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Ahbap E, Hasbal NB, Sevinc M, Basturk T, Sakaci T, Unsal A. Factors Associated with Long-Term Survival in Maintenance Hemodialysis Patients: A 5-Year Prospective Follow-Up Study. SISLI ETFAL HASTANESI TIP BULTENI 2022; 56:414-420. [PMID: 36304227 PMCID: PMC9580967 DOI: 10.14744/semb.2022.76983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 04/19/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES In addition to an increase in the prevalence of dialysis treatments for end-stage renal disease worldwide, the mortality rates among patients on maintenance hemodialysis remain higher than that of the general population. This study aims to evaluate factors associated with long-term survival in stable maintenance hemodialysis patients. METHODS A total of 100 patients initiating hemodialysis by February 2013 were included in this prospective cross-sectional 5-year follow-up study. Data on patient demographics, anthropometric-nutritional parameters, systolic and diastolic blood pressure levels, and hemodialysis parameters, including etiology of kidney failure, hemodialysis duration, peritoneal dialysis history, relative interdialytic weight gain (RIDWG), and Kt/V, were recorded. RESULTS Overall 5-year survival rate was 56.6%. The 5-year survival rate was higher in patients with younger age (71.4% below median vs. 42.0% above median, p=0.023), lower systolic (63.3 vs. 50%, respectively, p=0.005) and diastolic (62.5 vs. 51.0%, respectively, p=0.02) blood pressure levels, higher Kt/V (46.9 vs. 66.0%, respectively, p=0.044), lower RIDWG (54.0 vs. 32.7%, respectively, p=0.026), and lower serum leptin levels (63.3 vs. 50.0%, respectively, p=0.047). Cox-regression analysis revealed that only systolic blood pressure (B = 1.081, 95% CI, 0.152 to 0.756, p=0.08) was a significant risk factor for poor survival. CONCLUSION Our findings revealed pre-dialysis systolic blood pressure as the sole risk factor for poor long-term survival in stable maintenance hemodialysis patients. Malnutrition-inflammation, measures of nutrition, inflammation, and anemia had no significant impact on long-term survival.
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Affiliation(s)
- Elbis Ahbap
- Department of Nephrology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Teaching and Research Hospital, Istanbul, Türkiye
| | - Nuri Baris Hasbal
- Department of Nephrology, Basaksehir Cam and Sakura City Hospital, Istanbul, Türkiye
| | - Mustafa Sevinc
- Department of Nephrology, Taksim Teaching and Research Hospital, Istanbul, Türkiye
| | - Taner Basturk
- Department of Nephrology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Teaching and Research Hospital, Istanbul, Türkiye
| | - Tamer Sakaci
- Department of Nephrology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Teaching and Research Hospital, Istanbul, Türkiye
| | - Abdulkadir Unsal
- Department of Nephrology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Teaching and Research Hospital, Istanbul, Türkiye
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2
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Voorend CGN, van Oevelen M, Verberne WR, van den Wittenboer ID, Dekkers OM, Dekker F, Abrahams AC, van Buren M, Mooijaart SP, Bos WJW. OUP accepted manuscript. Nephrol Dial Transplant 2022; 37:1529-1544. [PMID: 35195249 PMCID: PMC9317173 DOI: 10.1093/ndt/gfac010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background Non-dialytic conservative care (CC) has been proposed as a treatment option for patients with kidney failure. This systematic review and meta-analysis aims at comparing survival outcomes between dialysis and CC in studies where patients made an explicit treatment choice. Methods Five databases were systematically searched from origin through 25 February 2021 for studies comparing survival outcomes among patients choosing dialysis versus CC. Adjusted and unadjusted survival rates were extracted and meta-analysis performed where applicable. Risk of bias analysis was performed according to the Cochrane Risk Of Bias In Non-randomized Studies of Interventions. Results A total of 22 cohort studies were included covering 21 344 patients. Most studies were prone to selection bias and confounding. Patients opting for dialysis were generally younger and had fewer comorbid conditions, fewer functional impairments and less frailty than patients who chose CC. The unadjusted median survival from treatment decision or an estimated glomerular filtration rate <15 mL/min/1.73 m2 ranged from 20 and 67 months for dialysis and 6 and 31 months for CC. Meta-analysis of 12 studies that provided adjusted hazard ratios (HRs) for mortality showed a pooled adjusted HR of 0.47 (95% confidence interval 0.39–0.57) for patients choosing dialysis compared with CC. In subgroups of patients with older age or severe comorbidities, the reduction of mortality risk remained statistically significant, although analyses were unadjusted. Conclusions Patients opting for dialysis have an overall lower mortality risk compared with patients opting for CC. However, a high risk of bias and heterogeneous reporting preclude definitive conclusions and results cannot be translated to an individual level.
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Affiliation(s)
| | | | - Wouter R Verberne
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Friedo Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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3
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Ou SH, Chen HY, Fang NW, Yin CH, Chen CL, Chen JS. Effect of anti-diabetic drugs in dialysis patients with diabetes: a nationwide retrospective cohort study. Cardiovasc Diabetol 2021; 20:179. [PMID: 34496858 PMCID: PMC8424811 DOI: 10.1186/s12933-021-01364-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/15/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus is common in patients undergoing dialysis. However, the association between anti-diabetic drug use and survival outcomes is rarely discussed. We aimed to investigate whether continued anti-diabetic medication use affects the survival of diabetic dialysis patients and whether different hypoglycemic drug use influences prognosis. METHODS Using a nationwide database, we enrolled patients with incident end-stage renal disease under maintenance dialysis during 2011-2015 into the pre-existing diabetes dialysis (PDD), incident diabetes after dialysis (IDD), and non-diabetic dialysis (NDD) groups. The PDD group was further subclassified into patients who continued (PDD-M) and discontinued (PDD-NM) anti-diabetic drug use after dialysis. RESULTS A total of 5249 dialysis patients were examined. The PDD-NM group displayed a significantly higher mortality rate than the IDD, PDD-M, and NDD groups (log-rank test P < 0.001). The PDD-M group had a significantly lower risk of death, regardless of insulin (P < 0.001) or oral hypoglycemic agent (OHA) (P < 0.001) use. Initial insulin administration or OHA had no statistically significant effect on overall mortality in the IDD group. But OHA use had better survival trends than insulin administration for the older (P = 0.02) and male subgroups (P = 0.05). CONCLUSIONS For dialysis patients with diabetes, continuous administration of anti-diabetic drugs after dialysis and choice of medication may affect outcomes.
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Affiliation(s)
- Shih-Hsiang Ou
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yu Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Nai-Wen Fang
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chien-Liang Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jin-Shuen Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
- Faculty of Medicine, School of Medicine, National Defense Medicine, Taipei, Taiwan.
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4
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Incidence and Risk of Carpal Tunnel Syndrome in End-Stage Renal Disease Patients on Dialysis: A Nationwide Population-Based Matched Cohort Study. Ann Plast Surg 2021; 84:S100-S106. [PMID: 31833895 DOI: 10.1097/sap.0000000000002181] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Carpal tunnel syndrome (CTS) is a common cause of compression neuropathy of the upper extremities. This retrospective nationwide matched cohort study was conducted using the data from the Taiwan National Health Insurance Research Database between January 2003 and December 2012. The incidence rate of CTS was 975.84 and 544.12/100,000 person-years, respectively, yielding an incidence rate ratio of 1.79 (95% confidence interval, 1.68-1.91, P < 0.0001). CTS patients with End-stage renal disease (ESRD) in the dialysis group were more likely to receive surgical intervention than those the control group (62.41% vs 12.89%, P < 0.0001). The risk of CTS was significantly higher in the ESRD on dialysis cohort (10-year cumulative incidence, 8.0%) than in the control cohort (5.1%), which yielded an adjusted hazard ratio of 13.95 (95% confidence interval, 10.95-17.76, P < 0.0001). The high risk of CTS in ESRD patients on dialysis suggests that timely referral to hand surgeons with appropriate treatment should prevent permanent median nerve damage by CTS and may possibly improve patients' quality of life.
