The effects of recombinant human erythropoietin on functional health and well-being in chronic dialysis patients

Efficacy of erythropoietin as a neuroprotective agent in CKD-associated cognitive dysfunction: A literature systematic review

Patients with chronic kidney disease (CKD) often experience mild cognitive impairment and other neurocognitive disorders. Studies have shown that erythropoietin (EPO) and its receptor have neuroprotective effects in cell and animal models of nervous system disorders. Recombinant human EPO (rHuEPO), commonly used to treat anemia in CKD patients, could be a neuroprotective agent. In this systematic review, we aimed to assess the published studies investigating the cognitive benefits of rHuEPO treatment in individuals with reduced kidney function. We comprehensively searched Pubmed, Cochrane Library, Scopus, and Web of Science databases from 1990 to 2023. After selection, 24 studies were analyzed, considering study design, sample size, participant characteristics, intervention, and main findings. The collective results of these studies in CKD patients indicated that rHuEPO enhances brain function, improves performance on neuropsychological tests, and positively affects electroencephalography measurements. These findings suggest that rHuEPO could be a promising neuroprotective agent for managing CKD-related cognitive impairment.

Impact of COVID 19 on erectile function

Purpose: COVID-19, a novel infection, presented with several complications, including socioeconomical and reproductive health challenges such as erectile dysfunction (ED). The present review summarizes the available shreds of evidence on the impact of COVID-19 on ED.Materials and methods: All published peer-reviewed articles from the onset of the COVID-19 outbreak to date, relating to ED, were reviewed. Results: Available pieces of evidence that ED is a consequence of COVID-19 are convincing. COVID-19 and ED share common risk factors such as disruption of vascular integrity, cardiovascular disease (CVD), cytokine storm, diabetes, obesity, and chronic kidney disease (CKD). COVID-19 also induces impaired pulmonary haemodynamics, increased ang II, testicular damage and low serum testosterone, and reduced arginine-dependent NO bioavailability that promotes reactive oxygen species (ROS) generation and endothelial dysfunction, resulting in ED. In addition, COVID-19 triggers psychological/mental stress and suppresses testosterone-dependent dopamine concentration, which contributes to incident ED.Conclusions: In conclusion, COVID-19 exerts a detrimental effect on male reproductive function, including erectile function. This involves a cascade of events from multiple pathways. As the pandemic dwindles, identifying the long-term effects of COVID-19-induced ED, and proffering adequate and effective measures in militating against COVID-19-induced ED remains pertinent.

Evaluation of recombinant human erythropoietin responsiveness by measuring erythrocyte creatine content in haemodialysis patients

Background

One of the main causes of anaemia in patients with end-stage renal disease is relative deficiency in erythropoietin production. Eythropoiesis stimulating agent (ESA), a potent haematopoietic growth factor, is used to treat anaemia in haemodialysis patients. The effect of ESA is usually assessed by haematological indices such as red blood cell count, haemoglobin concentration and haematocrit, but erythrocyte indices do not provide information of the rapid change in erythropoietic activity. As erythrocyte creatine directly assess erythropoiesis, the aim of this study was to evaluate the effect of ESA in haemodialysis patients by measuring the erythrocyte creatine content.

Methods

ESA dose was fixed 3 months prior to the enrollment and was maintained throughout the entire study period. Erythrocyte creatine was measured with haematologic indices in 83 haemodialysis patients. Haemoglobin was also measured 3 months after.

Results

ESA dose (152.4 ± 62.9 vs. 82.2 ± 45.5 units/kg/week, P = 0.0001) and erythrocyte creatine (2.07 ± 0.73 vs. 1.60 ± 0.41 μmol/gHb, p = 0.0003) were significantly higher in 27 patients with haemoglobin <10 g/dL compared to 56 patients with haemoglobin ≥10 g/dL. There was a fair correlation between ESA dose and the concentration of creatine in the erythrocytes (r = 0.55, P < 0.0001). Increase in haemoglobin (>0.1 g/dL) was observed in 37 patients, whereas haemoglobin did not increase in 46 patients. Erythrocyte creatine levels were significantly higher in those patients with an increase in haemoglobin compared to those without (2.04 ± 0.64 vs. 1.52 ± 0.39 μmol/gHb, p < 0.0001). When 8 variables (ESA dose, erythropoietin resistance index, C-reactive protein, intact parathyroid hormone, iron supplementation, presence of anaemia, erythrocyte creatine and reticulocyte) were used in the multivariate logistic analysis, erythrocyte creatine levels emerged as the most important variable associated with increase in haemoglobin (Chi-square = 6.19, P = 0.01).

Conclusion

Erythrocyte creatine, a useful marker of erythropoietic capacity, is a reliable marker to estimate ameliorative effectiveness of ESA in haemodialysis patients.

Managing Anemia across the Stages of Kidney Disease in Those Hyporesponsive to Erythropoiesis-Stimulating Agents

BACKGROUND

Patients with CKD frequently have anemia that results from iron-restricted erythropoiesis and inflammation. Anemia of CKD is currently managed with iron supplements and erythropoiesis-stimulating agents (ESAs) to promote erythropoiesis and with RBC transfusion in severe cases. Hyporesponse to ESAs, or the need for larger than usual doses to attain a given hemoglobin (Hb) level, is associated with increased morbidity and mortality and presents a pressing clinical challenge, particularly for patients on dialysis. This paper reviews ESA hyporesponse and potential new therapeutic options in the management of anemia of CKD.

SUMMARY

The most common causes of ESA hyporesponse include iron deficiency and inflammation, and to a lesser degree, secondary hyperparathyroidism, inadequate dialysis, malnutrition, and concomitant medications. Management of ESA hyporesponse is multipronged and involves treating low level infections, ensuring adequate nutrition, and optimizing iron status and dialysis modality, although some patients can remain refractory. Inflammation directly increases production and secretion of hepcidin, contributes to an impaired response to hypoxia, and suppresses proliferation of erythroid progenitors. Coordination of renal and hepatic erythropoietin (EPO) production and iron metabolism is under the control of hypoxia-inducible factors (HIF), which are in turn regulated by HIF-prolyl hydroxylases (HIF-PHs). HIF-PHs and hepcidin are therefore attractive potential drug targets particularly in patients with ESA hyporesponse. Several oral HIF-PH inhibitors have been evaluated in patients with anemia of CKD and have been shown to increase Hb and reduce hepcidin regardless of inflammation, iron status, or dialysis modality. These sustained effects are achieved through more modest increases in endogenous EPO compared with ESAs. Key Messages: Treatments that address ESA hyporesponse remain a significant unmet clinical need in patients with anemia of CKD. New therapies such as HIF-PH inhibitors have the potential to address fundamental aspects of ESA hyporesponse and provide a new therapeutic option in these patients.

Health-related quality of life in patients with chronic kidney disease

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.

