No Survival Benefit in Octogenarians and Nonagenarians with Extended Hemodialysis Treatment Time

Nutritional and Dietary Management of Chronic Kidney Disease Under Conservative and Preservative Kidney Care Without Dialysis

While dialysis has been the prevailing treatment paradigm for patients with advanced chronic kidney disease (CKD), emphasis on conservative and preservative management in which dietary interventions are a major cornerstone have emerged. Based on high-quality evidence, international guidelines support the utilization of low-protein diets as an intervention to reduce CKD progression and mortality risk, although the precise thresholds (if any) for dietary protein intake vary across recommendations. There is also increasing evidence demonstrating that plant-dominant low-protein diets reduce the risk of developing incident CKD, CKD progression, and its related complications including cardiometabolic disease, metabolic acidosis, mineral and bone disorders, and uremic toxin generation. In this review, we discuss the premise for conservative and preservative dietary interventions, specific dietary approaches used in conservative and preservative care, potential benefits of a plant-dominant low-protein diet, and practical implementation of these nutritional strategies without dialysis.

Impact of haemodialysis hours on outcomes in older patients

AIM

Previous studies report an association between longer haemodialysis treatment sessions and improved survival. Worldwide, there is a trend to increasing age among prevalent patients receiving haemodialysis. This analysis aimed to determine whether the mortality benefit of longer haemodialysis treatment sessions diminishes with increasing age.

METHODS

This was a retrospective cohort study of people who first commenced thrice-weekly haemodialysis aged ≥65 years, reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry from 2005 to 2015, included from 90 days after dialysis start. The primary outcome was all-cause mortality. Cox regression analysis was performed with haemodialysis session duration the exposure of interest.

RESULTS

Of 8224 people who commenced haemodialysis as their first treatment for kidney failure aged ≥65 years during this period, 4727 patients died. Longer dialysis hours per session was associated with a decreased risk of death in unadjusted analyses [hazard ratio, HR, for ≥5 h versus 4 to <4.5 h: 0.81 (0.75-0.88, p < .001)]. Patients having longer dialysis sessions were younger but had greater co-morbidity. In an adjusted model including age and other variables, the survival benefit of longer hours was only partially attenuated [HR for previous comparison: 0.75 (0.69-0.82, p < .001)], and no interaction between age and hours was demonstrated (p = .89).

CONCLUSION

The apparent survival benefit associated with longer haemodialysis session length appears to be preserved in patients 65 years or older. In practice, the benefit of longer dialysis hours should be carefully weighed against other factors in this patient group.

Kt/V: achievement, predictors and relationship to mortality in hemodialysis patients in the Gulf Cooperation Council countries: results from DOPPS (2012-18)

BACKGROUND

Dialysis adequacy, as measured by single pool Kt/V, is an important parameter for assessing hemodialysis (HD) patients' health. Guidelines have recommended Kt/V of 1.2 as the minimum dose for thrice-weekly HD. We describe Kt/V achievement, its predictors and its relationship with mortality in the Gulf Cooperation Council (GCC) (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates).

METHODS

We analyzed data (2012-18) from the prospective cohort Dialysis Outcomes and Practice Patterns Study for 1544 GCC patients ≥18 years old and on dialysis >180 days.

RESULTS

Thirty-four percent of GCC HD patients had low Kt/V (<1.2) versus 5%-17% in Canada, Europe, Japan and the USA. Across the GCC countries, low Kt/V prevalence ranged from 10% to 54%. In multivariable logistic regression, low Kt/V was more common (P < 0.05) with larger body weight and height, being male, shorter treatment time (TT), lower blood flow rate (BFR), greater comorbidity burden and using HD versus hemodiafiltration. In adjusted Cox models, low Kt/V was strongly related to higher mortality in women [hazard ratio (HR) = 1.91, 95% confidence interval (CI) 1.09-3.34] but not in men (HR = 1.16, 95% CI 0.70-1.92). Low BFR (<350 mL/min) and TT (<4 h) were common; 41% of low Kt/V cases were attributable to low BFR or TT (52% for women and 36% for men).

CONCLUSION

Relatively large proportions of GCC HD patients have low Kt/V. Increasing BFR to ≥350 mL/min and TT to ≥4 h thrice weekly will reduce low Kt/V prevalence and may improve survival in GCC HD patients-particularly among women.

Comparison of dialysis dose through real-time Kt/V by ultraviolet absorbance of spent dialysate, single-pool Daugirdas II, and Kt/BSA according to sex and age

BACKGROUND

Kt/V OnLine (Kt/VOL) avoids inaccuracies associated with the estimation of urea volume distribution (V). The study aimed to compare Kt/VOL, Kt/V Daugirdas II, and Kt/BSA according to sex and age.

METHODS

Urea volume distribution and body surface area were obtained by Watson and Haycock formulas in 47 patients. V/BSA was considered as a conversion factor from Kt/V to Kt/BSA. Dry weight was determined before the study. Kt/VOL was obtained on DIALOG machines.

RESULTS

Pearson correlation between Kt/VOL vs Kt/VII and Kt/VOL vs Kt/BSA was significant for males (r = 0.446, P = 0.012 and r = -0.476 P = 0.007) and individuals < 65 years (0.457, P = 0.019 and -0.549 P = 0.004), but not for females and individuals ≥ 65 years. V/BSA between individuals < 65 and individuals ≥ 65 years were 18.28 ± 0.15 and 18.18 ± 0.16 P = 0.000). No agreement between Kt/VII vs Kt/BSA. Men and individuals > 65 years received a larger dialysis dose than, respectively, females and individuals < 65 years, in the comparison between Kt/VOL versus Kt/VII. V/BSA ratios among men and women were respectively 18.29 ± 0.13 and 18.12 ± 0.15 P = 0.000.

CONCLUSIONS

Kt/VOL allows recognition of real-time dose regardless of sex and age.