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Hu PJ, Chen CH, Wong CS, Chen TT, Wu MY, Sung LC. Influenza vaccination reduces incidence of peripheral arterial occlusive disease in elderly patients with chronic kidney disease. Sci Rep 2021; 11:4847. [PMID: 33649465 PMCID: PMC7921588 DOI: 10.1038/s41598-021-84285-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 02/15/2021] [Indexed: 11/09/2022] Open
Abstract
An influenza vaccination might reduce the risk of incident peripheral arterial occlusive disease (PAOD) in patients with chronic kidney disease (CKD), but supporting evidence is limited. This case-crossover study analyzed data from Taiwan's real-world National Health Insurance Research Database. This study included elderly (≥ 67 years old) patients with CKD having incident PAOD from January 1, 2006, to June 30, 2015. We defined 1 year before PAOD onset as the index date for the self-control group. A conditional logistic regression model was used to investigate exposure to an influenza vaccination for estimating the risk for incident PAOD following vaccination. In total, this study included 46,782 elderly patients with CKD having incident PAOD. The odds ratios for incident PAOD were 0.85 (95% confidence interval 0.77-0.94), 0.85 (0.79-0.92), 0.84 (0.79-0.90), and 0.85 (0.81-0.90) at 1, 2, 3, and 4 months after an influenza vaccination, respectively. We observed consistent results for the subgroups of patients with CKD and concomitant diabetes. However, we did not observe any beneficial effects of influenza vaccination in patients with advanced CKD or end-stage renal disease. This study demonstrated that influenza vaccination may be associated with a reduced risk of incident PAOD among patients with early-stage CKD.
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Affiliation(s)
- Ping-Jen Hu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taitung, Taiwan.,Division of Gastroenterology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Master Program in Biomedicine, College of Science and Engineering, National Taitung University, Taitung, Taiwan
| | - Chia-Hsien Chen
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan.,Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
| | - Chung-Shun Wong
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Emergency Department, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tzu-Ting Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan
| | - Mei-Yi Wu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Primary Care Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,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, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
| | - Li-Chin Sung
- Department of Primary Care Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan.
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6
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Fu R, Sekercioglu N, Mathur MB, Couban R, Coyte PC. Dialysis Initiation and All-Cause Mortality Among Incident Adult Patients With Advanced CKD: A Meta-analysis With Bias Analysis. Kidney Med 2020; 3:64-75.e1. [PMID: 33604540 PMCID: PMC7873831 DOI: 10.1016/j.xkme.2020.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Rationale & Objectives Due to unmeasured confounding, observational studies have limitations when assessing whether dialysis initiation reduces mortality compared with conservative therapy among adults with advanced chronic kidney disease (CKD). We addressed this issue in this meta-analysis. Study Design Meta-analysis with bias analysis for unmeasured confounding. Setting & Study Population Adults with stage 4 or 5 CKD who had initiated dialysis or conservative treatment. Selection Criteria for Studies Prospective or retrospective cohort studies comparing survival of dialysis versus conservatively managed patients were searched on MEDLINE and Embase from January 2009 to March 20, 2019. Data Extraction HRs of all-cause mortality associated with dialysis initiation compared with conservative treatment. Analytical Approach We pooled HRs using a random-effects model. We estimated the percentage of effect sizes more protective than HRs of 0.80 and severity of unmeasured confounding that could reduce this percentage to only 10%. Subgroup analysis was performed for studies with only older patients (aged ≥ 65 years). Results 12 studies were included that involved 16,609 dialysis patients and 3,691 conservatively managed patients. A random-effects model suggested that dialysis initiation was associated with a mean mortality HR of 0.47 (95% CI, 0.34-0.64), in which 92% (95% CI, 50%-100%) of the true effects were more protective than HRs of 0.80. To reduce the percentage of HRs < 0.80 to 10%, unmeasured confounder(s) would need to be associated with both dialysis initiation and mortality by relative risks of 4.05 (95% CI, 2.39-4.15), which is equivalent to shifting each study's estimated HR by 2.31-fold (95% CI, 1.51-2.36). Restricting studies to include only older patients did not modify the results. Limitations Limited number of studies and evidence on the absence of publication bias. Conclusions Our findings suggest that dialysis initiation considerably reduces mortality among adults with advanced CKD. Future bias-adjusted meta-analyses need to assess outcomes beyond mortality.
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Affiliation(s)
- Rui Fu
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Nigar Sekercioglu
- Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Maya B Mathur
- Quantitative Sciences Unit, Stanford University, Stanford, CA
| | - Rachel Couban
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Peter C Coyte
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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7
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Hussien H, Apetrii M, Covic A. Health-related quality of life in patients with chronic kidney disease. Expert Rev Pharmacoecon Outcomes Res 2020; 21:43-54. [PMID: 33213186 DOI: 10.1080/14737167.2021.1854091] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: In the last three decades, health systems have continued to pay increasing attention to the quality of life (QOL) due to definitional changes in the concept of health and disease. The health-related quality of life (HRQOL) in patients with chronic kidney disease (CKD) is significantly affected, regardless of the stage of CKD. Areas covered: We attempt to thoroughly explore how CKD affects HRQOL domains with a quick primer on HRQOL assessment instruments in patients with CKD. Also, we pointed out the factors affecting HRQOL in patients with CKD as well as the clinical application of HRQOL in CKD management. Expert opinion: The general population enjoys higher HRQOL than patients with CKD in all domains. Similarly, pre-dialysis and kidney-transplant patients have better HRQOL than dialysis population. There are many factors which negatively impact HRQOL in CKD which include for example depression, anxiety, and cognitive impairment for the social domain, inactivity, and frailty for the physical domain as well as lack of social support and extroversion in the social domain. Additionally, social disparities and CKD-related factors would influence HRQOL. Of note, there is no global standard HRQOL assessment tool. Finally, HRQOL should be included in future CKD management guidelines.
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Affiliation(s)
- Hani Hussien
- Department of Nephrology, Grigore T Popa University of Medicine and Pharmacy, Faculty of Medicine , Iasi, Romania.,Department of Nephrology Dr C I Parhon University Hospital , Iasi, Romania
| | - Mugurel Apetrii
- Department of Nephrology, Grigore T Popa University of Medicine and Pharmacy, Faculty of Medicine , Iasi, Romania.,Department of Nephrology Dr C I Parhon University Hospital , Iasi, Romania
| | - Adrian Covic
- Department of Nephrology, Grigore T Popa University of Medicine and Pharmacy, Faculty of Medicine , Iasi, Romania.,Department of Nephrology Dr C I Parhon University Hospital , Iasi, Romania
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8
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Martin DE, Harris DCH, Jha V, Segantini L, Demme RA, Le TH, McCann L, Sands JM, Vong G, Wolpe PR, Fontana M, London GM, Vanderhaegen B, Vanholder R. Ethical challenges in nephrology: a call for action. Nat Rev Nephrol 2020; 16:603-613. [PMID: 32587403 DOI: 10.1038/s41581-020-0295-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.