Disability of Dialysis Patients and the Condition of Blood Vessels

The number of elderly hemodialysis patients is constantly increasing worldwide. This population has a high burden of comorbid conditions, which impair daily activities. The aim of the study was to analyze problems of disability in hemodialysis patients in the context of cardiovascular (CV) complications and vascular condition. In this cross-sectional study, 129 patients (mean age 64.5) were enrolled. The degree of disability in Barthel index (Bi) and 10-year cardiovascular risk (QRISK®3) were assessed. A Mobil-O-Graph monitor was used for measuring hemodynamic parameters. Only 6.2% of patients were professionally active, 19% used a wheelchair for transport, and 16% used crutches. More than half (51%) were independent in everyday activities reaching 80-100 points on Bi. The rest, with Bi < 80, were considered as dependent. The most common causes of disability were CV complications. The independent group (80-100 points) was characterized by significantly lower pulse wave velocity (PWV) and lower QRISK®3 compared to dependent patients. The degree of disability negatively correlated with age, PWV, and QRISK®3. Multivariate logistic regression revealed that disability (Bi < 80) was independently associated with CV events in the past adjusted odds ratio (adj.OR) 4.83 (95% confidence interval (95% CI): 1.74-13.41) and higher PWV adj.OR 1.45 (95% CI: 1.15-1.82). Our results indicate that CV diseases are the most important cause of functional impairment.

A Comparison of Quality of Life of Patients on Automated and Continuous Ambulatory Peritoneal Dialysis

Objective

Data on health-related quality of life (HRQOL) of automated peritoneal dialysis (APD) patients are scarce. The objectives of this study were ( 1 ) to explore HRQOL of APD patients and compare it with HRQOL of continuous ambulatory peritoneal dialysis (CAPD) patients and a general population sample, and ( 2 ) to study the relationship between HRQOL assessment outcomes and background variables.

Design

Home interviews of APD and CAPD patients. HRQOL, social-demographic, clinical, and treatment-related background data were collected at the interview and from patient charts. Multiple regression analysis and logistic regression analysis were used to study the relationship of HRQOL assessment outcomes with background variables.

Setting

Sixteen Dutch dialysis centers.

Patients

Convenience sample of 37 APD patients and 59 CAPD patients matched for total time on dialysis.

Main Outcome Measures

Four HRQOL instruments: Short-Form 36, EuroQol EQ-5D, Standard Gamble, and Time Trade Off.

Results

Physical functioning of both APD and CAPD patients was impaired compared with the general population; mental functioning was not different. In multivariate analyses, the mental health of APD patients was found to be better than that of CAPD patients. In addition, APD patients were less anxious and depressed than CAPD patients. With respect to physical aspects of HRQOL and role-functioning, no differences were observed between APD and CAPD patients. Other variables to explain HRQOL assessment outcomes were age, the number of comorbid diseases, and primary kidney disease.

Conclusions

HRQOL of APD patients is at least equal to HRQOL of CAPD patients.

A Prospective, Randomized Multicenter Study Comparing APD and CAPD Treatment

Objective

The goals for maintenance dialysis treatment are to improve patient survival, reduce patient morbidity, and improve patient quality of life. This is the first randomized prospective study comparing automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) treatment with respect to quality of life and clinical outcomes in relation to therapy costs.

Design

A prospective, randomized multicenter study.

Setting

Three Danish CAPD units.

Patients

Thirty-four adequately dialyzed patients with high or high-average peritoneal transport characteristics were included in the study. Twenty-five patients completed the study.

Interventions

After randomization, 17 patients were allocated to APD treatment and 17 patients to CAPD treatment for a period of 6 months. Medical and biochemical parameters were evaluated at monthly controls in the CAPD units. Quality-of-life parameters were assessed at baseline and after 6 months by the self-administered short-form SF-36 generic health survey questionnaire supplemented with disease- and treatment-specific questions. Therapy costs were compared by evaluating dialysis-related expenses.

Main Outcome Measures

Quality-of-life parameters, dialysis-related complications, dialysis-related expenses.

Results

The quality-of-life studies showed that significantly more time for work, family, and social activities was available to patients on APD compared to those on CAPD ( p < 0.001). Although the difference was not significant, there was a tendency for less physical and emotional discomfort caused by dialysis fluid in the APD group. Sleep problems, on the other hand, tended to be more marked in the APD group. Any positive effect of APD compared to CAPD on dialysis-related hospital days or complication rates could not be confirmed. With larger patient samples, it is possible, however, that a significant difference might have been achieved. The running costs for APD treatment were US $75 per day and for CAPD treatment US $61 per day.

Conclusion

If APD treatment can help to keep selected patients vocationally or socially active, paying the extra cost seems reasonable.

Relationship between Dialysis Adequacy and Quality of Life in Long-Term Peritoneal Dialysis Patients

Objective

The purpose of this study was to compare quality of life (QOL) between peritoneal dialysis (PD) patients with adequate and inadequate total solute clearance (TSC). We also tried to determine the relationship between QOL and TSC.

Design

A cross-sectional study design was used in which QOL was evaluated and compared between PD patients with adequate and inadequate TSC.

Setting

The PD unit of a university teaching hospital.

Patients

Sixty-seven patients were recruited, 38 on continuous ambulatory PD and 29 on continuous cycler-assisted PD.

Methods

Patients were divided into adequate and inadequate groups, based on the results of either total urea clearance (Kt/Vurea) or total creatinine clearance (weekly CCr). The demographic data, dialysis variables, and clinical parameters of these patients were all collected. QOL was evaluated using the SF-36 questionnaire, which contains eight domains and is a comprehensive and validated instrument for QOL evaluation. QOL of patients in adequate and inadequate groups was compared. The relationship between QOL and TSC was also examined.

Results

Among patients grouped by Kt/Vurea, patients in the adequate group had significantly higher scores in two domains of the SF-36, that is, physical and emotional role functioning, than did those in the inadequate group. The total SF-36 scores were positively correlated with Kt/Vureawhen all patients were pooled together. However, among patients grouped by weekly CCr, there was no significant difference in any of the eight domains of the SF-36 between patients in the adequate and inadequate groups. No correlation was found between the total SF-36 scores and weekly CCr.

Conclusion

Our study had two important findings: First, PD patients with adequate total solute clearance, based on Kt/Vureaand not on weekly CCr, had a better QOL. Second, Kt/Vureais better correlated with QOL than weekly CCr. These findings suggest that Kt/Vureais a better parameter for the clinical evaluation of total solute clearance from the viewpoint of QOL.

The anaemia control model: Does it help nephrologists in therapeutic decision-making in the management of anaemia?

INTRODUCTION

Anaemia is common in haemodialysis patients and treating it with erythropoiesis-stimulating agents (ESAs) is complex due to many factors.

OBJECTIVES

To assess the usefulness of the Anaemia Control Model (ACM) in the treatment of anaemia in haemodialysis.

METHODS

ACM is a software that predicts the optimal dose of darbepoetin and iron sucrose to achieve target haemoglobin (Hb) and ferritin levels, and makes prescription suggestions. Study conducted in dialysis clinics lasting 18months with two intervention phases (IPs) with ACM (IP1, n:213; IP2, n:218) separated by a control phase (CP, n:219). The primary outcome was the percentage of Hb in range and the median dose of ESAs, and the secondary outcomes were transfusion, hospitalisation and cardiovascular events. Clinical and patient analyses were performed. Hb variability was assessed by the standard deviation (SD) of the Hb. We also analysed the patients with most of the suggestions confirmed (ACM compliant group).

RESULTS

ACM increased the percentage of Hb in range: 80.9% in IP2, compared with 72.7% in the CP and reduced the intake of darbepoetin (IP1: 20 [70]; CP 30 [80] μg P=0.032) with less Hb fluctuation (0.91±0.49 in the CP to 0.82±0.37g/dl in IP2, P<0.05), improving in the ACM compliant group. The secondary outcomes decreased with the use of ACM.

CONCLUSIONS

ACM helps to obtain better anaemia results in haemodialysis patients, minimising the risks of treatment with ESAs and reducing costs.

