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Samaan F, Mendes Á, Carnut L. Privatization and Oligopolies of the Renal Replacement Therapy Sector on Contemporary Capitalism: A Systematic Review and the Brazilian Scenario. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:417-435. [PMID: 38765895 PMCID: PMC11100955 DOI: 10.2147/ceor.s464120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/03/2024] [Indexed: 05/22/2024] Open
Abstract
Worldwide the assistance on renal replacement therapy (RRT) is carried out mainly by private for-profit services and in a market with increase in mergers and acquisitions. The aim of this study was to conduct an integrative systematic review on privatization and oligopolies in the RRT sector in the context of contemporary capitalism. The inclusion criteria were scientific articles without language restrictions and that addressed the themes of oligopoly or privatization of RRT market. Studies published before 1990 were excluded. The exploratory search for publications was carried out on February 13, 2024 on the Virtual Health Library Regional Portal (VHL). Using the step-by-step of PRISMA flowchart, 34 articles were retrieved, of which 31 addressed the RRT sector in the United States and 26 compared for-profit dialysis units or those belonging to large organizations with non-profit or public ones. The main effects of privatization and oligopolies, evaluated by the studies, were: mortality, hospitalization, use of peritoneal dialysis and registration for kidney transplantation. When considering these outcomes, 19 (73%) articles showed worse results in private units or those belonging to large organizations, six (23%) studies were in favor of privatization or oligopolies and one study was neutral (4%). In summary, most of the articles included in this systematic review showed deleterious effects of oligopolization and privatization of the RRT sector on the patients served. Possible explanations for this result could be the presence of conflicts of interest in the RRT sector and the lack of incentive to implement the chronic kidney disease care line. The predominance of articles from a single nation may suggest that few countries have transparent mechanisms to monitor the quality of care and outcomes of patients on chronic dialysis.
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Affiliation(s)
- Farid Samaan
- Planning and Evaluation Group, São Paulo State Health Department, São Paulo, SP, Brazil
- Research Division, Dante Pazzanese Cardiology Institute, São Paulo, SP, Brazil
| | - Áquilas Mendes
- Public Health School, University of São Paulo, São Paulo, SP, Brazil
- Postgraduate Program, Pontifícia Universidade Católica, São Paulo, SP, Brazil
| | - Leonardo Carnut
- Center for the Development of Higher Education in Health, Federal University of São Paulo, São Paulo, SP, Brazil
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Bayin Donar G, Top M. Effects of treatment adherence and patient activation on health care utilization in chronic kidney disease. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2023. [DOI: 10.1080/20479700.2022.2162120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Gamze Bayin Donar
- Department of Health Care Management, Faculty of Economics and Administrative Sciences, Hacettepe University, Ankara, Turkey
| | - Mehmet Top
- Department of Health Care Management, Faculty of Economics and Administrative Sciences, Hacettepe University, Ankara, Turkey
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Caro Martínez A, González Vera MDLÁ, Prieto Velasco M, Olry de Labry Lima A. Evidence on outsourcing dialysis services: a scoping review. Nefrologia 2022; 42:621-632. [PMID: 36914543 DOI: 10.1016/j.nefroe.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/06/2021] [Indexed: 06/18/2023] Open
Abstract
INTRODUCTION Chronic kidney disease represents an important health problem, due to its high incidence and prevalence, as well as its significant morbidity and mortality and socioeconomic cost. AIMS compare the effectiveness and economic consequences of outsourcing versus hospital dialysis. METHOD A scoping review, for which different databases were consulted, using controlled and free terms. Those articles that compared concerted versus in hospital dialysis in terms of effectiveness were included. Likewise, those publications that compared, in the Spanish field, the cost between both modes of service provision and the public price rates of the different Autonomous Communities were included. RESULTS 11 articles were included in this review: 8 on comparison of effectiveness, all of them in the USA, and 3 on costs. A higher rate of hospitalization was observed in subsidized centers, but no differences in mortality were observed. Additionally, greater competition among providers was associated with lower hospitalization rates. The cost studies reviewed show that hospital hemodialysis is more expensive than in subsidized centers, due to the structural costs. The data of the public rates of the different Autonomous Communities show a wide heterogeneity in the payment of the concerts. CONCLUSIONS the coexistence in Spain of public and subsidized centers, the variability in the provision and costs of dialysis techniques, and the low of evidence on the effectiveness of outsourcing treatment show all the need to continue promoting strategies that result in improvement in the care for Chronic Kidney Disease.