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Affiliation(s)
- Dominique E Martin
- School of Medicine, Deakin University, Geelong Waurn Ponds Campus, Geelong, VIC, Australia.
| | - David C H Harris
- University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- University of Oxford, Oxford, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Luca Segantini
- International Society of Nephrology, Brussels, Belgium
- European Society for Organ Transplantation - ESOT c/o ESOT, Padova, Italy
| | - Richard A Demme
- Renal Division and Department of Medical Humanities and Bioethics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Thu H Le
- Nephrology Division, Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Laura McCann
- American Society of Nephrology, Washington, DC, USA
| | - Jeff M Sands
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Gerard Vong
- Center for Ethics, Emory University, Atlanta, GA, USA
| | | | - Monica Fontana
- European Renal Association - European Dialysis and Transplant Association, Parma, Italy
| | - Gerard M London
- Manhes Hospital, Nephrology Department GEPIR, Fleury-Mérogis, France
| | | | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Corneel Heymanslaan 10, B9000, Gent, Belgium
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9
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Felaco P, Felaco M, Franceschelli S, Ferrone A, Gatta DMP, Speranza L, Patruno A, De Lutiis MA, Ballerini P, Sirolli V, Grilli A, Bonomini M, Pesce M. Erythropoietin induces miRNA-210 by JAK2/STAT5 signaling in PBMCs of End-stage Renal Disease patients. FEBS J 2020; 287:5167-5182. [PMID: 32196922 DOI: 10.1111/febs.15302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 02/03/2020] [Accepted: 03/17/2020] [Indexed: 12/13/2022]
Abstract
Anemia of chronic kidney disease is associated with blunted response/resistance to erythropoietin-stimulating agents (ESAs) in hemodialysis (HD) patients. Several molecules have been successfully associated with ESA responsiveness; however, none of them is now considered a valid therapeutic biomarker of erythropoietin resistance in these patients. We performed an evaluation of the level of specific plasma circulating miRNAs in blood samples of HD patients, in relation to ESA treatment, with a follow-up of 1 year (T0-T3). We found significantly lower circulating levels of all miRNAs analyzed at baseline (T0) in HD patients vs. healthy control (HC). The plasmatic levels of miRNA-210 resulted significantly and negatively associated with Erythropoietin Resistance Index (ERI), and the variance of ΔmiRNA-210 (miRNA-210T3 minus miRNA-210T0 ) explained significant percentage of ΔERI (ERIT3 minus ERIT0 ) variance. The receiver operating characteristic analysis at T0 showed that the plasmatic level of miRNA-210 could distinguish HD patients with positive or negative trend in ERI at T3. In vitro, recombinant human erythropoietin (EPO) induced significant release of miRNA-210 from cultured peripheral blood mononuclear cells, through the activation of Janus kinase 2 (JAK2)/ signal transducer and activator of transcription 5 (STAT5) signaling, but not by the activation of the MAPK protein 38α and extracellular signal-regulated kinase ½. Accordingly, HD patients with negative ΔERI showed higher level of phosphor-Janus kinase 2 and nuclear translocation of phosphor-signal transducer and activator of transcription 5. vs. patients with positive ΔERI or HC. Our data highlighted that chronic HD significantly reduces the circulating level of the miRNAs evaluated; within the targets analyzed, the miRNA-210 could be considered as a prognostic indicator of ESA responsiveness and index for anemia management.
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Affiliation(s)
- Paolo Felaco
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Mario Felaco
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Sara Franceschelli
- Department of Psychological, Health and Territorial Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Alessio Ferrone
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Daniela M P Gatta
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Lorenza Speranza
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Antonia Patruno
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Maria A De Lutiis
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Patrizia Ballerini
- Department Neurosciences, Imaging and Clinical Sciences, University G. d'Annunzio, Chieti, Italy
| | - Vittorio Sirolli
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Alfredo Grilli
- Department of Medical, Oral and Biotechnological Sciences, University G. d'Annunzio, Chieti, Italy
| | - Mario Bonomini
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
| | - Mirko Pesce
- Department of Medicine and Aging Sciences, Medicine and Health Science School, University G. d'Annunzio, Chieti, Italy
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10
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Hu HY, Jian FX, Lai YJ, Yen YF, Huang N, Hwang SJ. Patient and provider factors associated with enrolment in the pre-end-stage renal disease pay-for-performance programme in Taiwan: a cross-sectional study. BMJ Open 2019; 9:e031354. [PMID: 31519682 PMCID: PMC6747641 DOI: 10.1136/bmjopen-2019-031354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The incidence and prevalence of end-stage renal disease (ESRD) in Taiwan have been ranked the highest worldwide. Therefore, the National Health Insurance Administration has implemented the pre-ESRD pay-for-performance (P4P) programme since November 2006, which had significantly reduced the incidence of dialysis and all-cause mortality. This study aimed to identify the factors associated with the enrolment in the pre-ESRD P4P programme. DESIGN Cross-sectional study. SETTING The National Health Insurance research database 2007-2012 in Taiwan. PARTICIPANTS Patients with prevalent pre-ESRD aged more than 18 years between January 2007 and December 2012 were enrolled. Patient demographics and hospital characteristics between P4P and non-P4P groups were compared. A logistic regression model was used to analyse the factors associated with P4P enrolment, and a generalised estimating equation was used to verify the results. PRIMARY OUTCOME MEASURE Enrolment in the pre-ESRD P4P programme. RESULTS In total, 82 991 patients were enrolled in the programme, with a 45.6% participation rate. Patients who were males (adjusted OR (AOR)=0.89, 95% CI=0.86 to 0.91) and employed (AOR=0.95, 95% CI=0.92 to 0.97) had a significantly lower probability to be enrolled in the programme. Older patients (66-75 years old, AOR=1.23, 95% CI=1.14 to 1.33) and those with higher Charlson Comorbidities Index (CCI 5+, AOR=4.01, 95% CI=3.55 to 4.53) tended to be enrolled in the programme, while those in the 76+ years age group were not (AOR=1.03, 95% CI=0.95 to 1.13). Hospitals located in the central (AOR=1.48, 95% CI=1.05 to 2.08) and Kao-Ping regions (AOR=1.62, 95% CI=1.18 to 2.22) also tended to enrol patients in the pre-ESRD P4P programme. Enrolment rates increased over time. CONCLUSION Pre-ESRD patients of the female gender, greater age and more comorbidities were more likely to be enrolled in the pre-ESRD P4P programme. Healthcare providers and health authorities should focus attention on patients who are male, younger and with less comorbidities to improve the healthcare quality and equality for all pre-ESRD patients.
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Affiliation(s)
- Hsiao-Yun Hu
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Feng-Xuan Jian
- Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yun-Ju Lai
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Puli Branch of Taichung Veterans General Hospital, Nantou, Taiwan
| | - Yung-Feng Yen
- Section of Infectious Diseases, Taipei City Hospital, Taipei, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Shang Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Chiang JK, Chen JS, Kao YH. Comparison of medical outcomes and health care costs at the end of life between dialysis patients with and without cancer: a national population-based study. BMC Nephrol 2019; 20:265. [PMID: 31311518 PMCID: PMC6636130 DOI: 10.1186/s12882-019-1440-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/25/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Palliative care has improved the quality of end-of-life (EOL) care and lowered the health care cost of cancer, and these benefits should be extended to patients with other serious illnesses including end-stage kidney disease. We evaluated the quality of EOL care, survival probabilities, and health care costs for dialysis patients in their last month of life. METHODS We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information of patient medical records, health care costs, and insurance system exit dates (our proxy for death between 2006 and 2011). RESULTS Data of 1177 adult patients who died of chronic hemodialysis or peritoneal dialysis were investigated. The mean age of these patients was 69.7 ± 11.9 years, and 585 (49.7%) were women. Some patients with dialysis received cardiopulmonary resuscitation (66.9%), died in a hospital (65.0%), or were admitted to an intensive care unit (51.0%) in the last month of life. We further classified these patients into two groups, namely dialysis with cancer (DC) (n = 149) and dialysis without cancer (D) (n = 1028). Only 19 dialysis patients received palliative care, and the proportion of patients receiving palliative care was higher in the DC group than in the D group (11.4% vs. 0.2%). The mean health care costs per person during the final month of life was similar between the DC and D groups (USD 2755 ± 259 vs. USD 2827 ± 88). Multivariate logistic regression showed that the DC group had lower odds of receiving cardiopulmonary resuscitation (CPR) (OR: 0.39, CI = 0.26-0.56, p < 0.001) procedures, higher odds of longer hospital stays than the third quartile (> 25 days) (OR: 1.52, CI = 1.01-2.29, p = 0.0046), and higher odds of being hospitalized more than once (OR: 2.26, CI = 1.42-3.59, p = 0.001) than the D group in the last month of life after adjustments. CONCLUSIONS DC patients received hospice care more frequently, received CPR less frequently, and had similar health care costs. DC patients also had a higher risk of a hospital stay that lasted more than 25 days and more than one hospitalization compared with D patients in the final month of life.