The Effect of Hemodialysis and Acetate-Free Biofiltration on Anemia

The authors monitored, for a period of 12 months, anemia-, nutrition-, and free radical-related parameters and the rHuEPO dose required to maintain target hemoglobin (Hb) in 20 patients with chronic renal failure. Ten patients each were randomized for treatment by either acetate-free biofiltration (AFB) or low-flux hemodialysis (HD). At baseline, Hb levels were 102±2 (AFB) vs. 98±2 g/L (HD) (not significant difference, NS), the rHuEPO dose was 4050±976 vs. 5100±1538 IU/week (NS). Compared with baseline and with HD, lower rHuEPO doses were required during AFB at months 8, 9, 10 and 11, and 12 when they were 2100±510 (AFB) vs. 6000±1153 (HD), p=0.008. Prealbumin, transferrin and cholinesterase levels rose in the AFB group. Kt/V, albumin, transferrin saturation, aluminium, bicarbonate in serum, superoxide dismutase and glutathione peroxidase in erythrocytes, and malondialdehyde and antioxidant capacity in plasma did not differ between the AFB and HD groups. In terms of anemia control, AFB using an AN69 membrane was found to be more advantageous than low-flux HD, AFB improves some nutritional parameters. The compared methods do not differ in their effect on lipid peroxidation and the antioxidant system. (Int J Artif Organs 2000; 23: 173–80)

Quality of life measures predict cardiovascular health and physical performance in chronic renal failure patients

BACKGROUND

Patients with advanced chronic kidney disease (CKD) experience complex functional and structural changes of the cardiopulmonary and musculoskeletal system. This results in reduced exercise tolerance, quality of life and ultimately premature death. We investigated the relationship between subjective measures of health related quality of life and objective, standardised functional measures for cardiovascular and pulmonary health.

METHODS

Between April 2010 and January 2013, 143 CKD stage-5 or CKD5d patients (age 46.0±1.1y, 62.2% male), were recruited prospectively. A control group of 83 healthy individuals treated for essential hypertension (HTN; age 53.2±0.9y, 48.22% male) were recruited at random. All patients completed the SF-36 health survey questionnaire, echocardiography, vascular tonometry and cardiopulmonary exercise testing.

RESULTS

Patients with CKD had significantly lower SF-36 scores than the HTN group; for physical component score (PCS; 45.0 vs 53.9, p<0.001) and mental component score (MCS; 46.9 vs. 54.9, p<0.001). CKD subjects had significantly poorer exercise tolerance and cardiorespiratory performance compared with HTN (maximal oxygen uptake; VO2peak 19.9 vs 25.0ml/kg/min, p<0.001). VO2peak was a significant independent predictor of PCS in both groups (CKD: b = 0.35, p = 0.02 vs HTN: b = 0.27, p = 0.001). No associations were noted between PCS scores and echocardiographic characteristics, vascular elasticity and cardiac biomarkers in either group. No associations were noted between MCS and any variable. The interaction effect of study group with VO2peak on PCS was not significant (ΔB = 0.08; 95%CI -0.28-0.45, p = 0.7). However, overall for a given VO2peak, the measured PCS was much lower for patients with CKD than for HTN cohort, a likely consequence of systemic uremia effects.

CONCLUSION

In CKD and HTN, objective physical performance has a significant effect on quality of life; particularly self-reported physical health and functioning. Therefore, these quality of life measures are indeed a good reflection of physical health correlating highly with objective physical performance measures.

Phase 2 studies of oral hypoxia-inducible factor prolyl hydroxylase inhibitor FG-4592 for treatment of anemia in China

BACKGROUND

FG-4592 (roxadustat) is an oral hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitor (HIF-PHI) promoting coordinated erythropoiesis through the transcription factor HIF. Two Phase 2 studies were conducted in China to explore the safety and efficacy of FG-4592 (USAN name: roxadustat, CDAN name: ), a HIF-PHI, in patients with anemia of chronic kidney disease (CKD), both patients who were dialysis-dependent (DD) and patients who were not dialysis-dependent (NDD).

METHODS

In the NDD study, 91 participants were randomized to low (1.1-1.75 mg/kg) or high (1.50-2.25 mg/kg) FG-4592 starting doses or to placebo. In the DD study, 87 were enrolled to low (1.1-1.8 mg/kg), medium (1.5-2.3 mg/kg) and high (1.7-2.3 mg/kg) starting FG-4592 doses or to continuation of epoetin alfa. In both studies, only oral iron supplementation was allowed.

RESULTS

In the NDD study, hemoglobin (Hb) increase ≥1 g/dL from baseline was achieved in 80.0% of subjects in the low-dose cohort and 87.1% in the high-dose cohort, versus 23.3% in the placebo arm (P < 0.0001, both). In the DD study, 59.1%, 88.9% (P = 0.008) and 100% (P = 0.0003) of the low-, medium- and high-dose subjects maintained their Hb levels after 5- and 6-weeks versus 50% of the epoetin alfa-treated subjects. In both studies, significant reductions in cholesterol were noted in FG-4592-treated subjects, with stability or increases in serum iron, total iron-binding capacity (TIBC) and transferrin (without intravenous iron administration). In the NDD study, hepcidin levels were significantly reduced across all FG-4592-treated arms as compared with no change in the placebo arm. In the DD study, hepcidin levels were also reduced in a statistically significant dose-dependent manner in the highest dose group as compared with the epoetin alfa-treated group. Adverse events were similar for FG-4592-treated and control subjects.

CONCLUSIONS

FG-4592 may prove an effective alternative for managing anemia of CKD. It is currently being investigated in a pivotal global Phase 3 program.

Male Sexual Dysfunction and Chronic Kidney Disease

Male sexual dysfunction is common in chronic kidney disease (CKD), particularly in end-stage renal disease. Historically, this cause of considerable morbidity has been under-reported and under-recognized. The ideal approach to diagnosis and management remains unclear due to a paucity of good quality data, but an understanding of the pathophysiology is necessary in order to address the burden of this important complication of CKD. This paper will review the endocrine dysfunction that occurs in renal disease, particularly the hypothalamic–pituitary–gonadal axis, discuss the causes of erectile dysfunction, infertility, and altered body image and libido in these patients and suggest appropriate treatment interventions.

Health-related quality of life assessment in end-stage renal failure

End-stage renal failure (ESRF) is a life-threatening condition and survival can be maintained only with renal replacement therapy. Furthermore, the complications of ESRF, its treatment and co-existing diseases have been found to have a significant impact on the physical health of patients. It is well documented that the health status of the renal patient population is worse than that of the general healthy population; for this reason the assessment of quality of life of ESRF patients has received considerable attention.

During the 1990s, the focus of health assessment moved away from the disease itself towards health status and wellbeing. The widespread use of the 36-item short-form (SF-36) questionnaire has promoted this. In ESRF studies from data using the SF-36 questionnaire it has been shown that it is the physical functional component of health that is most affected by the patient's condition, with co-morbidity having a significant impact.

There is growing consensus that health-related quality of life is more than just an assessment of health status. Rather, it is the relative importance given by the individuals themselves to the impact of the disease on their life. While this approach is emerging, some of the tools which have been developed to measure individualised quality of life require further scientific validation for use with the ESRF population.

