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Laham G, Pujol GS, Guzman J, Boccia N, Abib A, Diaz CH. Early start hemodialysis with a catheter may be associated with greater mortality: A propensity score analysis. Semin Dial 2023; 36:294-302. [PMID: 37088891 DOI: 10.1111/sdi.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/30/2022] [Accepted: 04/10/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Deciding when and how to initiate hemodialysis (HD) is still controversial. An early start (ES) seems to show a lack of benefit. "Lead time bias" and comorbidities have been associated with different outcomes in ES groups. On the other hand, it is well accepted that the impact the type of vascular access (VA) has on patient survival. Our aim was to evaluate survival with early start (ES) versus late start (LS) on HD, taking into account the vascular access (VA) used. METHODS Between 01/1995 and 06/2018, 503 incidental patients initiated HD at our Dialysis Unit. eGFR was estimated by the CKD-EPI equation. Diabetes mellitus (DM), coronary disease (CD), and peripheral vascular disease (PVD) were considered comorbid conditions. According to eGFR and VA, patients were divided into four groups: G1: ES (eGFR > 7 mL/min) with catheter (ES + C), G2: ES with fistula or graft (F/G) (ES + F/G), G3: LS (eGFR< 7 mL/min) with catheter (LS + C), and G4: LS with F/G (LS + F/G). The cut-off value to define ES or LS was based on median eGFR for these 503 patients. We compared patient's survival rates by Kaplan-Meier and log-rank test. The four groups were compared before and after matching with propensity scores (PS). Cox analysis was performed to determine the impact of predictors of mortality. RESULTS Median eGFR was 7 (5.3-9.5) mL/min/1.73 m2 , median follow-up time was 30.9 (13-50) months, 52.1% had F/G access at entry, and 46.9% died during the observation period. Among the four groups, the ES + C were significantly older, and there were more diabetics and comorbid conditions, while phosphatemia, iPTH, albumin, and hemoglobin were significantly higher in the LS groups. Before propensity score (PS) matching, the ES + C group had a poor survival rate (p < 0.0001), while LS + F/G access had the best survival. After PS, a total of 180 patients were selected in the same four groups and ES + C kept showing a statistically significant poorer survival. Multivariate analysis revealed that ES + C was an independent predictor of mortality. CONCLUSION In this retrospective study, ES + C on HD was associated with a higher mortality rate than LS. This association persisted after PS matching.
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Affiliation(s)
- Gustavo Laham
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Gervasio Soler Pujol
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Jenny Guzman
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Natalia Boccia
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Anabel Abib
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Carlos H Diaz
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
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Panaput T, Domrongkitchaiporn S, Thinkhamrop B, Sirivongs D, Praderm L, Anukulanantachai J, Kanokkantapong C, Tungkasereerak P, Pongskul C, Anutrakulchai S, Keobounma T, Narenpitak S, Intarawongchot P, Suwattanasin A, Tatiyanupanwong S, Niwattayakul K. Early as compared to late initiation of twice-weekly hemodialysis and short-term survival among end-stage renal disease patients. Hemodial Int 2022; 26:509-518. [PMID: 35726582 DOI: 10.1111/hdi.13031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 04/21/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The impact of timing of hemodialysis (HD) for end-stage renal disease (ESRD) patients treated with twice-weekly HD remains unclear. We aimed to determine the effects of late initiation of HD on short-term mortality and hospitalization. METHODS A multicenter cohort study was conducted in 11 HD centers in Northeastern Thailand (HEmodialysis Network of the NorthEastern Thailand study group). We recruited adult ESRD patients who were treated with twice-weekly HD for more than 3 months and had data on eGFR at HD initiation. Clinical and laboratory values at the time of recruitment were recorded. Late and early (eGFR at start <5 and >5 ml/min/1.73 m2 ) initiations were defined. Outcomes were disease-related death (excluding any accidental deaths) and first hospitalization. Data analysis was performed by multivariable cox-regression analysis. FINDINGS A total of 407 patients who had data on eGFR at HD initiation (303 in late group and 104 in early group) were included for analysis. There were 56.8% male with a mean age of 55 years. During the 15.1 months of follow-up, there were 27 (6.6%) disease-related deaths. The 1-year survival rate was similar among late and early initiation groups. The incidence density of first hospitalization in the late group was significantly lower than those in the early group (HR adjusted, 0.63; 95% CI, 0.40-0.99, p = 0.047). Among 303 patients who were in the late start group, patients with diabetes had a higher mortality rate (HR, 3.49; 95% CI, 1.40-8.70, p = 0.007) when compared to non-diabetic patients. DISCUSSION Early initiation of HD at eGFR >5 ml/min/1.73 m2 had no short-term survival benefit compared to the late group in ESRD patients treated with twice-weekly HD for at least 3 months in a resource-limited setting. A survival benefit from an early start of HD was found among diabetic patients.
