Survival and analysis of predictors of mortality in patients undergoing replacement renal therapy: a 20-year cohort

When physician supply does not meet patient demand: A looming epidemic in vascular and renal care for a community with the highest incidence of end-stage renal disease in the United States

BACKGROUND

South Texas and the Rio Grande Valley (RGV) are medically underserved-communities near the Texas-Mexico border with the highest incidence of end-stage renal disease (ESRD) in the nation, and a shortage of available full-time equivalent (FTE) specialty-physicians.

METHODS

Data on the incidence/prevalence of ESRD and workforce projections on vascular-surgeons and nephrologists were collected from the United States Renal Data System and Texas Department of State Health Services. We then merged data from both datasets to identify population-specific healthcare-trends.

RESULTS

Texas had the highest rates of ESRD from 2016 to 2020, with its border regions leading the state. By 2032, vascular-surgery and nephrology are projected to have the 1st and 4th worst physician-shortages in the state respectively, with the percentage of these FTE specialty-physicians available to meet the need of the RGV ranging from 42.3 to 58.4 ​%.

CONCLUSIONS

The RGV is experiencing increased rates of ESRD, while having a paradoxical-decline in specialty-physicians available to provide adequate care.

Does metabolic dysfunction-associated fatty liver disease increase the risk of chronic kidney disease? A meta-analysis of cohort studies

OBJECTIVE

Metabolic dysfunction-associated fatty liver disease (MAFLD) has been used to characterize patients with fatty liver and metabolic dysfunction. The association between MAFLD and chronic kidney disease (CKD) remains undefined. We present high-quality evidence obtained from cohort studies examining if MAFLD leads to an increased risk of CKD.

METHODS

PubMed, CENTRAL, Embase, Scopus, and Web of Science were searched from the earliest possible date to 17th May 2024 for cohort studies examining the link between MAFLD and CKD.

RESULTS

Eight studies with nine cohorts were included. Pooled analysis of all nine cohorts showed that MAFLD was an independent predictor of CKD (HR: 1.38 95% CI: 1.24, 1.53 I2 = 95%). No change in results was noted on sensitivity analysis. We also noted no change in the significance of effect size on subgroup analysis based on study design (prospective or retrospective), country of origin (China, Korea, Japan, or UK), the incidence of CKD in the cohort (> 10% or ≤ 10%) and if the study adjusted for cardiovascular disease, diabetes, hypertension, and smoking status. Further, meta-analysis showed that MAFLD was still a risk factor for CKD in men (HR: 1.38 95% CI: 1.22, 1.56 I2 = 86%), women (HR: 1.51 95% CI: 1.25, 1.82 I2 = 87%), overweight (HR: 1.41 95% CI: 1.20, 1.66 I2 = 89%) and non-overweight cohorts (HR: 1.35 95% CI: 1.20, 1.53 I2 = 9%).

CONCLUSION

MAFLD is an independent predictor of CKD. The association seems persistent irrespective of sex, body mass index, and other CKD risk factors.

Association between dietary fiber intake and chronic kidney disease in adults with and without hypertension in the United States: a cross-sectional study of NHANES 2009-2020

While previous research has highlighted the potential advantages of increasing dietary fiber intake (DFI) for managing hypertension and chronic kidney disease (CKD), there is a gap in large-scale empirical studies examining the relationship between DFI and CKD among hypertensive and nonhypertensive cohorts independently. This study involved 22,871 participants sourced from the NHANES database spanning 2009 to 2020, who were divided into hypertensive (n = 9,861) and nonhypertensive (n = 13,010) groups. The analysis revealed a significant inverse correlation between DFI and CKD prevalence across the sample after adjusting for various covariates (OR = 0.98, 95% CI: 0.97-0.99, p = 0.001). Within the subset of hypertensive individuals, this inverse association mirrors the findings of the overall sample, indicating that a higher DFI was associated with a reduced occurrence of CKD (OR = 0.97, 95% CI: 0.96-0.99, p < 0.001). However, this correlation was not detected in the nonhypertensive group (OR = 0.99, 95% CI: 0.98-1.01, p = 0.285). The RCS analysis further confirmed a pronounced nonlinear inverse relationship between DFI and CKD prevalence in both the entire cohort and the hypertensive group but not in the nonhypertensive group. Further scrutiny of the hypertensive group revealed that individuals with a higher DFI had 33% lower odds of CKD progression for the moderate risk level and 36% lower odds for the high to very high risk level. Subgroup analyses confirmed the consistency of these relationships across various demographics. In summary, this investigation revealed a significant inverse relationship between DFI and CKD prevalence in US adults with hypertension, a relationship not observed in nonhypertensive individuals.

Risk factors associated with mortality among patients on maintenance hemodialysis: The Thailand Renal Replacement Therapy registry

INTRODUCTION

End-stage kidney disease (ESKD) has been increasing in prevalence across the world, including Thailand, and patients with ESKD on hemodialysis have a high mortality risk.

METHODS

A retrospective cohort study was performed across 855 hemodialysis centers in the Thailand Renal Replacement Therapy registry. The database and mortality data were analyzed.

RESULTS

A total of 58 952 patients were included. The survival rates at 1, 3, and 5 years were 93.5%, 69.7%, and 41.2%, respectively. On multivariate analysis, factors such as aging, permanent catheter or arteriovenous graft, twice-weekly hemodialysis, low levels of urea reduction ratio, normalized protein catabolic rate, hemoglobin, transferrin saturation, serum albumin, LDL-cholesterol, intact-parathyroid hormone, uric acid, sodium, phosphate, and bicarbonate were significantly related to death.

CONCLUSION

Mortality is high in ESKD patients on hemodialysis. Age, type of vascular access, twice-weekly hemodialysis, inadequate dialysis, low protein intake, anemia, abnormal electrolytes, and bone mineral disorders are associated with all-cause mortality.

A Retrospective Analysis of Mortality Due to Pneumonia and Renal Disease in a Midwestern Patient Population

BACKGROUND

The impact of pneumonia (PNA) with concomitant renal disease (RD) has not been fully investigated in a United States Midwestern patient population, despite the morbidity and mortality associated with such diseases.

MATERIALS AND METHODS

A retrospective cohort study was performed on International Classification of Diseases, 10th Revision (ICD-10) data from a hospital system located in Southwest Missouri. Data was acquired from patients admitted between January 2019 and December 2021. Patients were separated into five groups (disease categories): acute kidney injury (AKI), chronic kidney disease (CKD), PNA, AKI with PNA, and CKD with PNA. The data were analyzed, and subset analysis was performed utilizing two-sample proportion tests (Wald test) to compare mortality rates. Informed consent was not needed due to the retrospective nature of the study.