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Affiliation(s)
- Jui-Kun Chiang
- Department of Family Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2, Minsheng Road, Dalin, 622, Chiayi, Taiwan
| | - Jean-Shi Chen
- Department of Nephrology, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), 670 Chung-Te Road, Tainan, 701, Taiwan
| | - Yee-Hsin Kao
- Department of Family Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), 670 Chung-Te Road, Tainan, 701, Taiwan.
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12
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Artificial Intelligence Prediction Model for the Cost and Mortality of Renal Replacement Therapy in Aged and Super-Aged Populations in Taiwan. J Clin Med 2019; 8:jcm8070995. [PMID: 31323939 PMCID: PMC6678226 DOI: 10.3390/jcm8070995] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/08/2019] [Accepted: 07/08/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prognosis of the aged population requiring maintenance dialysis has been reportedly poor. We aimed to develop prediction models for one-year cost and one-year mortality in aged individuals requiring dialysis to assist decision-making for deciding whether aged people should receive dialysis or not. METHODS We used data from the National Health Insurance Research Database (NHIRD). We identified patients first enrolled in the NHIRD from 2000-2011 for end-stage renal disease (ESRD) who underwent regular dialysis. A total of 48,153 Patients with ESRD aged ≥65 years with complete age and sex information were included in the ESRD cohort. The total medical cost per patient (measured in US dollars) within one year after ESRD diagnosis was our study's main outcome variable. We were also concerned with mortality as another outcome. In this study, we compared the performance of the random forest prediction model and of the artificial neural network prediction model for predicting patient cost and mortality. RESULTS In the cost regression model, the random forest model outperforms the artificial neural network according to the mean squared error and mean absolute error. In the mortality classification model, the receiver operating characteristic (ROC) curves of both models were significantly better than the null hypothesis area of 0.5, and random forest model outperformed the artificial neural network. Random forest model outperforms the artificial neural network models achieved similar performance in the test set across all data. CONCLUSIONS Applying artificial intelligence modeling could help to provide reliable information about one-year outcomes following dialysis in the aged and super-aged populations; those with cancer, alcohol-related disease, stroke, chronic obstructive pulmonary disease (COPD), previous hip fracture, osteoporosis, dementia, and previous respiratory failure had higher medical costs and a high mortality rate.
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13
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Ren Q, Shi Q, Ma T, Wang J, Li Q, Li X. Quality of life, symptoms, and sleep quality of elderly with end-stage renal disease receiving conservative management: a systematic review. Health Qual Life Outcomes 2019; 17:78. [PMID: 31053092 PMCID: PMC6500052 DOI: 10.1186/s12955-019-1146-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 04/22/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Older patients with end-stage renal disease (ESRD) have experienced diminished quality of life and debilitating symptoms. Conservative management may be a potential treatment option. Currently, limited studies have been conducted about the main outcome of conservative management, including quality of life, symptoms and sleep quality. The aim of this systematic review was to examine the quality of life, symptoms and sleep quality of elderly patients with ESRD undergoing conservative management. METHODS Evidence-based medicine database (JBI and Cochrane) and original literature database (PubMed, Medline, EMbase, Web of Science) were searched up to March 12, 2018. The quality of included papers was evaluated with the Newcastle-Ottawa Scale. RESULTS Eight studies met the inclusion criteria. The total of 1229 patients were involved with an average age of 60.6 ~ 82 years. Patients choosing conservative management were older and more functionally impaired compared to those opting for dialysis. 55% patients undergoing conservative management had stable or improved quality of life and symptoms in prospective cohort study. However, the results revealed that there were no significant differences in quality of life and symptom between conservative management and renal replacement therapy. Only one study assessed quality of life of older patients using SF-36, with a lower score in physical health subscale of conservative management patients than those of renal replacement therapy. Although more than 40% of the patients had poor sleep quality, no significant difference was found between conservative management and renal replacement therapy. Sleep disorders were associated with fatigue and other symptoms. CONCLUSIONS Although there is a limited literature, conservative management is likely to improve quality of life and alleviate symptoms of end-stage renal disease patients with considerable clinical implications mainly in elderly patients. Future study should pay more attention to the various treatment outcomes of conservative management, providing abundant evidence.
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Affiliation(s)
- Qingli Ren
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Qifang Shi
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Tong Ma
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Jing Wang
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Qian Li
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
| | - Xiaomei Li
- School of Nursing, Xi’an Jiaotong University, Xi’an, China
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14
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Ozdemir S, Jafar TH, Choong LHL, Finkelstein EA. Family dynamics in a multi-ethnic Asian society: comparison of elderly CKD patients and their family caregivers experience with medical decision making for managing end stage kidney disease. BMC Nephrol 2019; 20:73. [PMID: 30823872 PMCID: PMC6397496 DOI: 10.1186/s12882-019-1259-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/18/2019] [Indexed: 12/02/2022] Open
Abstract
Background Elderly end stage kidney patients face a decision concerning whether or not to initiate dialysis. In Asia, this decision is highly influenced by family caregivers. The objective of this paper was to understand patients’ experience with and preferences for family involvement in treatment decisions, and via a series of hypothetical vignettes, to identify whether there was discordance in treatment preferences between patients and their caregivers, and how any potential conflicts were reconciled. Methods We conducted a survey with 151 elderly (aged ≥65) chronic kidney disease patients and their caregivers at outpatient renal clinics. The survey asked, when making treatment decisions, whom they wish makes the final decisions (i.e., preference) and who usually makes the final decisions (i.e., experience). The survey also presented a series of choice vignettes for managing patient’s condition and asked respondents to choose between two hypothetical treatment profiles in each vignette. Patients and caregivers were first interviewed separately in tandem, and then were brought together to choose a treatment jointly for vignettes where the initial treatment choice differed within the dyad. We used multivariate regressions to investigate the predictors of discordance and reconciliation. Results We found that most (51%) patients preferred and experienced (64%) significant involvement from caregivers. However, 38% of patients preferred to make final decisions alone but only 27% of patients did. In the hypothetical vignettes, caregivers chose the more intensive option (i.e., dialysis) more than patients did (26% vs 19%; p < 0.01). Overall, 44% of the dyads had discordance in at least 3 vignettes, and the odds of discordance within patient-caregiver dyads was higher when caregivers chose dialysis or treatment with the higher cost (p < 0.01). In half the cases, discordance resolved in the patients’ favor, and this was more likely to be the case if the patient was employed and wanted to be in charge of final decisions (p < 0.01). Conclusions Our results highlight the important role of caregivers in decision-making but also the potential for them to overstep. Clinicians should be aware of this challenge and identify strategies that minimize the chances that patients may receive treatments not consistent with their preferences. Electronic supplementary material The online version of this article (10.1186/s12882-019-1259-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,Programme in Health Services and Systems Research Programme, Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857, Singapore
| | - Tazeen H Jafar
- Programme in Health Services and Systems Research Programme, Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857, Singapore
| | - Lina Hui Lin Choong
- Department of Renal Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore. .,Programme in Health Services and Systems Research Programme, Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857, Singapore.