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Affiliation(s)
| | | | | | - Dhavee Sirivongs
- Department of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | | | | | | | | | - Cholatip Pongskul
- Department of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Sirirat Anutrakulchai
- Department of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
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3
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Should we abandon GFR in the decision to initiate chronic dialysis? Pediatr Nephrol 2020; 35:1593-1600. [PMID: 31418062 DOI: 10.1007/s00467-019-04333-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 12/20/2022]
Abstract
The best time to start chronic dialysis during the course of CKD stage 5 is controversial. The first randomised control trial of dialysis initiation either in early or late CKD stage 5 in adults (IDEAL study), and 3 studies from the two largest paediatric registries, the U.S. Renal Data System (USRDS) and the European Society of Paediatric Nephrology (ESPN) Registry, have now provided us with evidence to guide us in this important decision-making process. The message 'no benefit from early start of dialysis' is the conclusion from all four studies. However, what are the limitations of these studies? Can GFR be assessed at CKD stages 4 and 5? What are the factors used to assess the benefit of early or late start? These issues are discussed in this review.
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Preka E, Bonthuis M, Harambat J, Jager KJ, Groothoff JW, Baiko S, Bayazit AK, Boehm M, Cvetkovic M, Edvardsson VO, Fomina S, Heaf JG, Holtta T, Kis E, Kolvek G, Koster-Kamphuis L, Molchanova EA, Muňoz M, Neto G, Novljan G, Printza N, Sahpazova E, Sartz L, Sinha MD, Vidal E, Vondrak K, Vrillon I, Weber LT, Weitz M, Zagozdzon I, Stefanidis CJ, Bakkaloglu SA. Association between timing of dialysis initiation and clinical outcomes in the paediatric population: an ESPN/ERA-EDTA registry study. Nephrol Dial Transplant 2019; 34:1932-1940. [PMID: 31038179 DOI: 10.1093/ndt/gfz069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/13/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is no consensus regarding the timing of dialysis therapy initiation for end-stage kidney disease (ESKD) in children. As studies investigating the association between timing of dialysis initiation and clinical outcomes are lacking, we aimed to study this relationship in a cohort of European children who started maintenance dialysis treatment. METHODS We used data on 2963 children from 21 different countries included in the European Society of Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry who started renal replacement therapy before 18 years of age between 2000 and 2014. We compared two groups according to the estimated glomerular filtration rate (eGFR) at start: eGFR ≥8 mL/min/1.73 m2 (early starters) and eGFR <8 mL/min/1.73 m2 (late starters). The primary outcomes were patient survival and access to transplantation. Secondary outcomes were growth and cardiovascular risk factors. Sensitivity analyses were performed to account for selection- and lead time-bias. RESULTS The median eGFR at the start of dialysis was 6.1 for late versus 10.5 mL/min/1.73 m2 for early starters. Early starters were older [median: 11.0, interquartile range (IQR): 5.7-14.5 versus 9.4, IQR: 2.6-14.1 years]. There were no differences observed between the two groups in mortality and access to transplantation at 1, 2 and 5 years of follow-up. One-year evolution of height standard deviation scores was similar among the groups, whereas hypertension was more prevalent among late initiators. Sensitivity analyses resulted in similar findings. CONCLUSIONS We found no evidence for a clinically relevant benefit of early start of dialysis in children with ESKD. Presence of cardiovascular risk factors, such as high blood pressure, should be taken into account when deciding to initiate or postpone dialysis in children with ESKD, as this affects the survival.