RESULTS

 The mortality rate of patients with PNA with AKI and PNA with CKD was 36.08% (32.87% to 39.28%, 95% CI) and 24.97% (21.93% to 28.00%, 95% CI), respectively, revealing a significant increase in mortality for thosediagnosed with PNA and AKI -higher than any other disease category. For reference, PNA without (w/o) RD, CKD w/o PNA, and AKI w/o PNA had much lower mortality rates at 9.45%, 7.87% and 12.19%, respectively, with AKI w/o PNA having a 2.63% to 6.00% higher (p<0.0001) and 0.99% to 4.49% higher (p=0.0020), mortality alone than CKD w/o PNA or PNA w/o RD, respectively.

DISCUSSION AND CONCLUSION

Mortality associated with RD and PNA was examined in a predominantly rural, relatively poor, Midwestern patient population presenting to a tertiary center with the key finding that the presence of AKI correlates with a much greater mortality rate in both patients with and without PNA. Looking forward, future studies may include a broader population base(including urban, suburban, and rural areas), allowing not only for more statistical power but also a broader assessment of the population.Such knowledge is invaluable as we continue to prioritize healthcare resources for critically ill patients suffering from RD and PNA in different settings.

Five-year survival analysis and predictors of mortality of adult hemodialysis patients in Indonesia: a nationwide database analysis

BACKGROUND

Hemodialysis (HD) is the modality of renal replacement therapy (RRT) with the highest mortality rate. The identification of prognostic factors will help achieve better outcomes among HD patients. In this study, we sought to conduct a survival analysis and determine the predictors of mortality among adult Indonesian HD patients using data obtained from Indonesian Renal Registry (IRR).

METHODS

This is a retrospective cohort study which reviewed all adult hemodialysis patients in Indonesia based on the records of IRR during 2007-2022. Variables analyzed in this study include age, sex, etiology of CKD, cause of death, HD frequency, and initial vascular access. A 5-year follow-up was performed until the outcome of death or drop out was found.

RESULTS

Among 99,552 eligible patients, the mean survival length was 1536.21 ± 2.50 days. The 5-year survival rate was 77%. Cox proportional hazard regression model revealed demographic and clinical characteristics that are significantly associated with mortality: male sex (HR: 1.038, 95% CI 1.002-1.075), age of 60 years or older (HR: 1.329, 95% CI 1.281-1.379), diabetic nephropathy (HR: 1.347, 95% CI 1.249-1.452), twice-weekly hemodialysis frequency (HR: 1.080, 95% CI 1.011-1.155), initial vascular accesses with femoral vein puncture (HR: 2.710, 95% CI 2.568-2.860), and CVC (HR: 2.992, 95% CI 2.848-3.144).

CONCLUSIONS

The 5-year survival rate of Indonesian HD patients is 77. Male sex, age of HD onset at 60 years or older, diabetic nephropathy, twice-weekly HD frequency, and the initial vascular accesses with femoral vein puncture and CVC are associated with increased risk of mortality.

Dapagliflozin cardiovascular effects on end-stage kidney disease (DARE-ESKD-2) trial: rationale and design

BACKGROUND

Dapagliflozin prevents myocardial dysfunction in chronic kidney disease patients regardless of residual kidney function. We hypothesized that this effect is extensible also to patients on dialysis.

RESEARCH DESIGN AND METHODS

The DARE-ESKD-2 is an ongoing, single-center, open-label randomized clinical trial designed to determine the effects of adding dapagliflozin to standard treatment on myocardial function and structure. Eligible patients were adults on a regular dialysis scheme for more than 3 months. Pregnancy, liver failure, allergy to the investigational drug, and prior use of SGLT2i were exclusion criteria. Participants were randomized in a 1:1 ratio to dapagliflozin or standard treatment groups for 24-weeks. The primary goal is to compare the change in NT-proBNP levels between study arms, and secondary goals include comparing the between-group difference in left ventricle global longitudinal strain, indexed mass, ejection fraction, and E/e` ratio, and on symptoms scale and 6-minute walk test distance. An exploratory analysis will evaluate changes in body composition and bone densitometry.

RESULTS

The trial has finished the enrollment of 80 patients, who are currently being followed-up.

CONCLUSIONS

This trial will provide novel data on myocardial effects of SGLT2i in dialysis recipients. Results from this study may provide evidence to support SGLT2i use in ESKD.

Nonstandardized High-Intensity Dialysis Dose Improves Survival in Patients With End-Stage Renal Disease

Introduction One of the most important critical determinants of quality of life and adequacy of hemodialysis (HD) performed in patients is the recorded survival and mortality rates. Nowadays, as an adequately performed HD dialysis, we accept the one with reaching values for the index single pool Kt/V (spKt/V) higher than 1.2. In recent years, more intensive HD regimens with spKt/V≥1.5 have been increasingly discussed, which can significantly improve patient survival. However, their benefit has yet to be proven, as extremely high spKt/V values can be misleading as they may result from malnutrition leading to reduced survival and increased relative risk of death. The aim of this study is to present to the community the impact of nonstandardized high dialysis doses (spKt/V>1.5) on annual survival and mortality rates in the dialysis population and to explore new strategies for enhancing quality of life and survival, as well as to promote their regular implementation in clinical practice and personalized patient care. Material and methods The present retrospective study was conducted at the Clinic of Nephrology and Dialysis at University Hospital St. Marina in Varna, Bulgaria for a period of five years. It involved a survival analysis of 100 dialysis patients who met the inclusion and exclusion criteria. The dialysis dose delivered was the criterion for their allocation into three studied groups: Group 1 with adequate dose (standardized) - spKt/V = 1.2-1.49, Group 2 with high dose (nonstandardized) - spKt/V≥1.5, and Group 3 with inadequate dose (low) - spKt/V≤1.19. We recorded total annual mortality and survival rates, analyzing their relationship with the delivered dialysis dose and assessing the relative risk of death and expected survival. Results The analysis results indicated that high-intensity regimens with an spKt/V≥1.5 were linked to a better patient prognosis, with a significantly lower risk of death compared to standard regimens and increased survival expectancy. Data from the survival analysis suggested that the long-term impact of increasing the dialysis dose (spKt/V≥1.5) on survival becomes evident after the third year. Additionally, nutritional status parameters emerged as key risk factors for deterioration, along with the indicators of dialysis adequacy. Discussion Improved survival rates have been observed in patients undergoing nocturnal HD. In the latter, significantly higher spKt/V values have been achieved due to extended dialysis sessions, as well as in those performing dialysis at home. Despite concerns about possible misinterpretation of extremely high spKt/V values (>1.5) as a sign of malnutrition when urea volume of distribution is reduced, it is found that when only urea clearance (Kt) is used, without volume counts, the risk of death decreases by 2% for each liter increase in clearance. This demonstrates that the assessment of dialysis adequacy is a much broader concept than the values of generally accepted indicators and should be focused on individualized care and risk assessment tailored to each patient. Conclusions We believe that the modern nephrological community should strive to achieve a high dialysis dose (spKt/V≥1.5) to improve clinical outcomes and patient prognosis. Assessing dialysis adequacy is complex and goes beyond a simple numerical value such as spKt/V. It requires careful monitoring of nutritional status and the management of all HD-related complications.