Neither Hematocrit Normalization nor Exercise Training Restores Oxygen Consumption to Normal Levels in Hemodialysis Patients

Patients treated with hemodialysis develop severely reduced functional capacity, which can be partially ameliorated by correcting anemia and through exercise training. In this study, we determined perturbations of an erythroid-stimulating agent and exercise training to examine if and where limitation to oxygen transport exists in patients on hemodialysis. Twenty-seven patients on hemodialysis completed a crossover study consisting of two exercise training phases at two hematocrit (Hct) values: 30% (anemic) and 42% (physiologic; normalized by treatment with erythroid-stimulating agent). To determine primary outcome measures of peak power and oxygen consumption (VO₂) and secondary measures related to components of oxygen transport and utilization, all patients underwent numerous tests at five time points: baseline, untrained at Hct of 30%, after training at Hct of 30%, untrained at Hct of 42%, and after training at Hct of 42%. Hct normalization, exercise training, or the combination thereof significantly improved peak power and VO₂ relative to values in the untrained anemic phase. Hct normalization increased peak arterial oxygen and arteriovenous oxygen difference, whereas exercise training improved cardiac output, citrate synthase activity, and peak tissue diffusing capacity. However, although the increase in arterial oxygen observed in the combination phase reached a value similar to that in healthy sedentary controls, the increase in peak arteriovenous oxygen difference did not. Muscle biopsy specimens showed markedly thickened endothelium and electron-dense interstitial deposits. In conclusion, exercise and Hct normalization had positive effects but failed to normalize exercise capacity in patients on hemodialysis. This effect may be caused by abnormalities identified within skeletal muscle.

Depressive Symptoms, Patient Satisfaction, and Quality of Life Over Time in Automated and Continuous Ambulatory Peritoneal Dialysis Patients: A Prospective Multicenter Propensity-Matched Study

Health-related quality of life (HRQOL) is an important clinical outcome for dialysis patients. However, relative superiority in HRQOL between automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) are not clearly known. We compared HRQOL over time between APD and CAPD patients and evaluated factors associated with HRQOL.All 260 incident patients initiating APD or CAPD at multiple centers throughout Korea were prospectively enrolled in this study between October 2010 and February 2013. HRQOL, depressive symptoms, and renal treatment satisfaction were assessed 1 and 12 months after the start of dialysis by the Kidney Disease Quality of Life Short Form 36 (KDQOL-36), the Beck Depression Inventory (BDI), and the Renal Treatment Satisfaction Questionnaire (RTSQ), respectively.Of 196 patients who completed all questionnaires and did not change the peritoneal dialysis (PD) modality during the 1-year follow-up period, 160 were matched. APD patients showed better baseline HRQOL than CAPD patients for the symptoms, patient satisfaction, pain, and social function domains. There were no differences in HRQOL between the 2 groups at 12 months, and CAPD patients had significantly greater improvements in symptoms (P = 0.02), the mental composite summary (P = 0.03), and health status domains (P = 0.03) than APD patients. There were similar improvements in depressive symptoms (P = 0.01) and patient satisfaction with treatment (P = 0.01) in CAPD and APD patients. Interestingly, depressive symptoms, not PD modality, was the most influential and consistent factor for HRQOL. Despite the spontaneous improvement of depressive symptoms, considerable PD patients still had depressive symptoms at the 1-year appointment.APD has no advantage over CAPD for HRQOL. Considering the substantial negative effect of depressive symptoms on HRQOL, it is important to evaluate PD patients for depression and to treat those with depression to improve their HRQOL.

Anemia Management in the China Dialysis Outcomes and Practice Patterns Study

BACKGROUND

As the utilization of hemodialysis increases in China, it is critical to examine anemia management.

METHODS

Using data from the China Dialysis Outcomes and Practice Patterns Study (DOPPS), we describe hemoglobin (Hgb) distribution and anemia-related therapies.

RESULTS

Twenty one percent of China's DOPPS patients had Hgb <9 g/dl, compared with ≤10% in Japan and North America. A majority of medical directors targeted Hgb ≥11. Patients who were female, younger, or recently hospitalized had higher odds of Hgb <9; those with insurance coverage or on twice weekly dialysis had lower odds of Hgb <9. Iron use and erythropoietin-stimulating agents (ESAs) dose were modestly higher for patients with Hgb <9 compared with Hgb in the range 10-12.

CONCLUSION

A large proportion of hemodialysis patients in China's DOPPS do not meet the expressed Hgb targets. Less frequent hemodialysis, patient financial contribution, and lack of a substantial increase in ESA dose at lower Hgb concentrations may partially explain this gap. Video Journal Club 'Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=442741.

CRIT-LINE: a noninvasive tool to monitor hemoglobin levels in pediatric hemodialysis patients

BACKGROUND

The national average for achieving the KDOQI-recommended hemoglobin (Hgb) target level of 11-12 g/dL is low with the current anemia management protocol of measuring Hgb levels every 2-4 weeks to guide intervention. The objective of this study was to correlate initial Hgb readings from the CRIT-LINE monitor with actual serum Hgb levels in pediatric patients on hemodialysis (HD).

METHODS

Data were collected from pediatric HD patients who had Hgb tests ordered for routine and/or clinical reasons. Hgb concentrations were read with the CRIT-LINE after 0.5 or 1 L of blood had been processed by HD in patients with a body weight of ≤20 or >20 kg, respectively. Ultrafiltration was kept at a minimum until the CRIT-LINE Hgb was read.

RESULTS

In total, 217 Hgb readings from 23 HD patients were analyzed. Results showed a statistically significant correlation between CRIT-LINE readings and laboratory Hgb measurements (r = 0.94, p < 0.0001) using Pearson correlation coefficients for well-distributed data. The mean Hgb levels measured by CRIT-LINE and the laboratory were 11.12 ± 1.63 and 11.31 ± 1.69 g/dL, respectively.

CONCLUSIONS

The CRIT-LINE monitor is an accurate instrument for monitoring Hgb levels in HD patients. Further studies will be needed to evaluate whether using CRIT-LINE Hgb levels to guide anemia management will improve the percentage of children with Hgb levels within target.

Biosimilar versus patented erythropoietins: learning from 5 years of European and Japanese experience

BACKGROUND

Patent expiries on leading biologics are creating new momentum in the market for biosimilars (copies of off-patent biologics), paving the way for their development. However, little is known about the factors influencing the competition between biosimilars and their reference products (REF).

OBJECTIVES

The aim of this study was to analyse key global erythropoietin (EPO) markets and factors affecting biosimilar EPO (BIOSIM-EPO) uptakes, and to identify countries where BIOSIM-EPOs have gained significant market shares.

METHODS

Inclusion criteria for countries in the study were a biosimilar regulatory framework similar to the EU framework, and biological market value higher than US$2.5 billion. Factors evaluated included EPO market size, EPO retail/hospital distribution mix, national incentives to use biosimilars and BIOSIM-EPO/REF price differences. IMS Health provided EPO consumption in volumes, values, and EPO ex-manufacturer prices from 2007 to 2012.

RESULTS

Japan: large-sized market, mixed retail/hospital distribution, no incentives, low BIOSIM-EPO uptake (6.8 % in 2012). France: large-sized market, dominant retail distribution, no incentives, low BIOSIM-EPO uptake (5.8 %). Spain and Italy: medium-sized market, dominant hospital distribution, no incentives, moderate BIOSIM-EPO uptakes (11.5 and 8.6 %). Germany: small-sized market, dominant retail distribution, presence of incentives, high BIOSIM-EPO uptake (30.4 %). UK: small-sized market, mixed retail/hospital distribution, no incentives, low BIOSIM-EPO uptake (2.0 %). BIOSIM-EPO/REF price differences play no role at a global level (-10.8 % in Germany and -26.9 % in Japan).

