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Shah S, Feustel PJ, Manning CE, Salman L. CMS ESRD quality incentive program has not improved patient dialysis vascular access. J Vasc Access 2023; 24:246-252. [PMID: 34219530 DOI: 10.1177/11297298211027054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Over 468,000 patients in the United States use hemodialysis to manage End Stage Renal Disease (ESRD). The purpose of this study was to determine whether the dialysis access Clinical Performance Measures (CPMs) of Centers for Medicare & Medicaid Services (CMS) ESRD Quality Incentive Program (QIP) have increased arteriovenous fistula (AVF) rates and decreased long-term tunneled hemodialysis catheter (TDC) rates among hemodialysis patients in United States. METHODS Retrospective observational study: evaluated reported AVF and long-term TDC rates of 4804 dialysis facilities which reported dialysis access data as part of the ESRD QIP from Payment Year (PY) 2014-2020. Facilities were also sorted by specific additional criteria to examine disparities in dialysis access. RESULTS Mean AVF rates of included facilities increased from 63.7% in PY 2014 to 67.2% in PY 2016 (p < 0.05), did not change in PY 2017 (p > 0.05), and declined significantly in PY 2018-2020 to 64.1% in PY 2020, near AVF rates at the inception of program. Long-term TDC rates decreased from 10.4% in PY 2014 to 9.88% in PY 2015 (p < 0.05), then increased in PY 2015-PY 2020 to rates higher than at the inception of program, at 11.8% in PY 2020 (p < 0.05). Facilities serving majority Black ZIP Code Tabulation Areas (ZCTAs) or ZCTAs with median income <$45,000 achieved significantly lower AVF rates (p < 0.05) with no significant difference in long-term TDC rates (p > 0.05). AVF rates correlated positively and long-term TDC rates correlated negatively with star rating of facilities (p < 0.05). CONCLUSION As one of the first financial QIPs in healthcare, the ESRD QIP has not achieved the stated goals of the CMS to increase AVF access rates above 68% and reduce long-term TDC clinical rates below 10%. Systemic disparities in race, geographic region, economic status, healthcare access, and education of providers and patients prevent successful attainment of goal metrics.
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Affiliation(s)
| | - Paul J Feustel
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | - Christina E Manning
- Division of Nephrology and Hypertension, Department of Medicine, Albany Medical College & Albany Medical Center, NY, USA
| | - Loay Salman
- Division of Nephrology and Hypertension, Department of Medicine, Albany Medical College & Albany Medical Center, NY, USA
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Influence of Tunneled Hemodialysis-Catheters on Inflammation and Mortality in Dialyzed Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147605. [PMID: 34300056 PMCID: PMC8304695 DOI: 10.3390/ijerph18147605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/14/2021] [Accepted: 07/14/2021] [Indexed: 12/18/2022]
Abstract
Older age and comorbidities in hemodialysis patients determines the use of tunneled catheters as vascular access despite their reported clinical and mortality disadvantages. This prospective matched study analyzes the impact of permanent catheters on inflammation and mortality in hemodialysis patients; We studied 108 patients, 54 with AV-fistula (AVF) and 54 with indwelling hemodialysis catheters (HDC) matched by sex, age, diabetes and time under renal-replacement therapy comparing dialysis efficacy, inflammation and micro-inflammation parameters as well as mortality. Cox-regression analysis was applied to determine predictors of mortality, HDC patients presented higher C-reactive-protein (CRP) blood levels and percentage of pro-inflammatory lymphocytes CD14+/CD16+ with worse dialysis-efficacy parameters. Thirty-six-months mortality appeared higher in the HDC group although statistical significance was not reached. Age with a Hazard Ratio (HR) = 1.06, hypoalbuminemia (HR = 0.43), hypophosphatemia (HR = 0.75) and the increase in CD14+/CD16+ monocyte count (HR = 1.02) were predictors of mortality; elder patients dialyzing through HDC show increased inflammation parameters as compared with nAVF bearing patients, although they do not present a significant increase in mortality when matched by covariates. Increasing age and percentage of pro-inflammatory monocytes as well as decreased phosphate and serum-albumin were predictors of mortality and indicate the main conclusions or interpretations.