Pulmonary vasodilators in patients with advanced chronic kidney disease and pre-capillary pulmonary hypertension-A case series

Pulmonary hypertension (PH) is a prevalent complication among patients with chronic kidney disease (CKD). In these patients, pulmonary vasodilators may be useful but are underused. We describe a group of patients with precapillary PH and advanced CKD treated with pulmonary vasodilators. This was a case series of patients with CKD stage 4 and 5 and precapillary PH (isolated or combined) based on right heart catheterization (RHC) treated with pulmonary vasodilators from 2018 to 2023. Of 263 patients with isolated precapillary or combined PH and advanced CKD, only 17 (6%) were treated with pulmonary vasodilators; 53% (n = 9) with precapillary PH and 47% (n = 8) with combined PH. Most patients (94%, n = 16) received phosphodiesterase-5 antagonists, while 12% (n = 2) received endothelin receptor antagonists. Adverse clinical outcomes were seen in 35% of patients within a year. The use of pulmonary vasodilator did not prevent adverse outcomes in patients with precapillary PH and advanced CKD.

A Metabolomics Approach to Identify Metabolites Associated With Mortality in Patients Receiving Maintenance Hemodialysis

Introduction

Uremic toxins contributing to increased risk of death remain largely unknown. We used untargeted metabolomics to identify plasma metabolites associated with mortality in patients receiving maintenance hemodialysis.

Methods

We measured metabolites in serum samples from 522 Longitudinal US/Canada Incident Dialysis (LUCID) study participants. We assessed the association between metabolites and 1-year mortality, adjusting for age, sex, race, cardiovascular disease, diabetes, body mass index, serum albumin, Kt/Vurea, dialysis duration, and country. We modeled these associations using limma, a metabolite-wise linear model with empirical Bayesian inference, and 2 machine learning (ML) models: Least absolute shrinkage and selection operator (LASSO) and random forest (RF). We accounted for multiple testing using a false discovery rate (pFDR) adjustment. We defined significant mortality-metabolite associations as pFDR < 0.1 in the limma model and metabolites of at least medium importance in both ML models.

Results

The mean age of the participants was 64 years, the mean dialysis duration was 35 days, and there were 44 deaths (8.4%) during a 1-year follow-up period. Two metabolites were significantly associated with 1-year mortality. Quinolinate levels (a kynurenine pathway metabolite) were 1.72-fold higher in patients who died within year 1 compared with those who did not (pFDR, 0.009), wheras mesaconate levels (an emerging immunometabolite) were 1.57-fold higher (pFDR, 0.002). An additional 42 metabolites had high importance as per LASSO, 46 per RF, and 9 per both ML models but were not significant per limma.

Conclusion

Quinolinate and mesaconate were significantly associated with a 1-year risk of death in incident patients receiving maintenance hemodialysis. External validation of our findings is needed.

Time to death and its predictors among patients with chronic kidney disease on hemodialysis at dialysis unit in Addis Ababa, Ethiopia: a retrospective cohort study

BACKGROUND

Chronic kidney disease is a progressive disease that affects more than 10% of the world's population and is also the leading cause of death in the twenty-first century. Furthermore, it imposes a significant financial burden on people undergoing hemodialysis. However, there is little research, particularly in the study area, on time to death and its predicators among hemodialysis patients in Ethiopia; therefore, knowing time to death and identifying predicators that affect survival time is crucial in order to improve survival time and enhance the prognosis of hemodialysis patients. The aim of this study was to assess time to death and its predictors among patients with chronic kidney disease on hemodialysis at a dialysis unit in Addis Ababa, Ethiopia, in 2023.

METHODS

An institution-based retrospective cohort study was carried out among 370 chronic kidney disease patients on hemodialysis from January 1st, 2017 to December 30th, 2022. Data were extracted from April 1st-May 20th, 2023, and each variable was coded and entered into Epi Data version 3.1 and then exported into STATA version 15 software for analysis. Kaplan-Meier and the log-rank test were done. Bivariable Cox-proportional regression was done, and a variable whose p-value was < 0.25 and fulfilled the proportional hazard assumption by using graphical and Shenfield residuals was entered into multivariable Cox-proportional regression. Finally, a variable whose p-value < 0.05 and adjusted hazard ratio with its CI were declared statistically significant predictors.

RESULT

In this study, the overall median survival time was 47 months (95% CI: 36.7, 56), with an incidence rate of death of 16.8 per 1000 people per month of observation (95% CI: 13.8-20.3). Age 64 and above (Adjusted Hazard Ration: 2.8; 95% CI: 1.67-4.98), catheter vascular access (Adjusted Hazard Ration: 3.47; 95% CI: 2.03-5.93), cardiovascular disease (Adjusted Hazard Ration: 1.88; 95% CI: 1.15-3.07), and blood group B (Adjusted Hazard Ration: 2.07; 95% CI: 1.17-3.69) were significant predictors of time to death among hemodialysis patients. CONCLUSION AND RECOMMENDATION: The median survival time was 47 months, with an interquartile range of 40. Cardiovascular disease, older adults, central venous catheters, and blood type B were significant predictors of time to death for hemodialysis patients. Therefore, in order to improve the survival of hemodialysis patients, health professionals and concerned bodies should give concern to and work on those predictors.

Prognostication After Dialysis Withdrawal

Introduction

Dialysis withdrawal represents an increasingly common cause of death in patients receiving kidney replacement therapy internationally. Prognostic information about stopping dialysis guides clinicians counseling patients and families regarding end-of-life care. However, few studies examine prognostication after withdrawal. We aimed to determine median survival time after withdrawal of dialysis, and to determine which patient and dialysis-related factors are significantly associated with prognosis.

Methods

This retrospective cohort study used registry data. We included all adult patients from the Western Renal Services who were receiving peritoneal dialysis (PD) or hemodialysis prior to death, whose cause of death was documented as "withdrawal from dialysis" and whose date of death was between January 1, 2016 and June 30, 2022. Demographic, clinical, and biochemical data was extracted. The primary outcome was time-to-death, defined as days from last dialysis session to date of death.

Results

Median survival time from last dialysis to death for the PD group (n = 53) was 4 days (interquartile range [IQR]: 3-10 days), not significantly different from the hemodialysis group which was 6 days (IQR: 2-11 days, P = 0.72). For PD, the only variable significantly associated with survival time was reason for withdrawing (P = 0.01). Median survival time was significantly longer for patients withdrawing for psychosocial reasons compared to those withdrawing for other reasons (P = 0.002). For hemodialysis (n = 186), variables significantly associated with survival time from last dialysis to death was reason for withdrawing (P = 0.001), urine production at the time of withdrawal (P = 0.005), serum sodium (P = 0.02) and smoking status (P = 0.009).