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Affiliation(s)
- Araceli Caro Martínez
- Escuela Andaluza de Salud Pública (EASP), Granada, Spain; Programa de Doctorado Interuniversitario en Ciencias de la Salud, Universidad de Jaén-Universidad de Sevilla (UJA-US), Sevilla, Spain
| | | | | | - Antonio Olry de Labry Lima
- Escuela Andaluza de Salud Pública (EASP), Granada, Spain; Instituto de Investigación Biosanitaria, ibs, Granada, Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Spain.
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Caro Martínez A, González Vera MDLÁ, Prieto Velasco M, Olry de Labry Lima A. Evidencia sobre la externalización de los servicios de diálisis: Una revisión de alcance. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Liu SY, Cheng CY, Wu MY, Zheng CM, Hsu CC, Wu MS, Lin YC. Effect of profit status in facilities on the mortality of patients on long-term haemodialysis: a nationwide cohort study. BMJ Open 2021; 11:e045832. [PMID: 34475147 PMCID: PMC8413873 DOI: 10.1136/bmjopen-2020-045832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Over the past two decades, debates on whether the profit status of dialysis facilities influences patient prognosis have been popular in the USA. Taiwan is one of the regions with the highest rate per capita of kidney replacement therapy worldwide, but no similar research has been conducted to date. This is the first study to address this issue. DESIGN This was a nationwide retrospective cohort study based on the Taiwan Renal Registry Data System. SETTING Patients were categorised into two groups based on the profit status (for-profit, not-for-profit (NFP)) of dialysis facilities, with 31 350 patients in each group. The patients were followed up from 2005 to 2012. PARTICIPANTS Patients with uraemia who underwent long-term haemodialysis in private dialysis facilities and public facilities were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES Survival analyses were performed to compare prognosis between the two groups. Adjustments to patients' basic profile, and facilities' geographical distribution, level, and length of ownership were carried out to minimise possible confounding effects. RESULTS Analysis revealed that NFP dialysis facilities had better outcomes (HR=0.91, 95% CI (0.89 to 0.93)). A favourable effect remains with the adjustment of the facilities' level, geographical distribution (HR=0.89, 95% CI (0.86 to 0.93)) or length of ownership (HR=0.95, 95% CI (0.89 to 0.95)). Survival analysis based on the geographical distribution and level of facilities was also conducted, which showed better prognosis in medical centres in the six municipalities, whereas worse prognosis was found in local hospitals not located in these municipalities. CONCLUSION Our findings suggest that in contemporary settings in Taiwan, treatment at NFP dialysis facilities was associated with a better prognosis. The results should be interpreted with caution since the possibility of residual confounding effects and uncertainty of casual relations exist due to the nature of observational studies.
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Affiliation(s)
- Sheng-Yu Liu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chung-Yi Cheng
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Wanfang Hospital, Taipei, Taiwan
- TMU Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
| | - Mei-Yi Wu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Cai-Mei Zheng
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Chih-Cheng Hsu
- National Health Research Institutes, Institute of Population Health Sciences, Zhunan, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Yen-Chung Lin
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
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Dickman S, Mirza R, Kandi M, Incze MA, Dodbiba L, Yameen R, Agarwal A, Zhang Y, Kamran R, Couban R, Guyatt G, Hanna S. Mortality at For-Profit Versus Not-For-Profit Hemodialysis Centers: A Systematic Review and Meta-analysis. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2020; 51:371-378. [PMID: 33323016 DOI: 10.1177/0020731420980682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We conducted a systematic review and meta-analysis to assess differences in risk-adjusted mortality rates between for-profit (FP) and not-for-profit (NFP) hemodialysis facilities. We searched 10 databases for studies published between January 2001 to December 2019 that compared mortality at private hemodialysis facilities. We included observational studies directly comparing adjusted mortality rates between FP and NFP private hemodialysis providers in any language or country. We excluded evaluations of dialysis facilities that changed their profit status, studies with overlapping data, and studies that failed to adjust for patient age and some measure of clinical severity. Pairs of reviewers independently screened all titles and abstracts and the full text of potentially eligible studies, abstracted data, and assessed risk of bias, resolving disagreement by discussion. We included nine observational studies of hemodialysis facilities representing 1,163,144 patient-years. In pooled random-effects meta-analysis, the odds ratio of mortality in FP relative to NFP facilities was 1.07 (95% CI 1.04-1.11). Patients at FP hemodialysis facilities have 7 percent greater odds of death annually than patients with similar risk profiles at NFP facilities. Approximately 3,800 excess deaths might be averted annually if U.S. FP hemodialysis operators matched NFP mortality rates.