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15
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Chao CT, Wang J, Huang JW, Chien KL. Acarbose Use and Liver Injury in Diabetic Patients With Severe Renal Insufficiency and Hepatic Diseases: A Propensity Score-Matched Cohort Study. Front Pharmacol 2018; 9:860. [PMID: 30131698 PMCID: PMC6090209 DOI: 10.3389/fphar.2018.00860] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 07/16/2018] [Indexed: 12/19/2022] Open
Abstract
Background: Acarbose has been deemed contraindicated in diabetic patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD), but such use is not uncommon. We tested whether this concept hold true in this population with different background hepatic diseases. Methods: All incident diabetic patients (n = 2,036,531) with stage 5 CKD/ESRD were enrolled from Taiwan between 2017 and 2013 and divided into those without chronic liver disease (CLD), with CLD but without cirrhosis, and those with cirrhosis. Among each group, acarbose users, defined as cumulative use >30 days within the preceding year, were propensity-score matched 1:2 to non-users. Our main outcome was the development of liver injury events during follow-up. Results: Acarbose users did not exhibit an increased incidence of liver injury during follow-up compared to non-users (hazard ratio and 95% confidence interval, 1.04 [0.88–1.25], 0.97 [0.61–1.56], and 0.71 [0.33–1.54] among those without CLD, with CLD but without cirrhosis, and those with cirrhosis, respectively), after adjusting for demographic profiles, comorbidities, potentially hepatotoxic medication use, and diabetic severity. Conclusions: The incidence of liver injury did not increase significantly among diabetic acarbose users with severe renal insufficiency than non-users, regardless of the presence or absence of chronic liver disease. Our findings support the renaissance of acarbose as a useful adjunct in diabetic patients with stage 5 and 5D chronic kidney disease.
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Affiliation(s)
- Chia-Ter Chao
- Department of Medicine, National Taiwan University Hospital BeiHu Branch, Taipei, Taiwan.,Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Geriatric and Community Medicine Research Center, National Taiwan University Hospital BeiHu Branch, Taipei, Taiwan
| | - Jui Wang
- College of Public Health, Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Jenq-Wen Huang
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuo-Liong Chien
- College of Public Health, Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
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16
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Postoperative Renal Outcomes of Patients Receiving Percutaneous Nephrolithotomy versus Pyelolithotomy: A Population-Based Cohort Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8582901. [PMID: 29854800 PMCID: PMC5954950 DOI: 10.1155/2018/8582901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/27/2018] [Indexed: 12/04/2022]
Abstract
The aim of this population-based cohort study was to explore postoperative renal outcomes of patients receiving pyelolithotomy versus percutaneous nephrolithotomy (PCNL). Data were retrieved from the Taiwan National Health Insurance Research Database. During the period from Jan 1, 1998, to Dec 31, 2012, there were 2549 and 21654 patients who underwent pyelolithotomy and PCNL, respectively. The postoperative incidence of new diagnosed end stage renal disease (ESRD) was statistically analyzed and compared between the pyelolithotomy and PCNL groups. The perioperative complications of two groups were also analyzed. In comparison to pyelolithotomy, PCNL achieved lower new diagnosed ESRD (1.38% versus 2.28%, p = 0.0004). Patients receiving PCNL had significantly higher rates of preoperative hypertension, diabetes mellitus, pulmonary disease, cerebrovascular disease, and coronary artery disease. The hospital stay was shorter in PCNL groups compared with pyelolithotomy groups (8.31 days versus 12.59 days, p = 0.0006). In conclusion, PCNL contributed to lower rates of new diagnosed ESRD and hospital stay when compared to pyelolithotomy.
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17
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Tam-Tham H, Quinn RR, Weaver RG, Zhang J, Ravani P, Liu P, Thomas C, King-Shier K, Fruetel K, James MT, Manns BJ, Tonelli M, Murtagh FEM, Hemmelgarn BR. Survival among older adults with kidney failure is better in the first three years with chronic dialysis treatment than not. Kidney Int 2018; 94:582-588. [PMID: 29803405 DOI: 10.1016/j.kint.2018.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 02/13/2018] [Accepted: 03/02/2018] [Indexed: 11/28/2022]
Abstract
Comparisons of survival between dialysis and nondialysis care for older adults with kidney failure have been limited to those managed by nephrologists, and are vulnerable to lead and immortal time biases. So we compared time to all-cause mortality among older adults with kidney failure treated vs. not treated with chronic dialysis. Our retrospective cohort study used linked administrative and laboratory data to identify adults aged 65 or more years of age in Alberta, Canada, with kidney failure (2002-2012), defined by two or more consecutive outpatient estimated glomerular filtration rates less than 10 mL/min/1.73m2, spanning 90 or more days. We used marginal structural Cox models to assess the association between receipt of dialysis and all-cause mortality by allowing control for both time-varying and baseline confounders. Overall, 838 patients met inclusion criteria (mean age 79.1; 48.6% male; mean estimated glomerular filtration rate 7.8 mL/min/1.73m2). Dialysis treatment (vs. no dialysis) was associated with a significantly lower risk of death for the first three years of follow-up (hazard ratio 0.59 [95% confidence interval 0.46-0.77]), but not thereafter (1.22 [0.69-2.17]). However, dialysis was associated with a significantly higher risk of hospitalization (1.40 [1.16-1.69]). Thus, among older adults with kidney failure, treatment with dialysis was associated with longer survival up to three years after reaching kidney failure, though with a higher risk of hospital admissions. These findings may assist shared decision-making about treatment of kidney failure.
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Affiliation(s)
- Helen Tam-Tham
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert R Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert G Weaver
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jianguo Zhang
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ping Liu
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chandra Thomas
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn King-Shier
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | - Karen Fruetel
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matt T James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fliss E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Brenda R Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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18
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Finkelstein EA, Ozdemir S, Malhotra C, Jafar TH, Choong HL, Suhardjono J. Identifying Factors That Influence Physicians' Recommendations for Dialysis and Conservative Management in Indonesia. Kidney Int Rep 2017; 2:212-218. [PMID: 29142957 PMCID: PMC5678627 DOI: 10.1016/j.ekir.2016.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 11/14/2016] [Accepted: 12/05/2016] [Indexed: 11/07/2022] Open
Abstract
Introduction For elderly end-stage renal disease (ESRD) patients with multiple comorbidities, dialysis may offer little survival benefit compared to conservative management (CM). Yet, many elderly ESRD patients undergo dialysis, partly due to physicians’ recommendations regarding treatment choice. This study aims to elucidate the factors that influence these recommendations. Methods We surveyed a convenience sample of physicians who attended the 9th Asian Forum of Chronic Kidney Disease Initiative conference. We used vignettes that vary by age and comorbidity status, and asked physicians to recommend dialysis or CM for a hypothetical patient with that profile and to predict survival with both treatment options. We also compared the physician’s recommendations to patients for what they would recommend for themselves if they were diagnosed with ESRD. Results On average, physicians believed that dialysis extends life relative to CM. Yet, a large subset believed that CM confers greater survival. Estimates range from 17.3% (for a 65-year-old with diabetes and CHF) to 50% for patients with advanced cancer. Results further reveal high discordance regarding treatment recommendations. For a 65-year-old patient with diabetes, 62% recommended dialysis and 38% did not. For advanced cancer, the split was 25% and 75%. Physicians were far more likely to recommend dialysis for themselves than for their patients. Discussion This study suggests that physicians would benefit from a greater understanding of survival benefits of dialysis and CM for elderly patients with different comorbidity profiles. This would allow patients to make more informed decisions.