Conclusion

Median survival time was longer for withdrawals for psychosocial reasons compared to medical reasons. The data presented could inform withdrawal discussions regarding prognostication and end-of-life planning with patients and family.

Peritoneal dialysis versus haemodialysis for people commencing dialysis

BACKGROUND

Peritoneal dialysis (PD) and haemodialysis (HD) are two possible modalities for people with kidney failure commencing dialysis. Only a few randomised controlled trials (RCTs) have evaluated PD versus HD. The benefits and harms of the two modalities remain uncertain. This review includes both RCTs and non-randomised studies of interventions (NRSIs).

OBJECTIVES

To evaluate the benefits and harms of PD, compared to HD, in people with kidney failure initiating dialysis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies from 2000 to June 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. MEDLINE and EMBASE were searched for NRSIs from 2000 until 28 March 2023.

SELECTION CRITERIA

RCTs and NRSIs evaluating PD compared to HD in people initiating dialysis were eligible.

DATA COLLECTION AND ANALYSIS

Two investigators independently assessed if the studies were eligible and then extracted data. Risk of bias was assessed using standard Cochrane methods, and relevant outcomes were extracted for each report. The primary outcome was residual kidney function (RKF). Secondary outcomes included all-cause, cardiovascular and infection-related death, infection, cardiovascular disease, hospitalisation, technique survival, life participation and fatigue.

MAIN RESULTS

A total of 153 reports of 84 studies (2 RCTs, 82 NRSIs) were included. Studies varied widely in design (small single-centre studies to international registry analyses) and in the included populations (broad inclusion criteria versus restricted to more specific participants). Additionally, treatment delivery (e.g. automated versus continuous ambulatory PD, HD with catheter versus arteriovenous fistula or graft, in-centre versus home HD) and duration of follow-up varied widely. The two included RCTs were deemed to be at high risk of bias in terms of blinding participants and personnel and blinding outcome assessment for outcomes pertaining to quality of life. However, most other criteria were assessed as low risk of bias for both studies. Although the risk of bias (Newcastle-Ottawa Scale) was generally low for most NRSIs, studies were at risk of selection bias and residual confounding due to the constraints of the observational study design. In children, there may be little or no difference between HD and PD on all-cause death (6 studies, 5752 participants: RR 0.81, 95% CI 0.62 to 1.07; I2 = 28%; low certainty) and cardiovascular death (3 studies, 7073 participants: RR 1.23, 95% CI 0.58 to 2.59; I2 = 29%; low certainty), and was unclear for infection-related death (4 studies, 7451 participants: RR 0.98, 95% CI 0.39 to 2.46; I2 = 56%; very low certainty). In adults, compared with HD, PD had an uncertain effect on RKF (mL/min/1.73 m2) at six months (2 studies, 146 participants: MD 0.90, 95% CI 0.23 to 3.60; I2 = 82%; very low certainty), 12 months (3 studies, 606 participants: MD 1.21, 95% CI -0.01 to 2.43; I2 = 81%; very low certainty) and 24 months (3 studies, 334 participants: MD 0.71, 95% CI -0.02 to 1.48; I2 = 72%; very low certainty). PD had uncertain effects on residual urine volume at 12 months (3 studies, 253 participants: MD 344.10 mL/day, 95% CI 168.70 to 519.49; I2 = 69%; very low certainty). PD may reduce the risk of RKF loss (3 studies, 2834 participants: RR 0.55, 95% CI 0.44 to 0.68; I2 = 17%; low certainty). Compared with HD, PD had uncertain effects on all-cause death (42 studies, 700,093 participants: RR 0.87, 95% CI 0.77 to 0.98; I2 = 99%; very low certainty). In an analysis restricted to RCTs, PD may reduce the risk of all-cause death (2 studies, 1120 participants: RR 0.53, 95% CI 0.32 to 0.86; I2 = 0%; moderate certainty). PD had uncertain effects on both cardiovascular (21 studies, 68,492 participants: RR 0.96, 95% CI 0.78 to 1.19; I2 = 92%) and infection-related death (17 studies, 116,333 participants: RR 0.90, 95% CI 0.57 to 1.42; I2 = 98%) (both very low certainty). Compared with HD, PD had uncertain effects on the number of patients experiencing bacteraemia/bloodstream infection (2 studies, 2582 participants: RR 0.34, 95% CI 0.10 to 1.18; I2 = 68%) and the number of patients experiencing infection episodes (3 studies, 277 participants: RR 1.23, 95% CI 0.93 to 1.62; I2 = 20%) (both very low certainty). PD may reduce the number of bacteraemia/bloodstream infection episodes (2 studies, 2637 participants: RR 0.44, 95% CI 0.27 to 0.71; I2 = 24%; low certainty). Compared with HD; It is uncertain whether PD reduces the risk of acute myocardial infarction (4 studies, 110,850 participants: RR 0.90, 95% CI 0.74 to 1.10; I2 = 55%), coronary artery disease (3 studies, 5826 participants: RR 0.95, 95% CI 0.46 to 1.97; I2 = 62%); ischaemic heart disease (2 studies, 58,374 participants: RR 0.86, 95% CI 0.57 to 1.28; I2 = 95%), congestive heart failure (3 studies, 49,511 participants: RR 1.10, 95% CI 0.54 to 2.21; I2 = 89%) and stroke (4 studies, 102,542 participants: RR 0.94, 95% CI 0.90 to 0.99; I2 = 0%) because of low to very low certainty evidence. Compared with HD, PD had uncertain effects on the number of patients experiencing hospitalisation (4 studies, 3282 participants: RR 0.90, 95% CI 0.62 to 1.30; I2 = 97%) and all-cause hospitalisation events (4 studies, 42,582 participants: RR 1.02, 95% CI 0.81 to 1.29; I2 = 91%) (very low certainty). None of the included studies reported specifically on life participation or fatigue. However, two studies evaluated employment. Compared with HD, PD had uncertain effects on employment at one year (2 studies, 593 participants: RR 0.83, 95% CI 0.20 to 3.43; I2 = 97%; very low certainty).

AUTHORS' CONCLUSIONS

The comparative effectiveness of PD and HD on the preservation of RKF, all-cause and cause-specific death risk, the incidence of bacteraemia, other vascular complications (e.g. stroke, cardiovascular events) and patient-reported outcomes (e.g. life participation and fatigue) are uncertain, based on data obtained mostly from NRSIs, as only two RCTs were included.

Enhancing medication management in hemodialysis patients: Exploring the impact of patient-centered pharmacist care and motivational interviewing

BACKGROUND

Patients on hemodialysis (HD) often uses several medications, making them highly susceptible to medication-related problems (MRP) thereby leading to medication nonadherence. Therefore, an innovative pharmaceutical care strategy incorporating drug therapy optimization (DTO) and motivational interviewing (MI) can mitigate medication-related problems and optimize patient care.

AIMS AND OBJECTIVE

The objective of this study is to assess the efficacy of pharmacist led interventions in utilizing DTO and MI techniques in managing medication related problems among patients undergoing hemodialysis.