CONCLUSIONS

EPO markets have proven to be highly country-specific. EPO market sizes, EPO retail/hospital distribution mixes and BIOSIM-EPO/REF price differences may not be determining factors of BIOSIM-EPO uptakes. Prescription and substitution incentives to use BIOSIM-EPO appear to be determining factors in Germany. The heterogeneity of national EPO markets makes it impossible to outline country profile types with significant BIOSIM-EPO penetrations.

Biomedical system dynamics to improve anemia control with darbepoetin alfa in long-term hemodialysis patients

OBJECTIVE

To determine the value of a biomedical system dynamics (BMSD) approach for optimization of anemia management in long-term hemodialysis patients because elevated hemoglobin levels and high doses of erythropoiesis-stimulating agents (ESAs) may negatively affect survival in this population.

PATIENTS AND METHODS

A model of erythropoiesis and its response to ESAs on the basis of a BMSD method (Mayo Clinic Anemia Management System [MCAMS]) was developed. Thereafter, an open-label, prospective, nonrandomized practice quality improvement project was performed with retrospective analysis in 8 community-based outpatient hemodialysis facilities. All prevalent hemodialysis patients seen from January 1, 2007, through December 31, 2010 (300-342 patients per month), were included with darbepoetin as the ESA. The primary outcome was the percentage of patients who attained the desired hemoglobin level. Secondary outcome measures included the percentage of patients with hemoglobin values above the desired range and mean dose of darbepoetin used.

RESULTS

The 3 treatment periods were (1) standard ESA protocol in 2007, (2) transition to the MCAMS (2008 to June 2009), and (3) stability period with the MCAMS used in all hemodialysis facilities (2009 to 2010). In the first 6 months of 2007, 69% of patients were in the desired range and 26% were above the range. In comparison, during the first 5 months of 2010, 83% were in and 6% were above the range (P<.001). The mean monthly darbepoetin dose per patient decreased from 304 μg in 2007 to 173 μg by the second half of 2009 (P<.001).

CONCLUSION

With the introduction of the MCAMS, more patients had hemoglobin levels in the desired range and fewer patients exceeded the target range, with a concomitant 40% reduction in darbepoetin use.

Roy's Adaptation Model-Based Patient Education for Promoting the Adaptation of Hemodialysis Patients

BACKGROUND

In addition to physical adaptation and psychosocial adjustment to chronic renal disease, hemodialysis (HD) patients must also adapt to dialysis therapy plan.

OBJECTIVES

The aim of the present study was to examine the effect of Roy's adaptation model-based patient education on adaptation of HD patients.

PATIENTS AND METHODS

This study is a semi-experimental research that was conducted with the participation of all patients with end-stage renal disease referred to the dialysis unit of Shahid Beheshti Hospital of Yasuj city, 2010. A total of 59 HD patients were randomly allocated to two groups of test and control. Data were collected by a questionnaire based on the Roy's Adaptation Model (RAM). Validity and reliability of the questionnaire were approved. Patient education was determined by eight one-hour sessions over eight weeks. At the end of the education plan, the patients were given an educational booklet containing the main points of self-care for HD patients. The effectiveness of education plan was assessed two months after plan completion and data were compared with the pre-education scores. All analyses were conducted using the SPSS software (version 16) through descriptive and inferential statistics including correlation, t-test, ANOVA and ANCOVA tests.

RESULTS

The results showed significant differences in the mean scores of physiological and self-concept models between the test and control groups (P = 0.01 and P = 0.03 respectively). Also a statistical difference (P = 0.04) was observed in the mean scores of the role function mode of both groups. There was no significant difference in the mean scores of interdependence modes between the two groups.

CONCLUSIONS

RAM based patient education could improve the patients' adaptation in physiologic and self-concept modes. In addition to suggesting further research in this area, nurses are recommended to pay more attention in applying RAM in dialysis centers.

Iron deficiency anemia in women across the life span

Anemia is a global health issue with disproportionately high prevalence in women. In addition to being an independent risk factor for decreased quality of life and increased morbidity and mortality, anemia in women has been linked to unfavorable outcomes of pregnancy and other issues for children born to anemic women. Iron deficiency is the leading cause of anemia in many populations. Guidelines recommend proactive screening for anemia, particularly in the preoperative setting. Once anemia is diagnosed, treatment should be based on etiology (most commonly, iron deficiency followed, in order of prevalence, by inflammation or chronic disease). Iron supplementation (oral and intravenous) offers safe and effective treatment for anemia associated with iron deficiency. Anemia of chronic disease may be more challenging to treat, and attention must be given to the underlying disease, along with use of hematinic agents. Given its enormous impact on the health and well-being of women and the availability of simple and effective treatment options, anemia should never be left unmanaged.

Systematic review of the impact of erythropoiesis-stimulating agents on fatigue in dialysis patients

BACKGROUND

One of the cardinal symptoms of anemia in chronic kidney disease (CKD) patients is fatigue. Recently, results from Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT) raised questions about the role of erythropoiesis-stimulating agents (ESAs) in improving fatigue and the appropriate hemoglobin (Hb) target in anemic patients with CKD. These discussions should be considered with all available evidence to determine the level of benefits and risks associated with ESA therapy on fatigue among both early-stage CKD patients and end-stage renal disease patients on dialysis.

METHODS

The study was a systematic review of the literature on fatigue in adults on maintenance dialysis therapy. The requirement for inclusion in the review was the measurement of fatigue before and after ESA treatment. Outcomes that were assessed were fatigue as measured by the Kidney Disease Questionnaire, the 36-item Short-Form general health survey, the Nottingham Health Profile, the Profile of Mood States or the Functional Assessment of Chronic Illness Therapy-Fatigue scale. Several different measures of fatigue were used in the studies.

RESULTS

Fifteen articles met the criteria for inclusion, including 10 distinct studies and one extension study. There was one placebo-controlled randomized clinical trial (RCT) and one extension, five single-arm, three high versus low, one intravenous versus subcutaneous and one switch from epoetin alfa to darbepoetin alfa. The only placebo-controlled RCT found a 22-26% improvement in fatigue. Single-arm cohort studies demonstrated a reduction in fatigue after a substantial increase in Hb. Studies with a baseline Hb <10 g/dL and partial correction to a minimum Hb ≥ 10 g/dL showed an average improvement in fatigue of 34.6%. Studies with a baseline Hb ≥ 11 g/dL and full correction to a minimum Hb ≥ 12 g/dL showed an average improvement in fatigue of 5.5%, while studies with no change in Hb (either placebo or control group) showed a decline of 0.7% in fatigue outcomes.

CONCLUSION

Partial correction of anemia with ESA results in improvement of fatigue among patients on dialysis, most strikingly in those patients with baseline Hb levels <10 g/dL.

Factors affecting employment at initiation of dialysis

BACKGROUND AND OBJECTIVES

Half the individuals who reach ESRD are working age (< 65 years old) and many are at risk for job loss. Factors that contribute to job retention among working-age patients with chronic kidney disease before ESRD are unknown. The purpose of the study is to understand factors associated with maintaining employment among working-age patients with advanced kidney failure.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this retrospective study we reviewed the United States Renal Data System database (1992 through 2003) and selected all patients (n = 102,104) who were working age and employed 6 months before dialysis initiation. Factors that were examined for an association with maintaining employment status included demographics, comorbid conditions, ESRD cause, insurance, predialysis erythropoietin use, and dialysis modality.