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Affiliation(s)
- Samuel Dickman
- Department of Medicine, University of California, San Francisco, California
| | - Reza Mirza
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maryam Kandi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario
| | - Michael A Incze
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Lorin Dodbiba
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Raad Yameen
- Department of Family Medicine, University of Winnipeg, Winnipeg, Manitoba, Canada
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ying Zhang
- Center for Evidence-based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Rakhshan Kamran
- Michael Degroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Steven Hanna
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario
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Pedrini LA, Winter AC, Cerino F, Zawada AM, Garbelli M, Feuersenger A, Feliciani A, Ruggiero P, Civardi S, Amato C, Canaud B, Stuard S, Karch A, Gauly A. Clinical outcomes of hemodialysis patients in a public-private partnership care framework in Italy: a retrospective cohort study. BMC Nephrol 2019; 20:35. [PMID: 30709341 PMCID: PMC6359808 DOI: 10.1186/s12882-019-1224-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/22/2019] [Indexed: 11/30/2022] Open
Abstract
Background Innovative care models such as public-private partnerships (PPPs) may help meet the challenge of providing cost-effective high-quality care for the steadily growing and complex chronic kidney disease population since they combine the expertise and efficiency of a specialized dialysis provider with the population care approach of a public entity. We report the five-years main clinical outcomes of a population of patients treated on hemodialysis within a PPP-care model in Italy. Methods This descriptive retrospective cohort study consisted of all consecutive hemodialysis patients treated in the NephroCare-operated Nephrology and Dialysis unit of the Seriate Hospital in 2012–2016, which exercises a PPP-care model. Clinical and treatment information was obtained from the European Clinical Database. Hospitalization outcomes and cumulative all-cause mortality incidences that accounted for competing risks were calculated. Results We included 401 hemodialysis patients (197 prevalent and 204 incident patients) in our study. The mean cohort age and age-adjusted Charlson Comorbidity Index were 67.0 years and 6.7, respectively. Patients were treated with online high-volume hemodiafiltration or high-flux hemodialysis. Parameters of treatment efficiency were above the recommended targets throughout the study period. Patients in the PPP experienced benefits in terms of hospitalization (average number of hospital admissions/patient-year: 0.79 and 1.13 for prevalent and incident patients, respectively; average length of hospitalization: 8.9 days for both groups) and had low cumulative all-cause mortality rates (12 months: 10.6 and 7.8%, 5 years: 42.0 and 35.9%, for prevalent and incident patients, respectively). Conclusions Results of our descriptive study suggest that hemodialysis patients treated within a PPP-care model framework received care complying with recommended treatment targets and may benefit in terms of hospitalization and mortality outcomes. Electronic supplementary material The online version of this article (10.1186/s12882-019-1224-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- L A Pedrini
- Department of Nephrology and DialysisNephroCare-ASST Bergamo-Est, Seriate, Italy
| | - A C Winter
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - F Cerino
- NephroCare S.p.A., Naples, Italy
| | - A M Zawada
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany.
