studies, especially in very elderly patients (≥75 years). We examined the characteristics of very elderly patients starting hemodialysis (HD) and the associated mortality and prognostic factors. METHODS Data were analyzed retrospectively using a nationwide cohort registry, the Korean Renal Data System. Patients who started HD between January 2016 and December 2020 were included and divided into three groups according to age at HD initiation (<65, 65-74, and ≥75 years). The primary outcome was all-cause mortality during the study period. Risk factors for mortality were analyzed using Cox proportional hazard models. RESULTS In total, 22,024 incident patients were included with 10,006, 5,668, and 6,350 in each group (<65, 65-74, and ≥75 years, respectively). Among the very elderly group, women had a higher cumulative survival rate than men. The survival rate was lower in patients with vascular access via a catheter than in those with an arteriovenous fistula or graft. Very elderly patients with more comorbid diseases had a significantly lower survival rate than those with fewer comorbidities. In the multivariate Cox models, old age, cancer presence, catheter use, low body mass index, low Kt/V, low albumin concentration, and capable status of partial self-care were associated with high risk of mortality. CONCLUSION Preparation of an arteriovenous fistula or graft when starting HD should be considered in very elderly patients with fewer comorbid diseases.
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Affiliation(s)
- Ji Hyeon Park
- Department of Internal Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Hayne Cho Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
- Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Do Hyoung Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
- Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Young Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
- Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - AJin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
- Hallym University Kidney Research Institute, Seoul, Republic of Korea
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Kim HW, Jhee JH, Joo YS, Yang KH, Jung JJ, Shin JH, Han SH, Yoo TH, Kang SW, Park JT. Clinical significance of hemodialysis quality of care indicators in very elderly patients with end stage kidney disease. J Nephrol 2022; 35:2351-2361. [PMID: 35666374 DOI: 10.1007/s40620-022-01356-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Hyung Woo Kim
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Su Joo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea.,Division of Nephrology, Department of Internal Medicine, Yongin Severance Hospital, Yongin, Gyeonggi-do, Korea
| | - Ki Hwa Yang
- Health Insurance Review and Assessment Service, Healthcare Review and Assessment Committee, Wonju, Korea
| | - Jin Ju Jung
- Quality Assessment Division, Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ji Hyeon Shin
- Quality Assessment Analytic Division, Quality Assessment Administration Department, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea.
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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment. Korean J Intern Med 2022; 37:701-718. [PMID: 35811360 PMCID: PMC9271711 DOI: 10.3904/kjim.2021.543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 12/05/2022] Open
Abstract
The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists' support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient's condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There are also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).
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Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon,
Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan,
Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University School of Medicine, Seoul,
Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul,
Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul,
Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul,
Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan,
Korea
| | | | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu,
Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul,
Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul,
Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
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Chou A, Li KC, Brown MA. Survival of Older Patients With Advanced CKD Managed Without Dialysis: A Narrative Review. Kidney Med 2022; 4:100447. [PMID: 35498159 PMCID: PMC9046625 DOI: 10.1016/j.xkme.2022.100447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Shared decision making is important when deciding the appropriateness of dialysis for any individual, particularly for older patients with advanced chronic kidney disease who have high mortality. Emerging evidence suggests that patients with advanced age, high comorbidity burden, and poor functional status may not have any survival advantage on dialysis compared with those on a conservative kidney management pathway. The purpose of this narrative review is to summarize the existing studies on the survival of older patients with stage 4 or 5 chronic kidney disease managed with or without dialysis and to evaluate the factors that may influence mortality in an effort to assist clinicians with shared decision making. Median survival estimates of conservative kidney management patients are widely varied, ranging from 1-45 months with 1-year survival rates of 29%-82%, making it challenging to provide consistent advice to patients. In existing cohort studies, the selected group of patients on dialysis generally survives longer than the conservative kidney management cohort. However, in patients with advanced age (aged ≥80 years), high comorbidity burden, and poor functional status, the survival benefit conferred by dialysis is no longer present. There is an overall paucity of data, and the variability in outcomes reflect the heterogeneity of the existing studies; further prospective studies are urgently needed.
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Affiliation(s)
- Angela Chou
- University of New South Wales, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
| | - Kelly Chenlei Li
- University of New South Wales, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
| | - Mark Ashley Brown
- University of New South Wales, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
- Address for Correspondence: Mark Ashley Brown, MBBS, FRACP, MD, Department of Renal Medicine, St George Hospital, Kogarah, Sydney, New South Wales 2217, Australia.
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Wong SPY, Rubenzik T, Zelnick L, Davison SN, Louden D, Oestreich T, Jennerich AL. Long-term Outcomes Among Patients With Advanced Kidney Disease Who Forgo Maintenance Dialysis: A Systematic Review. JAMA Netw Open 2022; 5:e222255. [PMID: 35285915 PMCID: PMC9907345 DOI: 10.1001/jamanetworkopen.2022.2255] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE An understanding of the long-term outcomes of patients with advanced chronic kidney disease not treated with maintenance dialysis is needed to improve shared decision-making and care practices for this population. OBJECTIVE To evaluate survival, use of health care resources, changes in quality of life, and end-of-life care of patients with advanced kidney disease who forgo dialysis. EVIDENCE REVIEW MEDLINE, Embase (Excerpta Medica Database), and CINAHL (Cumulative Index of Nursing and Allied Health Literature) were searched from inception through December 3, 2021, for all English language longitudinal studies of adults in whom there was an explicit decision not to pursue maintenance dialysis. Two investigators independently reviewed all studies and selected those reporting survival, use of health care resources, changes in quality of life, or end-of-life care during follow-up. Studies of patients who initiated and then discontinued maintenance dialysis and patients in whom it was not clear that there was an explicit decision to forgo dialysis were excluded. One author abstracted all study data, of which 12% was independently adjudicated by a second author (<1% error rate). FINDINGS Forty-one cohort studies comprising 5102 patients (range, 11-812 patients) were included in this systematic review (5%-99% men; mean age range, 60-87 years). Substantial heterogeneity in study designs and measures used to report outcomes limited comparability across studies. Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate ranging from 7 to 19 mL/min/1.73 m2. Patients generally experienced 1 to 2 hospital admissions, 6 to 16 in-hospital days, 7 to 8 clinic visits, and 2 emergency department visits per person-year. During an observation period of 8 to 24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the illness course. Among patients who died during follow-up, 20% to 76% had enrolled in hospice, 27% to 68% died in a hospital setting and 12% to 71% died at home; 57% to 76% were hospitalized, and 4% to 47% received an invasive procedure during the final month of life. CONCLUSIONS AND RELEVANCE Many patients who do not pursue dialysis survived several years and experienced sustained quality of life until late in the illness course. Nonetheless, use of acute care services was common and intensity of end-of-life care highly variable across cohorts. These findings suggest that consistent approaches to the study of conservative kidney management are needed to enhance the generalizability of findings and develop models of care that optimize outcomes among conservatively managed patients.
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Affiliation(s)
- Susan P. Y. Wong
- Health Services Research and Development Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Nephrology, University of Washington, Seattle
| | - Tamara Rubenzik
- Divisions of Nephrology and Geriatrics, Gerontology and Palliative Care, University of California, San Diego
| | - Leila Zelnick
- Division of Nephrology, University of Washington, Seattle
| | - Sara N. Davison
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Diana Louden
- Health Sciences Library, University of Washington, Seattle
| | - Taryn Oestreich
- Health Services Research and Development Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Nephrology, University of Washington, Seattle
| | - Ann L. Jennerich
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
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11
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Zheng S, Yang J, Tan TC, Belani S, Law D, Pravoverov LV, Kim SS, Go AS. Dialysis therapy and mortality in older adults with heart failure and advanced chronic kidney disease: A high-dimensional propensity-matched cohort study. PLoS One 2022; 17:e0262706. [PMID: 35061809 PMCID: PMC8782375 DOI: 10.1371/journal.pone.0262706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/03/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Heart failure (HF) and chronic kidney disease (CKD) frequently coexist, and the combination is linked to poor outcomes, but limited data exist to guide optimal management. We evaluated the outcome of dialysis therapy in older patients with HF and advanced CKD. METHODS We examined adults aged ≥70 years with HF and eGFR ≤20 ml/min/1.73 m2 between 2008-2012 and no prior renal replacement therapy, cancer, cirrhosis or organ transplant. We identified patients who initiated chronic dialysis through 2013 and matched patients who did not initiate dialysis on age, gender, diabetes status, being alive on dialysis initiation date, and a high-dimensional propensity score for starting dialysis. Deaths were identified through 2013. We used Cox regression to evaluate the association of chronic dialysis and all-cause death. RESULTS Among 348 adults with HF and advanced CKD who initiated dialysis and 947 matched patients who did not start dialysis, mean age was 80±5 years, 51% were women and 33% were Black. The crude rate of death was high overall but lower in those initiating vs. not initiating chronic dialysis (26.1 vs. 32.1 per 100 person-years, respectively, P = 0.02). In multivariable analysis, dialysis was associated with a 33% (95% Confidence Interval:17-46%) lower adjusted rate of death compared with not initiating dialysis. CONCLUSIONS Among older adults with HF and advanced CKD, dialysis initiation was associated with lower mortality, but absolute rates of death were very high in both groups. Randomized trials should evaluate net outcomes of dialysis vs. conservative management on length and quality of life in this high-risk population.
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Affiliation(s)
- Sijie Zheng
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, CA, United States of America
- Department of Medicine, University of California, San Francisco, CA, United States of America
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Thida C. Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Sharina Belani
- Department of Nephrology, Kaiser Permanente San Rafael Medical Center, San Rafael, CA, United States of America
| | - David Law
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, CA, United States of America
| | - Leonid V. Pravoverov
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, CA, United States of America
| | - Susan S. Kim
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Alan S. Go
- Department of Medicine, University of California, San Francisco, CA, United States of America
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
- Department of Health System Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America
- Departments of Epidemiology and Biostatistics, University of California, San Francisco, CA, United States of America
- Departments of Medicine, Health Research and Policy, Stanford University School of Medicine, Palo Alto, CA, United States of America
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12
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Voorend CGN, van Oevelen M, Verberne WR, van den Wittenboer ID, Dekkers OM, Dekker F, Abrahams AC, van Buren M, Mooijaart SP, Bos WJW. OUP accepted manuscript. Nephrol Dial Transplant 2022; 37:1529-1544. [PMID: 35195249 PMCID: PMC9317173 DOI: 10.1093/ndt/gfac010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background Non-dialytic conservative care (CC) has been proposed as a treatment option for patients with kidney failure. This systematic review and meta-analysis aims at comparing survival outcomes between dialysis and CC in studies where patients made an explicit treatment choice. Methods Five databases were systematically searched from origin through 25 February 2021 for studies comparing survival outcomes among patients choosing dialysis versus CC. Adjusted and unadjusted survival rates were extracted and meta-analysis performed where applicable. Risk of bias analysis was performed according to the Cochrane Risk Of Bias In Non-randomized Studies of Interventions. Results A total of 22 cohort studies were included covering 21 344 patients. Most studies were prone to selection bias and confounding. Patients opting for dialysis were generally younger and had fewer comorbid conditions, fewer functional impairments and less frailty than patients who chose CC. The unadjusted median survival from treatment decision or an estimated glomerular filtration rate <15 mL/min/1.73 m2 ranged from 20 and 67 months for dialysis and 6 and 31 months for CC. Meta-analysis of 12 studies that provided adjusted hazard ratios (HRs) for mortality showed a pooled adjusted HR of 0.47 (95% confidence interval 0.39–0.57) for patients choosing dialysis compared with CC. In subgroups of patients with older age or severe comorbidities, the reduction of mortality risk remained statistically significant, although analyses were unadjusted. Conclusions Patients opting for dialysis have an overall lower mortality risk compared with patients opting for CC. However, a high risk of bias and heterogeneous reporting preclude definitive conclusions and results cannot be translated to an individual level.
