The effect of gender on survival for hemodialysis patients: Why don't women live longer than men?

Comfort Level of Patients Undergoing Hemodialysis and Associated Factors in Turkey: A Cross-Sectional Study

BACKGROUND

Hemodialysis is one of the treatment methods for chronic kidney disease, which is a common disease around the world. The problems that occur during the hemodialysis process may cause discomfort in patients. Therefore, it is important to regularly evaluate the concept of comfort in hemodialysis patients.

AIM

To determine the comfort level of patients undergoing hemodialysis and the associated factors.

METHODS

This study was a descriptive cross-sectional study conducted among 95 patients who had been undergoing hemodialysis for at least 6 months. Data were collected using the sociodemographic characteristics form and the Hemodialysis Comfort Scale (HDCS).

RESULTS

The mean age of the participants was 58.37 ± 16.62 years. The median duration of hemodialysis was 5 (1-25) years. A total of 51% of the patients were male, 54.7% were married, 34.7% had completed primary school, and 85.3% had a comorbid chronic disease. The mean hemodialysis comfort score was 23.85 ± 6.93. The mean score was significantly higher in male patients (P = 0.041) and those without comorbid chronic disease (P = 0.013). There was a significant negative correlation between the age of hemodialysis patients and the mean hemodialysis comfort score (r = -0.260, P = 0.011).

CONCLUSION

The comfort level was significantly better in hemodialysis patients who were male, those without comorbid disease, and those who were younger. There is a need to periodically assess the comfort level of hemodialysis patients and intervene when necessary in order to improve their quality of life.

K, C. G. S, Reddy GG. Gender disparity in maintenance hemodialysis units in South India: a cross-sectional observational study

Background

Diseases manifest differently according to gender in many medical specialties. However, sex differences in kidney diseases have not been well explored worldwide, especially in India. These differences could also be attributed to sociocultural factors. Although CKD is more prevalent in women worldwide, most men are initiated on kidney replacement therapy (KRT). This study aimed to examine sex disparities in patients on maintenance hemodialysis.

Materials and methods

A cross-sectional observational study was conducted in two maintenance hemodialysis units at the Institute of Nephrourology, a tertiary care referral government center in Bengaluru, India. Demographic characteristics and laboratory parameters were also recorded.

Results

In total, 374 adult patients (aged >18 years) were included in the study. Most patients (72.7%) were men. Mean age in men was 46.95 ± 12.65 years, and women was 46.63 ± 13.66 years. There was no significant difference in marital status and the availability of caretakers between the groups. Spouses were the predominant caretakers for both sexes (64% men and 51% women, P = 0.14). Sons cared more for patients with mother than fathers (19.6% vs 8.8%, P = 0.074). Diabetic nephropathy was the most common cause of ESKD in both groups (33.1% vs 31.3%, P = 0.92). Men had a significantly longer duration of HTN and received more HD sessions per week than women. Mean hemoglobin (9.9 ± 1.79 vs 9.46 ± 1.47 g%) and mean serum creatinine (7.76 ± 2.65 vs 6.41 ± 2.27 mg/dl) were higher in men compared to women (P <0.002). Intradialytic complications, such as hypotension and cramps, were significantly more common in women than in men (P = 0.004). Most men (47.1%) were planning a kidney transplant (and were waitlisted) compared with fewer women (43%). There was no significant difference in the average number of hospitalizations per month or HD vintage.

Conclusion

Women tend to initiate dialysis later, and a lesser number are waitlisted for kidney transplantation, which might be partly related to varying access to or delivery of health care services. Factors such as lack of education, insufficient identification of and strategies to address cultural obstacles to healthcare, and a shortage of financial means to afford medical care are potentially correctable elements that might explain this discrepancy.

Long-term Trends in Infection-Related Mortality in Adults Treated With Maintenance Dialysis

RATIONALE & OBJECTIVE

Infection is 1 of the top 3 causes of death in patients receiving maintenance dialysis. We evaluated the trends over time and risk factors for infection-related deaths among people receiving dialysis.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

We included all adults who began dialysis between 1980 and 2018 in Australia and New Zealand.

EXPOSURE

Age, sex, dialysis modality, and dialysis era.

OUTCOME

Infection-related death.

ANALYTICAL APPROACH

Incidence was described and standardized mortality ratios (SMR) calculated for infection-related death. Fine-Gray subdistribution hazards models were fitted, with non-infection-related death and kidney transplantation treated as competing events.