METHOD AND DESIGN

A12-months, cross sectional prospective study was conducted among 63 End Stage Renal Disease (ESRD) patients on HD. DTO was conducted by the pharmacist to identify the MRP by reviewing complete medication list gathered from patient interview and medical records. All MRPs was classified using the PCNE classification version 9.00 and medication issues, that require patient involvement were categorized as patient-related, while those that necessitate physician intervention were classified as physician-related. The DTO was performed at the baseline, 6-month and at the final month of the study. Identified medication issues were communicated to the site nephrologist and was tracked during next follow up. Whereas MI was conducted physically at Month-3 and via telephone on month-6 and month-9 to address patient related medication issues.

RESULTS

Mean age of the study population was 48.5±14 years. While the mean number of prescribed medications was 8.1±2 with 57% of the patients taking more than 5 types of medication. After 12 months of pharmacist intervention using DTO and MI, a mean reduction in MRP was observed for both patient-related and physician-related MRPs across three time series. However, further analysis using repeated measure ANOVA revealed that the reduction in patient-related MRPs was statistically significant [F(1.491, 92.412) = 60.921, p < 0.05], while no statistically significant difference was detected in physician-related MRPs [F(2, 124) = 2.216, P = 0.113].

CONCLUSION

Pharmaceutical care service through DTO and MI can effectively reduce and prevent drug-related issues to optimize medication therapy among HD patients.

Advances in uremic toxin detection and monitoring in the management of chronic kidney disease progression to end-stage renal disease

Patients with end-stage kidney disease (ESKD) rely on dialysis to remove toxins and stay alive. However, hemodialysis alone is insufficient to completely remove all/major uremic toxins, resulting in the accumulation of specific toxins over time. The complexity of uremic toxins and their varying clearance rates across different dialysis modalities poses significant challenges, and innovative approaches such as microfluidics, biomarker discovery, and point-of-care testing are being investigated. This review explores recent advances in the qualitative and quantitative analysis of uremic toxins and highlights the use of innovative methods, particularly label-mediated and label-free surface-enhanced Raman spectroscopy, primarily for qualitative detection. The ability to analyze uremic toxins can optimize hemodialysis settings for more efficient toxin removal. Integration of multiple omics disciplines will also help identify biomarkers and understand the pathogenesis of ESKD, provide deeper understanding of uremic toxin profiling, and offer insights for improving hemodialysis programs. This review also highlights the importance of early detection and improved understanding of chronic kidney disease to improve patient outcomes.

Characterization of long-term survival in Medicare patients undergoing arteriovenous hemodialysis access

BACKGROUND

Patients undergoing arteriovenous (AV) access creation for hemodialysis often have significant comorbidities. Our goal was to quantify the long-term survival and associated risks factors for long-term mortality in these patients to aid in optimization of goals and expectations.

METHODS

The Vascular Implant Surveillance and Interventional Outcomes Network Vascular Quality Initiative Medicare linked data was used to assess long-term survival in the HD registry. Demographics, comorbidities, and interventions were recorded. Because the majority of hemodialysis patients are provided Medicare, Medicare linkage was used to obtain survival data. Multivariable analysis was used to identify independent associations with mortality.

RESULTS

There were 13,945 AV access patients analyzed including 10,872 (78%) AV fistulas and 3073 (22%) AV grafts. The median age was 67 years and 56% of patients were male. Approximately one-third had a prior AV access and 44.7% had prior tunneled dialysis catheters. Patients receiving an AV fistula, compared with AV grafts, were more often younger, male, White, obese, independently ambulatory, preoperatively living at home, and less often have a prior AV access and tunneled dialysis catheters (P < .05 for all). The 5-year mortality overall was 62.9% with 61.2% for AV fistulas and 68.8% for AV grafts (P < .001). On multivariable analysis for 5 year mortality, nonambulatory status (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.53-1.83; P < .001), lower extremity access (HR, 1.67; 95% CI, 1.35-2.05; P < .001), human immunodeficiency virus or acquired immunodeficiency syndrome (HR, 1.44; 95% CI, 1.13-1.82; P < .001), White race (HR, 1.43; 95% CI, 1.35-1.51; P < .001), congestive heart failure (HR, 1.33; 95% CI, 1.26-1.41; P < .001), chronic obstructive pulmonary disease (HR, 1.23; 95% CI, 1.15-1.31; P < .001), and AV graft placement (HR, 1.12; 95% CI, 1.02-1.23, P = .016) were most associated with poor survival. Factors associated with improved survival were never smoking (HR, .73; 95% CI, 0.67-0.79; P < .001), prior/quit smoking (HR, .78; 95% CI, 0.72-0.84; P < .001), preoperative home living (HR, .75; 95% CI, 0.68-0.83; P < .001), and hypertension (HR, .89; 95% CI, 0.8-0.99; P = .03).

CONCLUSIONS

Long-term survival in Medicare patients undergoing AV access creation is poor with nearly two-thirds of patients having died at 5 years. There are many modifiable risk factors that may improve survival in these patients and give an opportunity for transplantation.

Foot and Ankle Care by Podiatrists and Amputations in Patients With Diabetes and Kidney Failure

Importance

Patients with kidney failure have an increased risk of diabetes-related foot complications. The benefit of regular foot and ankle care in this at-risk population is unknown.

Objective

To investigate foot and ankle care by podiatrists and the outcomes of diabetic foot ulcers (DFUs) in patients with kidney failure.

Design, Setting, and Participants

This retrospective cohort study included Medicare beneficiaries with type 2 diabetes receiving dialysis who had a new DFU diagnosis. The analysis of the calendar year 2016 to 2019 data from the United States Renal Data System was performed on June 15, 2023, with subsequent updates on December 11, 2023.

Exposures

Foot and ankle care by podiatrists during 3 months prior to DFU diagnosis.

Main Outcomes and Measures

The outcomes were a composite of death and/or major amputation, as well as major amputation alone. Kaplan-Meier analysis was used to estimate 2 to 3 years of amputation-free survival. Foot and ankle care by podiatrists and the composite outcome was examined using inverse probability-weighted Cox regression, while competing risk regression models were used for the analysis of amputation alone.

Results

Among the 14 935 adult patients with kidney failure and a new DFU (mean [SD] age, 59.3 [12.7] years; 35.4% aged ≥65 years; 8284 men [55.4%]; Asian, 2.7%; Black/African American, 35.0%; Hispanic, 17.7%; White, 58.5%), 18.4% (n = 2736) received care by podiatrists in the 3 months before index DFU diagnosis. These patients were older, more likely to be male, and have more comorbidities than those without prior podiatrist visits. Over a mean (SD) 13.5 (12.0)-month follow-up, 70% of those with podiatric care experienced death and/or major amputation, compared with 74% in the nonpodiatric group. Survival probabilities at 36 months were 26.3% vs 22.8% (P < .001, unadjusted Kaplan-Meier survival analysis). In multivariate regression analysis, foot and ankle care was associated with an 11% lower likelihood of death and/or amputation (hazard ratio [HR], 0.89 95% CI, 0.84-0.93) and a 9% lower likelihood of major amputation (above or below knee) (HR, 0.91; 95% CI, 0.84-0.99) than those who did not.