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Affiliation(s)
| | | | - Wouter R Verberne
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Friedo Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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13
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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Executive Summary of the Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment. Kidney Res Clin Pract 2021; 40:578-595. [PMID: 34922430 PMCID: PMC8685366 DOI: 10.23876/j.krcp.21.700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 12/17/2022] Open
Abstract
The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists’ support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient’s condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There is also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).
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Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans College of Medicine, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Tae-Jin Park
- Asan Jin Internal Medicine Clinic, Seoul, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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14
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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment. Kidney Res Clin Pract 2021; 40:S1-S37. [PMID: 34923803 PMCID: PMC8694695 DOI: 10.23876/j.krcp.21.600] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 01/06/2023] Open
Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans College of Medicine, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Tae-Jin Park
- Asan Jin Internal Medicine Clinic, Seoul, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - for the Korean Society of Nephrology Clinical Practice Guideline Work Group
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans College of Medicine, Seoul, Republic of Korea
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
- Asan Jin Internal Medicine Clinic, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
- Truewords Dialysis Clinic, Incheon, Republic of Korea
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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15
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Hecking M, Tu C, Zee J, Bieber B, Hödlmoser S, Reichel H, Sesso R, Port FK, Robinson BM, Carrero JJ, Tong A, Combe C, Stengel B, Pecoits-Filho R. Sex-Specific Differences in Mortality and Incident Dialysis in the Chronic Kidney Disease Outcomes and Practice Patterns Study. Kidney Int Rep 2021; 7:410-423. [PMID: 35257054 PMCID: PMC8897674 DOI: 10.1016/j.ekir.2021.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/18/2021] [Accepted: 11/15/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction More men than women start kidney replacement therapy (KRT) although the prevalence of chronic kidney disease (CKD) is higher in women than men. We therefore aimed at analyzing sex-specific differences in clinical outcomes among 8237 individuals with CKD in stages 3 to 5 from Brazil, France, Germany, and the United States participating in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps). Methods Fine and Gray models, evaluating the effect of sex on time to events, were adjusted for age, Black race (model A); plus diabetes, cardiovascular disease, albuminuria (model B); plus estimated glomerular filtration rate (eGFR) slope during the first 12 months after enrollment and first eGFR after enrollment (model C). Results There were more men than women at baseline (58% vs. 42%), men were younger than women, and men had higher eGFR (28.9 ± 11.5 vs. 27.0 ± 10.8 ml/min per 1.73 m2). Over a median follow-up of 2.7 and 2.5 years for men and women, respectively, the crude dialysis initiation and pre-emptive transplantation rates were higher in men whereas that of pre-KRT death was more similar. The adjusted subdistribution hazard ratios (SHRs) between men versus women for dialysis were 1.51 (1.27–1.80) (model A), 1.32 (1.10–1.59) (model B), and 1.50 (1.25–1.80) (model C); for pre-KRT death, were 1.25 (1.02–1.54) (model A), 1.14 (0.92–1.40) (model B), and 1.15 (0.93–1.42) (model C); for transplantation, were 1.31 (0.73–2.36) (model A), 1.44 (0.76–2.74) (model B), and 1.53 (0.79–2.94) (model C). Conclusion Men had a higher probability of commencing dialysis before death, unexplained by CKD progression alone. Although the causal mechanisms are uncertain, this finding helps interpret the preponderance of men in the dialysis population.
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16
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Engelbrecht BL, Kristian MJ, Inge E, Elizabeth K, Guldager LT, Helbo TL, Jeanette F. Does conservative kidney management offer a quantity or quality of life benefit compared to dialysis? A systematic review. BMC Nephrol 2021; 22:307. [PMID: 34507554 PMCID: PMC8434727 DOI: 10.1186/s12882-021-02516-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background Patients with stage 5 chronic kidney disease (CKD5) collaborate with their clinicians when choosing their future treatment modality. Most elderly patients with CKD5 may only have two treatment options: dialysis or conservative kidney management (CKM). The objective of this systematic review was to investigate whether CKM offers a quantity or quality of life benefit compared to dialysis for some patients with CKD5. Methods The databases MEDLINE, EMBASE, the Cochrane Library, and CINAHL were systematically searched for studies comparing patients with CKD5 who had chosen or were treated with either CKM or dialysis. The primary outcomes were mortality and quality of life (QoL). Hospitalization, symptom burden, and place of death were secondary outcomes. For studies reporting hazard ratios, pooled values were calculated, and forest plots conducted. Results Twenty-five primary studies, all observational, were identified. All studies reported an increased mortality in patients treated with CKM (pooled hazard ratio 0.47, 95 % confidence interval 0.34–0.65). For patients aged ≥ 80 years and for elderly individuals with comorbidities, results were ambiguous. In most studies, CKM seemed advantageous for QoL and secondary outcomes. Findings were limited by the heterogeneity of studies and biased outcomes favouring dialysis. Conclusions In general, patients with CKD5 who have chosen or are on CKM live for a shorter time than patients who have chosen or are on dialysis. In patients aged ≥ 80 years old, and in elderly individuals with comorbidities, the survival benefits of dialysis seem to be lost. Regarding QoL, symptom burden, hospitalization, and place of death, CKM may have advantages. Higher quality studies are needed to guide patients and clinicians in the decision-making process. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02516-6.
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Affiliation(s)
- Buur Louise Engelbrecht
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Madsen Jens Kristian
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Eidemak Inge
- Department of Palliative Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Krarup Elizabeth
- Department of Renal Medicine, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | | | - Finderup Jeanette
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark. .,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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17
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Kalantar-Zadeh K, Jafar TH, Nitsch D, Neuen BL, Perkovic V. Chronic kidney disease. Lancet 2021; 398:786-802. [PMID: 34175022 DOI: 10.1016/s0140-6736(21)00519-5] [Citation(s) in RCA: 511] [Impact Index Per Article: 170.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA.
| | - Tazeen H Jafar
- Duke-NUS Graduate Medical School, Singapore; Department of Renal Medicine, Singapore General Hospital, Singapore; Duke Global Health Institute, Durham, NC, USA
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; United Kingdom Renal Registry, Bristol, UK; Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales Sydney, Sydney, NSW, Australia
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18
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Buades JM, Craver L, Del Pino MD, Prieto-Velasco M, Ruiz JC, Salgueira M, de Sequera P, Vega N. Management of Kidney Failure in Patients with Diabetes Mellitus: What Are the Best Options? J Clin Med 2021; 10:2943. [PMID: 34209083 PMCID: PMC8268456 DOI: 10.3390/jcm10132943] [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: 05/23/2021] [Revised: 06/22/2021] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
Diabetic kidney disease (DKD) is the most frequent cause of kidney failure (KF). There are large variations in the incidence rates of kidney replacement therapy (KRT). Late referral to nephrology services has been associated with an increased risk of adverse outcomes. In many countries, when patients reach severely reduced glomerular filtration rate (GFR), they are managed by multidisciplinary teams led by nephrologists. In these clinics, efforts will continue to halt chronic kidney disease (CKD) progression and to prevent cardiovascular mortality and morbidity. In patients with diabetes and severely reduced GFR and KF, treating hyperglycemia is a challenge, since some drugs are contraindicated and most of them require dose adjustments. Even more, a decision-making process will help in deciding whether the patient would prefer comprehensive conservative care or KRT. On many occasions, this decision will be conditioned by diabetes mellitus itself. Effective education should cover the necessary information for the patient and family to answer these questions: 1. Should I go for KRT or not? 2. If the answer is KRT, dialysis and/or transplantation? 3. Dialysis at home or in center? 4. If dialysis at home, peritoneal dialysis or home hemodialysis? 5. If transplantation is desired, discuss the options of whether the donation would be from a living or deceased donor. This review addresses the determinant factors with an impact on DKD, aiming to shed light on the specific needs that arise in the management and recommendations on how to achieve a comprehensive approach to the diabetic patient with chronic kidney disease.
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Affiliation(s)
- Juan M. Buades
- Department of Nephrology, Hospital Universitario Son Llàtzer, Balearic Islands, 07198 Palma de Mallorca, Spain
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma de Mallorca, Spain
| | - Lourdes Craver
- Department of Nephrology, Hospital Universitario Arnau de Vilanova, 25198 Lleida, Spain;
| | - Maria Dolores Del Pino
- Department of Nephrology, Complejo Hospitalario Torrecárdenas de Almería, 04009 Almería, Spain;
| | - Mario Prieto-Velasco
- Department of Nephrology, Complejo Asistencial Universitario de Leon, 24001 León, Spain;
| | - Juan C. Ruiz
- Department of Nephrology, Valdecilla Hospital, University of Cantabria, 39008 Santander, Spain;
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain
| | - Mercedes Salgueira
- Department of Nephrology, Hospital Universitario Virgen Macarena, 41009 Seville, Spain;
- Biomedical Engineering Group, Medicine Department, University of Seville, 41092 Seville, Spain
- Center for Biomedical Research Network in Bioengineering Biomaterials and Nanomedicina (CIBER-BBN), 28029 Madrid, Spain
| | - Patricia de Sequera
- Department of Nephrology, Hospital Universitario Infanta Leonor, 28031 Madrid, Spain;
- Medicine Department, Universidad Complutense de Madrid, 28031 Madrid, Spain
| | - Nicanor Vega
- Department of Nephrology, Hospital Universitario de Gran Canaria Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain;
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Prouvot J, Pambrun E, Couchoud C, Vigneau C, Roche S, Allot V, Potier J, Francois M, Babici D, Prelipcean C, Moranne O. Low performance of prognostic tools for predicting dialysis in elderly people with advanced CKD. J Nephrol 2021; 34:1201-1213. [PMID: 33394346 DOI: 10.1007/s40620-020-00919-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/13/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Clinical decision-making about care plans can be difficult for very elderly people with advanced chronic kidney disease (CKD). Current guidelines propose the use of prognostic tools predicting end stage renal disease (ESRD) to assist in a patient-centered shared decision-making approach. Our objective was to evaluate the existing risk model scores predicting ESRD, from data collected for a French prospective multicenter cohort of mainly octogenarians with advanced CKD. METHODS We performed a rapid review to identify the risk model scores predicting ESRD developed from CKD patient cohorts and evaluated them with data from a prospective multicenter French cohort of elderly (> 75 years) patients with advanced CKD (estimated glomerular filtration rate [eGFR] < 20 mL/min/1.75m2), followed up for 5 years. We evaluated these scores (in absolute risk) for discrimination, calibration and the Brier score. For scores using the same time frame, we made a joint calibration curve and compared areas under the curve (AUCs). RESULTS The PSPA cohort included 573 patients; their mean age was 83 years and their median eGFR was 13 mL/min/1.73 m2. At the end of follow-up, 414 had died and 287 had started renal replacement therapy (RRT). Our rapid review found 12 scores that predicted renal replacement therapy. Five were evaluated: the TANGRI 4-variable, DRAWZ, MARKS, GRAMS, and LANDRAY scores. No score performed well in the PSPA cohort: AUCs ranged from 0.57 to 0.65, and Briers scores from 0.18 to 0.25. CONCLUSIONS The low predictiveness for ESRD of the scores tested in a cohort of octogenarian patients with advanced CKD underlines the need to develop new tools for this population.
