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Dahm MR, Raine SE, Slade D, Chien LJ, Kennard A, Walters G, Spinks T, Talaulikar G. Shared decision making in chronic kidney disease: a qualitative study of the impact of communication practices on treatment decisions for older patients. BMC Nephrol 2023; 24:383. [PMID: 38129771 PMCID: PMC10734071 DOI: 10.1186/s12882-023-03406-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Effective interpersonal communication is critical for shared decision-making (SDM). Previous SDM communication training in nephrology has lacked context-specific evidence from ethnographic analysis of SDM interactions with older patients considering treatment options of end stage kidney disease (ESKD). This study explores communication strategies in SDM discussions in nephrology, specifically focusing on older patients considering dialysis as kidney replacement therapy (KRT). METHODS We conducted a qualitative study analysing naturally-occurring audio-recorded clinical interactions (n = 12) between Australian kidney doctors, patients aged 60+, and carers. Linguistic ethnography and qualitative socially-oriented functional approaches were used for analysis. RESULTS Two types of communication strategies emerged: (1) Managing and advancing treatment decisions: involving active checking of knowledge, clear explanations of options, and local issue resolution. (2) Pulling back: Deferring or delaying decisions through mixed messaging. Specifically for non-English speaking patients, pulling back was further characterised by communication challenges deferring decision-making including ineffective issue management, and reliance on family as interpreters. Age was not an explicit topic of discussion among participants when it came to making decisions about KRT but was highly relevant to treatment decision-making. Doctors appeared reluctant to broach non-dialysis conservative management, even when it appears clinically appropriate. Conservative care, an alternative to KRT suitable for older patients with co-morbidities, was only explicitly discussed when prompted by patients or carers. CONCLUSIONS The findings highlight the impact of different communication strategies on SDM discussions in nephrology. This study calls for linguistic-informed contextualised communication training and provides foundational evidence for nephrology-specific communication skills training in SDM for KRT among older patients. There is urgent need for doctors to become confident and competent in discussing non-dialysis conservative management. Further international research should explore naturally-occurring SDM interactions in nephrology with other vulnerable groups to enhance evidence and training integration.
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Affiliation(s)
- Maria R Dahm
- Institute for Communication in Health Care (ICH), College of Arts and Social Sciences, Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Canberra, ACT, 2601, Australia.
| | - Suzanne Eggins Raine
- Institute for Communication in Health Care (ICH), College of Arts and Social Sciences, Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Canberra, ACT, 2601, Australia
| | - Diana Slade
- Institute for Communication in Health Care (ICH), College of Arts and Social Sciences, Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Canberra, ACT, 2601, Australia
| | - Laura J Chien
- Institute for Communication in Health Care (ICH), College of Arts and Social Sciences, Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Canberra, ACT, 2601, Australia
| | - Alice Kennard
- Canberra Hospital Renal Service, Canberra, Australia
- College of Health and Medicine, Australian National University, Canberra, Australia
| | - Giles Walters
- Canberra Hospital Renal Service, Canberra, Australia
- College of Health and Medicine, Australian National University, Canberra, Australia
| | - Tony Spinks
- Canberra Hospital Renal Service, Canberra, Australia
| | - Girish Talaulikar
- Canberra Hospital Renal Service, Canberra, Australia
- College of Health and Medicine, Australian National University, Canberra, Australia
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Higashisaka K, Takeya S, Kamada H, Obana M, Maeda M, Kabayama M, Yamamoto K, Ishida N, Isaka R, Tsujino H, Nagano K, Tomiyama N, Rakugi H, Fujio Y, Kamide K, Tsutsumi Y. Identification of biomarkers of chronic kidney disease among kidney-derived proteins. Clin Proteomics 2022; 19:3. [PMID: 35016606 PMCID: PMC8903635 DOI: 10.1186/s12014-021-09340-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/30/2021] [Indexed: 12/16/2022] Open
Abstract
Background Chronic kidney disease (CKD) has few objective symptoms, and it is difficult to make an early diagnosis by using existing methods. Therefore, new biomarkers enabling diagnosis of renal dysfunction at an early stage need to be developed. Here, we searched for new biomarkers of CKD by focusing on kidney-derived proteins that could sensitively reflect that organ’s disease state. Methods To identify candidate marker proteins, we performed a proteomics analysis on renal influx and efflux blood collected from the same individual. Results Proteomics analysis revealed 662 proteins in influx blood and 809 in efflux. From these identified proteins, we selected complement C1q as a candidate; the plasma C1q level was significantly elevated in the renal efflux of donors. Moreover, the plasma concentration of C1q in a mouse model of diabetic nephropathy was significantly increased, in association with increases in blood glucose concentration and urinary protein content. Importantly, we demonstrated that the tendency of C1q to increase in the plasma of CKD patients was correlated with a decrease in their estimated glomerular filtration rate. Conclusion Overall, our results indicate that our approach of focusing on kidney-derived proteins is useful for identifying new CKD biomarkers and that C1q has potential as a biomarker of renal function. Supplementary Information The online version contains supplementary material available at 10.1186/s12014-021-09340-y.