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Affiliation(s)
- Evgenia Preka
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Jerome Harambat
- Department of Pediatrics, Bordeaux University Hospital, Bordeaux, France
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Jaap W Groothoff
- Amsterdam UMC, University of Amsterdam, Department of Paediatric Nephrology, Emma Children's Academic Medical Center, Amsterdam, The Netherlands
| | - Sergey Baiko
- Department of Pediatrics, Belarusian State Medical University, Minsk, Belarus
| | - Aysun K Bayazit
- Department of Pediatric Nephrology, School of Medicine, Cukurova University, Adana, Turkey
| | - Michael Boehm
- Department of Pediatric Nephrology, University Children's Hospital, Vienna, Austria
| | - Mirjana Cvetkovic
- Nephrology Department, University Children's Hospital, Belgrade, Serbia
| | - Vidar O Edvardsson
- Children's Medical Center, Landspitali-The National University Hospital of Iceland, and Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Svitlana Fomina
- Department of Pediatric Nephrology, National Academy of Medical Sciences of Ukraine, Kiev, Ukraine
| | - James G Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Tuula Holtta
- Children's Hospital, University of Helsinki, Helsinki, Finland
| | - Eva Kis
- Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - Gabriel Kolvek
- Pediatric Department, Faculty of Medicine, Safarik University, Kosice, Slovakia
| | - Linda Koster-Kamphuis
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Elena A Molchanova
- Department of Kidney Transplantation, Russian Children's Clinical Hospital, Moscow, Russia
| | - Marina Muňoz
- Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Gisela Neto
- Paediatric Nephrology Unit, Hospital de Dona Estefânia, Lisbon, Portugal
| | - Gregor Novljan
- Department of Pediatric Nephrology, University Medical Center Ljubjana, Faculty of Medicine, University of Ljubjana, Slovenia
| | - Nikoleta Printza
- 1st Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Lisa Sartz
- Department of Clinical Sciences, Pediatric Nephrology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Manish D Sinha
- Department of Paediatric Nephrology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Enrico Vidal
- Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Karel Vondrak
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Isabelle Vrillon
- Pediatric Nephrology Department, Nancy University Hospital, Nancy, France
| | - Lutz T Weber
- Pediatric Nephrology, Childreńs and Adolescents` Hospital, University Hospital of Cologne, Cologne, Germany
| | - Marcus Weitz
- Pediatric Nephrology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ilona Zagozdzon
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland
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Zhao Y, Pei X, Zhao W. Timing of Dialysis Initiation and Mortality Risk in Chronic Kidney Disease: A Meta-Analysis. Ther Apher Dial 2018; 22:600-608. [PMID: 30062691 DOI: 10.1111/1744-9987.12721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 05/07/2018] [Accepted: 06/05/2018] [Indexed: 12/26/2022]
Abstract
The optimal time of dialysis initiation among patients with chronic kidney disease (CKD) is unclear in recent years. We performed a meta-analysis to assess the association of early vs. late initiation of dialysis with estimated glomerular filtration rate. PUBMED, EMBASE, the Cochrane Library, and article reference lists were searched for relevant observational trials. A pooled hazard ratio (HR) with 95% CI was used to estimate the mortality risk. Twenty-six cohort studies and one randomized controlled trial were identified. Early start of dialysis was associated with the increased risk of mortality (HR = 1.23, 95% CI: 1.04-1.43) compared with late start of dialysis. In the subgroup analysis, age younger than 65 years at the early start of dialysis demonstrated higher mortality (HR = 1.20, 95% CI: 1.05-1.35) than the late start. Compared with peritoneal dialysis, the pooled HR with HD was 1.25 (95% CI: 1.17-1.34). Early start of dialysis increased the mortality risk compared with late start among patients with CKD.
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Affiliation(s)
- Yaya Zhao
- Department of Geriatrics, Division of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaohua Pei
- Department of Geriatrics, Division of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weihong Zhao
- Department of Geriatrics, Division of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Shubin NJ, Pham TN, Staudenmayer KL, Parent BA, Qiu Q, O'Keefe GE. A Potential Mechanism for Immune Suppression by Beta-Adrenergic Receptor Stimulation following Traumatic Injury. J Innate Immun 2018; 10:202-214. [PMID: 29455206 DOI: 10.1159/000486972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/17/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND β-Adrenergic agents suppress inflammation and may play an important role in posttraumatic infections. Mechanisms may include inhibition of MAP kinase signaling. We sought to determine whether MKP-1 contributed to catecholamine suppression of innate immunity and also wanted to know whether early catecholamine treatment after traumatic injury increases the risk of later nosocomial infection. METHODS We performed experiments using THP-1 cells and peripheral blood mononuclear cells from healthy individuals. We exposed cells to epinephrine and/or LPS and measured inflammatory gene transcription and MAP kinase activation. We inhibited MKP-1 activity to determine its role in catecholamine-induced immune suppression. Finally, we studied injured subjects to determine whether early catecholamine treatment was associated with nosocomial infection. RESULTS Epinephrine increases MKP-1 transcripts and protein and decreases LPS-induced p38 and JNK phosphorylation and TNF-α gene transcription. RNAi inhibition of MKP-1 at least partially restores LPS-induced TNF-α gene expression (p = 0.024). In the clinical cohort, subjects treated with β-adrenergic agents had an increased risk of ventilator-associated pneumonia (aOR = 1.9; 95% CI = 1.3-2.6) and bacteremia (aOR = 1.5; 95% CI = 1.1-2.3). CONCLUSIONS MKP-1 may have a role in catecholamine-induced suppression of innate immunity, and exogenous catecholamines might contribute to nosocomial infection risk.