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Affiliation(s)
| | | | | | - Tazeen H Jafar
- Duke-NUS Medical School Singapore, Singapore.,Singapore General Hospital, Singapore
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19
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Chao CT, Tang CH, Cheng RWY, Wang MYH, Hung KY. Protein-energy wasting significantly increases healthcare utilization and costs among patients with chronic kidney disease: a propensity-score matched cohort study. Curr Med Res Opin 2017; 33:1705-1713. [PMID: 28699849 DOI: 10.1080/03007995.2017.1354823] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Disease-related malnutrition is highly prevalent, and has prognostic implications for patients with chronic kidney disease (CKD); however, few studies have investigated the impact of malnutrition, or protein-energy wasting (PEW), on healthcare utilization and medical expenditure among CKD patients. METHODS Using claim data from the National Health Insurance in Taiwan, this study identified patients with CKD between 2009-2013 and categorized them into those with mild, moderate, or severe CKD. Cases with PEW after CKD was diagnosed were propensity-score matched with controls in a 1:4 ratio. Healthcare resource utilization metrics were compared, including outpatient and emergency department visits, frequency and duration of hospitalization, and the cumulative costs associated with different CKD severity. RESULTS From among 347,501 CKD patients, eligible cohorts of 66,872 with mild CKD (49.2%), 27,122 with moderate CKD (19.9%), and 42,013 with severe CKD (30.9%) were selected. Malnourished CKD patients had significantly higher rates of hospitalization (p < .001 for all severities) and re-admission (p = .015 for mild CKD, p = .002 for severe CKD) than non-malnourished controls. Cumulative medical costs for outpatient and emergency visits, and hospitalization, were significantly higher among all malnourished CKD patients than non-malnourished ones (p < .001); total medical costs were also higher among malnourished patients with mild (62.9%), moderate (59.6%), or severe (43.6%) CKD compared to non-malnourished patients (p < .001). CONCLUSIONS In a nationally-representative cohort, CKD patients with PEW had significantly more healthcare resource utilization and higher aggregate medical costs than those without, across the spectrum of CKD: preventing PEW in CKD patients should receive high priority if we would like to reduce medical costs.
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Affiliation(s)
- Chia-Ter Chao
- a Department of Medicine , National Taiwan University Hospital Jin-Shan branch , Wuhu Village, Jinshan Dist. , New Taipei City , Taiwan
- b Department of Internal Medicine , National Taiwan University Hospital , Taipei , Taiwan
| | - Chao-Hsiun Tang
- c School of Health Care Administration, College of Management , Taipei Medical University , Taipei , Taiwan
| | | | | | - Kuan-Yu Hung
- b Department of Internal Medicine , National Taiwan University Hospital , Taipei , Taiwan
- e Department of Internal Medicine , National Taiwan University Hospital Hsin-Chu branch , Hsinchu City , Taiwan
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20
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Chao CT, Wang J, Wu HY, Chien KL, Hung KY. Dipeptidyl peptidase 4 inhibitor use is associated with a lower risk of incident acute kidney injury in patients with diabetes. Oncotarget 2017; 8:53028-53040. [PMID: 28881791 PMCID: PMC5581090 DOI: 10.18632/oncotarget.18081] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 05/10/2017] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Dipeptidyl peptidase 4 inhibitor (DPP4i) use potentially slows the progression of diabetic kidney disease, but its effects on the risk of acute kidney injury (AKI) are unclear. We aimed to assess the association between DPP4i use and incident AKI episodes from a nationally representative cohort in Taiwan. MATERIALS AND METHODS All patients newly diagnosed with diabetes mellitus (DM) between 2008, when DPP4i use was first approved in Taiwan, and mid-2013 were enrolled. Propensity score-matched diabetic DPP4i users, who received DPP4i for at least 90 days, and nonusers were selected. The primary and secondary outcomes were incident AKI and dialysis-requiring AKI during follow-up. Cox proportional hazard analyses were performed to examine the effect of DPP4i on the risk of AKI. RESULTS We enrolled 923,936 diabetic patients; of these, 83,638 DPP4i users (75.7% sitagliptin, 14.6% vildagliptin, and 9.7% saxagliptin) were propensity score-matched to 83,638 non-users. After an average 3.6-year follow-up, 1.56% and 0.35% of DPP4i users and 2.53% and 0.56% of non-users developed incident AKI and dialysis-requiring AKI, respectively. DPP4i use was significantly associated with lower risk of incident AKI (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.53-0.61) and risk of dialysis-requiring AKI (HR 0.57, 95% CI 0.49-0.66). The risk reduction was consistent regardless of DPP4i type, the presence of chronic kidney disease, the previous acute kidney injury, and age. CONCLUSIONS DPP4i use is associated with reduced risk of mild and severe forms of AKI among patients with incident DM. DPP4i may be an important class of anti-glycaemic agent with reno-protective effects.
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Affiliation(s)
- Chia-Ter Chao
- Department of Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Jui Wang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hon-Yen Wu
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Kuan-Yu Hung
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu City, Taiwan
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Wu CH, Yang YW, Hung SC, Kuo KL, Wu KD, Wu VC, Hsieh TC. Ketoanalogues supplementation decreases dialysis and mortality risk in patients with anemic advanced chronic kidney disease. PLoS One 2017; 12:e0176847. [PMID: 28475591 PMCID: PMC5419544 DOI: 10.1371/journal.pone.0176847] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 04/18/2017] [Indexed: 12/20/2022] Open
Abstract
Background The benefit of alpha-Ketoanalogues (KA) supplementation for chronic kidney disease (CKD) patients that followed low-protein diet (LPD) remains undetermined. Methods We extracted longitudinal data for all CKD patients in the Taiwan National Health Insurance from January 1, 2000 through December 31, 2010. A total of 1483 patients with anemic advanced CKD treated with LPD, who started KA supplementation, were enrolled in this study. We analyzed the risks of end stage renal disease and all-cause mortality using Cox proportional hazard models with influential drugs as time-dependent variables. Results A total of 1113 events of initiating long-term dialysis and 1228 events of the composite outcome of long-term dialysis or death occurred in patients with advanced CKD after a mean follow-up of 1.57 years. Data analysis suggests KA supplementation is associated with a lower risk for long-term dialysis and the composite outcome when daily dosage is more than 5.5 tablets. The beneficial effect was consistent in subgroup analysis, independent of age, sex, and comorbidities. Conclusions Among advanced CKD patients that followed LPD, KA supplementation at an appropriate dosage may substantially reduce the risk of initiating long-term dialysis or of developing the composite outcome. KA supplementation represents an additional therapeutic strategy to slow the progression of CKD.