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Affiliation(s)
- Kazuma Higashisaka
- Laboratory of Toxicology and Safety Science, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Sonoko Takeya
- Laboratory of Toxicology and Safety Science, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Haruhiko Kamada
- Laboratory of Biopharmaceutical Research, National Institutes of Biomedical Innovation, Health and Nutrition, Ibaraki, Osaka, Japan.,Center for Drug Design Research, National Institutes of Biomedical Innovation, Health and Nutrition, Ibaraki, Osaka, Japan.,Global Center for Medical Engineering and Informatics, Osaka University, Suita, Osaka, Japan
| | - Masanori Obana
- Laboratory of Clinical Science and Biomedicine, Graduate School of Pharmaceutical Sciences, Osaka University, Suita, Osaka, Japan
| | - Makiko Maeda
- Advanced Research of Medical and Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Osaka University, Suita, Osaka, Japan
| | - Mai Kabayama
- Department of Health Promotion Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Nanan Ishida
- Laboratory of Toxicology and Safety Science, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryo Isaka
- Laboratory of Toxicology and Safety Science, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hirofumi Tsujino
- Laboratory of Toxicology and Safety Science, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kazuya Nagano
- Laboratory of Toxicology and Safety Science, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Noriyuki Tomiyama
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yasushi Fujio
- Laboratory of Clinical Science and Biomedicine, Graduate School of Pharmaceutical Sciences, Osaka University, Suita, Osaka, Japan.,Advanced Research of Medical and Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Osaka University, Suita, Osaka, Japan
| | - Kei Kamide
- Department of Health Promotion Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yasuo Tsutsumi
- Laboratory of Toxicology and Safety Science, Graduate School of Pharmaceutical Sciences, Osaka University, 1-6, Yamadaoka, Suita, Osaka, 565-0871, Japan. .,Global Center for Medical Engineering and Informatics, Osaka University, Suita, Osaka, Japan.
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Pérez-Torres A, González García ME, Ossorio-González M, Álvarez García L, Bajo MA, del Peso G, Castillo Plaza A, Selgas R. The Effect of Nutritional Interventions on Long-Term Patient Survival in Advanced Chronic Kidney Disease. Nutrients 2021; 13:nu13020621. [PMID: 33672996 PMCID: PMC7918910 DOI: 10.3390/nu13020621] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/16/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) are at high risk of malnutrition and subsequent related mortality when starting dialysis. However, there have been few clinical studies on the effect of nutritional interventions on long-term patient survival. A 2-year longitudinal study was conducted from January 2012 to December 2016. A total of 186 patients with non-dialysis ESKD started the nutritional education program (NEP), and 169 completed it. A total of 128 patients participated in a NEP over 6 months (personalized diet, education and oral supplementation, if needed). The control group (n = 45) underwent no specific nutritional intervention. The hospitalization rate was significantly lower for the patients with NEP (13.7%) compared with the control patients (26.7%) (p = 0.004). The mortality odds ratio for the patients who did not receive NEP was 2.883 (95% CI 0.993-8.3365, p = 0.051). The multivariate analysis showed an independent association between mortality and age (OR, 1.103; 95% CI 1.041-1.169; p = 0.001) and between mortality and the female sex (OR, 3.332; 95% CI 1.054-10.535; p = 0.040) but not between mortality and those with NEP (p = 0.051). Individualized nutrition education has long-term positive effects on nutritional status, reduces hospital admissions and increases survival among patients with advanced CKD who are starting dialysis programs.