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Affiliation(s)
- Julien Prouvot
- EA2415, Université de Montpellier, Montpellier, France.,Service de Nephrologie, Dialyse et Apherese, Hôpital Universitaire de Caremeau, Nimes, France
| | - Emilie Pambrun
- Service de Nephrologie, Dialyse et Apherese, Hôpital Universitaire de Caremeau, Nimes, France
| | - Cecile Couchoud
- Registre REIN, Agence de la Biomedecine, Saint-Denis La Plaine, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, Villeurbanne, France
| | - Cecile Vigneau
- CHU Pontchaillou, Service de Néphrologie-Dialyse-Transplantation, Université Rennes 1, IRSET 1085, Rennes, France
| | - Sophie Roche
- Service de Néphrologie-Dialyse, CH Macon, Macon, France
| | - Vincent Allot
- CHU Limoges, Service de Néphrologie, Dialyse, Transplantation, Limoges, France
| | - Jerome Potier
- Service de Néphrologie-Dialyse, CH St Brieuc, Saint Brieuc, France
| | - Maud Francois
- CHU Tours, Service de Néphrologie-Dialyse-Transplantation, Tours, France
| | - Daniela Babici
- Hôpital Emile Muller, Service Néphrologie-Dialyse, GHR MSA, Mulhouse, France
| | - Camelia Prelipcean
- Service de Nephrologie, Dialyse et Apherese, Hôpital Universitaire de Caremeau, Nimes, France
| | - Olivier Moranne
- EA2415, Université de Montpellier, Montpellier, France. .,Service de Nephrologie, Dialyse et Apherese, Hôpital Universitaire de Caremeau, Nimes, France.
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Sprangers B, Van der Veen A, Hamaker ME, Rostoft S, Latcha S, Lichtman SM, de Moor B, Wildiers H. Initiation and termination of dialysis in older patients with advanced cancer: providing guidance in a complicated situation. THE LANCET. HEALTHY LONGEVITY 2021; 2:e42-e52. [DOI: 10.1016/s2666-7568(20)30060-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/09/2020] [Accepted: 11/23/2020] [Indexed: 01/19/2023] Open
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21
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Zarantonello D, Rhee CM, Kalantar-Zadeh K, Brunori G. Novel conservative management of chronic kidney disease via dialysis-free interventions. Curr Opin Nephrol Hypertens 2021; 30:97-107. [PMID: 33186220 DOI: 10.1097/mnh.0000000000000670] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW In advanced chronic kidney disease (CKD) patients with progressive uremia, dialysis has traditionally been the dominant treatment paradigm. However, there is increasing interest in conservative and preservative management of kidney function as alternative patient-centered treatment approaches in this population. RECENT FINDINGS The primary objectives of conservative nondialytic management include optimization of quality of life and treating symptoms of end-stage renal disease (ESRD). Dietetic-nutritional therapy can be a cornerstone in the conservative management of CKD by reducing glomerular hyperfiltration, uremic toxin generation, metabolic acidosis, and phosphorus burden. Given the high symptom burden of advanced CKD patients, routine symptom assessment using validated tools should be an integral component of their treatment. As dialysis has variable effects in ameliorating symptoms, palliative care may be needed to manage symptoms such as pain, fatigue/lethargy, anorexia, and anxiety/depression. There are also emerging treatments that utilize intestinal (e.g., diarrhea induction, colonic dialysis, oral sorbents, gut microbiota modulation) and dermatologic pathways (e.g., perspiration reduction) to reduce uremic toxin burden. SUMMARY As dialysis may not confer better survival nor improved patient-centered outcomes in certain patients, conservative management is a viable treatment option in the advanced CKD population.
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Affiliation(s)
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
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22
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Burns RB, Waikar SS, Wachterman MW, Kanjee Z. Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2020; 173:217-225. [PMID: 32745449 PMCID: PMC10585656 DOI: 10.7326/m20-2640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
About 15% of adults in the United States-37 million persons-have chronic kidney disease (CKD). Chronic kidney disease is divided into 5 groups, ranging from stage 1 to stage 5 CKD, whereas end-stage kidney disease (ESKD) is defined as permanent kidney failure. The treatment options for ESKD are kidney replacement therapy (KRT) and conservative management. The options for KRT include hemodialysis (either in-center or at home), peritoneal dialysis, and kidney transplant. Conservative management, a multidisciplinary model of care for patients with stage 5 CKD who want to avoid dialysis, is guided by patient values, preferences, and goals, with a focus on quality of life and symptom management. In 2015, the Kidney Disease Outcomes Quality Initiative recommended that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both KRT and conservative management. In 2018, the National Institute for Health and Care Excellence recommended that assessment for KRT or conservative management start at least 1 year before the need for therapy. It also recommended that in choosing a management approach, predicted quality of life, predicted life expectancy, patient preferences, and other patient factors be considered, because little difference in outcomes has been found among options. Here, 2 experts-a nephrologist and a general internist-palliative care physician-reflect on the care of a patient with advanced CKD and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among the options.
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Affiliation(s)
- Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
| | - Sushrut S Waikar
- Boston University Medical Center, Boston, Massachusetts (S.S.W.)
| | | | - Zahir Kanjee
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
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Farrington C, Lee TC. The New Age of Vascular Access: Choosing the Right Access for the Right Reason in Older Hemodialysis Patients. Am J Kidney Dis 2020; 76:457-459. [PMID: 32712015 DOI: 10.1053/j.ajkd.2020.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 03/30/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Crystal Farrington
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Timmy C Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Division of Nephrology, Veterans Affairs Medical Center, Birmingham, AL.
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24
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Hall RK, Rutledge J, Luciano A, Hall K, Pieper CF, Colón-Emeric C. Physical Function Assessment in Older Hemodialysis Patients. Kidney Med 2020; 2:425-431. [PMID: 32775982 PMCID: PMC7406854 DOI: 10.1016/j.xkme.2020.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
RATIONALE & OBJECTIVE Physical function is not routinely measured in older adults receiving dialysis. We evaluated the appropriateness of repeated measurements of physical function, including Short Physical Performance Battery (SPPB), handgrip strength, and activities of daily living (ADLs), in older adults receiving dialysis. STUDY DESIGN Prospective study. SETTING & PARTICIPANTS 37 community-dwelling adults 65 years and older receiving in-center hemodialysis at 5 dialysis units located in North Carolina. EXPOSURES SPPB (an assessment of standing balance, chair stands, and gait speed), handgrip strength, and Katz and Lawton ADLs at baseline and subsequent 3-month intervals up to 6 months. OUTCOMES Completion rate, presence of floor or ceiling effects, and presence of clinically meaningful change in physical function measurements. RESULTS Of 55 potential participants, we enrolled 37 (67%) older adults receiving hemodialysis. Among 35 enrolled participants who completed baseline assessment in a dialysis unit, mean age was 70.1 (SD, 5) years, 46% (n = 16) were women, 77% (n = 27) were African American, and median time receiving dialysis was 2.7 (IQR, 0.6-5.0) years. There were 3 deaths within the observation period, and study retention at 3 and 6 months was 83% (n = 29) and 74% (n = 26), respectively. Participants tolerated measurements; only 2 participants did not attempt 1 of the performance-based tests at a study visit. Baseline median SPPB score, grip strength, and gait speed were 6 (IQR, 4-9), 55 (IQR, 42-70) kg, and 0.76 (IQR, 0.46-0.86) m/s, respectively. Baseline median for Katz and Lawton ADLs were 6 (IQR, 6-6) and 7 (IQR, 4-8), respectively; ceiling effects were observed for both measures. For some participants, clinically meaningful changes (improvement or decline) in SPPB score, grip strength, and gait speed occurred at each 3-month interval. LIMITATIONS Limited geographic and ethnic variation. CONCLUSIONS SPPB, handgrip strength, and gait speed alone are appropriate measures for interval physical function assessment in community-dwelling older adults receiving in-center hemodialysis.
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Affiliation(s)
- Rasheeda K. Hall
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, NC
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
| | - Jeanette Rutledge
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC
| | - Alison Luciano
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
| | - Katherine Hall
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Division of Geriatric Medicine, Department of Medicine, Duke University, Durham, NC
| | - Carl F. Pieper
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Cathleen Colón-Emeric
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Division of Geriatric Medicine, Department of Medicine, Duke University, Durham, NC
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25
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Duarte I, Gameiro J, Resina C, Outerelo C. In-hospital mortality in elderly patients with acute kidney injury requiring dialysis: a cohort analysis. Int Urol Nephrol 2020; 52:1117-1124. [PMID: 32372303 DOI: 10.1007/s11255-020-02482-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/21/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine risk factors for in-hospital mortality in elderly patients with acute kidney injury (AKI) requiring dialysis. INTRODUCTION AKI requiring dialysis is frequent in elderly and is associated with an increased intra-hospital mortality. With the growing number of older individuals among hospitalized patients with AKI demands a thorough investigation of the factors that contribute to their mortality to improve outcomes. METHODS We performed a retrospective analysis of patients older than 80 years, admitted due to AKI requiring dialysis between January 2016 and December 2017. Patients who need intensive-care units (ICU) admission were excluded. The primary outcome was all-cause in-hospital mortality. RESULTS A total of 154 patients were evaluated. The mean age was 85.3 ± 4.0 years and 76 patients (49.4%) were male. The overall mortality rate was 26.6%. On the multivariate analysis, serum albumin (OR 0.42 [95% CI 0.21-0.85], p 0.016), C reactive protein/albumin ratio (OR 1.04 [95% CI 0.99-1.09], and renal function recovery (OR 018 [95% CI 0.49-0.65], p 0.009) were the factors associated with higher in-hospital mortality. CONCLUSIONS Lower albumin level, higher C reactive protein/albumin ratio at admission, and absence of renal function recovery are associated with increased in-hospital mortality's risk in elderly with acute kidney injury requiring dialysis.