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Affiliation(s)
- Che-Hsiung Wu
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ya-Wen Yang
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Chun Hung
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
| | - Ko-Lin Kuo
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail: (VW); (T-CH)
| | - Tsung-Cheng Hsieh
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
- * E-mail: (VW); (T-CH)
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Renal Function Replacement by Hemodialysis: Forty-Year Anniversary and a Glimpse into the Future at Hand. Int J Artif Organs 2017; 40:313-322. [DOI: 10.5301/ijao.5000623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 12/24/2022]
Abstract
From its introduction in 1943 and until the late 1970s, hemodialysis (HD) has been a lengthy and cumbersome treatment administered by a few skilled physicians and technicians to a very limited number of terminal kidney patients. The technological innovations introduced over the years made HD a treatment administered and supervised by nursing personnel to a very large numbers of kidney patients, hopefully until recovery of kidney functions or kidney transplantation. In 2013, it is estimated that 2.250.00 kidney patients were treated worldwide, and their number is steadily increasing. Shortage of transplant kidneys and quality of current treatments has contributed to increasing the survival of HD patients. Today, it is not unusual to find patients who have been on HD for longer than twenty years. All this generated the feeling that performance of membranes and dialysis technology has reached its limit. Recently, the increasing economic burden of healthcare caused by people ageing and the increasing incidence of degenerative diseases (e.g. diabetes and cardiovascular diseases), and the economic crisis has pushed many governments and health insurances to cut resources for healthcare. The main consequence is that investments in research and development in HD have been significantly reduced. The question is whether there is indeed no need for innovation in HD. In this paper, it is discussed how the paradigm of HD has changed and what possibly are now the drivers for innovation in HD. A few ideas are proposed that could be developed by adapting existing technologies to the future needs of HD.
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Chen SW, Chang CH, Lin YS, Wu VCC, Chen DY, Tsai FC, Hung MJ, Chu PH, Lin PJ, Chen TH. Effect of dialysis dependence and duration on post-coronary artery bypass grafting outcomes in patients with chronic kidney disease: A nationwide cohort study in Asia. Int J Cardiol 2016; 223:65-71. [PMID: 27532236 DOI: 10.1016/j.ijcard.2016.08.121] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 08/04/2016] [Accepted: 08/05/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with adverse outcomes in patients who undergo coronary artery bypass grafting (CABG). However, the impact of preoperative dialysis dependence and duration in CKD patients on outcomes after CABG has limited research. OBJECTIVES To evaluate the effect of preoperative dialysis dependence and duration on CABG outcomes in patients with CKD. METHODS A total of 33,920 patients without CKD and 2573 patients with CKD, all of whom underwent isolated CABG between 1998 and 2009, were identified using the Taiwan National Health Insurance Research Database. The patients with CKD were divided into non-dialysis (N=1167), dialysis<3years (N=749), and dialysis≥3years (N=657) groups. The primary outcomes were cumulative incidence of all-cause mortality, cardiovascular (CV) death, and myocardial infarction (MI) or repeat revascularization. RESULTS After adjustment of all covariates, a higher all-cause mortality was associated with dialysis≥3years than with dialysis<3years (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.35-1.80; P<0.001) and with non-dialysis (HR, 1.41; 95% CI, 1.20-1.66; P<0.001) after 2years of follow-up. Similar results were observed for CV death. In addition, both the dialysis groups had a higher risk of MI or revascularization than the non-dialysis group. Furthermore, subgroup analysis revealed that longer duration was associated with a higher risk of 30-day mortality (P for linear trend <0.001). CONCLUSIONS Among the CABG recipients, dialysis dependence is associated with a higher incidence of MI or repeat revascularization, and longer dialysis duration is associated with a higher risk of mortality.
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Affiliation(s)
- Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chih-Hsiang Chang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan; Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Yu-Sheng Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch, Chiayi Branch and Linkou Medical Center, Taoyuan City, Taiwan
| | - Victor Chien-Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch, Chiayi Branch and Linkou Medical Center, Taoyuan City, Taiwan
| | - Dong-Yi Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch, Chiayi Branch and Linkou Medical Center, Taoyuan City, Taiwan
| | - Feng-Chun Tsai
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Ming-Jui Hung
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch, Chiayi Branch and Linkou Medical Center, Taoyuan City, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch, Chiayi Branch and Linkou Medical Center, Taoyuan City, Taiwan
| | - Pyng-Jing Lin
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Tien-Hsing Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch, Chiayi Branch and Linkou Medical Center, Taoyuan City, Taiwan.
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Effects of DPP-4 inhibitors on cardiovascular outcomes in patients with type 2 diabetes and end-stage renal disease. Int J Cardiol 2016; 218:170-175. [PMID: 27236110 DOI: 10.1016/j.ijcard.2016.05.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Recent clinical trials have evaluated the cardiovascular outcomes of dipeptidyl peptidase-4 (DPP-4) inhibitors in patients with type 2 diabetes mellitus (T2DM), but those with end-stage renal disease (ESRD) were ineligible for participation in these trials. We aimed to characterize the impact of DPP-4 inhibitors on major adverse cardiovascular events (MACEs) in patients with T2DM and ESRD undergoing chronic dialysis. METHODS This nationwide observational study utilized data from 3556 patients aged ≥20years with T2DM and ESRD who initiated treatment with DPP-4 inhibitors between 1 March 2009 and 31 June 2013, retrieved from Taiwan's National Health Insurance Research Database. Each DPP-4 inhibitor user was matched to a non-user control subject using propensity scores. The primary outcomes were all-cause mortality and MACEs (ischemic stroke and myocardial infarction). The secondary outcomes were hospitalization for heart failure and hypoglycemia. All subjects were followed until death or 31 December 2013. RESULTS Compared with non-users, DPP-4 inhibitor users had lower risks of all-cause mortality (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.39-0.47), MACEs (HR 0.76, 95% CI 0.65-0.90), and ischemic stroke (HR 0.77, 95% CI 0.61-0.97); the risks of myocardial infarction and hospitalization for heart failure and hypoglycemia did not differ. This treatment effect remained consistent in subgroup analyses according to age, sex, comorbidities, dialysis modality, and insulin use. CONCLUSIONS In this nationwide ESRD cohort, DPP-4 inhibitor use was associated with reduced risks of all-cause mortality and ischemic stroke.
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Stage 5-CKD under nephrology care: to dialyze or not to dialyze, that is the question. J Nephrol 2015; 29:153-161. [PMID: 26584810 DOI: 10.1007/s40620-015-0243-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 10/24/2015] [Indexed: 01/26/2023]
Abstract
Appropriate timing of starting chronic dialysis in patients with advanced chronic kidney disease (CKD) under nephrology care still is undefined. We systematically reviewed the most recent studies that have compared outcomes of stage 5-CKD under conservative versus substitutive treatment. Eleven studies, most in elderly patients, were identified. Results indicate no advantage of dialysis over conservative management in terms of survival, hospitalization or quality of life. This information is integrated with a case report on a middle-aged CKD patient followed in our clinic who has remained for 15 years in stage 5 despite severe disease. The patient is a diabetic woman who underwent right nephrectomy in 1994 because of renal tuberculosis. In 1999, she commenced regular nephrology care in our clinic and, since 2000, when she was 53 years old, her estimated glomerular filtration rate (eGFR) has been ≤15 ml/min/1.73 m(2). Over the last decade, despite, several episodes of acute kidney injury and placement of permanent percutaneous nephrostomy in 2001, renal function has remained remarkably stable, though severely impaired (eGFR 7.7-5.6 ml/min/1.73 m(2)). Our systematic analysis of the literature and this case report highlight the need for further studies, not limited exclusively to elderly patients, to verify the efficacy of non-dialysis treatment in stage 5-CKD patients. Meanwhile, nephrologists may consider that their intervention can safely prolong for several years the dialysis-free condition in ESRD independently of age.