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Affiliation(s)
- Nicholas J Shubin
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington, USA
| | - Tam N Pham
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | | | - Brodie A Parent
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Qian Qiu
- Harborview Injury Prevention and Research Center, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Grant E O'Keefe
- Harborview Injury Prevention and Research Center, Department of Surgery, University of Washington, Seattle, Washington, USA
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Chesnaye NC, van Stralen KJ, Bonthuis M, Harambat J, Groothoff JW, Jager KJ. Survival in children requiring chronic renal replacement therapy. Pediatr Nephrol 2018; 33:585-594. [PMID: 28508132 PMCID: PMC5859702 DOI: 10.1007/s00467-017-3681-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/21/2017] [Accepted: 04/12/2017] [Indexed: 01/19/2023]
Abstract
Survival in the pediatric end-stage renal disease (ESRD) population has improved substantially over recent decades. Nonetheless, mortality remains at least 30 times higher than that of healthy peers. Patient survival is multifactorial and dependent on various patient and treatment characteristics and degree of economic welfare of the country in which a patient is treated. In this educational review, we aim to delineate current evidence regarding mortality risk in the pediatric ESRD population and provide pediatric nephrologists with up-to-date information required to counsel affected families.
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Affiliation(s)
- Nicholas C Chesnaye
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.
| | | | - Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Jérôme Harambat
- Department of Pediatrics, Bordeaux University Hospital and INSERM U1219, Bordeaux, France
| | - Jaap W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital AMC, Amsterdam, Netherlands
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
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Effect of the timing of dialysis initiation on left ventricular hypertrophy and ınflammation in pediatric patients. Pediatr Nephrol 2017; 32:1595-1602. [PMID: 28396941 DOI: 10.1007/s00467-017-3660-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/01/2017] [Accepted: 03/23/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND The optimal time for dialysis initiation in adults and children with chronic kidney disease remains unclear. The aim of this study was to evaluate the impact of dialysis timing on different outcome parameters, in particular left ventricular (LV) morphology and inflammation, in pediatric patients receiving peritoneal dialysis and hemodialysis. METHODS The medical records of pediatric dialysis patients who were followed-up in nine pediatric nephrology centers in Turkey between 2008 and 2013 were retrospectively reviewed. In addition to demographic data, we retrieved anthropometric measurements, data on dialysis treatment modalities, routine biochemical parameters, complete blood count, serum ferritin, parathormone, C-reactive protein (CRP), and albumin levels, as well as echocardiographic data and hospitalization records. The patients were divided into two groups based on their estimated glomerular filtration rate (eGFR) levels at dialysis initiation, namely, an early-start group, characterized by an eGFR of >10 ml/min/1.73 m2, and a late-start group, with an eGFR of < 7 ml/min/1.73 m2. The collected data were compared between these groups. RESULTS A total of 245 pediatric dialysis patients (mean age ± standard deviation 12.3 ± 5.1 years, range 0.5-21 years) were enrolled in this study. Echocardiographic data were available for 137 patients, and the mean LV mass index (LVMI) was 58 ± 31 (range 21-215) g/m2.7. The LVMI was 75 ± 30 g/m2.7(n = 81) and 34 ± 6 g/m2.7(n = 56) in patients with or without LV hypertrophy (LVH) (p < 0.001). Early-start (eGFR >10 ml/min/1.73 m2) versus late-start dialysis (eGFR < 7 ml/min/1.73 m2) groups did not significantly differ in LVMI and LVH status (p > 0.05) nor in number of hospitalizations. Serum albumin levels were significantly higher in the early-dialysis group compared with the late-dialysis group (3.3 ± 0.7 vs. 3.1 ± 0.7 g/dl, respectively; p < 0.05). The early-start group had relatively higher time-averaged albumin levels (3.2 ± 0.5 vs. 3.1 ± 0.5 g/dl; p = > 0.05) and relatively lower CRP levels (3.64 ± 2.00 vs. 4.37 ± 3.28 mg/L, p > 0.05) than the late-start group, but these differences did not reach statistical significance. CONCLUSION Although early dialysis initiation did not have a significant effect on important clinical outcome parameters, including LVH, inflammatory state, and hospitalization, in our pediatric dialysis patients, this area of study deserves further attention.
