Characteristics and predictors of mortality on haemodialysis in Brazil: a cohort of 5,081 incident patients

Predictors of excess fluid volume in hemodialysis patients: an observational study

OBJECTIVES

to assess risk factors for excess fluid volume in hemodialysis patients.

METHODS

a retrospective case-control study was conducted. A total of 392 patients (196 cases and 196 controls) from two hemodialysis centers were included. Sociodemographic data and 23 risk factors for excess fluid volume were assessed using a data collection form. Data were analyzed using a multivariate logistic regression model.

RESULTS

the insufficient knowledge (OR=2.06), excessive fluid intake (OR=2.33), inadequate fluid removal during hemodialysis (OR=2.62) and excessive sodium intake (OR=1.91) risk factors may increase the chance of occurrence of excess fluid volume in hemodialysis patients by approximately two times. Education level (OR=0.95) and age (OR=0.97) are protective factors for excessive fluid volume.

CONCLUSIONS

knowing these risk factors may help nurses with accurate and rapid diagnostic inference of the risk of excessive fluid volume.

Comparison of 1-year survival between patients initiating chronic hemodialysis under public and private health insurance: register-based data analysis from Brazil

PURPOSE

Brazil has one of the world's highest numbers of patients on hemodialysis (HD). Most dialysis centers are private and perform HD for patients with private and public health insurance. We compared 1-year survival between patients initiating chronic HD with public and private health insurance.

METHODS

This is an HD register-based retrospective cohort. Adult patients starting HD from January 2011 to December 2021 were included. Survival analysis was stratified according to the period entered in the HD register. Multivariate Cox regression focused on 1-year survival differences between private and public patients.

RESULTS

In the final sample (n = 5114), 68.5% of participants had public and 31.3% to private health insurance, with overall 1-year survival of 92.8% and 89.9%, respectively (p = 0.002). Crude analysis showed a slightly higher survival rate among patients with public health insurance than those with private health insurance (91 vs. 87%, p = 0.030) in the first period (2019-21). However, the adjusted hazard ratio (HR) did not remain significantly higher for patients with private health insurance compared to those with public health insurance (HR = 1.07; 95% CI 0.80-1.41; p = 0.651), even after propensity score matching of the groups by several baseline features.

CONCLUSION

Brazilian chronic HD patients funded by either private health plans or the public system have a similar 1-year mortality risk after controlling for several sociodemographic and clinical parameters.

Health-literacy, self-efficacy and health-outcomes of patients undergoing haemodialysis: Mediating role of self-management

BACKGROUND

Health literacy, self-efficacy and self-management are known to influence health-related well-being. However, the precise influence of self-management, health literacy and self-efficacy on health outcomes in Asian countries is under-researched.

OBJECTIVES

To examine the impact of health literacy and self-efficacy (independent variables) and self-management (mediator) on patients' health outcomes (dependent variable).

DESIGN

An observational, cross-sectional design was conducted between 1 March 2022 and 31 August 2022.

PARTICIPANTS

Outpatients receiving haemodialysis (n = 200) at a Taiwanese medical centre were assessed.

MEASUREMENTS

The survey included demographic questions and standardised scales: the 3-item Brief Health Literacy Screen, the 8-item Perceived Kidney/Dialysis Self-Management Scale as a measure of self-efficacy, and the 20-item Haemodialyses Self-Management Instrument. Health outcomes were responses on the 12-item Short-Form Health Survey version 2 and clinical blood results from the past 3 months.

RESULTS

Participants aged over 60 exhibited common comorbidities, with 34% showing low health literacy. Biochemical markers (e.g., haemoglobin and albumin) significantly correlated with physical and mental health scores. Mediating coefficients revealed that self-management significantly influenced associations between health outcomes, health literacy (β = 0.31; p < 0.01), and self-efficacy (β = 0.19; p < 0.01).

IMPLICATIONS FOR PRACTICE

Self-management can modify the overall influence of health literacy and self-efficacy on patients' quality of physical and emotional health. When managing a chronic condition, 'knowing' how to self-manage does not always result in 'doing so' by the patient. Continuous monitoring and promoting self-management behaviours and support by nurses are crucial to enhance health outcomes.

Survival in hemodialysis in Brazil according to the source of payment for the treatment: Public Healthcare System (SUS) versus private insurance

INTRODUCTION

Brazil has the largest public and universal healthcare system in the world, but little is known about the outcomes of patients on hemodialysis (HD) in the country according to the source of funding for the treatment.

OBJECTIVE

To compare the profile and survival of patients under HD treatment funded by the Public Healthcare System (SUS) to those with private insurance.

METHODS

Retrospective analysis of adults undergoing HD between 2012 and 2017 in 21 dialysis centers in Brazil that provided both by the SUS and private health insurance. Participants, regardless of the paying source, received similar dialysis treatment. Data were censored after 60 months of follow-up or at the end of 2019.

RESULTS

4,945 patients were included, 59.7% of which were financed by the SUS. Patients financed by SUS, compared to those with private insurance, were younger (58 vs. 60 years; p < 0.0001) and with a lower prevalence of diabetes (35.8% vs. 40.9%; p < 0.0001). The 60-month survival rates in these groups were 51.1% and 52.1%, respectively (p = 0.85). In the analysis of the subdistribution proportional hazard ratio by the Fine-Gray model, including adjustment for concurrent outcomes, a significant increase in the risk ratio for death was found (1.22 [95% confidence interval 1.04 to 1.43]) in patients with treatment funded by the SUS.

CONCLUSIONS

Patients on HD with treatment funded by the SUS have a higher adjusted risk of death when compared to those with private insurance, despite similar dialysis treatment. Factors not directly related to dialysis therapy could explain this difference.

