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Hafeez MS, Abdul-Malak OM, Eslami MH, Chaer RA, Yuo TH. Carotid Endarterectomy Should Not Be Recommended to End-Stage Kidney Disease Patients with Asymptomatic Carotid Artery Disease. Ann Vasc Surg 2024; 101:53-61. [PMID: 37914071 PMCID: PMC10957297 DOI: 10.1016/j.avsg.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/06/2023] [Accepted: 08/21/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Carotid endarterectomy (CEA) for asymptomatic carotid artery disease is advised for patients with low perioperative stroke risk and life expectancy of 3-5 years. We sought to explore the role of risk stratification and postoperative medical management in identifying appropriate asymptomatic candidates for CEA in the end-stage kidney disease (ESKD) population. METHODS We identified ESKD patients on dialysis from the United States Renal Data System that underwent CEA (2008-2014) for asymptomatic carotid artery disease. We used the Liu comorbidity index as well as a novel risk prediction model based on Cox proportional hazards model to stratify patients. The primary outcome evaluated was 3-year survival, and Kaplan-Meier methods were used to generate survival estimates. We further conducted a subanalysis of patients with Medicare part D data to determine postoperative usage of the following medications: statins, antiplatelets, and antihypertensives. We evaluated the association of medication utilization and 3-year survival using Kaplan-Meier methods and Cox proportional hazards modeling. RESULTS We analyzed 1,813 patients meeting inclusion criteria. The population was predominantly older (mean age 70.2 ± 9.1), White (84.8%), and had a high prevalence of cardiovascular comorbidities, such as hypertension (90.7%), diabetes (62.5%), and congestive heart failure (35.4%). Among the entire cohort, 23.0% had a Liu comorbidity index ≤8, 35.0% had index 9-12, and 42.0% had index >12. Increasing Liu comorbidity index was associated with worse survival (P < 0.01); however, even the group with Liu index ≤8 had poor 3-year survival of 58.8% (53.9-63.4). The Cox proportional hazards model identified variables for inclusion in the risk model such as age >80 (adjusted hazard ratio [aHR] = 2.49, 95% confidence interval [CI] [1.87-3.33], P < 0.001), congestive heart failure (aHR = 1.31, 95% CI [1.14-1.51], P < 0.001), and Liu comorbidity index >12(aHR = 1.89, 95% CI [1.56-2.28], P < 0.001). The risk score generated ranged from 0 to 6.5, and patients were divided into 3 groups: score ≤2 (43.4%), 2-4 (41.2%), and >4 (15.4%). Increasing risk score was associated with worse survival (P < 0.01) but even the "low-risk" group had 3-year survival of 58.5% (54.9-61.9). Subanalysis of the 1,249 (68.8% of total) patients with part D data found that statins and calcium channel blocker use was associated with improved survival, although observed rates for patients on drug were still low. CONCLUSIONS The overall long-term survival of ESKD patients undergoing CEA for asymptomatic carotid artery disease is low. Risk stratification and analysis of postoperative medical management did not identify a subgroup of patients with adequate 3-year survival. Hence, the preventive benefits of CEA are not realized in these patients.
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Affiliation(s)
- Muhammad Saad Hafeez
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Othman M Abdul-Malak
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Theodore H Yuo
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Toapanta N, Comas J, León Román J, Ramos N, Azancot M, Bestard O, Tort J, Soler MJ. Mortality in elderly patients starting hemodialysis program. Semin Dial 2022. [PMID: 35817409 DOI: 10.1111/sdi.13114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/31/2022] [Accepted: 06/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The incidence of older patients over 80 years old with chronic kidney disease who start hemodialysis (HD) program has been increasing in the last decade. METHODS We aimed to identify risk factors for morbidity and mortality in patients older than 80 years with end-stage renal disease who started HD. We conducted a retrospective observational study of the Catalan Renal registry (RMRC). RESULTS A total of 2833 patients equal or older than 80 years (of 15,137) who started HD between 2002 and 2019 from the RMRC were included in the study. In this group, the first dialysis was performed through an arteriovenous fistula in 44%, percutaneous catheter in 28.2%, and tunneled catheter in 26.6%. Conventional dialysis was used in 65.7% and online HD in 34.3%. The most frequent cause of death was cardiac disease (21.8%), followed by social problems (20.4%) and infections (15.9%). Overall survival in older HD during the first year was 84% versus 91% in younger than 80 years (p < 0.001). Cox regression analysis identified the start of HD in the period 2002-2010, chronic obstructive pulmonary disease (COPD), and the onset of HD through vascular graft depicted as risk factors for first-year mortality after dialysis initiation in patients older than 80 years with end-stage renal disease who started HD. CONCLUSIONS In conclusion, patients older than 80 years who started HD program had higher mortality, especially those who presented exacerbation of kidney disease, those with COPD, and those who started with a vascular graft.
