Hemodialysis interval and its association with emergency care and mortality: A nationwide population-based cohort study

Emergency Department Use Among Adults Receiving Dialysis

Importance

People with kidney failure receiving maintenance dialysis visit the emergency department (ED) 3 times per year on average, which is 3- to 8-fold more often than the general population. Little is known about the factors that contribute to potentially preventable ED use in this population.

Objective

To identify the clinical and sociodemographic factors associated with potentially preventable ED use among patients receiving maintenance dialysis.

Design, Setting, and Participants

This cohort study used linked administrative health data within the Alberta Kidney Disease Network to identify adults aged 18 years or older receiving maintenance dialysis (ie, hemodialysis or peritoneal dialysis) between April 1, 2010, and March 31, 2019. Patients who had been receiving dialysis for more than 90 days were followed up from cohort entry (defined as dialysis start date plus 90 days) until death, outmigration from the province, receipt of a kidney transplant, or end of study follow-up. The Andersen behavioral model of health services was used as a conceptual framework to identify variables related to health care need, predisposing factors, and enabling factors. Data were analyzed in March 2024.

Main Outcomes and Measures

Rates of all-cause ED encounters and potentially preventable ED use associated with 4 kidney disease-specific ambulatory care-sensitive conditions (hyperkalemia, heart failure, volume overload, and malignant hypertension) were calculated. Multivariable negative binomial regression models were used to examine the association between clinical and sociodemographic factors and rates of potentially preventable ED use.

Results

The cohort included 4925 adults (mean [SD] age, 60.8 [15.5] years; 3071 males [62.4%]) with kidney failure receiving maintenance hemodialysis (3183 patients) or peritoneal dialysis (1742 patients) who were followed up for a mean (SD) of 2.5 (2.0) years. In all, 3877 patients had 34 029 all-cause ED encounters (3100 [95% CI, 2996-3206] encounters per 1000 person-years). Of these, 755 patients (19.5%) had 1351 potentially preventable ED encounters (114 [95% CI, 105-124] encounters per 1000 person-years). Compared with patients with a nonpreventable ED encounter, patients with a potentially preventable ED encounter were more likely to be in the lowest income quintile (38.8% vs 30.9%; P < .001); to experience heart failure (46.8% vs 39.9%; P = .001), depression (36.6% vs 32.5%; P = .03), and chronic pain (60.1% vs 54.9%; P = .01); and to have a longer duration of dialysis (3.6 vs 2.6 years; P < .001). In multivariable regression analyses, potentially preventable ED use was higher for younger adults (incidence rate ratio [IRR], 1.69 [95% CI, 1.33-2.15] for those aged 18 to 44 years) and patients with chronic pain (IRR, 1.35 [95% CI, 1.14-1.61]), greater material deprivation (IRR, 1.57 [95% CI, 1.16-2.12]), a history of hyperkalemia (IRR, 1.31 [95% CI, 1.09-1.58]), and historically high ED use (ie, ≥3 ED encounters in the prior year; IRR, 1.46 [95% CI, 1.23-1.73).

Conclusions and Relevance

In this study of adults receiving maintenance dialysis in Alberta, Canada, among those with ED use, 1 in 5 had a potentially preventable ED encounter; reasons for such encounters were associated with both psychosocial and medical factors. The findings underscore the need for strategies that address social determinants of health to avert potentially preventable ED use in this population.

The value of venous system ultrasound in predicting the need for emergency haemodialysis in haemodialysis patients

BACKGROUND

Emergency haemodialysis (HD) is a therapeutic procedure performed in serious clinical situations. This study investigated venous Doppler ultrasound parameters for predicting emergency HD in patients on routine HD treatment for end-stage renal disease in the emergency department (ED).

METHOD

Adult patients on a routine HD program in a tertiary care ED between April and December 2022 were enrolled in the study. Inferior vena cava, hepatic, and portal vein flow parameters and the venous excess ultrasound (VExUS) score calculated from these parameters were noted in order to predict emergency HD indications. Hyperkalaemia, hypervolemia, missing more than one session, uremic findings, and metabolic acidosis were regarded as emergency HD indications.

RESULTS

One hundred twenty-nine venous ultrasound examinations were performed on 43 patients with routine HD during the study period. The rate of emergency HD was 30.2%. The most common indication of it was hypervolemia (76.9%), followed by missing more than one session (23.1%). Only the portal vein had an AUC value of 0.714, with a sensitivity of 61.5% and specificity of 83.3% for predicting emergency HD. Other parameters including the IVC, hepatic vein, and VExUS score were of no diagnostic value.

CONCLUSION

The findings of this study show that only the portal vein Doppler flow parameter has very limited diagnostic value for emergency HD in patients on a routine HD program in the ED. This study can serve as a guide to further research.

Characteristics of Vascular Access Cannulation Complications in End Stage Kidney Disease Patients in West Java from 2018 to 2022: A Retrospective Observational Study

Background

End-stage kidney disease (ESKD) is associated with a tremendous financial burden. Data in Indonesia shows an increasing number of patients with ESKD taking hemodialysis as a routine procedure every year. Establishment and maintenance of vascular access are important in the management of ESKD. Vascular complications that often arise due to hemodialysis are common and one of the main reasons for hospitalization. Cannulation complications ranged from minor hematomas to acute bleeding from pseudoaneurysms that required emergency surgical procedures. This study aims to assess the different clinicopathological characteristics of ESKD patients with vascular access cannulation complications and the surgical management related to the complications.