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Affiliation(s)
- Almudena Pérez-Torres
- Nutrition Department, Hospital Universitario Santa Cristina, 28009 Madrid, Spain;
- Nephrology Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (M.O.-G.); (L.Á.G.); (M.A.B.); (G.d.P.); (A.C.P.); (R.S.)
| | - M. Elena González García
- Nephrology Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (M.O.-G.); (L.Á.G.); (M.A.B.); (G.d.P.); (A.C.P.); (R.S.)
- Correspondence: ; Tel.: +34-917277382
| | - Marta Ossorio-González
- Nephrology Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (M.O.-G.); (L.Á.G.); (M.A.B.); (G.d.P.); (A.C.P.); (R.S.)
| | - Laura Álvarez García
- Nephrology Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (M.O.-G.); (L.Á.G.); (M.A.B.); (G.d.P.); (A.C.P.); (R.S.)
| | - M. Auxiliadora Bajo
- Nephrology Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (M.O.-G.); (L.Á.G.); (M.A.B.); (G.d.P.); (A.C.P.); (R.S.)
| | - Gloria del Peso
- Nephrology Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (M.O.-G.); (L.Á.G.); (M.A.B.); (G.d.P.); (A.C.P.); (R.S.)
| | - Ana Castillo Plaza
- Nephrology Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (M.O.-G.); (L.Á.G.); (M.A.B.); (G.d.P.); (A.C.P.); (R.S.)
| | - Rafael Selgas
- Nephrology Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (M.O.-G.); (L.Á.G.); (M.A.B.); (G.d.P.); (A.C.P.); (R.S.)
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Association of Serum Uric Acid Concentration and Its Change with Cardiovascular Death and All-Cause Mortality. DISEASE MARKERS 2020; 2020:7646384. [PMID: 32076464 PMCID: PMC7008257 DOI: 10.1155/2020/7646384] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/29/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023]
Abstract
Objective There is no consensus on the role of abnormal uric acid (UA) levels in the prognosis of patients undergoing hemodialysis. We therefore aimed to investigate the effects of changes in UA concentration on the risk of all-cause death and cardiac death in such patients. Method In this retrospective cohort study, patients admitted to two hemodialysis centers performing maintenance hemodialysis (MHD) in Wuhan First Hospital and Fourth Hospital Hemodialysis Center from January 1, 2007, to October 31, 2017, were included. Results In all, 325 patients undergoing MHD aged 59.7 ± 14.7 years, including 195 men (60%), were enrolled, with a median follow-up of 37 months. Serum UA (p < 0.001) was significantly higher in the surviving group than in the death group. No significant difference was found in UA variability (p < 0.001) was significantly higher in the surviving group than in the death group. No significant difference was found in UA variability (p < 0.001) was significantly higher in the surviving group than in the death group. No significant difference was found in UA variability (p < 0.001) was significantly higher in the surviving group than in the death group. No significant difference was found in UA variability (p < 0.001) was significantly higher in the surviving group than in the death group. No significant difference was found in UA variability (p < 0.001) was significantly higher in the surviving group than in the death group. No significant difference was found in UA variability (p < 0.001) was significantly higher in the surviving group than in the death group. No significant difference was found in UA variability (p < 0.001) was significantly higher in the surviving group than in the death group. No significant difference was found in UA variability ( Conclusion Low UA levels were closely related to all-cause mortality in patients undergoing MHD. Although UA levels had no significant effect on cardiac death, they had a good predictive value for long-term prognosis in patients on MHD.
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Sim JJ, Zhou H, Shi J, Shaw SF, Henry SL, Kovesdy CP, Kalantar-Zadeh K, Jacobsen SJ. Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters. Int Urol Nephrol 2018. [PMID: 29532308 DOI: 10.1007/s11255-018-1837-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD. METHODS A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics. RESULTS Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06-3.30) in HD with fistula/graft patients and 3.77 (2.17-6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5-9 (HR 1.68) at transition were also associated with higher early mortality risk. CONCLUSION Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making.