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Affiliation(s)
- Inês Duarte
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.
| | - Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Cristina Resina
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Cristina Outerelo
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
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26
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Sheshadri A, Cullaro G, Johansen KL, Lai JC. Association of Karnofsky Performance Status with waitlist mortality among older and younger adults awaiting kidney transplantation. Clin Transplant 2020; 34:e13848. [PMID: 32112458 PMCID: PMC10123007 DOI: 10.1111/ctr.13848] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 12/20/2022]
Abstract
Patients with end-stage renal disease (ESRD) have impaired functional status compared with the general population. We sought to explore the association between Karnofsky Performance Status (KPS) and death/delisting from the kidney transplantation waitlist and whether this association differed by age. Patients listed for single-organ kidney transplantation in the United Network for Organ Sharing/Organ Procurement and Transplantation Network from January 1, 2015, to January 1, 2018, were included. We performed competing-risk regression analyses to determine the association between KPS ("Severely impaired", "Moderately impaired", "Non-impaired") and death/delisting, with deceased-donor kidney transplantation as a competing risk. We tested for interactions between age and KPS on death/delisting. Of the 89,819 patients analyzed, 39% were impaired (KPS < 80) and 20% were aged ≥ 65 years. Older age and lower KPS were independently associated with higher risk of death/delisting (age 45-64 years, HR 1.97 [95% CI 1.73-2.24]; age ≥ 65 years, HR 3.62 [95% CI 3.33-3.92] compared with age < 45 years; moderately impaired, HR 1.68 [95% CI 1.45-1.95]; severely impaired, HR 4.80 [95% CI 3.71-6.21] compared with non-impaired). Lower KPS was associated with higher risk of death/delisting among all ages, but this effect was slightly less pronounced among individuals aged ≥ 65 years. Performance status should be used when counseling patients with ESRD on their risks for death/delisting.
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Affiliation(s)
- Anoop Sheshadri
- Division of Nephrology Department of Medicine University of California San Francisco California USA
- San Francisco Veterans Affairs Medical Center San Francisco California USA
| | - Giuseppe Cullaro
- Division of Gastroenterology/Hepatology Department of Medicine University of California San Francisco California USA
| | - Kirsten L. Johansen
- Division of Nephrology Hennepin County Medical Center Minneapolis Minnesota USA
- Division of Nephrology University of Minnesota Minneapolis Minnesota USA
| | - Jennifer C. Lai
- Division of Gastroenterology/Hepatology Department of Medicine University of California San Francisco California USA
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Schmidt RJ, Landry DL, Cohen L, Moss AH, Dalton C, Nathanson BH, Germain MJ. Derivation and validation of a prognostic model to predict mortality in patients with advanced chronic kidney disease. Nephrol Dial Transplant 2020; 34:1517-1525. [PMID: 30395311 DOI: 10.1093/ndt/gfy305] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Guiding patients with advanced chronic kidney disease (CKD) through advance care planning about future treatment obliges an assessment of prognosis. A patient-specific integrated model to predict mortality could inform shared decision-making for patients with CKD. METHODS Patients with Stages 4 and 5 CKD from Massachusetts (749) and West Virginia (437) were prospectively evaluated for clinical parameters, functional status [Karnofsky Performance Score (KPS)] and their provider's response to the Surprise Question (SQ). A predictive model for 12-month mortality was derived with the Massachusetts cohort and then validated externally on the West Virginia cohort. Logistic regression was used to create the model, and the c-statistic and Hosmer-Lemeshow statistic were used to assess model discrimination and calibration, respectively. RESULTS In the derivation cohort, the SQ, KPS and age were most predictive of 12-month mortality with odds ratios (ORs) [95% confidence interval (CI)] of 3.29 (1.87-5.78) for a 'No' response to the SQ, 2.09 (95% CI 1.19-3.66) for fair KPS and 1.41 (95% CI 1.15-1.74) per 10-year increase in age. The c-statistic for the 12-month mortality model for the derivation cohort was 0.80 (95% CI 0.75-0.84) and for the validation cohort was 0.74 (95% CI 0.66-0.83). CONCLUSIONS Our integrated prognostic model for 12-month mortality in patients with advanced CKD had good discrimination and calibration. This model provides prognostic information to aid nephrologists in identifying and counseling advanced CKD patients with poor prognosis who are facing the decision to initiate dialysis or pursue medical management without dialysis.
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Affiliation(s)
- Rebecca J Schmidt
- Department of Medicine, Sections of Nephrology and Supportive Care, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Daniel L Landry
- Division of Nephrology, Baystate Medical Center, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Lewis Cohen
- Department of Psychiatry, Baystate Medical Center, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Alvin H Moss
- Department of Medicine, Sections of Nephrology and Supportive Care, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Cheryl Dalton
- Department of Medicine, Sections of Nephrology and Supportive Care, West Virginia University School of Medicine, Morgantown, WV, USA
| | | | - Michael J Germain
- Division of Nephrology, Baystate Medical Center, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
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Han Q, Zhang D, Zhao Y, Liu L, Li J, Zhang F, Luan F, Duan J, Liu Z, Cai G, Chen X, Zhu H. The practicality of different eGFR equations in centenarians and near-centenarians: which equation should we choose? PeerJ 2020; 8:e8636. [PMID: 32117641 PMCID: PMC7039118 DOI: 10.7717/peerj.8636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 01/26/2020] [Indexed: 11/20/2022] Open
Abstract
Background No studies have examined the practicality of the Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiological Collaboration (CKD-EPI) and Berlin Initiative Study 1 (BIS1) equations for the estimated glomerular filtration rate (eGFR) in a large sample of centenarians. We aim to investigate the differences among the equations and suggest the most suitable equation for centenarians and near-centenarians. Methods A total of 966 centenarians and 787 near-centenarians were enrolled, and the eGFR was calculated using the three equations mentioned above. Agreement among the equations was investigated with the κ statistic and Bland-Altman plots. Sources of discrepancy were investigated using a partial correlation analysis. Results The three equations for assessing eGFR are not considered interchangeable in centenarians and near-centenarians. Δ(MDRD, CKD-EPI) and Δ(MDRD, BIS1) increased with age, but Δ(CKD-EPI, BIS1) was relatively stable with age. Δ(MDRD, CKD-EPI) and Δ(MDRD, BIS1) were considerable in subjects with Scr levels less than 0.7 mg/dL and decreased with the Scr level. A considerable difference between CKD-EPI and BIS1 was observed for participants with Scr levels ranging from 0.5 to 1.5 mg/dL. This difference increased with Scr levels ranging from 0.5 to 0.7 mg/dL, was relatively stable for Scr levels ranging from 0.7 to 0.9 mg/dL, and decreased with Scr levels ranging from 0.9 to 1.5 mg/dL. The differences in the three comparisons were all greater in women than in men (p < 0.05). Conclusions We tend to suggest the MDRD equation to calculate the glomerular filtration rate (GFR) in elderly individuals >95 years old who have no risk factors for cardiovascular disease; the BIS1 equation to calculate the eGFR for elderly individuals younger than 94 years old who have risk factors for cardiovascular disease; the CKD-EPI equation to calculate the eGFR of elderly individuals with Scr levels greater than 1.5 mg/dL; and the BIS1 equation to calculate the eGFR of older women with Scr levels less than 0.7 mg/dL.
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Affiliation(s)
- Qiuxia Han
- Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, China.,School of Medicine, Nankai University, Tianjin, China.,The First Affiliated Hospital of Zhengzhou University, Research Institute of Nephrology of Zhengzhou University, Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China
| | - Dong Zhang
- Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, China
| | - Yali Zhao
- Central Laboratory, Hainan Branch of Chinese PLA General Hospital, Sanya, China
| | - Liang Liu
- Management Department, Hainan Branch of Chinese PLA General Hospital, Sanya, China
| | - Jing Li
- Management Department, Hainan Branch of Chinese PLA General Hospital, Sanya, China
| | - Fu Zhang
- Management Department, Hainan Branch of Chinese PLA General Hospital, Sanya, China
| | - Fuxin Luan
- Management Department, Hainan Branch of Chinese PLA General Hospital, Sanya, China
| | - Jiayu Duan
- The First Affiliated Hospital of Zhengzhou University, Research Institute of Nephrology of Zhengzhou University, Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China
| | - Zhangsuo Liu
- The First Affiliated Hospital of Zhengzhou University, Research Institute of Nephrology of Zhengzhou University, Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China
| | - Guangyan Cai
- Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, China.,School of Medicine, Nankai University, Tianjin, China
| | - Xiangmei Chen
- Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, China.,School of Medicine, Nankai University, Tianjin, China
| | - Hanyu Zhu
- Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, China
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Povlsen JV, Ivarsen P. Assisted Automated Peritoneal Dialysis (Aapd) for the Functionally Dependent and Elderly Patient. Perit Dial Int 2020. [DOI: 10.1177/089686080502503s15] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
♦ Objective To describe basic demographics and clinical outcomes among elderly end-stage renal disease (ESRD) patients physically dependent on a caregiver and maintained on an assisted automated peritoneal dialysis (AAPD) program. ♦ Design Retrospective single-center study based on patient records and data files. ♦ Setting University Hospital. ♦ Patients 64 physically dependent AAPD patients followed for 1.012 treatment months. Assistance and care was delivered by 52 briefly trained teams of visiting nurses or nursing home staff. ♦ Result Crude 1-year survival was 58% and 2-year survival was 48%. Crude 1- and 2-year survivals, excluding deaths within 90 days, were 66% and 54% respectively. We found no significant effect on survival by main causes of ESRD, gender, age, late referral, need for acute start, social isolation, physical dependency on help at inclusion, or residence in a nursing home. 10% of patient-days on AAPD were spent in hospital. 13 (20%) of the patients were converted permanently to hemodialysis due to PD technique failure. The incidence of peritonitis was 1 in every 25.3 treatment-months. ♦ Conclusions AAPD may be a feasible and safe option for renal replacement therapy for frail, elderly, and physically dependent patients with ESRD. Despite the special patient selection for this AAPD program, we achieved results of international standards for patient survival, PD technique survival, and incidence of acute peritonitis. These results do not justify withholding dialysis from this group of patients.