Conclusions and Relevance

The findings of this study suggest that patients with kidney failure at risk for DFUs who receive foot and ankle care from podiatrists may be associated with a reduced likelihood of diabetes-related amputations.

A retrospective cohort study on the cost-effectiveness analysis of kidney transplantation compared to dialysis in Cameroon: evidence for policy

Introduction

chronic kidney disease affects one in ten adults in Cameroon. Haemodialysis was the only renal replacement therapy (for adults) in Cameroon and its sub-region until November 10, 2021. Thereafter through May 2022, the Yaoundé General Hospital successfully completed four living-donor kidney transplants. This paper examines policy implications.

Methods

medical records of cohorts of kidney failure patients who started haemodialysis at Yaoundé General Hospital in 2012 (n=106) and 2017 (n=118) were abstracted retrospectively through 2021 and their survival analyzed with Microsoft Excel and Kaplan-Meier curves. Using hospital data, the literature, and price indexes, the annual medical cost per patient of dialysis and living-donor kidney transplantation in 2022 prices was derived.

Results

the 9.5-year survival rate for the 2012 cohort was 11% and the 5-year rate for the 2017 cohort was 18%. Annual haemodialysis cost per patient averaged $17,681 (26.5% from households and 73.5% from government). Initial transplantation costs averaged $10,530 per patient, all borne by the government. Under the brand-drug option, first-year transplantation follow-up costs $19,070 (4% for laboratory and 96% for drugs).

Conclusion

annually, haemodialysis in Cameroon costs per patient 12 times the country's average income ($1,537), driven especially by the costs of equipment purchase, maintenance, and consumables. Cameroon's initial cost of transplantation is lower than in other African countries. Generic drugs could lower annual follow-up costs by 89%. If Cameroon could achieve long-term survival with generic drugs after kidney transplantation, that modality would become a reasonable option for selected kidney failure patients (e.g. younger and without other comorbidities).

Cost-Effectiveness of Drug-Coated Balloon Angioplasty versus Plain Old Balloon Angioplasty for Arteriovenous Fistula Stenosis

OBJECTIVE

To compare the cost-effectiveness of drug-coated balloon angioplasty (DCB) versus plain old balloon angioplasty (POBA) for treatment of arteriovenous fistula (AVF) stenosis.

METHODS

A Markov model was created to compare DCB versus POBA for AVF stenosis over a 2-year time horizon from a United States payer's perspective. Probabilities related to complications, restenosis, retreatment, and all-cause mortality were obtained from published literature. Costs were calculated using Medicare reimbursement rates and data from published cost analyses, inflation-adjusted to 2021. Health outcomes were measured with quality-adjusted life years (QALY). Probabilistic and deterministic sensitivity analyses were performed with a willingness-to-pay threshold of $100,000/QALY.

RESULTS

Base case calculation showed better quality-of-life outcomes but increased cost with POBA compared to DCB, with an incremental cost-effectiveness ratio of $27,413/QALY, making POBA the more cost-effective strategy in the base case model. Sensitivity analyses showed that DCB becomes cost-effective if the 24-month mortality rate after DCB is no more than 3.4% higher than that after POBA. In secondary analyses where mortality rates were equalized, DCB was more cost-effective than POBA until its additional cost reached more than $4213 per intervention.

CONCLUSION

When modeled from a payer's perspective over 2 years, the cost utility of DCB versus POBA varies with mortality outcomes. POBA is cost-effective if 2-year all-cause mortality after DCB is greater than 3.4% higher than after POBA. If 2-year mortality after DCB is less than 3.4% higher than after POBA, DCB is cost-effective until its additional cost per procedure exceeds $4213 more than POBA.

LEVEL OF EVIDENCE IV

HISTORICALLY CONTROLLED STUDY.: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Joint modeling on serum creatinine and time to end stage of renal disease for chronic kidney disease patients under treatment at the University of Gondar Referral Hospital

Background and Aims

Chronic kidney disease (CKD) is a major health problem worldwide. The general objective of this study is to identify the joint factors of serum creatinine (SCr) and time to end stage of renal disease (ESRD) for CKD patients under treatment at University of Gondar Referral Hospital (UOGRH).

Methods

A retrospective cohort study was conducted. The collected information was secondary data type obtained from 311 CKD patient's medical charts in the UOGRH from September 2019 to January 2022 G.C. Joint modeling analysis contained a linear mixed model for SCr and the Cox-PH model for time to ESRD of CKD patients under treatment was used.

Result

From the total of 311 patients, 104 (33.4%) patients were developed the ESRD, while the other 207 (66.6%) were censored patients. In the longitudinal submodel, the variable sex, age, electrolyte, visit time, anemia, diabetes mellitus, chronic heart disease, hypertension, and hepatitis have a significant effect on the variable SCr. In survival process, anemia (HR = 2.53, p = < 0.001), diabetes mellitus (HR = 2.206, p = < 0.0047), chronic heart disease (HR = 2.83, p = < 0.0011), HIV (HR = 2.778, p = < 0.0045), hypertension (HR = 2.616, p = < 0.001), and hepatitis (HR = 4.4, p = < 0.0074) have a significant effect on the variable ESRD. On the basis of the result of the joint model, the variable anemia, diabetes mellitus, chronic heart disease, hypertension, and hepatitis were common significant factors.

Conclusion

The majority of patients 207 (66.6%) of CKD patients were censored. On the basis of the smaller information criteria value and the significance association value, the joint model better fits the data. In the joint model, the variable anemia, diabetes mellitus, chronic heart disease, hypertension, and hepatitis were common factors of two responses, and also concluded that the rate of progression of longitudinal measure SCr decreased over time.

Evaluation of laboratory values affecting mortality of end-stage renal disease patients: a competing risks approach

BACKGROUND

Chronic Kidney Disease (CKD) is a prevalent and life-threatening situation recognized as an emerging health issue. The present study aimed to evaluate the effect of demographic and laboratory parameters on the survival of patients with End-Stage Renal Disease (ESRD) in a hemodialysis (HD) center in Iran.

MATERIALS AND METHODS

This study was conducted on patients receiving chronic HD in Iran Helal Pharmaceutical and Clinical Complex between 2014 and 2018. The survival time was considered as the time interval between HD initiation and death. Receiving kidney transplantation was regarded as a competing risk, and an improper form of two-parameter Weibull distribution was utilized to simultaneously model the time to both death and renal transplantation. The Bayesian approach was conducted for parameters estimation.