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Abstract
The optimal timing of initiation of maintenance dialysis in patients with end-stage renal disease currently is unknown. This transition period is one of exceptionally high vulnerability for patients; annual mortality rates in stage 5 chronic kidney disease through the first year of maintenance dialysis exceed 20%. The results of the Initiating Dialysis Early and Late (IDEAL) study, a randomized trial that tested the impact of dialysis initiation at two different levels of kidney function on outcomes, showed no significant difference in survival or other patient-centered outcomes between treatment groups. These data have challenged the established paradigm of using estimates of glomerular filtration as the primary guide for initiation of maintenance dialysis and illustrate the compelling need for research to optimize the high-risk transition period from chronic kidney disease to end-stage renal disease. This article reviews the findings of the IDEAL study and summarizes the evolution of research findings, updated clinical practice guidelines, and trends in dialysis initiation practices in the United States in the 6 years since the publication of the results from IDEAL. Complementary strategies to the use of estimated glomerular filtration rate to optimally time the initiation of maintenance dialysis and potentially improve patient-centered outcomes also are considered.
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Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, WA.
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, WA
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10
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Lin X, Zeng XZ, Ai J. The Glomerular Filtration Rate (GFR) at Dialysis Initiation and Mortality in Chronic Kidney Disease (CKD) in East Asian Populations: A Meta-analysis. Intern Med 2016; 55:3097-3104. [PMID: 27803401 PMCID: PMC5140856 DOI: 10.2169/internalmedicine.55.6520] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 02/24/2016] [Indexed: 11/06/2022] Open
Abstract
Objective The impact of dialysis initiation on survival is still somewhat controversial. Given that race or ethnicity has been observed to be a predictor of mortality and the rate of progression of chronic kidney disease, we conducted a meta-analysis to investigate the effect of early vs. late dialysis initiation on mortality in East Asian populations. Methods All eligible cohort studies of target were selected from the MEDLINE (PubMed), EMBASE, The Cochrane Library and the Clinical Trials Registry databases from inception to October 2014. The data were extracted with all-cause mortality rates as the primary outcome, and pooled adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. Results Ten studies examined the association between early vs. late dialysis initiation and mortality. Compared to late dialysis initiation, patients who received early dialysis initiation had a higher overall mortality risk (adjusted HR, 1.36; 95% CI, 1.0-1.85; p<0.05) in East Asian populations. In a subgroup analysis, baseline characteristic differences (adjusted HR, 2.0; 95%CI, 1.56-2.57; p<0.001), initial dialysis modalities (adjusted HR, 2.12; 95% CI, 1.72-2.62; p<0.001) and follow up duration (adjusted HR, 1.59; 95% CI, 1.19-2.12; p=0.002), demonstrated that the association between early dialysis initiation and mortality were significant. Conclusion A higher glomerular filtration rate (early) at the initiation of dialysis is associated with a higher all-cause mortality risk in East Asian populations.