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Huang HM, Jiang X, Meng LB, Di CY, Guo P, Qiu Y, Dai YL, Lv XQ, Shi CJ. Reducing catheter-associated complications using 4% sodium citrate versus sodium heparin as a catheter lock solution. J Int Med Res 2019; 47:4204-4214. [PMID: 31304818 PMCID: PMC6753535 DOI: 10.1177/0300060519859143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Use of a catheter lock solution plays a decisive role in vascular access. The
effects of different concentrations of heparin and different types of
catheter lock solutions are controversial. Therefore, this study aimed to
compare the efficacy and safety of sodium citrate and sodium heparin
catheter lock solutions. Methods A total of 120 patients were divided into four groups (30 patients per group)
according to the use of catheter lock solution as follows: 6250 U/mL sodium
heparin, 5000 U/mL sodium heparin, 2500 U/mL sodium heparin, and 4% sodium
citrate. Coagulation function and the incidence of catheter occlusion,
hemorrhage, and catheter-related infections were recorded. Results The different catheter lock solutions were significantly related to conduit
blockage, hemorrhage, infection, and leakage levels. In the 4% sodium
citrate group, the odds ratio was 0.688 for conduit blockage (95% confidence
interval [CI], 0.206–2.297), 0.286 for hemorrhage (95% CI, 0.091–0.899),
0.266 for infection (95% CI, 0.073–0.964), and 0.416 for leakage (95% CI,
0.141–1.225) compared with the 6250 U/mL sodium heparin. Conclusions The solution 4% sodium citrate can effectively reduce the risk of catheter
obstruction, bleeding, infection, and leakage better than sodium heparin in
patients with long-term intravenous indwelling catheters.
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Affiliation(s)
- He-Ming Huang
- Geriatric Department, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Xin Jiang
- Geriatric Department, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Ling-Bing Meng
- School of Basic Medical Sciences, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chen-Yi Di
- School of Basic Medicine, Peking University, Beijing, China
| | - Peng Guo
- Department of Orthopedics, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yong Qiu
- Anesthesiology Department, Beijing Hospital, National Center of Gerontology, Dong Dan, Beijing, China
| | - Ya-Lun Dai
- Epidemiology Department, Beijing Hospital, National Center of Gerontology, Dong Dan, Beijing, China
| | - Xian-Qiang Lv
- Department of Urinary Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chang-Jin Shi
- Department of Urinary Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Nath KA, O'Brien DR, Croatt AJ, Grande JP, Ackerman AW, Nath MC, Yamada S, Terzic A, Tchkonia T, Kirkland JL, Katusic ZS. The murine dialysis fistula model exhibits a senescence phenotype: pathobiological mechanisms and therapeutic potential. Am J Physiol Renal Physiol 2018; 315:F1493-F1499. [PMID: 30019935 DOI: 10.1152/ajprenal.00308.2018] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
There is no therapy that promotes maturation and functionality of a dialysis arteriovenous fistula (AVF). The search for such therapies largely relies on evaluation of vascular responses and putative therapies in experimental AVFs. We studied an AVF in mice with chronic kidney disease (CKD). We demonstrate numerous stressors in the vein of the AVF-CKD group, including pathological shear, mitogenic, inflammatory, and hypoxia-reoxygenation stress. Because stress promotes premature senescence, we examined whether senescence is induced in the vein of the AVF-CKD model. We demonstrate a senescence phenotype in the AVF-CKD model, as indicated by increased expression of p16Ink4a, p21Cip1, and p53 and expected changes for certain senescence-associated microRNAs. RNA-sequencing analysis demonstrated differential expression of ~10,000 genes, including upregulation of proinflammatory and proliferative genes, in the vein of the AVF-CKD group. The vein in the AVF-CKD group exhibited telomere erosion and increased senescence-associated β-galactosidase activity and staining. Senescence was induced in the artery of the AVF-CKD group and in the vein of the AVF without CKD. Finally, given the rapidly rising clinical interest in senolytics, we provide proof of concept of senolytics as a therapeutic approach by demonstrating that senolytics decrease p16Ink4a expression in the AVF-CKD model. This study introduces a novel concept underlying the basis for maturational and functional failure in human dialysis AVFs and identifies a new target for senolytic therapy.