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Affiliation(s)
- Néstor Toapanta
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Jordi Comas
- Catalan Transplantation Organization, Barcelona, Spain
| | - Juan León Román
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Natalia Ramos
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - María Azancot
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Oriol Bestard
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Jaume Tort
- Catalan Transplantation Organization, Barcelona, Spain
| | - María José Soler
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
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The impact of muscle mass loss and deteriorating physical function on prognosis in patients receiving hemodialysis. Sci Rep 2021; 11:22290. [PMID: 34785712 PMCID: PMC8595648 DOI: 10.1038/s41598-021-01581-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/25/2021] [Indexed: 01/06/2023] Open
Abstract
Muscle mass loss and worsening physical function are crucial issues in patients receiving hemodialysis (HD). However, few studies have investigated the association between temporal changes in muscle mass and physical function in a large number of HD patients. We examined 286 patients receiving HD (males, 58%; age, 66.8 ± 13.0 years) at a single center, and calculated the percent changes in psoas muscle mass index (%PMI) using computed tomography over two screenings, once per year (July 2011–June 2013). Physical function was evaluated using the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) (range 0–4). The observation period was from July 2012 to June 2021. The median %PMI was -9.5%, and those with the lowest quartile of %PMI (< −20.5%) showed a significantly poor prognosis compared with other patients (p < 0.001). Multivariable logistic regression analysis revealed that these patients tended to have decreased physical function (ECOG-PS 2–4) [odds ratio (OR): 2.46, p < 0.001] and albumin levels (OR: 0.22, p = 0.007). Multiple-factor-adjusted Cox regression analyses showed that %PMI (hazard ratio: 0.99, p = 0.004) and each ECOG-PS stage (1–4 vs. 0) (p < 0.01) were associated with mortality. Augmenting physical activities in daily life and serum albumin levels should be considered to maintain muscle mass and improve the prognosis of patients receiving HD.
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Song YH, Cai GY, Xiao YF, Chen XM. Risk factors for mortality in elderly haemodialysis patients: a systematic review and meta-analysis. BMC Nephrol 2020; 21:377. [PMID: 32867718 PMCID: PMC7457491 DOI: 10.1186/s12882-020-02026-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 08/18/2020] [Indexed: 12/16/2022] Open
Abstract
Background Older haemodialysis patients accompany a high burden of functional impairment, limited life expectancy, and healthcare utilization. This meta-analysis aimed to evaluate how various risk factors influenced the prognosis of haemodialysis patients in late life, which might contribute to decision making by patients and care providers. Methods PubMed, Embase, and Cochrane Central were searched systematically for studies evaluating the risk factors for mortality in elderly haemodialysis patients. Twenty-eight studies were included in the present systematic review. The factors included age, cardiovascular disease, diabetes mellitus, type of vascular access, dialysis initiation time, nutritional status and geriatric impairments. Geriatric impairments included frailty, cognitive or functional impairment and falls. Relative risks with 95% confidence intervals were derived. Results Functional impairment (OR = 1.45, 95% CI: 1.20–1.75), cognitive impairment (OR = 1.46, 95% CI: 1.32–1.62) and falls (OR = 1.14, 95% CI: 1.06–1.23) were significantly and independently associated with increased mortality in elderly haemodialysis patients. Low body mass index conferred a mortality risk (OR = 1.43, 95% CI: 1.31–1.56) paralleling that of frailty as a marker of early death. The results also confirmed that the older (OR = 1.43, 95% CI: 1.22–1.68) and sicker (in terms of Charlson comorbidity index) (OR = 1.41, 95% CI: 1.35–1.50) elderly haemodialysis patients were, the more likely they were to die. In addition, increased mortality was associated with early-start dialysis (OR = 1.18, 95% CI: 1.01–1.37) and with the use of a central venous catheter (OR = 1.53, 95% CI: 1.44–1.62). Conclusions Multiple factors influence the risk of mortality in elderly patients undergoing haemodialysis. Geriatric impairment is related to poor outcome. Functional/cognitive impairment and falls in elderly dialysis patients are strongly and independently associated with mortality.