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Affiliation(s)
- Johan V. Povlsen
- Department of Renal Medicine C, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark
| | - Per Ivarsen
- Department of Renal Medicine C, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark
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Lobbedez T, Moldovan R, Lecame M, de Ligny BH, Haggan WE, Ryckelynck JP. Assisted Peritoneal Dialysis. Experience in a French Renal Department. Perit Dial Int 2020. [DOI: 10.1177/089686080602600611] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BackgroundThe French healthcare system offers the possibility of increasing the use of peritoneal dialysis (PD) by involving in patient care nurses who work in the private system.ObjectiveThis study was conducted to evaluate the impact of a private home-nurse network on one dialysis program.MethodsThis was a retrospective study of 239 dialysis patients who started dialysis in our center between 1 January 1998 and 31 December 2003.ResultsOf these 239 patients, 142 were treated with hemodialysis and 97 with PD during the study period. Among the PD patients, 36 of 97 were treated with assisted PD and 61 of 97 with self-care PD. Assisted-PD patients were older (74 ± 10 vs 52 ± 18 years, p < 0.001) and presented more comorbidity (Charlson Comorbidity Index 7 ± 2.5 vs 4.3 ± 2.4, p < 0.05) compared with self-care patients. Continuous ambulatory PD was the modality of choice in the assisted group (32/36). Assisted patients were frequently hospitalized (31/36); actuarial survival free of hospitalization at 6 months was 46%. Patients with nurse assistance had a high risk of peritonitis (actuarial survival free of peritonitis: 52% at 1 year). Technique survival was 85% at 6 months and 58% at 1 year. Actuarial patient survival was 90% at 6 months and 83% at 1 year.ConclusionAssisted PD enables increased use of PD in incident dialysis patients. However, in view of the comorbidities of the assisted-PD patients, the need for frequent hospitalization has to be taken into account in such a program.
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Affiliation(s)
| | | | - Marie Lecame
- Nephrology Department, CHU Clemenceau, Caen, France
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Ma X, Shi Y, Tao M, Jiang X, Wang Y, Zang X, Fang L, Jiang W, Du L, Jin D, Zhuang S, Liu N. Analysis of risk factors and outcome in peritoneal dialysis patients with early-onset peritonitis: a multicentre, retrospective cohort study. BMJ Open 2020; 10:e029949. [PMID: 32060152 PMCID: PMC7045164 DOI: 10.1136/bmjopen-2019-029949] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To investigate the risk factors associated with early-onset peritonitis (EOP) and their influence on patients' technique survival and mortality. STUDY DESIGN Retrospective, cohort study. SETTING Three peritoneal dialysis (PD) units in Shanghai. PARTICIPANTS PD patients from 1 June 2006 to 1 May 2018 were recruited and followed up until 31 December 2018. According to time-to-first episode of peritonitis, patients were divided into non-peritonitis (n=144), EOP (≤6 months, n=74) and late-onset peritonitis (LOP) (>6 months, n=139). PRIMARY AND SECONDARY OUTCOME MEASURES EOP was defined as the first episode of peritonitis occurring within 6 months after the initiation of PD. The outcomes were all-cause mortality and technique failure. RESULTS Of the 357 patients, 74 (20.7%) patients developed their first episode of peritonitis within the first 6 months. Compared with the LOP group, the EOP group had older ages, more female patients, higher Charlson Comorbidity Index (CCI) score, lower serum albumin levels and renal function at the time of initiation of PD, and higher diabetes mellitus and peritonitis rates (p<0.05). Staphylococcus was the most common Gram-positive organism in both EOP and LOP groups. The multivariate logistic regression analysis showed that factors associated with EOP included a higher CCI score (OR 1.285, p=0.011), lower serum albumin level (OR 0.924, p=0.016) and lower Kt/V (OR 0.600, p=0.018) at start of PD. In the Cox proportional-hazards model, EOP was more likely a predictor of technique failure (HR 1.801, p=0.051). There was no difference between EOP and LOP for all-cause mortality. CONCLUSION A higher CCI score and lower serum albumin level and Kt/V at PD initiation were significantly associated with EOP. EOP also predicted a high peritonitis rate and poor clinical outcome.
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Affiliation(s)
- Xiaoyan Ma
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yingfeng Shi
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Min Tao
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaolu Jiang
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi Wang
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiujuan Zang
- Department of Nephrology, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Lu Fang
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei Jiang
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lin Du
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dewei Jin
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shougang Zhuang
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Na Liu
- Department of Nephrology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Raj R, Thiruvengadam S, Ahuja KDK, Frandsen M, Jose M. Discussions during shared decision-making in older adults with advanced renal disease: a scoping review. BMJ Open 2019; 9:e031427. [PMID: 31767590 PMCID: PMC6887047 DOI: 10.1136/bmjopen-2019-031427] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES This review summarises the information available for clinicians counselling older patients with kidney failure about treatment options, focusing on prognosis, quality of life, the lived experiences of treatment and the information needs of older adults. DESIGN We followed the Joanna Briggs Institute Methodology for Scoping Reviews. The final report conforms to the PRISMA-ScR guidelines. DATA SOURCES PubMed, PsycINFO, CINAHL, Embase, Scopus, Web of Science, TRIP and online repositories (for dissertations, guidelines and recommendations from national renal associations). ELIGIBILITY CRITERIA FOR INCLUSION Articles in English studying older adults with advanced kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m2); published between January 2000 and August 2018. Articles not addressing older patients separately or those comparing between dialysis modalities were excluded. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened articles for inclusion and grouped them by topic as per the objectives above. Quantitative data were presented as tables and charts; qualitative themes were identified and described. RESULTS 248 articles were included after screening 15 445 initial results. We summarised prognostic scores and compared dialysis and non-dialytic care. We highlighted potentially modifiable factors affecting quality of life. From reports of the lived experiences, we documented the effects of symptoms, of ageing, the feelings of disempowerment and the need for adaptation. Exploration of information needs suggested that patients want to participate in decision-making and need information, in simple terms, about survival and non-survival outcomes. CONCLUSION When discussing treatment options, validated prognostic scores are useful. Older patients with multiple comorbidities do not do well with dialysis. The modifiable factors contributing to the low quality of life in this cohort deserve attention. Older patients suffer a high symptom burden and functional deterioration; they have to cope with significant life changes and feelings of disempowerment. They desire greater involvement and more information about illness, symptoms and what to expect with treatment.
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Affiliation(s)
- Rajesh Raj
- Department of Nephrology, Launceston General Hospital, Launceston, Tasmania, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | | | | | - Mai Frandsen
- Faculty of Health, University of Tasmania, Launceston, Tasmania, Australia
| | - Matthew Jose
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
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Wachterman MW, Leveille T, Keating NL, Simon SR, Waikar SS, Bokhour B. Nephrologists' emotional burden regarding decision-making about dialysis initiation in older adults: a qualitative study. BMC Nephrol 2019; 20:385. [PMID: 31651262 PMCID: PMC6814056 DOI: 10.1186/s12882-019-1565-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 09/26/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Conservative management, an approach to treating end-stage kidney disease without dialysis, while generally associated with shorter life expectancy than treatment with dialysis, is associated with fewer hospitalizations, better functional status and, potentially, better quality of life. Conservative management is a well-established treatment approach in a number of Western countries, including the United Kingdom (U.K.). In contrast, despite clinical practice guidelines in the United States (U.S.) recommending that nephrologists discuss all treatment options, including conservative management, with stage 4 and 5 chronic kidney disease patients, studies suggest that this rarely occurs. Therefore, we explored U.S. nephrologists' approaches to decision-making about dialysis and perspectives on conservative management among older adults. METHODS We conducted a qualitative research study. We interviewed 20 nephrologists - 15 from academic centers and 5 from community practices - utilizing a semi-structured interview guide containing open-ended questions. Interview transcripts were analyzed using grounded thematic analysis in which codes were generated inductively and iteratively modified, and themes were identified. Transcripts were coded independently by two investigators, and interviews were conducted until thematic saturation. RESULTS Twenty nephrologists (85% white, 75% male, mean age 50) participated in interviews. We found that decision-making about dialysis initiation in older adults can create emotional burden for nephrologists. We identified four themes that reflected factors that contribute to this emotional burden including nephrologists' perspectives that: 1) uncertainty exists about how a patient will do on dialysis, 2) the alternative to dialysis is death, 3) confronting death is difficult, and 4) patients do not regret initiating dialysis. Three themes revealed different decision-making strategies that nephrologists use to reduce this emotional burden: 1) convincing patients to "just do it" (i.e. dialysis), 2) shifting the decision-making responsibility to patients, and 3) utilizing time-limited trials of dialysis. CONCLUSIONS A decision not to start dialysis and instead pursue conservative management can be emotionally burdensome for nephrologists for a number of reasons including clinical uncertainty about prognosis on dialysis and discomfort with death. Nephrologists' attempts to reduce this burden may be reflected in different decision-making styles - paternalistic, informed, and shared decision-making. Shared decision-making may relieve some of the emotional burden while preserving patient-centered care.
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Affiliation(s)
- Melissa W. Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, 150 South Huntington Ave., Bldg. 9, Boston, MA 02130 USA
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | | | - Nancy L. Keating
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
| | - Steven R. Simon
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, 150 South Huntington Ave., Bldg. 9, Boston, MA 02130 USA
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | - Sushrut S. Waikar
- Harvard Medical School, Boston, MA USA
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Barbara Bokhour
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA USA
- Center for Healthcare Organization and Implementation of Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, MA USA
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Li M, Yan J, Zhang H, Wu Q, Wang J, Liu J, Xing C, Zhou Y. Analysis of outcome and factors correlated with maintenance peritoneal dialysis. J Int Med Res 2019; 47:4683-4690. [PMID: 31446816 PMCID: PMC6833380 DOI: 10.1177/0300060519862091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objectives This study aimed to analyze the outcome and factors correlated with maintenance peritoneal dialysis (PD) to provide guidance for improving prognosis, and prolonging the catheterization and survival times of patients on PD with end-stage renal disease. Methods Clinical data of patients at The Third Xiangya Hospital of Central South University were retrospectively analyzed. We compared the survival and technique survival rates of patients, and analyzed relevant factors. Results A total of 510 cases of PD were included. Two hundred thirty-nine patients continued to receive PD treatment, 73 received kidney transplants, 72 transferred to hemodialysis, and 126 died. The main reasons of death were cardiovascular (27.00%) and cerebrovascular diseases (23.80%). The main reasons of transfer to HD were peritonitis and inadequate dialysis. The survival rates at 1, 2, 3, 5, and 7 years were 95.75%, 90.34%, 82.35%, 66.21%, and 54.32%, respectively. The technique survival rates at 1, 2, 3, 5, and 7 years were 93.22%, 86.76%, 77.91%, 63.16%, and 47.67%, respectively. Female sex and older age were protective factors that affected patients’ withdrawal from PD and survival time. Conclusions Death is the primary reason for withdrawal from PD. Female sex and older age affect patients’ withdrawal from PD and survival.