Materials and Methods

This research is a retrospective observational study. The research subjects in this study were ESKD patients in the vascular and endovascular surgery division of the tertiary hospital in West Java, Indonesia. There were 121 study subjects. Clinicopathological characteristics of vascular cannulation complications and surgical management are extracted from the medical record.

Results

Three major vascular complications were ruptured pseudoaneurysms 64/121 (52.9%), impending rupture pseudoaneurysms 28/121 (23.1%), and pseudoaneurysms 21/121 (17.4%). Common surgical procedures were ligation of the draining vein 47/121 (38.8%), arterial primary repair 28/121 (23.1%), and arterial patch repair 18/121 (14.9%). There was a significant relationship between symptoms of bleeding in ruptured pseudoaneurysms and bulging masses in pseudoaneurysms (p = 0.001). There was a significant relationship between the diameter of the vascular mass, vascular defect size, and hematoma and the type of surgical procedure taken (p < 0.010).

Conclusion

Ruptured, impending rupture, and pseudoaneurysms are major complications of vascular access in ESKD patients, and there was a significant relationship between the carried-out surgical procedure and the size of the vascular mass, defect, and hematoma.

Establishment of a Nomogram Model for Predicting Cardiovascular and Cerebrovascular Events in Diabetic Nephropathy Patients Receiving Maintenance Hemodialysis

Objective. The objective of this study is to explore the risk factors of cardiovascular and cerebrovascular events (CCE) in patients with diabetic nephropathy (DN) receiving maintenance hemodialysis, and to establish a nomogram model on this basis. Method. 144 patients with DN receiving maintenance hemodialysis from February 2020 to February 2021 were selected and followed up for 12 months. They were divided into the occurrence and nonoccurrence groups according to whether CCE occurred. The multivariate logistic regression analysis was used to analyze the influencing factors of CCE, and a predictive nomogram model was established. The receiver operating characteristic (ROC) curve was drawn to evaluate the predictive effect of the nomogram model. The Hosmer-Lemeshow method was used to test the calibration degree. Results. Among the patients, 63 patients (43.75%) encountered CCE. Multivariate logistic regression analysis showed that age >60 years old, history of CCE, dialysis age >12 months, systolic blood pressure >140 mmHg, blood phosphorus level >1.5 mmol/L, triglyceride (TG) level >2.30 mmol/l, adiponectin (ADPN) level <5 mg/L, high-sensitivity-C-reactive protein (hs-CRP) level >10 mg/L, hemoglobin (Hb) level <120 g/L, serum creatinine (SCr) level >720 μmol/L, and albumin (ALB) level <40 g/L were independent risk factors for CCE. Based on the above independent risk factors, a nomogram model of CCE was created. ROC curve analysis showed that the area under curve for predicting CCE was 0.881 (95% CI: 0.833~0.919), indicating that the nomogram model had great predictive effect. The Hosmer-Lemeshow method showed that the calibration curve was in good agreement with the standard curve. Conclusion. Age, history of CCE, dialysis age, systolic blood pressure and serum phosphorus, and TG, ADPN, hs-CRP, Hb, SCr, and ALB levels are all influencing factors for the occurrence of CCE in patients with DN receiving maintenance hemodialysis, and the nomogram model has a great predictive effect on CCE.

Infrequent use of nighttime dialysis for emergency admission due to worsening heart failure in patients on maintenance hemodialysis

In the emergency admission due to worsening heart failure (HF) in patients on maintenance hemodialysis, emergent dialysis may be indicated, which increases personnel expenses. To clarify the characteristics and in-hospital management of the patients, we conducted a multicenter retrospective study including 142 patients on maintenance hemodialysis emergently admitted for worsening HF (71.6 ± 9.2 years, 69.0% male, 44.4% HF with preserved [≥50%] ejection fraction). The interval between last hemodialysis and admission was long (median 55 h), suggesting that fluid accumulation triggered HF events. Although most patients (73.9%) were admitted in the nighttime (5 p.m. to 9 a.m.), only 17.9% of them needed nighttime dialysis and were managed medically until the first in-hospital dialysis, with the use of noninvasive positive pressure ventilation in 45.1% and oxygen supplementation in 95.8%. While patients on hemodialysis with worsening HF were frequently admitted in the nighttime, nighttime dialysis was indicated in a limited population.

Free Standing, Large-Area Silicon Nitride Membranes for High Toxin Clearance in Blood Surrogate for Small-Format Hemodialysis

Developing highly-efficient membranes for toxin clearance in small-format hemodialysis presents a fabrication challenge. The miniaturization of fluidics and controls has been the focus of current work on hemodialysis (HD) devices. This approach has not addressed the membrane efficiency needed for toxin clearance in small-format hemodialysis devices. Dr. Willem Kolff built the first dialyzer in 1943 and many changes have been made to HD technology since then. However, conventional HD still uses large instruments with bulky dialysis cartridges made of ~2 m² of 10 micron thick, tortuous-path membrane material. Portable, wearable, and implantable HD systems may improve clinical outcomes for patients with end-stage renal disease by increasing the frequency of dialysis. The ability of ultrathin silicon-based sheet membranes to clear toxins is tested along with an analytical model predicting long-term multi-pass experiments from single-pass clearance experiments. Advanced fabrication methods are introduced that produce a new type of nanoporous silicon nitride sheet membrane that features the pore sizes needed for middle-weight toxin removal. Benchtop clearance results with sheet membranes (~3 cm²) match a theoretical model and indicate that sheet membranes can reduce (by orders of magnitude) the amount of membrane material required for hemodialysis. This provides the performance needed for small-format hemodialysis.