RESULTS

Maintaining employment at the same level during the final 6 months before dialysis was more likely among (1) white men ages 30 to 49 years; (2) patients with either glomerulonephritis, cystic, or urologic causes of renal failure; (3) patients choosing peritoneal dialysis for their first treatment; (4) those with employer group or other health plans; and (5) erythropoietin usage before ESRD. Maintaining employment status was less likely among patients with congestive heart failure, cardiovascular disease, cancer, and other chronic illnesses.

CONCLUSIONS

The rate of unemployment in working-age patients with chronic kidney disease and ESRD is high compared with that of the general population. Treating anemia with erythropoietin before kidney failure and educating patients about work-friendly home dialysis options might improve job retention.

Design and rationale of health-related quality of life and patient-reported outcomes assessment in the Frequent Hemodialysis Network trials

BACKGROUND

End-stage renal disease patients experience significant impairments in health-related quality of life (HRQOL). Testing various strategies to improve patient HRQOL in multicenter clinical trials, such as the Frequent Hemodialysis Network (FHN) trials is vitally important.

AIMS

The aim of this paper is to describe the design and conduct of HRQOL and patient-reported outcomes (PRO) assessment in the FHN trials.

METHODS

In the FHN trials, HRQOL was examined as a multidimensional concept, and the SF-36 RAND Physical Health Composite score was one of the co-primary outcomes. The instruments completed to assess HRQOL included the Medical Outcomes Study Short Form SF-36, Health Utilities Index 3, Sleep Problems Index, Beck Depression Inventory and feeling thermometer. These instruments have been shown to have high reliability, validity and responsiveness to change in the end-stage renal disease population. Additional items evaluating PRO including sexual function, time to recovery after dialysis and patients' self-perceived burden to caregiver were also assessed. All questionnaires were administered by trained interviewers using computer-assisted telephone interviewing to ensure blinding and minimizing selection bias. Interim analysis reveals that these instruments can be used to collect a comprehensive set of HRQOL measures with minimal patient burden.

CONCLUSIONS

Accurate measurement of HRQOL and PRO can help us test whether hemodialysis interventions improve the health and well-being of this compromised patient population. We have shown that a comprehensive set of HRQOL measures can be centrally collected through telephone interviews in a blinded fashion, in a way that is well tolerated with minimum respondent burden.

Half standard deviation estimate of the minimally important difference in HRQOL scores?

In addition to statistical significance, it is important to evaluate the magnitude of differences in health-related quality of life over time. Interest in establishing the minimal difference that is clinically important or the minimally important difference has burgeoned over the last few years. This review summarizes some of the leading approaches to estimating the minimally important difference, offers caveats on the minimally important difference estimation based on existing literature and provides recommendations for future work. The authors recommend using multiple anchors to estimate the minimally important difference, using only anchors that correspond to minimal change in health-related quality of life, reporting information about the variation around the estimates, and providing bounded estimates to reflect the uncertainty.

Impact of haemoglobin and erythropoietin dose changes on mortality: a secondary analysis of results from a randomized anaemia management trial

BACKGROUND

Anaemia is a common complication of chronic kidney disease. A number of studies have identified an adverse association between haemoglobin (Hgb) variability and mortality. To date, no study has evaluated the impact of Hgb variability on mortality in the setting of a uniform Hgb target and erythropoiesis-stimulating agents (ESA) dosing strategy.

METHODS

One hundred and fifty-four haemodialysis (HD) patients from a previous randomized anaemia management study were followed up for up to 6 years. The impact of Hgb variability and ESA dosing parameters on subsequent mortality risk were evaluated.

RESULTS

More rapid rises in Hgb (Hgb deflect(pos)) and ESA dose increases were independently associated with mortality in multivariate analysis, whereas more rapid Hgb declines (Hgb deflect(neg)) and ESA dose decreases were not. Each gram per litre per week increase in Hgb deflect(pos) was associated with an adjusted hazard ratio (HR) of 1.23 (1.03-1.48), while for every 1000-unit increase in ESA dose, the adjusted HR was 1.12 (1.01-1.24). Factors associated with positive Hgb deflections included frequency and magnitude of ESA dose changes, baseline Hgb, patient weight and presence of an HD catheter.

CONCLUSIONS

Rapid Hgb rises and greater average Eprex dose increases were independently associated with a higher mortality risk in HD patients after adjustment for baseline Hgb and Eprex dose. A randomized controlled trial evaluating different ESA dosing strategies in response to individual patient ESA responsiveness is needed.

Impact of pain and symptom burden on the health-related quality of life of hemodialysis patients

CONTEXT

Dialysis patients experience tremendous symptom burden and substantial impaired health-related quality of life (HRQL).

OBJECTIVES

We determined the association between symptom burden and HRQL in 591 hemodialysis patients.

METHODS

Patients completed the modified Edmonton Symptom Assessment System and the Kidney Dialysis Quality of Life Short Form at baseline and after six months.

RESULTS

There were no demographic, serological, or dialysis-related predictors for either HRQL or symptom burden. Pain, tiredness, lack of well-being, and depression were the only independent predictors of mental HRQL, accounting for 42.5% of the variation in the baseline mental health composite (MHC). Pain, fatigue, lack of well-being, and shortness of breath were the only independent predictors of physical HRQL, accounting for 38.5% of the variation in the baseline physical health composite (PHC). After follow-up, only changes in depression, anxiety, tiredness, and lack of appetite were independently associated with a change in MHC score, accounting for 48.7% of the variability. Only changes in pain, tiredness, and lack of appetite were independently associated with a change in PHC, accounting for 44.6% of the variability in the final multivariate regression model. No change in biochemical parameters predicted a change in either the MHC or the PHC.

CONCLUSION

Symptom burden in end-stage renal disease was substantial and had a tremendous negative impact on all aspects of hemodialysis patients' HRQL. These patients, therefore, would likely benefit from the institution of programs to reduce symptom burden.

A comparison of SF-36 and SF-12 composite scores and subsequent hospitalization and mortality risks in long-term dialysis patients

BACKGROUND AND OBJECTIVES

The Short Form 12 (SF-12) has not been validated for long-term dialysis patients. The study compared physical and mental component summary (PCS/MCS) scores from the SF-36 with those from the embedded SF-12 in a national cohort of dialysis patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

All 44,395 patients who had scorable SF-36 and SF-12 from January 1, 2006, to December 31, 2006, and were treated at Fresenius Medical Care, North America facilities were included. Death and first hospitalization were followed for up to 1 year from the date of survey. Correlation and agreement were obtained between PCS-36 and PCS-12 and MCS-36 and MCS-12; then Cox models were constructed to compare associated hazard ratios (HRs) between them.

RESULTS

Physical and mental dimensions both exhibited excellent intraclass correlation coefficients of 0.94. Each incremental point for both PCS-12 and PCS-36 was associated with a 2.4% lower adjusted HR of death and 0.4% decline in HR for first hospitalization (both P < 0.0001). Corresponding improvement in HR of death for each MCS point was 1.2% for MCS-12 and 1.3% for MCS-36, whereas both had similar 0.6% lower HR for hospitalization per point (all P < 0.0001).

CONCLUSIONS

The use of the SF-12 alone or as part of a larger survey is valid in dialysis patients. Composite scores from the SF-12 and SF-36 have similar prognostic association with death and hospitalization risk. Prospective longitudinal studies of SF-12 surveys that consider responsiveness to specific clinical, situational, and interventional changes are needed in this population.