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Affiliation(s)
- Min Li
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Jin Yan
- Department of Nursing, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Hao Zhang
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Qiongying Wu
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Jianwen Wang
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Jishi Liu
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Chengling Xing
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Yuqiong Zhou
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
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Brown L, Gardner G, Bonner A. A randomized controlled trial testing a decision support intervention for older patients with advanced kidney disease. J Adv Nurs 2019; 75:3032-3044. [DOI: 10.1111/jan.14112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/03/2019] [Accepted: 04/17/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Leanne Brown
- School of Nursing and Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane Qld Australia
| | - Glenn Gardner
- School of Nursing and Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane Qld Australia
| | - Ann Bonner
- School of Nursing and Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane Qld Australia
- Chronic Kidney Disease Centre for Research Excellence University of Queensland Brisbane Qld Australia
- Visiting Research Fellow, Kidney Health Service Metro North Hospital and Health Service Brisbane Qld Australia
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Weigert A, Drozdz M, Silva F, Frazão J, Alsuwaida A, Krishnan M, Kleophas W, Brzosko S, Johansson FK, Jacobson SH. Influence of gender and age on haemodialysis practices: a European multicentre analysis. Clin Kidney J 2019; 13:217-224. [PMID: 32296527 PMCID: PMC7147302 DOI: 10.1093/ckj/sfz069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/30/2019] [Indexed: 11/25/2022] Open
Abstract
Background Women of all ages and elderly patients of both genders comprise an increasing proportion of the haemodialysis population. Worldwide, significant differences in practice patterns and treatment results exist between genders and among younger versus older patients. Although efforts to mitigate sex-based differences have been attempted, significant disparities still exist. Methods This retrospective cohort study included all 1247 prevalent haemodialysis patients in DaVita units in Portugal (five dialysis centres, n = 730) and Poland (seven centres, n = 517). Demographic data, dialysis practice patterns, vascular access prevalence and the achievement of a variety of Kidney Disease: Improving Global Outcomes (KDIGO) treatment targets were evaluated in relation to gender and age groups. Results Body weight and the prescribed dialysis blood flow rate were lower in women (P < 0.001), whereas treated blood volume per kilogram per session was higher (P < 0.01), resulting in higher single-pool Kt/V in women than in men (P < 0.001). Haemoglobin was significantly higher in men (P = 0.01), but the proportion of patients within target range (10–12 g/dL) was similar. Men more often had an arteriovenous fistula than women (80% versus 73%; P < 0.01) with a similar percentage of central venous catheters. There were no gender-specific differences in terms of dialysis adequacy, anaemia parameters or mineral and bone disorder parameters, or in the attainment of KDIGO targets between women and men >80 years of age. Conclusions This large, multicentre real-world analysis indicates that haemodialysis practices and treatment targets are similar for women and men, including the most elderly, in DaVita haemodialysis clinics in Europe.
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Affiliation(s)
| | - Maciej Drozdz
- Department of Nephrology, DaVita International, Krakow, Poland
| | - Fatima Silva
- Department of Nephrology, DaVita, Lisbon, Portugal
| | - João Frazão
- Department of Nephrology, DaVita, Porto, Portugal
| | | | | | | | | | - Fredrik K Johansson
- Unit for Medical Statistics, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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Msaad R, Essadik R, Mohtadi K, Meftah H, Lebrazi H, Taki H, Kettani A, Madkouri G, Ramdani B, Saïle R. Predictors of mortality in hemodialysis patients. Pan Afr Med J 2019; 33:61. [PMID: 31448023 PMCID: PMC6689835 DOI: 10.11604/pamj.2019.33.61.18083] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 05/05/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction Mortality in patients with chronic renal failure is high compared to the general population. The objective of our study is to evaluate the predictive factors related to mortality in hemodialysis. Methods This is a retrospective study involving 126 hemodialysis patients in the Nephrology Department of Ibn Rochd Hospital, Casablanca. Data were collected between January 2012 and January 2016. For each of our patients, we analyzed demographic, clinical, biological and anthropometric data. The Kaplan-Meier method and the log-rank test were used to evaluate and compare survival curves. To evaluate the effect of predictors of mortality, we used the proportional Cox hazard model. Results The analysis of the results showed that the surviving patients were younger than the deceased patients (43.07±13.52 years versus 53.09±13.56 years, p=0.001). Also, the latter has a significantly lower albumin and prealbumin levels (p=0.01 and p=0.04 respectively). Overall survival was 80.2%. Cox regression analysis at age (HR=1.26, p<0.0002), inflammation (HR=1.15, p<0.03), AIP> 0.24 (HR=2.1, p<0.002) and cardiovascular disease (RR=2.91, p<0.001) were associated with global and cardiovascular mortality. Conclusion Our study showed that the mortality rate is high in our cohort. In addition, cardiovascular diseases, under nutrition and inflammation are predictive factors for mortality. Treatment and early management of these factors are essential for reducing morbidity and mortality.
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Affiliation(s)
- Rajaa Msaad
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Rajaa Essadik
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Karima Mohtadi
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Hasnaa Meftah
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Halima Lebrazi
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Hassan Taki
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Anass Kettani
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
| | - Ghizlane Madkouri
- Department of Nephrology-Transplantation and Hemodialysis of the University Hospital Center Ibn Rochd of Casablanca, Casablanca, Morocco
| | - Benyounes Ramdani
- Department of Nephrology-Transplantation and Hemodialysis of the University Hospital Center Ibn Rochd of Casablanca, Casablanca, Morocco
| | - Rachid Saïle
- Laboratory of Biology and Health, URAC 34, Hassan II University-Casablanca, Faculty of Sciences Ben M'Sik, Avenue Cdt Driss El Harti BP 7955, Sidi Othmane, Casablanca, Morocco
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Villain C, Ecochard R, Bouchet JL, Daugas E, Drueke TB, Hannedouche T, Jean G, London G, Roth H, Fouque D. Relative prognostic impact of nutrition, anaemia, bone metabolism and cardiovascular comorbidities in elderly haemodialysis patients. Nephrol Dial Transplant 2019; 34:848-858. [PMID: 30202988 DOI: 10.1093/ndt/gfy272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The prognostic impact of nutrition and chronic kidney disease (CKD) complications has already been described in elderly haemodialysis patients but their relative weights on risk of death remain uncertain. Using structural equation models (SEMs), we aimed to model a single variable for nutrition, each CKD complication and cardiovascular comorbidities to compare their relative impact on elderly haemodialysis patients' survival. METHODS This prospective study recruited 3165 incident haemodialysis patients ≥75 years of age from 178 French dialysis units. Using SEMs, the following variables were computed: nutritional status, anaemia, mineral and bone disorder and cardiovascular comorbidities. Systolic blood pressure was also used in the analysis. Survival analyses used Poisson models. RESULTS The population average age was 81.9 years (median follow-up 1.51 years, 35.5% deaths). All variables were significantly associated with mortality by univariate analysis. Nutritional status was the variable most strongly associated with mortality in the multivariate analysis, with a negative prognostic impact of low nutritional markers {incidence rate ratio [IRR] 1.42 per 1 standard deviation [SD] decrement [95% confidence interval (CI) 1.32-1.53]}. The 'cardiovascular comorbidities' variable was the second variable associated with mortality [IRR 1.19 per 1 SD increment (95% CI 1.11-1.27)]. A trend towards low intact parathyroid hormone and high serum calcium and low values of systolic blood pressure were also associated with poor survival. The variable 'anaemia' was not associated with survival. CONCLUSIONS These findings should help physicians prioritize care in elderly haemodialysis patients with CKD complications, with special focus on nutritional status.
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Affiliation(s)
- Cédric Villain
- Université Versailles-Saint-Quentin, INSERM U-1018, CESP équipe 5, EpRec, Service de Néphrologie, Hôpital Ambroise Paré, APHP, Boulogne-Billancourt, France
| | - René Ecochard
- Université Lyon 1, CNRS, UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Service de Biostatistique et Bioinformatique, Hospices Civils de Lyon, Lyon, France
| | - Jean-Louis Bouchet
- Centre de Traitement des Maladies Rénales Saint-Augustin, Bordeaux, France
| | - Eric Daugas
- Service de Néphrologie, Hôpital Bichat, APHP, INSERM U1149, Université Paris Diderot, Paris, France
| | - Tilman B Drueke
- INSERM U-1018, CESP équipe 5, EpRec, Hôpital Paul Brousse, Villejuif, France
| | - Thierry Hannedouche
- Service de Néphrologie-Hémodialyse, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Gérard London
- Service de Néphrologie, Hôpital Manhes, Fleury-Merogis, France
| | - Hubert Roth
- Centre de Recherche en Nutrition Humaine Rhône-Alpes, Centre Hospitalo-Universitaire des Alpes, INSERM U1055, Laboratoire de Bioénergétique Fondamentale et Appliquée, Université Grenoble-Alpes, Grenoble, France
| | - Denis Fouque
- Univ Lyon, UCBL, INSERM CarMeN, CENS, Service de Néphrologie-Nutrition-Dialyse, Centre Hospitalier Lyon Sud, Pierre, Bénite, France
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Kanno A, Nakayama M, Sanada S, Sato M, Sato T, Taguma Y. Suboptimal initiation predicts short-term prognosis and vulnerability among very elderly patients who start haemodialysis. Nephrology (Carlton) 2019; 24:94-101. [PMID: 29131496 DOI: 10.1111/nep.13194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 11/26/2022]
Abstract
AIM A recent, growing concern regarding haemodialysis in Japan is a sustained increase in the elderly population. Among very elderly people who start haemodialysis, the prognosis is considered to be poor; however, this has not been fully elucidated. This study aimed to discover the short-term prognosis and related factors in very elderly patients who commence haemodialysis. METHODS Between January 2008 and December 2013, 122 patients aged ≥85 years at haemodialysis initiation were documented in our hospital. Predictors of 90-day and 1-year mortality after haemodialysis initiation were assessed with Cox proportional hazards regression analysis. Selection of covariates for the multivariate model was based on forward stepwise selection using the probability of a likelihood ratio statistics. RESULTS The subjects' mean age was 87.4 ± 2.5 years, and 48% were female. The most common cause of death was infection (38% of patients) and the leading cause of infectious death was pneumonia. The 90-day and 1-year survival rates were 81% and 62%, respectively. Suboptimal initiation was a significant prognostic factor for 90-day [hazard ratio (HR) 3.98, 95% confidence interval (CI) 1.18-13.43] and 1-year [HR 3.19, 95% CI 1.51-6.76] mortality after adjusting for confounders in multivariate analysis. CONCLUSION Very elderly patients who started haemodialysis had a poor prognosis, and suboptimal initiation significantly predicted outcome. Shared decision-making with patients and their families is needed for initiating haemodialysis on the conditions that appropriate information on the expected prognosis is provided.