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Affiliation(s)
- Xin Lin
- Department of Nephrology, People's Hospital of Guizhou Province, China
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Zhang YF, Wang Q, Su YY, Yang S, Guo J, Luo J, Tang JM, Li HY. Potassium supplementation and long-term outcomes in chronic peritoneal dialysis patients with end-stage renal disease: a propensity score matching study. Ren Fail 2016; 38:1594-1600. [PMID: 27771983 DOI: 10.3109/0886022x.2015.1128237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Yun-fang Zhang
- Department of Nephrology, Huadu District People's Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Qi Wang
- Department of Nephrology, Huadu District People's Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Yan-yan Su
- Department of Nephrology, Huadu District People's Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Shen Yang
- Department of Nephrology, Huadu District People's Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Jian Guo
- Department of Nephrology, Huadu District People's Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Jie Luo
- Department of Nephrology, Huadu District People's Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Jia-min Tang
- Department of Nephrology, Huadu District People's Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Hong-yan Li
- Department of Nephrology, Huadu District People's Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
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Bae E, Cho HJ, Shin N, Kim SM, Yang SH, Kim DK, Kim YL, Kang SW, Yang CW, Kim NH, Kim YS, Lee H. Lower serum uric acid level predicts mortality in dialysis patients. Medicine (Baltimore) 2016; 95:e3701. [PMID: 27310949 PMCID: PMC4998435 DOI: 10.1097/md.0000000000003701] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We evaluated the impact of serum uric acid (SUA) on mortality in patients with chronic dialysis. A total of 4132 adult patients on dialysis were enrolled prospectively between August 2008 and September 2014. Among them, we included 1738 patients who maintained dialysis for at least 3 months and had available SUA in the database. We categorized the time averaged-SUA (TA-SUA) into 5 groups: <5.5, 5.5-6.4, 6.5-7.4, 7.5-8.4, and ≥8.5 mg/dL. Cox regression analysis was used to calculate the hazard ratio (HR) of all-cause mortality according to SUA group. The mean TA-SUA level was slightly higher in men than in women. Patients with lower TA-SUA level tended to have lower body mass index (BMI), phosphorus, serum albumin level, higher proportion of diabetes mellitus (DM), and higher proportion of malnourishment on the subjective global assessment (SGA). During a median follow-up of 43.9 months, 206 patients died. Patients with the highest SUA had a similar risk to the middle 3 TA-SUA groups, but the lowest TA-SUA group had a significantly elevated HR for mortality. The lowest TA-SUA group was significantly associated with increased all-cause mortality (adjusted HR, 1.720; 95% confidence interval, 1.007-2.937; P = 0.047) even after adjusting for demographic, comorbid, nutritional covariables, and medication use that could affect SUA levels. This association was prominent in patients with well nourishment on the SGA, a preserved serum albumin level, a higher BMI, and concomitant DM although these parameters had no significant interaction in the TA-SUA-mortality relationship except DM. In conclusion, a lower TA-SUA level <5.5 mg/dL predicted all-cause mortality in patients with chronic dialysis.
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Affiliation(s)
- Eunjin Bae
- Department of Internal Medicine, Gyeongsang National University Hospital, Changwon
| | - Hyun-Jeong Cho
- Department of Internal Medicine, Seoul National University Hospital
| | - Nara Shin
- Department of Internal Medicine, Yeolin Medical Foundation, Seoul
| | - Sun Moon Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju
| | - Seung Hee Yang
- Kidney Research Institute, Seoul National University, Seoul
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine
| | - Chul Woo Yang
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul
| | - Nam Ho Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital
- Kidney Research Institute, Seoul National University, Seoul
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital
- Kidney Research Institute, Seoul National University, Seoul
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Vanholder R, Lameire N, Annemans L, Van Biesen W. Cost of renal replacement: how to help as many as possible while keeping expenses reasonable? Nephrol Dial Transplant 2015; 31:1251-61. [PMID: 26109485 DOI: 10.1093/ndt/gfv233] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 05/12/2015] [Indexed: 02/06/2023] Open
Abstract
The treatment of kidney diseases consumes a substantial amount of the health budget for a relatively small fraction of the overall population. If the nephrological community and society do not develop mechanisms to contain those costs, it will become impossible to continue assuring optimal outcomes and quality of life while treating all patients who need it. In this article, we describe several mechanisms to maintain sustainability of renal replacement therapy. These include (i) encouragement of transplantation after both living and deceased donation; (ii) stimulation of alternative dialysis strategies besides classical hospital haemodialysis, such as home haemodialysis, peritoneal dialysis or self-care and necessitating less reimbursement; (iii) promotion of educational activities guiding the patients towards therapies that are most suited for them; (iv) consideration of one or more of cost containment incentives such as bundling of reimbursement (if not affecting quality of the treatment), timely patient referral, green dialysis, start of dialysis based on clinical necessity rather than renal function parameters and/or prevention of CKD or its progression; (v) strategically planned adaptations to the expected growth of the ageing population in need of renal replacement; (vi) the necessity for support of research in the direction of helping as large as possible patient populations for acceptable costs; and (vii) the need for more patient-centred approaches. We also extend the discussion to the specific situation of kidney diseases in low- and middle-income countries. Finally, we point to the dramatic differences in accessibility and reimbursement of different modalities throughout Europe. We hope that this text will offer a framework for the nephrological community, including patients and nurses, and the concerned policy makers and caregivers on how to continue reaching all patients in need of renal replacement for affordable expenses.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
| | - Norbert Lameire
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
| | - Lieven Annemans
- Department of Public Health, University Ghent, Ghent, Belgium
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
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