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Affiliation(s)
- Yu-Huan Song
- Department of Nephrology, Aerospace Center Hospital, 15 Yuquan Road, Beijing, 100049, China.,Department of Nephrology, Chinese PLA Generl Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, 28 Fuxing Road, Beijing, 100853, China
| | - Guang-Yan Cai
- Department of Nephrology, Chinese PLA Generl Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, 28 Fuxing Road, Beijing, 100853, China.
| | - Yue-Fei Xiao
- Department of Nephrology, Aerospace Center Hospital, 15 Yuquan Road, Beijing, 100049, China.
| | - Xiang-Mei Chen
- Department of Nephrology, Chinese PLA Generl Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, 28 Fuxing Road, Beijing, 100853, China
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de Alencar SBV, Dias LDA, Dias VDA, de Lima FM, Montarroyos UR, de Petribú KCL. Quality of life may be a more valuable prognostic factor than depression in older hemodialysis patients. Qual Life Res 2020; 29:1829-1838. [PMID: 32062755 DOI: 10.1007/s11136-020-02445-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2020] [Indexed: 01/23/2023]
Abstract
PURPOSE Depression and impairment of quality of life (QoL) reduce the survival of individual on hemodialysis (HD). However, few studies evaluated the impact of these conditions on the survival of older patients undergoing HD. METHODS A retrospective cohort study was performed including patients aged ≥ 60 years on HD in Recife, Brazil, assessed in 2013 and monitored until 2017. Depression was evaluated with the Mini-International Neuropsychiatric Interview and QoL with the Control, Autonomy, Self-realization, and Pleasure Questionnaire (CASP-16). Survival differences according to the depression and QoL status were measured by Kaplan-Meier analysis and Cox regression. Death Certificates were analyzed to assess the cause of death. RESULTS A total of 171 patients were included (mean age 68.7 ± 6.9 years). The mean follow-up time was 3 years (maximum 4.5 years) and there were 98 deaths (57.3% of the sample). In a multivariate model that included depression and QoL, only QoL impairment was associated with a higher risk of death (HR 1.62, p = 0.035). Among CASP domains, only "Control" was associated with survival (HR 0.90, p = 0.014). Depression was unrelated to the cause of death, but there was a trend for death by endocrine diseases if QoL was impaired (p = 0.057). CONCLUSION QoL impairment is a key predictor of prognosis in older patients on HD and may be more important than depression. It is important that teams dealing with this population include in protocols an assessment of QoL, in order to offer a range of care according to the needs of these patients.
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Affiliation(s)
- Saulo Barbosa Vasconcelos de Alencar
- Postgraduate in Health Sciences Program, Universidade de Pernambuco, Av. Gov. Agamenon Magalhães, S/N - Santo Amaro, Recife, PE, 50100-010, Brazil.
| | - Luana do Amaral Dias
- Postgraduate in Health Sciences Program, Universidade de Pernambuco, Av. Gov. Agamenon Magalhães, S/N - Santo Amaro, Recife, PE, 50100-010, Brazil
| | - Victor do Amaral Dias
- Postgraduate in Health Sciences Program, Universidade de Pernambuco, Av. Gov. Agamenon Magalhães, S/N - Santo Amaro, Recife, PE, 50100-010, Brazil
| | - Fábia Maria de Lima
- Postgraduate in Health Sciences Program, Universidade de Pernambuco, Av. Gov. Agamenon Magalhães, S/N - Santo Amaro, Recife, PE, 50100-010, Brazil
| | - Ulisses Ramos Montarroyos
- Postgraduate in Health Sciences Program, Universidade de Pernambuco, Av. Gov. Agamenon Magalhães, S/N - Santo Amaro, Recife, PE, 50100-010, Brazil
| | - Kátia Cristina Lima de Petribú
- Postgraduate in Health Sciences Program, Universidade de Pernambuco, Av. Gov. Agamenon Magalhães, S/N - Santo Amaro, Recife, PE, 50100-010, Brazil
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