Sobrevida na hemodiálise no Brasil de acordo com a fonte pagadora do tratamento: Sistema Único de Saúde versus convênio privado

Resumo Introdução: O Brasil possui o maior sistema público e universal de saúde do mundo, mas pouco se sabe sobre os desfechos dos pacientes em hemodiálise (HD) no país de acordo com a fonte de financiamento do tratamento. Objetivo: Comparar o perfil e a sobrevida dos pacientes que têm o tratamento de HD custeado pelo Sistema Único de Saúde (SUS) com aqueles com convênio privado. Métodos: Análise retrospectiva dos adultos incidentes em HD entre 2012 e 2017 em 21 centros de diálise no Brasil que atendiam tanto pelo SUS quanto por convênios privados. Os participantes, independentemente da fonte pagadora, receberam tratamento dialítico semelhante. Os dados foram censurados com 60 meses de acompanhamento ou ao final de 2019. Resultados: Foram incluídos 4945 pacientes, sendo 59,7% financiados pelo SUS. Os pacientes financiados pelo SUS, em comparação aos que tinham convênio privado, eram mais jovens (58 vs 60 anos; p < 0,0001) e com menor prevalência de diabetes (35,8% vs 40,9%; p < 0,0001). As taxas de sobrevida, em 60 meses nesses grupos foram de 51,1% e 52,1%, respectivamente (p = 0,85). Na análise da razão de risco proporcional de subdistribuição pelo modelo de Fine-Gray, incluindo ajuste para desfechos concorrentes, foi encontrado um aumento significativo na razão de risco para morte (1,22 [intervalo de confiança de 95% 1,04 a 1,43]) nos pacientes com tratamento custeado pelo SUS. Conclusões: Pacientes em HD com tratamento custeado pelo SUS têm um risco ajustado de morte mais elevado do que aqueles com convênio privado, apesar do tratamento dialítico semelhante. Fatores não relacionados diretamente à terapia dialítica poderiam justificar esta diferença.

Health insurance provider and endovascular treatment availability are associated with different hemodialysis vascular access profiles: A Brazilian national survey

In Brazil, most hemodialysis (HD) patients are treated by the country's public health system. However, accessibility to healthcare is different for public and private patients. This study aimed to identify the profile of vascular access in a Brazilian HD sample. Additionally, it aimed to examine the influence of public and private health insurance, accessibility to endovascular treatments, and timely arteriovenous access creation on the prevalence of tunneled catheters (TCs), non-tunneled catheters (NTCs), and arteriovenous (AV) access. We conducted a cross-sectional electronic survey across 834 centers. Centers were inquired about the number of patients with public and private health insurance, the profiles of vascular access, time for AV access creation, accessibility to TC insertion and endovascular treatments, and the availability of peritoneal dialysis and kidney transplantation. Logistic regression and multilevel logistic regression were performed to evaluate possible interactions between the independent variables. A total of 7,973 patients across 47 HD centers were included in the survey. Public health patients accounted for 77% of the study sample. The overall vascular access profiles of the public and private insurance groups were significantly different (p < 0.001). For patients with public health insurance, the prevalence of any catheter was 25%, while that for private patients was 31.8% (p < 0.001). The prevalence of TCs was more common in private patients (15.3% vs. 23.1%, p < 0.001). AV accesses were more common in public health patients (75% vs. 68.2%, p < 0.001), as were fistulas (72.4% vs. 63.1%, p < 0.001). AV grafts were more prevalent among patients with private insurance (2.6 vs. 5.1%, p < 0.001). The availability of endovascular treatments increased the chance of having a TC by 2.3-fold (OR = 2.33, 95% CI = 1.30-4.18); however, it did not reduce the chance of having any catheter. A high chance of having a catheter was found when the time to AV access creation exceeded 60 days. The differences between public and private patients may be explained by underpayments and the decreased accessibility to care infrastructure in the public system, especially for endovascular treatments. In this sample, public health patients had a decreased risk of having a TC over an NTC. Differences in care accessibility and insurance type might influence the type of vascular access.

Bioimpedance Indices of Fluid Overload and Cardiorenal Outcomes in Heart Failure and Chronic Kidney Disease: a Systematic Review

BACKGROUND

Bioimpedance-based estimates of fluid overload have been widely studied and systematically reviewed in populations of those undergoing dialysis, but data from populations with heart failure or nondialysis chronic kidney disease (CKD) have not.

METHODS AND RESULTS

We conducted a systematic review of studies using whole-body bioimpedance from populations with heart failure and nondialysis CKD that reported associations with mortality, cardiovascular outcomes and/or CKD progression. We searched MEDLINE, Embase databases and the Cochrane CENTRAL registry from inception to March 14, 2022. We identified 31 eligible studies: 20 heart failure and 11 CKD cohorts, with 2 studies including over 1000 participants. A wide range of various bioimpedance methods were used across the studies (heart failure: 8 parameters; CKD: 6). Studies generally reported positive associations, but between-study differences in bioimpedance methods, fluid overload exposure definitions and modeling approaches precluded meta-analysis. The largest identified study was in nondialysis CKD (Chronic Renal Insufficiency Cohort, 3751 participants), which reported adjusted hazard ratios (95% confidence intervals) for phase angle < 5.59 vs ≥ 6.4 of 2.02 (1.67-2.43) for all-cause mortality; 1.80 (1.46-2.23) for heart failure events; and 1.78 (1.56-2.04) for CKD progression.

CONCLUSIONS

Bioimpedance indices of fluid overload are associated with risk of important cardiorenal outcomes in heart failure and CKD. Facilitation of more widespread use of bioimpedance requires consensus on the optimum device, standardized analytical methods and larger studies, including more detailed characterization of cardiac and renal phenotypes.