RESULTS

The study comprised 46,074 patients who received hemodialysis and 20,653 who were treated with peritoneal dialysis who were followed for 164,536 and 69,846 person-years, respectively. There were 38,463 deaths during the follow-up period, 12% of which were ascribed to infection. The overall rate of mortality from infection (per 10,000 person-years) was 185 and 232 for patients treated with hemodialysis and peritoneal dialysis, respectively. The rates were 184 and 219 for males and females, respectively; and 99, 181, 255, and 292 for patients aged 18-44, 45-64, 65-74, 75 years and over, respectively. The rates were 224 and 163 for those commencing dialysis in years 1980-2005 and 2006-2018, respectively. The overall SMR declined over time, from 37.1 (95% CI, 35.5-38.8) in years 1980-2005 to 19.3 (95% CI, 18.4-20.3) in years 2006-2018, consistent with the declining 5-year SMR trend (P<0.001). Infection-related mortality was associated with being female, older age, and Aboriginal and/or a Torres Strait Islander or Māori.

LIMITATIONS

Mediation analyses defining the causal relationships between infection type and infection-related death could not be undertaken as disaggregating the data was not feasible.

CONCLUSIONS

The excess risk of infection-related death in patients on dialysis has improved substantially over time but remains more than 20 times higher than in the general population.

Individualized hemodialysis: Is similar hemodialysis adequacy possible using less water?

Background and aim

There are over 60,000 hemodialysis (HD) patients in Türkiye, and the number of patients is increasing yearly. Dialysate flow rate (Qd) is a factor in HD adequacy. Approximately 150 L of water are consumed per session to prepare the dialysate. We aimed to investigate whether HD effectiveness can be achieved at a low Qd in different patient groups for the purpose of saving water.

Materials and methods

This prospective study included 81 HD patients from 2 centers. The patients underwent an aggregate total of 486 HD sessions, including 3 sessions at a Qd of 500 mL/min and 3 sessions at a Qd of 300 mL/min for each patient. We used online Kt/V readings recorded at the end of each dialysis session to compare the effectiveness of these 2 types of HD session performed at a different Qd.

Results

The online Kt/V readings were similar between the standard (500) and low (300) Qd HD (1.51 ± 0.41 and 1.49 ± 0.44, respectively, p = 0.069). In the subgroup analyses, men had higher online Kt/V values at the standard Qd compared to the low Qd (1.35 ± 0.30 and 1.30 ± 0.32, respectively, p = 0.019), but the Kt/V values were not different for women. While the low Qd did not reduce online Kt/V in patients using small surface area dialysis membranes (1.75 ± 0.35 for 300 Qd and 1.75 ± 0.32 for 500 Qd, p = 0.931), it was associated with reduced online Kt/V in patients using large surface area dialysis membranes (1.12 ± 0.25 for 300 Qd and 1.17 ± 0.24 for 500 Qd, p = 0.006). The low Qd did not result in differences in online Kt/V among low-weight patients. However, online Kt/V values were better with the standard Qd in patients weighing 65 kg and above.

Conclusion

In our study, dialysis adequacy at a reduced dialysate flow was not inferior for women, patients with low body weight, or patients using small surface area membranes. Individualized HD at a reduced Qd of 300 mL/min in eligible patients can save 48 L of water per HD session and an average of 7500 L of water per year.

Mortality, health-related quality of life, and depression symptoms in younger and older men and women undergoing hemodialysis

BACKGROUND AND OBJECTIVE

Some studies on maintenance hemodialysis (MHD) patients report a longer survival, albeit with poorer health-related quality of life (HRQoL), and more depression symptoms in women than in men. Whether these gender differences vary with age is uncertain. We tested the associations of gender with mortality, depression symptoms, and HRQoL in MHD patients of different age groups.

METHODS

We used data from 1504 adult MHD patients enrolled in the PROHEMO, a prospective cohort in Salvador, Brazil. The KDQOL-SF was used for the component summaries of the mental (MCS) and physical (PCS) HRQoL scales. Depression symptoms were assessed by the complete version of the Center for Epidemiological Studies Depression Screening Index (CES-D). To test for gender differences, extensively adjusted linear models were used for depression and HRQoL scores, and Cox models for death hazard ratio (HR).

RESULTS

Women reported worse HRQoL than men, particularly for ages ⩾60 years. In the age group ⩾60 years, the adjusted difference (AD) in score was -3.45; 95% CI: -6.81, -0.70 for MCS -3.16; -5.72, -0.60 for PCS. Older (⩾60 years) women also had more depression symptoms (AD 4.98; 2.33, 7.64). Mortality was slightly lower in women than in men with an adjusted HR of 0.89 (0.71, 1.11) and consistent across age categories.

CONCLUSIONS

In a sample of Brazilian MHD patients, women had a slightly lower mortality, albeit with more depression symptoms and poorer HRQoL than men, particularly among older patients. This study highlights the need to investigate gender inequalities for MHD patients across different cultures and populations.