| | - M Garbelli
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - A Feuersenger
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - A Feliciani
- Department of Nephrology and DialysisNephroCare-ASST Bergamo-Est, Seriate, Italy
| | - P Ruggiero
- Department of Nephrology and DialysisNephroCare-ASST Bergamo-Est, Seriate, Italy
| | - S Civardi
- Fresenius Medical Care Italia S.p.A, Palazzo Pignano, Italy
| | - C Amato
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - B Canaud
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - S Stuard
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - A Karch
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - A Gauly
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
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Lee YK, Choi HY, Kim K, Cho AJ, Kang WH, Choi YI, Kim DJ. Effect of patient solicitation on mortality among patients receiving hemodialysis in Korea. Patient Prefer Adherence 2019; 13:1073-1082. [PMID: 31308639 PMCID: PMC6619421 DOI: 10.2147/ppa.s208344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/29/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There is concern that overcompetition and illegal activities such as patient solicitation by some dialysis units may threaten patients' health in Korea. Therefore, we investigated the effect of nephrologists' patient-soliciting activity on hemodialysis practices and patients' survival using the Korean Health Insurance Review and Assessment Service database. METHODS We selected 19 soliciting hemodialysis facilities and matched them with 19 non-soliciting facilities located nearby to eliminate location bias. Soliciting behavior was defined as the reduction of medical fees or providing money to attract dialysis patients. RESULTS A total of 2,231 incident dialysis patients were included and followed for a median of 37.2 months. Soliciting facilities had a lower percentage of nephrologists, a higher average daily number of hemodialysis patients per physician, and a higher number of hemodialysis patients per nurse compared with non-soliciting facilities. Survival analysis showed that the crude mortality was significantly higher in patients treated in soliciting facilities than in those treated in non-soliciting facilities, even after adjustment for the effects of many other independently predictive covariates. CONCLUSIONS This study demonstrated that in Korea, the overall mortality rate in incident dialysis patients was higher in those attending soliciting facilities than in those attending non-soliciting facilities.
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Affiliation(s)
- Young-Ki Lee
- Department of Internal Medicine, Hallym Kidney Institute, Hallym University College of Medicine, Seoul, Korea
| | - Hyung-Yun Choi
- Department of Management of Chronic Disease, Korea Centers for Disease Control & Prevention, Cheongju, Chungcheongbuk-do, Korea
| | - Kiwon Kim
- Department of Internal Medicine, National Cancer Center, Goyang, Gyeonggi-do, Korea
| | - AJin Cho
- Department of Internal Medicine, Hallym Kidney Institute, Hallym University College of Medicine, Seoul, Korea
| | - Woo Hun Kang
- Department of Internal Medicine, Samsung Myungin Internal Medicine Clinic, Icheon, Gyeonggi-do, Korea
| | - Young Il Choi
- Department of Internal Medicine, Young IL Choi Internal Medicine Clinic, Suwon, Gyeonggi-do, Korea
| | - Dae Joong Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence: Dae Joong KimDepartment of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul06351, KoreaTel +82 23 410 3441Fax +82 2 829 5309 Email
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Lin E, Kurella Tamura M, Montez-Rath ME, Chertow GM. Re-evaluation of re-hospitalization and rehabilitation in renal research. Hemodial Int 2016; 21:422-429. [PMID: 27766736 DOI: 10.1111/hdi.12497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The use of administrative data to capture 30-day readmission rates in end-stage renal disease is challenging since Medicare combines claims from acute care, inpatient rehabilitation (IRF), and long-term care hospital stays into a single "Inpatient" file. For data prior to 2012, the United States Renal Data System does not contain the variables necessary to easily identify different facility types, making it likely that prior studies have inaccurately estimated 30-day readmission rates. METHODS For this report, we developed two methods (a "simple method" and a "rehabilitation-adjusted method") to identify acute care, IRF, and long-term care hospital stays from United States Renal Data System claims data, and compared them to methods used in previously published reports. FINDINGS We found that prior methods overestimated 30-day readmission rates by up to 12.3% and overestimated average 30-day readmission costs by up to 11%. In contrast, the simple and rehabilitation-adjusted methods overestimated 30-day readmission rates by 0.1% and average 30-day readmission costs by 1.8%. The rehabilitation-adjusted method also accurately identified 96.8% of IRF stays. DISCUSSION Prior research has likely provided inaccurate estimates of 30-day readmissions in patients undergoing dialysis. In the absence of data on specific facility types particularly when using data prior to 2012, future researchers could employ our method to more accurately characterize 30-day readmission rates and associated outcomes in patients with end-stage renal disease.