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Zimbudzi E, Samlero R, Kerr PG, Zoungas S. How much is enough? An investigation of the relationship between haemodialysis adequacy and quality of life of elderly patients. Nephrology (Carlton) 2015; 21:314-20. [PMID: 26369623 DOI: 10.1111/nep.12594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 08/13/2015] [Accepted: 08/15/2015] [Indexed: 11/28/2022]
Abstract
AIM The average age of patients requiring haemodialysis is on the rise and has resulted in an increase in the number of elderly people receiving dialysis. While haemodialysis is one of the treatment options for this patient group, questions about its effectiveness have been raised. A second question centres on how much haemodialysis is actually needed to maintain quality of life (QoL). This study examined the relationship between dialysis adequacy and the QoL of elderly patients on haemodialysis. METHOD A prospective cohort of 40 haemodialysis patients aged 75 years and above was recruited and studied over 3 months. Quality of life was assessed with the European Quality of Life-5 Dimensions questionnaire and dialysis adequacy with the urea reduction ratio (URR), and the relationship between the two examined using a simple linear regression model. RESULTS The average age of the participants was 79.8 ± (3.9 years; 45% were women, and diabetes was the main cause of kidney disease (42.5%). The mean URR, visual analogue scale, European Quality of Life-5 Dimensions indices score and Charlson comorbidity index scores were 78.1 ± (5.5)%, 65.4 ± (13.7)%, 0.7 ± (0.27) and 6.3 ± (2.15), respectively. There was no clear relationship between dialysis adequacy and QoL, r = 0.093. Dialysis adequacy did not significantly predict QoL (P = 0.09). CONCLUSION There was no evidence for an association between haemodialysis adequacy and QoL in elderly patients receiving haemodialysis across a URR range of 64.0% to 88.9%. Attempts to improve dialysis adequacy beyond these levels may not be necessary for maintaining the QoL of elderly patients on dialysis. KEY MESSAGE Modern therapy should embrace the concept of quality of life and focus more on symptom relief and optimization of self-management skills to improve the well-being of the elderly patients with ESKD.
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Affiliation(s)
- Edward Zimbudzi
- Department of Nephrology, Monash Health and Monash University, Melbourne, Victoria, Australia.,Monash Centre for Health Research and Implementation - MCHRI, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Reggie Samlero
- Department of Nephrology, Monash Health and Monash University, Melbourne, Victoria, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health and Monash University, Melbourne, Victoria, Australia
| | - Sophia Zoungas
- Monash Centre for Health Research and Implementation - MCHRI, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Victoria, Australia, Australia.,The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
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Gomez AT, Kiberd BA, Royston JP, Alfaadhel T, Soroka SD, Hemmelgarn BR, Tennankore KK. Comorbidity burden at dialysis initiation and mortality: A cohort study. Can J Kidney Health Dis 2015; 2:34. [PMID: 26351568 PMCID: PMC4562341 DOI: 10.1186/s40697-015-0068-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/24/2015] [Indexed: 11/14/2022] Open
Abstract
Background A high level of comorbidity at dialysis initiation is associated with an increased risk of death. However, contemporary assessments of the validity and prognostic value of comorbidity indices are lacking. Objectives To assess the validity of two comorbidity indices and to determine if a high degree of comorbidity is associated with mortality among dialysis patients. Design Cohort study. Setting QEII Health Sciences Centre (Halifax, Nova Scotia, Canada). Patients Incident, chronic dialysis patients between 01 Jan 2006 and 01 Jul 2013. Measurements Exposure: The Charlson Comorbidity Index (CCI) and End-Stage Renal Disease Comorbidity Index (ESRD-CI) were used to classify individual comorbid conditions into an overall score. Comorbidities were classified using patient charts and electronic records. Outcome: All-cause mortality. Confounders: Patient demographics, dialysis access, cause of ESRD and baseline laboratory data. Methods Regression coefficients were estimated on the CCI and ESRD-CI. Discrimination for death was assessed using Harrell’s c-index. Adjusted Cox proportional hazard models were used to calculate relative hazards and 95 % confidence intervals for each category of the CCI and ESRD-CI. Results The cohort consisted of 771 ESRD patients from 01 Jan 2006 to 01 Jul 2013. Most were male (62 %) and Caucasian (91 %). The cohort had a high proportion of diabetes (48 %), history of previous myocardial infarction (31 %) and heart failure (22 %). Regression coefficients on the CCI and ESRD-CI were 0.55 and 0.52, respectively. The c-index, for the prediction of death, was 0.61 for the CCI and 0.63 for the ESRD-CI. ESRD-CI scores of 4, 5 and ≥6 were associated with a similar mortality risk (adjusted relative hazard of 1.95, 1.89 and 1.99, respectively). There was a small increased mortality risk for CCI scores of 4, 5 and ≥6 (adjusted relative hazard of 1.86, 2.38 and 2.71, respectively). Limitations Classification of comorbidities for each patient was determined by clinical impression. Conclusions The CCI and ESRD-CI have a limited ability to discriminate mortality risk for incident dialysis patients. Acknowledging the frequency with which they are used, this study emphasizes the need to re-examine the usefulness of previously derived comorbidity indices in contemporary dialysis cohorts.
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Affiliation(s)
- Alwyn T Gomez
- Faculty of Medicine, Dalhousie University, Halifax, NS Canada
| | - Bryce A Kiberd
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada ; Nova Scotia Health Authority, 5820 University Avenue, Halifax, NS Canada B3H 1V8
| | | | - Talal Alfaadhel
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada
| | - Steven D Soroka
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada ; Nova Scotia Health Authority, 5820 University Avenue, Halifax, NS Canada B3H 1V8
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB Canada ; Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
| | - Karthik K Tennankore
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada ; Nova Scotia Health Authority, 5820 University Avenue, Halifax, NS Canada B3H 1V8
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Ladin K, Weiner DE. Better informing older patients with kidney failure in an era of patient-centered care. Am J Kidney Dis 2015; 65:372-4. [PMID: 25704042 DOI: 10.1053/j.ajkd.2015.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 12/29/2014] [Indexed: 11/11/2022]
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Broers NJH, Cuijpers ACM, van der Sande FM, Leunissen KML, Kooman JP. The first year on haemodialysis: a critical transition. Clin Kidney J 2015; 8:271-7. [PMID: 26034587 PMCID: PMC4440468 DOI: 10.1093/ckj/sfv021] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/12/2015] [Indexed: 01/05/2023] Open
Abstract
The first year following the start of haemodialysis (HD) is associated with increased mortality, especially during the first 90–120 days after the start of dialysis. Whereas the start of dialysis has important effects on the internal environment of the patient, there are relatively few studies assessing changes in phenotype and underlying mechanisms during the transition period following pre-dialysis to dialysis care, although more insight into these parameters is of importance in unravelling the causes of this increased early mortality. In this review, changes in cardiovascular, nutritional and inflammatory parameters during the first year of HD, as well as changes in physical and functional performance are discussed. Treatment-related factors that might contribute to these changes include vascular access and pre-dialysis care, dialysate prescription and the insufficient correction of the internal environment by current dialysis techniques. Patient-related factors include the ongoing loss of residual renal function and the progression of comorbid disease. Identifying phenotypic changes and targeting risk patterns might improve outcome during the transition period. Given the scarcity of data on this subject, more research is needed.
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Affiliation(s)
- Natascha J H Broers
- Department of Internal Medicine, Division of Nephrology , Maastricht University Medical Centre , Maastricht , The Netherlands ; NUTRIM School of Nutrition and Translational Research in Metabolism, Department of Internal Medicine , Maastricht UMC+ , Maastricht , The Netherlands
| | - Anne C M Cuijpers
- Department of Internal Medicine, Division of Nephrology , Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Frank M van der Sande
- Department of Internal Medicine, Division of Nephrology , Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Karel M L Leunissen
- Department of Internal Medicine, Division of Nephrology , Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Jeroen P Kooman
- Department of Internal Medicine, Division of Nephrology , Maastricht University Medical Centre , Maastricht , The Netherlands ; NUTRIM School of Nutrition and Translational Research in Metabolism, Department of Internal Medicine , Maastricht UMC+ , Maastricht , The Netherlands
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