Approaches and Recommendations for Estimating Minimally Important Differences for Health-Related Quality of Life Measures

We describe currently available approaches for estimating the minimally important difference (MID) and their associated strengths and weaknesses. Specifically, we show that anchor-based methods should be the primary method of estimating the MID because of the limitations of distribution-based methods. In addition, we provide recommendations for estimating the MID in future research.

Large-dose intravenous ferric carboxymaltose injection for iron deficiency anemia in heavy uterine bleeding: a randomized, controlled trial

BACKGROUND

The objective was to evaluate efficacy and safety of rapid, large-dose intravenous (IV) administration of ferric carboxymaltose compared to oral iron in correcting iron deficiency anemia due to heavy uterine bleeding.

STUDY DESIGN AND METHODS

In a randomized, controlled trial, 477 women with anemia, iron deficiency, and heavy uterine bleeding were assigned to receive either IV ferric carboxymaltose (<or=1000 mg over 15 min, repeated weekly to achieve a total calculated replacement dose) or 325 mg of ferrous sulfate (65 mg elemental iron) prescribed orally thrice daily for 6 weeks.

RESULTS

Compared to those assigned to ferrous sulfate, more patients assigned to ferric carboxymaltose responded with a hemoglobin (Hb) increase of 2.0 g/dL or more (82% vs. 62%, 95% confidence interval for treatment difference 12.2-28.3, p < 0.001), more achieved a 3.0 g/dL or more increase (53% vs. 36%, p < 0.001), and more achieved correction (Hb >or= 12 g/dL) of anemia (73% vs. 50%, p < 0.001). Patients treated with ferric carboxymaltose compared to those prescribed ferrous sulfate reported greater gains in vitality and physical function and experienced greater improvement in symptoms of fatigue (p < 0.05). There were no serious adverse drug events.

CONCLUSIONS

In patients with iron deficiency anemia due to heavy uterine bleeding, rapid IV administration of large doses of a new iron agent, ferric carboxymaltose, is more effective than oral iron therapy in correcting anemia, replenishing iron stores, and improving quality of life.

Relation Between Depression, Some Laboratory Parameters, and Quality of Life in Hemodialysis Patients

Depression is common in patients with end-stage renal disease (ESRD) and is associated with increased mortality and morbidity. Several investigators have estimated that depression occurs in about 20% to 30% of dialysis patients. The aim of this study was to investigate the relationship between depression, some laboratory parameters, and quality of life (QOL) in hemodialysis patients. Forty-three hemodialysis patients (mean age 40.5+/-15.2; M=28, F=15) were included in the study. Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), and short form with 36 (SF-36) were used for evaluation. Subsequently, patients were divided into two groups according to HAMD scores: group 1, those who had a low HAMD score (between 0 and 7), and group 2, those who had a high HAMD score (over 7). The two groups were compared in terms of anxiety scores, QOL scores, and some laboratory parameters. The group 2 patients (n=21; M= 13, F=8) had lower levels of hemoglobin than the group 1 patients (9.5+/-1.7 vs. 10.7+/- 1.4 g/dL, respectively; p<0.01). Group 2 patients also had lower SF-36 scores than group 1 patients (91.5+/-21.3 vs. 74.9+/- 13.6, respectively; p=0.03). On the contrary, the patients of group 2 had higher HAMA scores than group 1 patients (16.6+/-6.9 vs. 6.3+/-3.5, respectively; p<0.01) and CRP level (10.7+/-4.6 vs. 4.5+/-3.8, respectively; p<0.001). A significant correlation was found between depression scores and C-reactive protein (CRP) (r= 0.57, p < 0.001) and HAMA scores (r=-0.43, p<0.05). In contrast, a negative correlation was found between HAMD scores and albumin (r=-0.43, p<0.05), hemoglobin (r=-0.38, p=0.015) and SF-36 scores (r=0.39, p=0.032). These findings demonstrate that there is a relationship among high depression score, low levels of hemoglobin and albumin, high CRP level, low SF-36 score, and high anxiety score. Evaluation of psychiatric status should be part of the care provided to hemodialysis patients.

Blood transfusion use in non-dialysis-dependent chronic kidney disease patients aged 65 years and older

BACKGROUND

Erythropoiesis stimulating agents (ESA) have alleviated the need for blood transfusions in dialysis patients. Their impact on transfusion frequency in elderly chronic kidney disease (CKD) patients aged 65 years and older with non-dialysis-dependent CKD has not been studied.

METHODS

We conducted a retrospective cohort study of Medicare beneficiaries with CKD, point prevalent as of 1 January of each calendar year 1992-2004 (n = 301 000), and a concurrent group of beneficiaries without CKD (n = 15 772 039). During the entry year, we used administrative claim data to assemble a comorbidity profile for each participant. Transfusion event rates, ESA use and parenteral iron use were of primary interest.

RESULTS

CKD patients were at least four times more likely than non-CKD patients to receive transfusions. Transfusion rates adjusted for case mix fell from 194.2 transfusions per 1000 patient-years in 1992 to 112.2 in 2004. The decline in transfusions was highest for anaemic CKD patients receiving ESAs, which were given to 0.8% of CKD patients in 1992 and to 7.5% in 2004.

CONCLUSIONS

Transfusion use in non-dialysis-dependent CKD patients has decreased considerably but continues to be common. ESA use and possibly changed attitudes towards transfusion use explain most of the reduction noted.

Ethnicity, socioeconomic status, and attainment of clinical practice guideline standards in dialysis patients in the United kingdom

BACKGROUND AND OBJECTIVES

The role of socioeconomic status (SES) and its contribution to ethnic differences in standards attainment among dialysis patients is not known.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We examined associations between area- level SES (Townsend index) and ethnicity (white, black, South Asian) and standards attainment in 14,117 incident dialysis patients (1997-2004) in the UK.

RESULTS

Deprived patients were less likely to achieve hemoglobin (Hb) > or = 10 g/dl (trend P < 0.001) but not after controlling for patient and center characteristics (trend P = 0.1). There was no association with hemodialysis dose and parathyroid hormone (PTH) standard but deprived patients had better attainment of phosphate (PO4) <5.6 mg/dl, calcium (Ca) and Calcium-phosphate (CaPO4) standard (e.g., most deprived versus least deprived adjusted odds ratio [OR] 1.25, 95% confidence intervals [CI] 1.12, 1.38). There was no association with SES using a lower limit for PO4 (3.5 - 5.5 mg/dl). Compared with Whites, Blacks had lower attainment of Hb (adjusted OR 0.57, 95% CI 0.45, 0.71) and PTH standards (adjusted OR 0.27, 95% CI 0.22, 0.33) but better attainment of PO4 and CaPO4, while South Asians experienced better or comparable outcomes for most standards except Ca and PTH.

CONCLUSIONS

There was no evidence of socioeconomic inequity in standards attainment or a consistent pattern of inequity by ethnic group. The lower attainment of some standards in ethnic minorities may reflect biologic differences rather than ethnicity-related inequity of care.

Erythropoietin therapy and left ventricular mass index in CKD and ESRD patients: a meta-analysis

BACKGROUND AND OBJECTIVES

The purpose was to evaluate changes in the left ventricular mass index (LVMi) among anemic chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients treated with recombinant human erythropoietin (EPO).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A systematic review of the literature, reporting LVMi for patients before and after EPO therapy, was performed. The change in LVMi from baseline to the end of treatment was calculated and stratified by severity of anemia at baseline, target hemoglobin (Hb), and stage of kidney disease.