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Affiliation(s)
- Atsuhiro Kanno
- Department of Nephrology, Japan Community Health Care Organization (JCHO) Sendai Hospital, Sendai, Japan
| | - Masaaki Nakayama
- Research Division of Chronic Kidney Disease and Dialysis Treatment, Tohoku University Hospital, Tohoku University, Sendai, Japan
| | - Satoru Sanada
- Department of Nephrology, Japan Community Health Care Organization (JCHO) Sendai Hospital, Sendai, Japan
| | - Mitsuhiro Sato
- Department of Nephrology, Japan Community Health Care Organization (JCHO) Sendai Hospital, Sendai, Japan
| | - Toshinobu Sato
- Department of Nephrology, Japan Community Health Care Organization (JCHO) Sendai Hospital, Sendai, Japan
| | - Yoshio Taguma
- Department of Nephrology, Japan Community Health Care Organization (JCHO) Sendai Hospital, Sendai, Japan
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Hassan R, Akbari A, Brown PA, Hiremath S, Brimble KS, Molnar AO. Risk Factors for Unplanned Dialysis Initiation: A Systematic Review of the Literature. Can J Kidney Health Dis 2019; 6:2054358119831684. [PMID: 30899532 PMCID: PMC6419254 DOI: 10.1177/2054358119831684] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/14/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Unplanned dialysis initiation is common in patients with chronic kidney disease (CKD). Objective: To determine common definitions and patient risk factors for unplanned dialysis. Design: Systematic review. Setting: MEDLINE, EMBASE, and the Cochrane Library were searched from inception to February 2018. Patients: Studies that included incident chronic dialysis patients or patients with CKD that cited a definition or examined risk factors for unplanned dialysis were included. Measurements: Definitions and criteria for unplanned dialysis reported across studies. Patient characteristics associated with unplanned dialysis. Methods: Two reviewers independently extracted data using a standardized data abstraction form and assessed study quality using a modified New Castle Ottawa Scale. Results: From 2797 citations, 48 met eligibility criteria. Reported definitions for unplanned dialysis were variable. Most publications cited dialysis initiation under emergency conditions and/or with a central venous catheter. The association of patient characteristics with unplanned dialysis was reported in 26 studies, 18 were retrospective and 21 included incident dialysis patients. The most common risk factors in univariate analyses were (number of studies) increased age (n = 7), cause of kidney disease (n = 6), presence of cardiovascular disease (n = 7), lower serum hemoglobin (n = 9), lower serum albumin (n = 10), higher serum phosphate (n = 6), higher serum creatinine or lower estimated glomerular filtration rate (eGFR) at dialysis initiation (n = 7), late referral (n = 5), lack of dialysis education (n = 6), and lack of follow-up in a predialysis clinic prior to dialysis initiation (n = 5). A minority of studies performed multivariable analyses (n = 10); the most common risk factors were increased age (n = 4), increased comorbidity score (n = 3), late referral (n = 5), and lower eGFR at dialysis initiation (n = 3). Limitations: Comparison of results across studies was limited by inconsistent definitions for unplanned dialysis. High-quality data on patient risk factors for unplanned dialysis are lacking. Conclusions: Well-designed prospective studies to determine modifiable risk factors are needed. The lack of a consensus definition for unplanned dialysis makes research and quality improvement initiatives in this area more challenging.
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Rubio Rubio MV, Lou Arnal LM, Gimeno Orna JA, Munguía Navarro P, Gutiérrez-Dalmau A, Lambán Ibor E, Paúl Ramos J, Pernaute Lavilla R, Campos Gutiérrez B, San Juan Hernández-Franch A. Survival and quality of life in elderly patients in conservative management. Nefrologia 2019; 39:141-150. [PMID: 30827372 DOI: 10.1016/j.nefro.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/29/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Conservative Management (CM) has become a therapeutic option in Advanced Chronic Kidney Disease in the elderly. However, there is a lack of evidence about prognosis of these patients in terms of survival and health related quality of life (HRQoL). OBJECTIVE Establish predictive variables associated with mortality and analyse HRQoL in CM patients. PATIENTS AND METHODS Prospective cohort study. An assessment of renal function parameters and a comprehensive geriatric assessment were made, including: analysis of comorbidity, functional, cognitive, fragility, nutritional, social and HRQoL status. RESULTS 82 patients with a mean age of 84 years and significant pluripathology were studied: 56% had history of vascular event and Charlson >8. The mortality rate was 23/1,000 patients per month, with a homogeneous mortality rate after 6 months. Survival differed significantly depending on whether they presented with a previous vascular event (36.7 vs. 14.8; p=0.028), Charlson score ≥10 (42 vs. 17; p=0.002), functional status (48.4 vs. 19; p=0.002) and fragility (27 vs. 10; p=0.05). Mortality predictors included eGFR and proteinuria, the presence of previous vascular events, Charlson comorbidity score, malnutrition-inflammation parameters (albumin and MNA score), degree of dependency, physical HRQoL and increase of PTH level. The presence of previous vascular event, comorbidity, decreased albumin and elevated PTH were independent predictors of mortality. HRQoL remained stable over time and no significant worsening occurred during treatment. CONCLUSIONS Having knowledge of the factors associated with mortality and HRQoL assessment can be a useful tool to helping decision making during CM. Previous vascular events, comorbidity, decreased albumin and increased PTH were independent predictors of mortality.
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Affiliation(s)
| | | | | | | | | | - Elena Lambán Ibor
- Servicio de Medicina Interna, Hospital Ernest Lluch, Calatayud, Zaragoza, España
| | - Javier Paúl Ramos
- Servicio de Nefrología, Hospital Universitario Miguel Servet, Zaragoza, España
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Castro MCM. Conservative management for patients with chronic kidney disease refusing dialysis. J Bras Nefrol 2019; 41:95-102. [PMID: 30048562 PMCID: PMC6534024 DOI: 10.1590/2175-8239-jbn-2018-0028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/14/2018] [Indexed: 12/24/2022] Open
Abstract
Estimates suggest that 20-30% of the deaths of patients with chronic kidney disease with indication to undergo dialysis occur after refusal to continue dialysis, discontinuation of dialysis or inability to offer dialysis on account of local conditions. Contributing factors include aging, increased comorbidity associated with chronic kidney disease, and socioeconomic status. In several occasions nephrologists will intervene, but at times general practitioners or family physicians are on their own. Knowledge of the main etiologies of chronic kidney disease and the metabolic alterations and symptoms associated to end-stage renal disease is an important element in providing patients with good palliative care. This review aimed to familiarize members of multidisciplinary care teams with the metabolic alterations and symptoms arising from chronic kidney disease treated clinically without the aid of dialysis.
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Moderate Protein Restriction in Advanced CKD: A Feasible Option in An Elderly, High-Comorbidity Population. A Stepwise Multiple-Choice System Approach. Nutrients 2018; 11:nu11010036. [PMID: 30586894 PMCID: PMC6356994 DOI: 10.3390/nu11010036] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/08/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023] Open
Abstract
Background: Protein restriction may retard the need for renal replacement therapy; compliance is considered a barrier, especially in elderly patients. Methods: A feasibility study was conducted in a newly organized unit for advanced kidney disease; three diet options were offered: normalization of protein intake (0.8 g/kg/day of protein); moderate protein restriction (0.6 g/kg/day of protein) with a “traditional” mixed protein diet or with a “plant-based” diet supplemented with ketoacids. Patients with protein energy wasting (PEW), short life expectancy or who refused were excluded. Compliance was estimated by Maroni-Mitch formula and food diary. Results: In November 2017–July 2018, 131 patients started the program: median age 74 years (min–max 24-101), Charlson Index (CCI): 8 (min-max: 2–14); eGFR 24 mL/min (4–68); 50.4% were diabetic, BMI was ≥ 30 kg/m2 in 40.4%. Normalization was the first step in 75 patients (57%, age 78 (24–101), CCI 8 (2–12), eGFR 24 mL/min (8–68)); moderately protein-restricted traditional diets were chosen by 24 (18%, age 74 (44–91), CCI 8 (4–14), eGFR 22 mL/min (5–40)), plant-based diets by 22 (17%, age 70 (34–89), CCI 6.5 (2–12), eGFR 15 mL/min (5–46)) (p < 0.001). Protein restriction was not undertaken in 10 patients with short life expectancy. In patients with ≥ 3 months of follow-up, median reduction of protein intake was from 1.2 to 0.8 g/kg/day (p < 0.001); nutritional parameters remained stable; albumin increased from 3.5 to 3.6 g/dL (p = 0.037); good compliance was found in 74%, regardless of diets. Over 1067 patient-months of follow-up, 9 patients died (CCI 10 (6–12)), 7 started dialysis (5 incremental). Conclusion: Protein restriction is feasible by an individualized, stepwise approach in an overall elderly, high-comorbidity population with a baseline high-protein diet and is compatible with stable nutritional status.
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Sgroi MD, McFarland G, Itoga NK, Sorial E, Garcia-Toca M. Arteriovenous Fistula and Graft Construction in Patients with Implantable Cardiac Devices: Does Side Matter? Ann Vasc Surg 2018; 54:66-71. [PMID: 30339901 DOI: 10.1016/j.avsg.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 10/02/2018] [Accepted: 10/09/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Limited reports have documented the effect cardiac implantable electronic devices (CIEDs) have on arteriovenous (AV) access patency. Current recommendations suggest placing the access on the contralateral side of the CIEDs, as there is concern for increased central venous stenosis and access failure. The goal of this study is to review our single-center AV access patency rates for dialysis patients with an ipsilateral or contralateral side CIED. METHODS A retrospective review was performed from 2008 to 2016 at a single institution identifying all patients who have received a CIED and the diagnosis of end-stage renal disease (ESRD). Medical records were queried to identify each patient's dialysis access and whether it was ipsilateral or contralateral to the CIED. Primary outcomes of study were primary and secondary patency rates. RESULTS A total of 44 patients were identified to have ESRD and CIED. Of these patients, 28 patients with fistulas or grafts (13 ipsilateral and 15 contralateral) had follow-up with regards to their AV access. There were 3 primary failures in both groups. For patients who had the CIED placed after already starting the dialysis, patency was based on when the cardiac device was implanted. Primary patency for ipsilateral and contralateral access was 20.2 and 22.2 months, respectively. With secondary interventions, ipsilateral and contralateral mean patency was 39 and 48.8 months, respectively. Six-month and 1-year primary patency for arteriovenous fistula or arteriovenous graft on patients with ipsilateral access was 69.2% and 53.8%, respectively. Ipsilateral 1-year cumulative patency was 39 months. CONCLUSIONS CIED may lead to stenosis or occlusion to one's AV access; however, primary assisted and secondary patency rates are still acceptable at 6 months and 1 year compared to Kidney Disease Outcomes Quality Initiative guidelines. Despite a CIED, a surgeon's algorithm should not lead to the abandonment of an ipsilateral access if the central venous system is patent.