RESULTS

Overall, 29 (26.6%) patients expired, and 19 (17.4%) received kidney transplants. The male gender was related to poor survival, having nearly 4.6 folds higher hazard of mortality (90% HPD region: 1.36-15.49). Moreover, Serum calcium levels [Formula: see text]9.5 mg/dL (adjusted Sub-hazard ratio (S-HR)=2.33, 90% HPD region: 1.05-5.32) and intact parathyroid hormone (iPTH) [Formula: see text]150 pg/mL (adjusted S-HR = 2.56, 90% HPD region: 1.09-6.15) were associated with an elevated hazard of mortality. The cumulative incidence function (CIF) for transplantation was greater than death in the first two years of the study. Subsequently, the CIF for death exceeded transplantation in the following two years. The 4-year cumulative incidence of death and kidney transplantation was 63.7% and 36.3%, respectively.

CONCLUSION

Male gender, hypercalcemia, and hypoparathyroidism were associated with worse outcomes. Correcting mentioned laboratory parameters may improve patients' survival in the HD population.

Higher Muscle Mass and Higher Serum Prealbumin Levels Are Associated with Better Survival in Hemodialysis Patients during a Five-Year Observation Period

BACKGROUND

Dialysis is the most commonly used renal replacement therapy in patients with end-stage renal disease. The mortality rate of hemodialysis patients is 15-20%, with cardiovascular complications being the most common. There is an association between the severity of atherosclerosis and both the development of protein-calorie malnutrition and inflammatory mediators. The aim of this study was to assess the relationship between biochemical markers of nutritional status, body composition and survival in hemodialysis patients.

METHODS

Fifty-three hemodialysis patients were included in the study. Serum albumin, prealbumin, and IL-6 levels were measured, as well as body weight, body mass index, fat content and muscle mass. The five-year survival of patients was calculated using Kaplan-Meier estimators. The long-rank test was used for univariate comparison of survival curves, and the Cox proportional hazards model was used for multivariate analysis of survival predictors.

RESULTS

There were 47 deaths, 34 of which were due to cardiovascular disease. The hazard ratio (HR) for age in the middle-aged group (55-65 years) was 1.28 (confidence interval [CI] 0.58, 2.79) and 5.43 (CI 2.1, 14.07; statistically significant) for the oldest age group (over 65 years). A prealbumin level above 30 mg/dl was associated with an HR of 0.45 (CI 0.24, 0.84). Serum prealbumin (odds ratio [OR] = 5.23; CI 1.41, 19.43; p = 0.013) and muscle mass (OR = 7.5; CI 1.31, 43.03; p = 0.024) were significant predictors of all-cause mortality.

CONCLUSIONS

Prealbumin level and muscle mass were associated with increased mortality risk. Identification of these factors may improve the survival of hemodialysis patients.

Caring for Patients With Advanced Chronic Kidney Disease: Dietary Options and Conservative Care Instead of Maintenance Dialysis

An expert advisory board discussed the prevention and treatment of chronic kidney disease (CKD), with a focus on dietary options. This is timely, given the uptake of value based models for kidney care in the United States. Timing of dialysis start is influenced by patients' clinical status and complex patient-clinician interactions. Patients value personal freedom and quality of life and may want to delay dialysis, whilst physicians are sometimes more concerned with clinical outcomes. Kidney-preserving therapy can prolong the dialysis-free period and preserve residual kidney function, thus patients are asked to adjust their lifestyle and diet, to follow a low- or very low-protein diet, with or without ketoacid analogues. Multi-modal approaches include pharmacotherapies, management of symptoms, and a gradual, individualized dialysis transition. Patient empowerment is vital, including CKD education and involvement in decision making. These ideas may help patients, their families, and clinical teams to improve the management of CKD.

Projecting the potential cost-effectiveness of dapagliflozin for chronic kidney disease in Kuwait

INTRODUCTION

In 2019, the prevalence of dialysis in Kuwait were 465 patient/million population, while the annual mortality rate among dialysis patients reached 12%. To improve resource allocation within the health care system, a cost-effectiveness model was conducted from a societal perspective to assess the cost-effectiveness of the use of dapagliflozin as an add-on-therapy against SoC (ramipril) among CKD patients with or without type-2 diabetes over their lifetime.

METHODOLOGY

A Markov process model was utilized to assess the cost-effectiveness of dapagliflozin + ramipril versus ramipril alone on a cohort of patients with an eGFR of 25 to 75 mL/min/1.73, with or without type-2 diabetes and a urinary ACR of 200 to 5,000 over their lifetime. The model included nine health states: (i) the six stages of CKD representing stages 1, 2, 3a, 3b, 4 and 5; (ii)ESRD, which represents RRT as dialysis or kidney transplant and (iii) death. Most of the clinical data were captured from the DAPA-CKD study. We assumed that the mortality risk of our study was similar to DAPA-CKD. The utility data were captured from different studies. Direct medical and indirect costs were captured from local data sources. Sensitivity analyses were conducted.

RESULTS

The difference in QALY between dapagliflozin + ramipril versus ramipril was 0.2. The difference in cost between the two arms was KWD -4,120 (-USD25750). Dapagliflozin + ramipril generate better QALYs and lower costs than ramipril in CKD patients. Dapagliflozin improved the outcomes and generated cost savings in CKD patients.

CONCLUSION

Adoption of dapagliflozin + ramipril is considered to be a cost saving option in addition to the improvement in QALYs in CKD patients with or without type-2 diabetes due to its nephroprotective effect, regardless of the aetiology of CKD, which eventually leads to reduction of dialysis and the transplantation cost burden on the Kuwaiti health care system. This study was focussed only on DAPA-CKD cohort.

Comparison of Survival in Recipients of Marginal and Standard Cadaveric Donor Kidneys

BACKGROUND

Renal transplantation is the main treatment for end-stage renal disease and has rapidly increased in number over the past 3 decades, leading to an increasing need for organs. The disparity between organ access and the number of patients on the waiting list has led transplant surgeons to use marginal cadaveric donors. As a consequence, the concept of "marginal cadaveric kidney donor" has been developed.

METHODS

We retrospectively evaluated 120 patients who received kidneys from cadaveric donors between September 2009 and August 2021. The donors were divided into standard and marginal cadaveric donors, and their age, sex, cause of death, criteria of acceptance as marginal donors, and Kidney Donor Profile Index (KDPI) were recorded RESULTS: The donors included 69 men and 51 women, with a mean age of 52.9 ± 16.8 years. There were 52 standard donors and 68 marginal donors. Graft and donor survival were compared based on the KDPI values of the donors, and were respectively found to be higher in those with a KDPI of 0 to 60 than in those with a KDPI of 81 to 100 (P = .011 and .039, respectively). There was no significant difference between those with a KDPI of 61 to 80 and the other groups.

CONCLUSIONS

Expanded criteria donor organs, which offer greater survival benefits than hemodialysis, can be used safely to meet the increasing need for donors. Expanded criteria donor organs should thus be considered a valuable alternative in this patient group.