RESULTS

Fifteen eligible studies involving 1731 patients were identified. Cohorts with severe anemia at baseline (<10 g/dl), when given EPO using a lower target level (Hb <or= 12 g/dl or Hct <or= 36%) experienced significant reductions in LVMi (-32.7 g/m(2); 95% CI: -49.4 to -16.1, P < 0.05). However, these studies lacked control groups. Cohorts with moderate anemia at baseline showed insignificant changes in LVMi: 5.3 g/m(2) (95% CI: -0.8 to 11.3) for patients assigned to a lower target, and -6.6 g/m(2) (95% CI: -17.2 to 4.0) for patients assigned to a higher target (Hb > 12 g/dl or Hct > 36%). The effect size was similar in direction for both CKD and ESRD cohorts.

CONCLUSIONS

Aggregated results from multiple studies suggest that in severe anemia conventional Hb targets for EPO therapy are associated with a reduction in LVMi, but that in moderate anemia target Hb above 12 g/dl does not have a significant beneficial impact on LVMi compared with conventional targets.

Individual quality of life in chronic kidney disease: influence of age and dialysis modality

BACKGROUND AND OBJECTIVES

Novel individualized quality-of-life (IQOL) measures permit patients with chronic kidney disease (CKD) to nominate unique areas of their lives that contribute to their well-being. This study assessed for differences in domains nominated by patients with CKD. We also examined the strength of association between (1) multidimensional health-related quality-of-life measures and IQOL and (2) psychosocial factors and IQOL.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a cross-sectional study of 151 patients who were undergoing peritoneal dialysis or hemodialysis or had stages 4 through 5 CKD. Patients completed the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQOL-DW), an instrument that assesses IQOL on the basis of patient-identified domains. Patients also completed health-related quality-of-life and psychosocial health measures.

RESULTS

Patients with CKD nominated many domains on the SEIQOL-DW, but family and health were the most common for all groups. Kidney disease was listed more frequently by peritoneal dialysis compared with hemodialysis patients or patients with CKD (31 versus 14 versus 5%, respectively). There were no significant differences in SEIQOL-DW scores between subgroups. SEIQOL-DW scores correlated with mental well-being and inversely correlated with chronic stress and depression.

CONCLUSIONS

Patients with advanced CKD demonstrate compromised quality-of-life scores comparable to dialysis patients. IQOL measures provide unique information that may help guide interventions that are better tailored to address patients' concerns about their well-being. These findings also suggest that renal clinics should have staff available to address psychosocial aspects of patient well-being.

The controversy surrounding hemoglobin and erythropoiesis-stimulating agents: what should we do now?

Treatment of the anemia of chronic kidney disease (CKD) with erythropoiesis-stimulating agents (ESAs) has been intensely debated during the past 2 years. Treatment with ESAs has transformed the lives of millions of patients with CKD, with fewer blood transfusions and improved quality of life. However, randomized trials have suggested that targeting greater hematocrits/hemoglobin levels and/or exposure to high doses of ESAs is associated with a greater risk of cardiovascular complications and mortality. The US Food and Drug Administration has inserted a boxed warning for ESAs and, along with the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (KDOQI), decreased recommended target hemoglobin ranges for ESA therapy. The Centers for Medicare & Medicaid Services has decreased ESA dosing recommendations in the Medicare claims policy for ESAs. Managing the anemia of CKD in the era of the hemoglobin level and ESA controversy has required aiming for appropriate hemoglobin levels, using the lowest effective ESA dose, and better managing the problem of ESA hyporesponsiveness.

[Hemoglobin variability in patients with chronic renal insuffiency]

Several recent articles have examined the time-dependent effects of epoetin therapy and the variability of hemoglobin (HGb) levels and what epoetin does in hemodialysis patients. A recent preliminary report also found that HGG cycling was common among hemodialysis patients, with only 10% of patients remaining within their initial HGb range (less than 11 g/dl, 11 to 12.5 g/dl, greater than 12.5 g/dl) during a six-month period. Factors associated with HGb cycling were changes in epoetin dose, intravenous-iron administration or a change in dose and hospitalization. What is not known is whether there are adverse clinical outcomes associated with HGb variability, although preliminary data indicate, perhaps predictably, that a decreasing HGb level is associated with a higher mortality risk. This is certainly an area that merits further study.

The effects of kidney-disease-related loss on long-term dialysis patients' depression and quality of life: positive affect as a mediator

BACKGROUND AND OBJECTIVES

In kidney disease, the concept of loss is widely discussed but minimally researched. It appears that dialysis patients who grieve a range of losses suffer increased depression and reduced quality of life (QoL). Limited research is partly due to the lack of a relevant loss measure. The study presented here developed a measure and tested the criterion validity of loss in relation to depression and QoL.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a cross-sectional observational study, 151 long-term dialysis patients were interviewed using standardized psychometric measures and the Kidney Disease Loss Scale (KDLS), developed for the study. Factor, path and multigroup analyses were conducted.

RESULTS

The factor structure and reliability of KDLS were supported. The path analyses supported the criterion validity of loss. It was a stronger contributor to depression than other clinical variables. Its effect on QoL was fully mediated by depression and positive affect (coping). The magnitude of the paths from loss to QoL through depression and positive affect was larger in home-based dialysis patients than in hospital-based patients.

CONCLUSIONS

KDLS is a promising measure of loss. Patient-defined losses may contribute to the high level of depression and in turn a reduction in patients' coping and QoL. These findings suggest several points of intervention to improve long-term dialysis patients' QoL.

Temporal trends in red blood transfusion among US dialysis patients, 1992-2005

BACKGROUND

Studies addressing patterns and trends in red blood cell transfusion use in US hemodialysis patients surprisingly have received little attention in the last decade.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Point prevalent (as of January 1 of each calendar year 1992 to 2005) dialysis patients with Medicare Part A and Part B as primary insurance (n = 77,347 in 1992, n = 164,933 in 2005). The 6 months preceding January 1 of each year were used to assemble a comorbidity profile based on administrative claims data.

PREDICTORS

Hemoglobin levels, patient characteristics, comorbid conditions.

OUTCOMES

Blood transfusion events obtained from Part A and Part B files using code files for both whole and packed red blood cell transfusions and hemoglobin levels.

MEASUREMENTS

Comorbid conditions were defined by the presence of 1 or more inpatient/outpatient institutional claims (inpatient hospitalization, skilled nursing facility, or home health agency), 2 or more outpatient or physician/supplier claims, or 1 or more outpatient and 1 or more physician/supplier claims for atherosclerotic heart disease, congestive heart failure, cerebrovascular accidents/transient ischemic attacks, peripheral vascular disease, other cardiovascular diseases, chronic obstructive pulmonary disease, gastrointestinal disorders, liver disease, arrhythmia, and diabetes mellitus.

RESULTS

Raw transfusion rates decreased in both outpatient and inpatient settings from 535.33/1,000 patient-years for 1992 prevalent dialysis patients to 263.65/1,000 patient-years in 2005 (P for trend < 0.001, 1992 versus 1999 and 1999 versus 2005). Adjusted rates decreased similarly. This phenomenon could not be explained by changes in case mix.

LIMITATIONS

Cause, effect, and confounding cannot be separated in this observational study. The accuracy of blood transfusion billing data is unknown. Temporal trends may be related to factors other than erythropoiesis-stimulating agent use.

CONCLUSION

Transfusion events in hemodialysis patients decreased more than 2-fold from 1992 to 2005; most of the decrease occurred in the first 5 years after erythropoietin was introduced.