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Affiliation(s)
- Eugene Lin
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA.,Geriatric Research and Education Clinical Center, Palo Alto VA Health Care System, Palo Alto, California, USA
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
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Combe C, Rigothier C. Peritoneal dialysis or haemodialysis in end-stage renal disease: do registry data matter? Nephrol Dial Transplant 2016; 31:6-7. [DOI: 10.1093/ndt/gfv332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 08/13/2015] [Indexed: 11/15/2022] Open
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Argyropoulos C, Roumelioti ME, Sattar A, Kellum JA, Weissfeld L, Unruh ML. Dialyzer Reuse and Outcomes of High Flux Dialysis. PLoS One 2015; 10:e0129575. [PMID: 26057383 PMCID: PMC4461247 DOI: 10.1371/journal.pone.0129575] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 05/11/2015] [Indexed: 11/23/2022] Open
Abstract
Background The bulk of randomized trial evidence for the expanding use of High Flux (HF) hemodialysis worldwide comes from two randomized controlled trials, one of which (HEMODIALYSIS, HEMO) allowed, while the other (Membrane Outcomes Permeability, MPO) excluded, the reuse of membranes. It is not known whether dialyzer reuse has a differential impact on outcomes with HF vs low flyx (LF) dialyzers. Methods Proportional Hazards Models and Joint Models for longitudinal measures and survival outcomes were used in HEMO to analyze the relationship between β2-microglobulin (β2M) concentration, flux, and reuse. Meta-analysis and regression techniques were used to synthesize the evidence for HF dialysis from HEMO and MPO. Findings In HEMO, minimally reused (< 6 times) HF dialyzers were associated with a hazard ratio (HR) of 0.67 (95% confidence interval, 95%CI: 0.48–0.92, p = 0.015), 0.64 (95%CI: 0.44 – 0.95, p = 0.03), 0.61 (95%CI: 0.41 – 0.90, p = 0.012), 0.53 (95%CI: 0.28 – 1.02, p = 0.057) relative to minimally reused LF ones for all cause, cardiovascular, cardiac and infectious mortality respectively. These relationships reversed for extensively reused membranes (p for interaction between reuse and flux < 0.001, p = 0.005) for death from all cause and cardiovascular causes, while similar trends were noted for cardiac and infectious mortality (p of interaction between reuse and flux of 0.10 and 0.08 respectively). Reduction of β2M explained only 1/3 of the effect of minimally reused HF dialyzers on all cause mortality, while non-β2M related factors explained the apparent attenuation of the benefit with more extensively reused dialyzers. Meta-regression of HEMO and MPO estimated an adjusted HR of 0.63 (95% CI: 0.51–0.78) for non-reused HF dialyzers compared with non-reused LF membranes. Conclusions This secondary analysis and synthesis of two large hemodialysis trials supports the widespread use of HF dialyzers in clinical hemodialysis over the last decade. A mechanistic understanding of the effects of HF dialysis and the reuse process on dialyzers may suggest novel biomarkers for uremic toxicity and may accelerate membrane technology innovations that will improve patient outcomes.
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Affiliation(s)
- Christos Argyropoulos
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuqurque, New Mexico, United States of America
- * E-mail:
| | - Maria-Eleni Roumelioti
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuqurque, New Mexico, United States of America
| | - Abdus Sattar
- Department of Epidemiology and Biostatistics School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - John A. Kellum
- Department of Critical Care Medicine, CRISMA Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Lisa Weissfeld
- Department of Critical Care Medicine, CRISMA Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Biostatistics University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mark L. Unruh
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuqurque, New Mexico, United States of America
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Nissenson AR. For-Profit Dialysis Providers. Health Aff (Millwood) 2014; 33:2082. [DOI: 10.1377/hlthaff.2014.1100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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