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Affiliation(s)
- John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, 4700 Sunset Bl, Los Angeles, CA, USA.
| | - Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jiaxiao Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Sally F Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Shayna L Henry
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, CA, USA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Piccoli GB, Sofronie AC, Coindre JP. The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions. BMC Med Ethics 2017; 18:61. [PMID: 29121886 PMCID: PMC5680775 DOI: 10.1186/s12910-017-0219-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/31/2017] [Indexed: 12/16/2022] Open
Abstract
Background Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions. Case presentation Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy). In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”. Conclusions An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy. .,Nephrology, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
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Mikolasevic I, Lukenda V, Racki S, Milic S, Sladoje-Martinovic B, Orlic L. Nonalcoholic fatty liver disease (NAFLD) - a new factor that interplays between inflammation, malnutrition, and atherosclerosis in elderly hemodialysis patients. Clin Interv Aging 2014; 9:1295-303. [PMID: 25143715 PMCID: PMC4132229 DOI: 10.2147/cia.s65382] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background/aim In the past decade, in most regions of the world, an increasing number of adults aged 65 years and older were started on renal replacement therapy each year. In contrast to the general population for whom overnutrition or obesity is associated with increased cardiovascular risk, for patients who are maintained on hemodialysis (HD), malnutrition and malnutrition-inflammation complex syndrome are associated with poor outcome. In recent years, nonalcoholic fatty liver disease (NAFLD) has been considered to be the liver manifestation of metabolic syndrome, and the development of NAFLD is strongly associated with all components of metabolic syndrome (arterial hypertension, dyslipidemia, obesity, and diabetes mellitus type 2) in the general population. The primary end point of this study was to determine the patient’s survival in relation to nutritional and inflammatory state and the presence or absence of NAFLD. The secondary end point of this analysis was the association among NAFLD and various clinical and laboratory data, with the nutritional and inflammatory state of our elderly HD patients. Methods Using a single-center, prospective, cohort study design, we followed the progress of 76 patients who were ≥65 years and treated with chronic HD for at least 6 months, at the Department of Nephrology, Dialysis and Transplantation. All patients were followed for a minimum of 18 months or until death. Survival was defined as the time from study initiation to death (or end of study, if still alive). Results The main findings of our study were a remarkable positive correlation between NAFLD and high-sensitivity C-reactive protein (hs-CRP) (r=0.659; P<0.0001) and consequent negative correlation with the nutritional parameter, serum albumin (r=−0.321; P=0.004). Interestingly, we showed that in contrast to the general population, where NAFLD is associated with obesity, in the present study, there was no statistically significant association between NAFLD and overnutrition in elderly HD patients. Furthermore, the presence of NAFLD, low serum albumin levels, and high hs-CRP were strong predictors of poor outcome in our elderly HD patients. Conclusion Our results indicated that NAFLD probably interplays between inflammation, malnutrition, and atherosclerosis in elderly HD patients. NAFLD could be a new factor that contributes to type 2 malnutrition in elderly HD patients, who may be amenable to adequate nutritional and HD support.
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Affiliation(s)
- Ivana Mikolasevic
- Department of Nephrology, Dialysis and Transplantation, Rijeka University Hospital Center, Rijeka, Croatia
| | - Vesna Lukenda
- Department of Internal Medicine, Dr Josip Bencevic General Hospital, Slavonski Brod, Croatia
| | - Sanjin Racki
- Department of Nephrology, Dialysis and Transplantation, Rijeka University Hospital Center, Rijeka, Croatia
| | - Sandra Milic
- Department of Gastroenterology, Rijeka University Hospital Center, Rijeka, Croatia
| | - Branka Sladoje-Martinovic
- Department of Nephrology, Dialysis and Transplantation, Rijeka University Hospital Center, Rijeka, Croatia
| | - Lidija Orlic
- Department of Nephrology, Dialysis and Transplantation, Rijeka University Hospital Center, Rijeka, Croatia
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