Fistula and Survival Outcomes after Fistula Creation among Predialysis Chronic Kidney Disease Stage 5 Patients

Late creation of vascular access increased post-hemodialysis mortality, hospitalization, and health-care expenditure: A population-based cohort study in Taiwan

BACKGROUND/PURPOSE

The optimal timing of vascular access (VA) creation for hemodialysis (HD) and whether this timing affects mortality and health-care utilization after HD initiation remain unclear. Thus, we conducted a population-based study to explore their association.

METHODS

We used Taiwan's National Health Insurance Research Database to analyze health-care outcomes and utilization in a cohort initiating HD during 2003-2013. We stratified patients by the following VA creation time points: >180, 91-180, 31-90, and ≤30 days before and ≤30 days after HD initiation and examined all-cause mortality, ambulatory care utilization/costs, hospital admission/costs, and total expenditure within 2 years after HD. Cox regression, Poisson regression, and general linear regression were used to analyze mortality, health-care utilization, and costs respectively.

RESULTS

We identified 77,205 patients who started HD during 2003-2013. Compared with the patients undergoing VA surgery >180 days before HD initiation, those undergoing VA surgery ≤30 days before HD initiation had the highest mortality-15.92 deaths per 100-person-years, crude hazard ratio (HR) 1.56, and adjusted HR 1.28, the highest hospital admissions rates- 2.72 admission per person-year, crude rate ratio (RR) 1.48 and adjusted RR 1.32, and thus the highest health-care costs- US$31,390 per person-year, 7% increase of costs and 6% increase with adjustment within the 2-year follow-up after HD initiation.

CONCLUSION

Late VA creation for HD can increase all-cause mortality, hospitalization, and health-care costs within 2 years after HD initiation. Early preparation of VA has the potential to reduce post-HD mortality and healthcare expenses for the ESKD patients.

Association between urinary C-megalin levels and progressive kidney dysfunction: a cohort study based on the diabetes distress and care registry at Tenri (DDCRT 24)

AIMS

The aim of this cohort study was to evaluate the association between urinary levels of C-megalin, a full-length form of megalin, and kidney dysfunction progression and its dependence on the urinary albumin-creatinine ratio (UACR) in individuals with diabetes.

METHODS

We enrolled 1,547 individuals with diabetes who visited the ambulatory clinic at Tenri Hospital, a regional tertiary-care hospital in Tenri City, Nara Prefecture, Japan, with an estimated glomerular filtration (eGFR) of ≥ 30 mL/min/1.73 m2. The hazard ratio (HR) and 95% confidence interval (CI) were estimated using Cox proportional hazard models to examine the association between urinary C-megalin levels and eGFR decline by ≥ 40% from baseline.

RESULTS

Urinary C-megalin level was not associated with ≥ 40% eGFR decline in an age-, sex-, eGFR-, systolic blood pressure-, hemoglobin-, and UACR-adjusted model in the 1,547 patients enrolled in the study. However, urinary C-megalin levels were associated with a ≥ 40% decline in eGFR when accounting for the relationship between urinary C-megalin levels and UACR in the model. This association was UACR-dependent.

CONCLUSIONS

High urinary C-megalin levels were associated with progressive kidney dysfunction in individuals with diabetes, and this association was attenuated by high UACRs.

Temporary central venous catheter at hemodialysis initiation and reasons for use: a cross-sectional study

Background

Creating permanent vascular access (VA) is recommended before hemodialysis initiation in patients with end-stage renal disease (ESRD). Although many patients are still introduced to hemodialysis with temporary central venous catheters (CVCs), the reasons for their use remain unclear. We aimed to clarify the characteristics of Japanese patients introduced to hemodialysis using temporary CVCs, the reasons for their use, and whether this rate can be reduced in the future.

Methods

We conducted this cross-sectional study in an acute care general hospital in Japan. We enrolled 393 patients aged ≥ 18 years who received a permanent VA creation for initiating hemodialysis. We classified participants into the temporary CVC group or the permanent VA group according to the VA type at hemodialysis initiation and compared their backgrounds. We identified why permanent VA could not be used at hemodialysis initiation for patients in the temporary CVC group.

Results

Of the 393 patients, 137 (35%) initiated hemodialysis with a temporary CVC, and arteriovenous fistulas (AVFs) were created as the first VA in all patients during hospitalization following hemodialysis initiation. The remaining 256 patients (65%) initiated hemodialysis via AVF cannulation. The duration of predialysis nephrology care was significantly shorter in the temporary CVC group than that in the permanent VA group. The median time from AVF creation to the first successful cannulation was also shorter in the temporary CVC group (8 vs. 66 days, P < 0.001), but the estimated glomerular filtration rate values at hemodialysis initiation did not differ. Reasons for temporary CVC use were varied and complex. Problems on the part of healthcare providers, patient behavioral issues, and characteristics of causative kidney disease itself were underlying reasons. Delayed referral to a nephrologist was less frequent than expected (16%) and the most commonly reported reason (20%) was that a nephrologist was unable to predict the timing of hemodialysis initiation.

Conclusions

Patients with ESRD should be referred to a nephrologist earlier for AVF creation. However, given the already relatively high rate of hemodialysis initiation with permanent VA in Japan, we considered it surprisingly difficult to further reduce the temporary CVC usage rate in Japan.