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Affiliation(s)
- Michael D Sgroi
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA.
| | - Graeme McFarland
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Nathan K Itoga
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Ehab Sorial
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
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Zaoui P, Hannedouche T, Combe C. [Cardiovascular protection of diabetic patient with chronic renal disease and particular case of end-stage renal disease in elderly patients]. Nephrol Ther 2018; 13:6S16-6S24. [PMID: 29463395 DOI: 10.1016/s1769-7255(18)30036-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Type 2 diabetes has an increasing prevalence. Life expectancy is dominated by cardiovascular risk, which is the leading cause of death in these patients. Up to one third of diabetic patients will develop diabetic nephropathy related to micro-angiopathy. Renal impairment further increases cardiovascular risk. Reducing cardiovascular morbidity and mortality is a major public health issue, as well as early preventing and managing chronic kidney disease (CKD). Good glycemic control prevents the micro-vascular complications of the disease (retinopathy, nephropathy, etc.) and, more recently recognized through prolonged monitoring of the VADT cohort, prevents cardiovascular complications. Control of blood pressure and dyslipidemia are essential in primary or secondary cardiovascular prevention. In addition, the blockers of the renin-angiotensin system slow down the progression of the MRC. Elderly patients with chronic kidney disease (CKD) form another growing group of the nephrologist daily patient pool. Especially for very elderly patients with comorbidities, the question of favoring conservative treatment rather than starting or pursuing dialysis may arise. Survival and quality of life are indeed not necessarily better in elderly patients undergoing dialysis, complications can occur eventually leading to discontinuation, and are occasionally associated with a feeling of stubbornness. Creation of prognostic score is a useful tool to help the decision-making process. However, dialogue with the patient and his/her family, as well as multidisciplinary collaboration remain fundamentals to determine the most suitable care.
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Affiliation(s)
- P Zaoui
- Pôle Digestif Uro-Néphro-Endocrinologie (DIGIDUNE), AGDUC, CHU Université Grenoble Alpes, Pole Santé, France.
| | - T Hannedouche
- Service de Néphrologie, Hôpitaux Universitaires de Strasbourg, Faculté de Médecine, Strasbourg, France.
| | - C Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France Unité INSERM 1026 Biotis, Université de Bordeaux, Bordeaux, France.
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The Factors Affecting Survival in Geriatric Hemodialysis Patients. Int J Nephrol 2018; 2018:5769762. [PMID: 30112210 PMCID: PMC6077547 DOI: 10.1155/2018/5769762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 05/27/2018] [Accepted: 06/21/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction The number of geriatric patients is increasing in hemodialysis population over the years and mortality is higher in this group of patients. This study evaluated the factors affecting geriatric hemodialysis patient survival. Materials and Methods This retrospective cohort study enrolled patients discharged from our nephrology clinic from 2009 to 2014. Data collected included demographics, Eastern Cooperative Oncology Group-Performance Status, vascular access type, and metabolic parameters. Comorbidity was quantified using the modified Liu comorbidity index. The outcome measure was mortality. Results The study enrolled 99 elderly dialysis patients (42.4% women (n = 42); mean age 75 ± 7 years). The mean follow-up duration was 19.7 ± 11 months. The mortality rate over the four years was 47.5% (n = 46). The modified Liu comorbidity index score, patient age, and Eastern Cooperative Oncology Group-Performance Status were significantly related to mortality in univariate and multivariate analyses. Conclusion The present study revealed that comorbidities and low performance status at the onset of dialysis had shortened the survival time in the geriatric hemodialysis patient group.
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Verberne WR, Dijkers J, Kelder JC, Geers ABM, Jellema WT, Vincent HH, van Delden JJM, Bos WJW. Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study. BMC Nephrol 2018; 19:205. [PMID: 30115028 PMCID: PMC6097302 DOI: 10.1186/s12882-018-1004-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/06/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Conservative care is argued to be a reasonable treatment alternative for dialysis in older patients with advanced chronic kidney disease (CKD). However, comparisons are scarce and generally focus on survival only. Comparative data on more patient-relevant outcomes are needed to truly foster shared decision-making on an individual level, and cost comparison is needed to assess value of care. METHODS We conducted a retrospective observational single-center cohort study in 366 patients aged ≥70 years with advanced CKD, who chose dialysis (n = 240) or conservative care (n = 126) after careful counselling by a multidisciplinary team in a non-academic teaching hospital in The Netherlands. Using a value-based health care approach (value = outcomes/cost): survival, health-related quality of life-cross-sectionally assessed with the Kidney Disease Quality of Life Short Form™-treatment burden, and treatment costs were evaluated. RESULTS The overall survival benefit of patients on a dialysis pathway compared with patients on conservative care diminished or lost significance in patients aged ≥80 years or with severe comorbidity. There were no differences between patients managed conservatively and dialysis patients on physical and mental health summary scores (all P > 0.1). Patients on conservative care had 352.7 hospital free days per year versus 282.7 in patients on a dialysis pathway, calculated from treatment decision (adjusted incidence rate ratio: 1.15, 95% confidence interval: 1.09 to 1.21, P < 0.001). Annual treatment costs were lower in patients on conservative care (adjusted cost ratio: 0.43, 95% confidence interval: 0.28 to 0.67, P < 0.001). CONCLUSIONS In this study, conservative care is shown to be a viable treatment option in older patients with advanced CKD, particularly in the oldest old and those with severe comorbidity. By achieving similar outcomes at lower treatment burden and treatment costs, value was generated for older patients choosing conservative care and society.
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Affiliation(s)
- Wouter R. Verberne
- Department of Internal Medicine, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Utrecht Nieuwegein, The Netherlands
| | - Janneke Dijkers
- Department of Internal Medicine, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Utrecht Nieuwegein, The Netherlands
| | - Johannes C. Kelder
- Department of Clinical Epidemiology and Medical Statistics, St Antonius Hospital, Nieuwegein, Utrecht The Netherlands
| | - Anthonius B. M. Geers
- Department of Internal Medicine, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Utrecht Nieuwegein, The Netherlands
| | - Wilbert T. Jellema
- Department of Internal Medicine, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Utrecht Nieuwegein, The Netherlands
| | - Hieronymus H. Vincent
- Department of Internal Medicine, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Utrecht Nieuwegein, The Netherlands
| | - Johannes J. M. van Delden
- University Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Willem Jan W. Bos
- Department of Internal Medicine, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Utrecht Nieuwegein, The Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, Zuid-Holland The Netherlands
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Wong SPY, Yu MK, Green PK, Liu CF, Hebert PL, O'Hare AM. End-of-Life Care for Patients With Advanced Kidney Disease in the US Veterans Affairs Health Care System, 2000-2011. Am J Kidney Dis 2018; 72:42-49. [PMID: 29331475 PMCID: PMC6019112 DOI: 10.1053/j.ajkd.2017.11.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 11/04/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known about patterns of end-of-life care for patients with advanced kidney disease not treated with maintenance dialysis. STUDY DESIGN Case series. SETTING & PARTICIPANTS A sample of 14,071 patients with sustained estimated glomerular filtration rates < 15mL/min/1.73m2 treated in the US Veterans Affairs health care system who died during 2000 to 2011. Before death, 12,756 of these patients had been treated with dialysis, 503 had been discussing and/or preparing for dialysis therapy, and for 812, there had been a decision not to pursue dialysis therapy. OUTCOMES Hospitalization and receipt of an intensive procedure during the final month of life, in-hospital death, and palliative care consultation and hospice enrollment before death. RESULTS Compared with decedents treated with dialysis, those for whom a decision not to pursue dialysis therapy had been made were less often hospitalized (57.3% vs 76.8%; OR, 0.40 [95% CI, 0.34-0.46]), less often the recipient of an intensive procedure (3.5% vs 24.6%; OR, 0.15 [95% CI, 0.10-0.22]), more often the recipient of a palliative care consultation (52.6% vs 21.6%; OR, 4.19 [95% CI, 3.58-4.90]), more often used hospice services (38.7% vs 18.2%; OR, 3.32 [95% CI, 2.83-3.89]), and died less frequently in a hospital (41.4% vs 57.3%; OR, 0.78 [95% CI, 0.74-0.82]). Hospitalization (55.5%; OR, 0.39 [95% CI, 0.32-0.46]), receipt of an intensive procedure (13.7%; OR, 0.60 [95% CI, 0.46-0.77]), and in-hospital death (39.0%; OR, 0.47 [95% CI, 0.39-0.56]) were also less common among decedents who had been discussing and/or preparing for dialysis therapy, but their use of palliative care and hospice services was similar. LIMITATIONS Findings may not be generalizable to groups not well represented in the Veterans Affairs health care system. CONCLUSIONS Among decedents, patients not treated with dialysis before death received less intensive patterns of end-of-life care than those treated with dialysis. Decedents for whom there had been a decision not to pursue dialysis therapy before death were more likely to receive palliative care and hospice.
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Affiliation(s)
- Susan P Y Wong
- Health Service Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA.
| | - Margaret K Yu
- Department of Medicine, Stanford University, Palo Alto, CA
| | - Pamela K Green
- Health Service Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA
| | - Chuan-Fen Liu
- Health Service Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA; Department of Health Services, University of Washington, Seattle, WA
| | - Paul L Hebert
- Health Service Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA; Department of Health Services, University of Washington, Seattle, WA
| | - Ann M O'Hare
- Health Service Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
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Tam-Tham H, Quinn RR, Weaver RG, Zhang J, Ravani P, Liu P, Thomas C, King-Shier K, Fruetel K, James MT, Manns BJ, Tonelli M, Murtagh FEM, Hemmelgarn BR. Survival among older adults with kidney failure is better in the first three years with chronic dialysis treatment than not. Kidney Int 2018; 94:582-588. [PMID: 29803405 DOI: 10.1016/j.kint.2018.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 02/13/2018] [Accepted: 03/02/2018] [Indexed: 11/28/2022]
Abstract
Comparisons of survival between dialysis and nondialysis care for older adults with kidney failure have been limited to those managed by nephrologists, and are vulnerable to lead and immortal time biases. So we compared time to all-cause mortality among older adults with kidney failure treated vs. not treated with chronic dialysis. Our retrospective cohort study used linked administrative and laboratory data to identify adults aged 65 or more years of age in Alberta, Canada, with kidney failure (2002-2012), defined by two or more consecutive outpatient estimated glomerular filtration rates less than 10 mL/min/1.73m2, spanning 90 or more days. We used marginal structural Cox models to assess the association between receipt of dialysis and all-cause mortality by allowing control for both time-varying and baseline confounders. Overall, 838 patients met inclusion criteria (mean age 79.1; 48.6% male; mean estimated glomerular filtration rate 7.8 mL/min/1.73m2). Dialysis treatment (vs. no dialysis) was associated with a significantly lower risk of death for the first three years of follow-up (hazard ratio 0.59 [95% confidence interval 0.46-0.77]), but not thereafter (1.22 [0.69-2.17]). However, dialysis was associated with a significantly higher risk of hospitalization (1.40 [1.16-1.69]). Thus, among older adults with kidney failure, treatment with dialysis was associated with longer survival up to three years after reaching kidney failure, though with a higher risk of hospital admissions. These findings may assist shared decision-making about treatment of kidney failure.
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Affiliation(s)
- Helen Tam-Tham
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert R Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert G Weaver
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jianguo Zhang
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ping Liu
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chandra Thomas
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn King-Shier
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | - Karen Fruetel
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matt T James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fliss E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Brenda R Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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