Access to treatment in chronic kidney disease, dialysis and transplantation. Is there gender equality?

Sex and gender are often used as synonyms. However, while sex describes only a biological state, gender is a dynamic concept that takes into account psychosocial and cultural aspects of human existence that can change according to place and time. Inequality in medicine has been described in several areas. Among them, gender inequality has been disregarded for many years and is now a matter of concern. Chronic kidney disease (CKD) is a growing epidemic worldwide, affecting approximately 10% of the population. Although both men and women are affected, gender equality, especially in access to different treatments, is a matter of concern. We decided to investigate gender equality in patients with CKD. To this end, we conducted a literature narrative review to determine whether gender inequalities were found in CKD patients in general and in access to different treatment modalities in particular. A non-language restricted search was performed until November 30th 2022 in PubMed, SciELO, Trip Database, Google Scholar, MEDES y MEDLINE. We also investigated the situation in this regard in our country. We found that CKD is more prevalent in women than men, nevertheless this prevalence decreases along the CKD stages to the point that more men reach end stage kidney disease (ESKD) and dialysis. Access to transplant (ATT) is higher in men than in women although posttransplant survival shows no gender differences. Finally, most series have shown that women are more frequently Kidney transplantation (KT) living donors than men. Results in our country are similar to the published literature with the exception of a higher proportion of men as KT living donors. As in other areas, gender inequality in Nephrology has been largely overlooked. In this review we have highlighted gender differences in CKD patients. Gender inequality in Nephrology exists and needs to be looked upon in order to reach a personalized clinical approach.

Sex and Gender in Randomized Controlled Trials of Adults Receiving Maintenance Dialysis: A Meta-epidemiologic Study

RATIONALE & OBJECTIVE

How sex and gender concepts are incorporated into randomized controlled trials (RCTs) in adults with kidney failure receiving maintenance dialysis is largely unknown. We describe these practices in published journal articles as well as investigate the proportion of women and female participants in these studies.

STUDY DESIGN

Meta-epidemiologic study.

SETTING & STUDY POPULATIONS

RCTs in maintenance dialysis.

SELECTION CRITERIA FOR STUDIES

Trials published in high-impact journals in 2000-2020.

DATA EXTRACTION

Implemented in duplicate with conflicts resolved by a third reviewer.

ANALYTICAL APPROACH

Meta-regression was performed to identify trial characteristics independently associated with the proportion of women and female participants.

RESULTS

Among 561 included RCTs, 69.7% were parallel and 28.0% were crossover in design; 80.6% were conducted in the hemodialysis population; and 25% of trials compared the treatment of interest with a placebo arm, 25% with a usual care treatment arm, and 50% with an active alternative therapy arm. Of the RCTS, 37.6% were masked. The median size was 60 (IQR, 26-151) participants, and the median follow-up period was 154 (IQR, 42-365) days. The mean proportion of women or female participants was 0.40±0.13 (SD): 39.0% of trials reported sex, and 26.6% reported the gender of the participants. Also, 56.2% referred to participants as females, 25.3% referred to participants as women, and 15.5% referred to both females and women. No trial characteristic other than region (β of 0.062 [95% CI, 0.007-0.117] for Asia) was associated with the proportion of women or female participants. Considering trial design and conduct, 2.7% of trials used sex and/or gender as an inclusion criterion, 26.6% as an exclusion criterion, 4.5% for randomization, 4.8% for subgroup analyses, and 15.7% for covariate adjustment.

LIMITATIONS

Only high-impact journal articles were studied; and the included studies lacked pediatric trials, those addressing chronic kidney disease or kidney transplantation, any trials from Africa and underrepresentation of other regions, and missing data.

CONCLUSIONS

RCTs in dialysis are representative of the general dialysis population with regard to sex and gender but they uncommonly report both and often do not include either in their reporting or analysis.

Sex-Based Differences in Risk Factors and Complications of Chronic Kidney Disease

Globally, females are ∼30% more likely to have pre-dialysis chronic kidney disease (CKD) than males for reasons that are not fully understood. CKD is associated with numerous adverse health outcomes which makes understanding and working to eradicating sex based disparities in CKD prevalence essential. This review maps both what is known, and what is unknown, about the way sex and gender impacts (1) the epidemiology and risk factors for CKD including age, diabetes, hypertension, obesity, smoking, and cerebrovascular disease, and (2) the complications from CKD including kidney disease progression, cardiovascular disease, CKD mineral and bone disorders, anaemia, quality-of-life, cancer and mortality. This mapping can be used to guide future research.