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Affiliation(s)
- Karl A Nath
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic , Rochester, Minnesota
| | - Daniel R O'Brien
- Division of Biomedical Statistics and Informatics, Department of Health Science Research, Mayo Clinic , Rochester, Minnesota
| | - Anthony J Croatt
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic , Rochester, Minnesota
| | - Joseph P Grande
- Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota
| | - Allan W Ackerman
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic , Rochester, Minnesota
| | - Meryl C Nath
- Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota
| | - Satsuki Yamada
- Department of Cardiovascular Medicine, Mayo Clinic , Rochester, Minnesota.,Center for Regenerative Medicine, Mayo Clinic , Rochester, Minnesota
| | - Andre Terzic
- Department of Cardiovascular Medicine, Mayo Clinic , Rochester, Minnesota.,Center for Regenerative Medicine, Mayo Clinic , Rochester, Minnesota
| | - Tamara Tchkonia
- Robert and Arlene Kogod Center on Aging, Mayo Clinic , Rochester, Minnesota
| | - James L Kirkland
- Robert and Arlene Kogod Center on Aging, Mayo Clinic , Rochester, Minnesota
| | - Zvonimir S Katusic
- Departments of Anesthesiology and Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
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Segal JH, Hirth RA. The Cost of Putting Fistula First. Am J Kidney Dis 2018; 72:1-3. [DOI: 10.1053/j.ajkd.2018.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 11/11/2022]
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Ravani P, Quinn R, Oliver M, Robinson B, Pisoni R, Pannu N, MacRae J, Manns B, Hemmelgarn B, James M, Tonelli M, Gillespie B. Examining the Association between Hemodialysis Access Type and Mortality: The Role of Access Complications. Clin J Am Soc Nephrol 2017; 12:955-964. [PMID: 28522650 PMCID: PMC5460718 DOI: 10.2215/cjn.12181116] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 02/24/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES People receiving hemodialysis to treat kidney failure need a vascular access (a fistula, a graft, or a central venous catheter) to connect to the blood purification machine. Higher rates of access complications are considered the mechanism responsible for the excess mortality observed among catheter or graft users versus fistula users. We tested this hypothesis using mediation analysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied incident patients who started hemodialysis therapy from North America, Europe, and Australasia (the Dialysis Outcomes and Practice Patterns Study; 1996-2011). We evaluated the association between access type and time to noninfectious (e.g., thrombosis) and infectious complications of the access (mediator model) and the relationship between access type and time-dependent access complications with 6-month mortality from the creation of the first permanent access (outcome model). In mediation analysis, we formally tested whether access complications explain the association between access type and mortality. RESULTS Of the 6119 adults that we studied (mean age =64 [SD=15] years old; 58% men; 47% patients with diabetes), 50% had a permanent catheter for vascular access, 37% had a fistula, and 13% had a graft. During the 6-month study follow-up, 2084 participants (34%) developed a noninfectious complication of the access, 542 (8.9%) developed an infectious complication, and 526 (8.6%) died. Access type predicted the occurrence of access complications; both access type and complications predicted mortality. The associations between access type and mortality were nearly identical in models excluding and including access complications (hazard ratio, 2.00; 95% confidence interval, 1.55 to 2.58 versus hazard ratio, 2.01; 95% confidence interval, 1.56 to 2.59 for catheter versus fistula, respectively). In mediation analysis, higher mortality with catheters or grafts versus fistulas was not the result of increased rates of access complications. CONCLUSIONS Hemodialysis access complications do not seem to explain the association between access type and mortality. Clinical trials are needed to clarify whether these associations are causal or reflect confounding by underlying disease severity.
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Affiliation(s)
- Pietro Ravani
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert Quinn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Oliver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Neesh Pannu
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada; and
| | - Jennifer MacRae
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden Manns
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew James
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
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