Vicarious trauma on the hemodialysis healthcare workers in the besieged Ethiopia's Tigray region: a call to action

BACKGROUND

The war on Ethiopia's Tigray broke out on November 4, 2020. Amid the armed conflict, governmental institutions were destroyed, people were displaced, and thousands of civilians were killed. The region was experiencing an on-and-off type of blockade since the war broke out until June 28, 2021, at which time the federal government of Ethiopia imposed a siege cutting off the region from the rest of the world. Due to the shortage of medicines and medical supplies, witnessing deaths that otherwise were preventable under normal conditions has become the daily predicament of healthcare workers. The burden of healthcare disintegration is particularly carried by patients with chronic medical illnesses including patients on dialysis.

MAIN BODY

Ayder hospital, Tigray's flagship healthcare institution, hosts the only hemodialysis center in the entire region. This center is currently unable to give appropriate care to kidney failure patients for a lack of access to dialysis supplies and consumables due to the ongoing war and siege. This has resulted in vicarious trauma manifested with compassion fatigue, irritability, a feeling of bystander guilt; sadness about the patient's victimization, and hopelessness among healthcare workers caring for dialysis patients.

CONCLUSION

The suffering of veteran patients and witnessing preventable deaths have continued to haunt and torment healthcare workers in the dialysis unit leading to vicarious trauma. Cognizant of the fact that vicarious trauma has serious health ramifications on healthcare workers; we call up the international community to advocate for a full resumption of access to healthcare and the provision of mental health support and educate and train healthcare workers dealing with end-stage kidney disease patients on hemodialysis.

Findings and Implications of the REVEAL-CKD Study Investigating the Global Prevalence of Undiagnosed Stage G3 Chronic Kidney Disease

Chronic kidney disease (CKD) is a progressive condition that can lead to kidney failure and the requirement for renal dialysis or transplantation. Early-stage CKD is often missed because the disorder is initially asymptomatic; hence, many patients with CKD already have symptomatic advanced disease (Stages G4–G5) at the time of diagnosis. This is an important issue because the drugs available for the treatment of CKD are most effective when given during the early stages of the disease (Stages G1–G3). EMJ conducted interviews in July 2022 with two key opinion leaders, Navdeep Tangri from the University of Manitoba, Winnipeg, Canada, and Luca De Nicola from the University of Campania Luigi Vanvitell, Naples, Italy, both of whom have a wealth of experience in the management of patients with CKD. The experts provided important insights into the ongoing REVEAL-CKD study, which was designed to explore the global prevalence of undiagnosed Stage G3 CKD. This article describes the main findings of the REVEAL-CKD study published to date and their implications. Possible approaches to improving the diagnosis of CKD are also discussed.

Study protocol: Effectiveness of patient centered pharmacist care in improving medication adherence, clinical parameters and quality of life among hemodialysis patients

BACKGROUND

Patients requiring hemodialysis (HD) often have several chronic comorbidities, which necessitate the use of several medications and hence put them at high risk of polypharmacy. Medication-related problems (MRPs) among HD patients are a serious issue as they can increase morbidity and nonadherence with medications. To overcome this issue, a unique pharmacy practice model including medication review (MR) and motivational interviewing (MI) is needed to improve medication adherence, by reducing MRPs and optimizing therapeutic outcomes. The present study aims to assess the effectiveness of MR and MI in improving medication adherence, quality of life (QOL) and clinical outcomes among end-stage renal disease (ESRD) patients who are on dialysis.

METHOD AND DESIGN

This pre-post study will be conducted prospectively among patients with ESRD who have been on dialysis at the Hemodialysis Unit, Hospital Kuala Lumpur and the Hemodialysis Affiliated Centers of the University Malaya Medical Centre, from August 2020 till August 2021. Medication adherence will be assessed using the General Medication Adherence Scale (GMAS), whilst patients' HRQOL will be assessed using the Kidney Disease Quality of Life Short Form 36 (KDQOL-36). Clinical parameters such as blood glucose level, calcium, phosphate, hemoglobin and serum low-density lipoprotein (LDL) levels will be obtained from medical records. A total of 70 patients will be recruited.

DISCUSSION

We hypothesize that the implementation of pharmacy-based MR and MI may expect an increase in medication adherence scores and increase in HRQOL scores from baseline as well as achieving the clinical lab parameters within the desired range. This would indicate a need for a pharmacist to be involved in the multidisciplinary team to achieve a positive impact on medication adherence among hemodialysis patients.

TRIAL REGISTRATION

Ethical approval has been obtained from the National Medical Research and Ethics Committee NMRR: 20-1135-54435 and Medical Research Ethics Committee, University Malaya Medical Centre MREC ID NO: 202127-9811.

Hypoalbuminaemia and One-Year Mortality in Haemodialysis Patients with Heart Failure: A Cohort Analysis

INTRODUCTION

The prevalence of chronic kidney disease (CKD) and heart failure (HF) has been rising over the past decade, with a prevalence close to 40%. Cardiovascular disease and malnutrition are common comorbidities and known risk factors for mortality in haemodialysis (HD) patients. We aimed to evaluate the one-year mortality rate after dialysis induction, and the impact of serum albumin levels on survival outcomes, in patients with CKD and HF.

METHODS

This was a retrospective analysis of patients with CKD and HF who underwent chronic HD between January 2016 and December 2019 in a tertiary-care Portuguese hospital. Variables were submitted to univariate and multivariate analysis to determine factors predictive of one-mortality after HD start.

RESULTS

In total, 204 patients were analysed (mean age 75.1 ± 10.3 years). Within the first year of HD start, 28.7% of patients died. These patients were significantly older [79.8 ± 7.2 versus 72.9 ± 10.9 years, p < 0.001; OR 1.08 (1.04-1.13), p < 0.001] and had a higher mean Charlson Index [9.0 ± 1.8 versus 8.3 ± 2.0, p = 0.015; OR 1.22 (1.04-1.44), p = 0.017], lower serum creatinine [5.1 ± 1.6 mg/dL versus 5.8 ± 2.0 mg/dL; p = 0.021; OR 0.80 (0.65-0.97), p = 0.022], lower albumin levels [3.1 ± 0.6 g/dL versus 3.4 ± 0.6 g/dL, p < 0.001; OR 0.38 (0.22-0.66), p = 0.001] and started haemodialysis with a central venous catheter more frequently [80.4% versus 66.2%, p = 0.050]. Multivariate analysis identified older age [aOR 1.07 (1.03-1.12), p = 0.002], lower serum creatinine [aOR 0.80 (0.64-0.99), p = 0.049] and lower serum albumin [aOR 0.41 (0.22-0.75), p = 0.004] as predictors of one-year mortality.

CONCLUSION

In our cohort, older age, lower serum creatinine and lower serum albumin were independent risk factors for one-year mortality, highlighting the prognostic importance of malnutrition in patients starting chronic HD.