Dietary protein intake and the risk of all-cause and cardiovascular mortality in maintenance hemodialysis patients: A multicenter, prospective cohort study

OBJECTIVES

The association between dietary protein intake (DPI) and mortality in people receiving maintenance hemodialysis (MHD) remains uncertain. We aimed to explore the relationship of DPI with all-cause and cardiovascular (CV) mortality, and to examine the possible modifiers for the associations, in Chinese MHD patients.

METHODS

This multicenter prospective cohort study was conducted in eight outpatient dialysis centers in South China. We enrolled 1044 MHD patients in 2014 and 2015. The DPI was assessed using a 3-d 24-h dietary recall. Using Cox proportional hazard models, we estimated the hazard ratios (HRs) with their corresponding 95% confidence intervals (CIs) for all analyzed end points.

RESULTS

During a median follow-up of 45 mo, there were 354 (33.9%) deaths, 210 of which were CV related. Compared with patients with a DPI of 1.0 to < 1.4 g/kg ideal body weight (IBW)/d, a significantly higher risk of all-cause mortality was found in those with a DPI < 1.0 g/kg IBW/d (adjusted HR, 1.84; 95% CI, 1.42-2.38) or ≥ 1.4 g/kg IBW/d (adjusted HR, 1.49; 95% CI, 1.00-2.22). Similar trends were found for CV mortality. Moreover, we found a significantly stronger positive association between DPI (≥ 1.4 versus 1.0 to < 1.4 g/kg IBW/d) and all-cause mortality in women (adjusted HR, 2.05; 95% CI, 1.00-4.22) than in men (adjusted HR, 0.89; 95% CI, 0.49-1.63; P for interaction = 0.0487).

CONCLUSION

In Chinese MHD patients, a DPI of 1.0 to < 1.4 g/kg IBW/d was associated with lower risks of all-cause and CV mortality.

Effect of altitude on mortality of end-stage renal disease patients on hemodialysis in Peru

Background

In Latin America, the prevalence of end-stage kidney disease (ESKD) has risen tremendously during the last decade. Previous studies have suggested that receiving dialysis at high altitude confers mortality benefits; however, this effect has not been demonstrated at >2000 m above sea level (masl) or in developing countries.

Methods

This historical cohort study analyzed medical records from six Peruvian hemodialysis (HD) centers located at altitudes ranging from 44 to 3827 masl. Adult ESKD patients who started maintenance HD between 2000 and 2010 were included. Patients were classified into two strata based on the elevation above sea level of their city of residence: low altitude (<2000 masl) and high altitude (≥2000 masl). Death from any cause was collected from national registries and Cox proportional hazards models were built.

Results

A total of 720 patients were enrolled and 163 (22.6%) resided at high altitude. The low-altitude group was significantly younger, more likely to have diabetes or glomerulonephritis as the cause of ESKD and higher hemoglobin. The all-cause mortality rate was 84.3 per 1000 person-years. In the unadjusted Cox model, no mortality difference was found between the high- and low-altitude groups {hazard ratio [HR] 1.20 [95% confidence interval (CI) 0.89-1.62]}. After multivariable adjustment, receiving HD at high altitude was not significantly associated with higher mortality, but those with diabetes as the cause of ESKD had significantly higher mortality [HR 2.50 (95% CI 1.36-4.59)].

Conclusions

In Peru, patients receiving HD at high altitudes do not have mortality benefits.

The renal replacement therapy landscape in 2030: reducing the global cardiovascular burden in dialysis patients

Despite the significant progress made in understanding chronic kidney disease and uraemic pathophysiology, use of advanced technology and implementation of new strategies in renal replacement therapy, the clinical outcomes of chronic kidney disease 5 dialysis patients remain suboptimal. Considering residual suboptimal medical needs of short intermittent dialysis, it is our medical duty to revisit standards of dialysis practice and propose new therapeutic options for improving the overall effectiveness of dialysis sessions and reduce the burden of stress induced by the therapy. Several themes arise to address the modifiable components of the therapy that are aimed at mitigating some of the cardiovascular risks in patients with end-stage kidney disease. Among them, five are of utmost importance and include: (i) enhancement of treatment efficiency and continuous monitoring of dialysis performances; (ii) prevention of dialysis-induced stress; (iii) precise handling of sodium and fluid balance; (iv) moving towards heparin-free dialysis; and (v) customizing electrolyte prescriptions. In summary, haemodialysis treatment in 2030 will be substantially more personalized to the patient, with a clear focus on cardioprotection, volume management, arrhythmia surveillance, avoidance of anticoagulation and the development of more dynamic systems to align the fluid and electrolyte needs of the patient on the day of the treatment to their particular circumstances.