Key comorbid conditions that are predictive of survival among hemodialysis patients

Kidney transplantation outcomes: Is it possible to improve when good results are falling down?

Famure et al describe that close to 50% of their patients needed early or very early hospital readmissions after their kidney transplantation. As they taught us the variables related to those outcomes, we describe eight teaching capsules that may go beyond what they describe in their article. First two capsules talk about the ideal donors and recipients we should choose for avoiding the risk of an early readmission. The third and fourth capsules tell us about the reality of cadaveric donors and recipients with comorbidities, and the way transplant physicians should choose them to maximize survival. Fifth capsule shows that any mistake can result in an early readmission, and thus, in poorer outcomes. Sixth capsule talks about economic losses of early readmissions, cost-effectiveness of transplantation, and how to improve outcomes and reduce costs by managing a risky patient-portfolio. Seventh capsule argues about knowing your risk behavior to better manage your portfolio; and Eighth capsule about the importance of the center experience in transplanting complex patients. We finish with some lessons of the importance of the transplantation process and the collaboration with other disciplines in order to prevent the conditions that lead to early readmissions.

Comparison of blood volume biofeedback hemodialysis and conventional hemodialysis on cardiovascular stability and blood pressure control in hemodialysis patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Despite the improvements in hemodialysis (HD) technology, 20-30% of sessions are still complicated by hypotension or hypotension-related symptoms. Biofeedback systems have proven to reduce the occurrence of such events, but no conclusive findings can lead to wider adoption of these systems. We conducted this systematic review and meta-analysis of randomized clinical trials to establish whether the use of blood volume tracking systems compared to conventional hemodialysis (C-HD) reduces the occurrence of intradialytic hypotension.

METHODS

The PRISMA guidelines were used to carry out this systematic review. Randomized clinical trials that evaluated the incidence of intradialytic hypotension during C-HD and blood volume tracking-HD were searched in the current literature. PROSPERO registration number: CRD42023426328.

RESULTS

Ninety-seven randomized clinical trials were retrieved. Nine studies, including 347 participants and 13,274 HD treatments were considered eligible for this systematic review. The results showed that the use of biofeedback systems reduces the risk of intradialytic hypotension (log odds ratio = 0.63, p = 0.03) in hypotension-prone patients (log odds ratio = 0.54, p = 0.04). When analysis was limited to fluid overloaded or hypertensive patients, it did not show the same effect (log odds ratio = 0.79, p = 0.38). No correlation was found in systolic blood pressure drop during dialysis and in post-dialysis blood pressure.

CONCLUSIONS

The use of blood volume tracking systems may be effective in reducing the incidence of intradialytic hypotension and allowing for easier attainment of the patients' ideal dry body weight. New studies to examine the long-term effects of the use of blood volume tracking systems on real hard endpoints are needed.

Anticoagulation in chronic kidney disease: current status and future perspectives

Chronic kidney disease (CKD) is being diagnosed increasingly worldwide. It is often identified in individuals with comorbidities, which may increase the already heightened risk of thrombosis and hemorrhage associated with CKD. Oral anticoagulation is an effective means of reducing rates of ischemic stroke and systemic embolism in patients with atrial fibrillation and minimizes the morbidity and mortality caused by venous thromboembolic disease. Despite the proven benefits in the majority of patients, these have not been so clearly realized in patients with CKD due to the precarious balance between bleeding and thromboembolic complications. In this review, the current status of anticoagulant utilization in CKD is examined, and some practical recommendations are put forward to assist in the decision-making process of safely anticoagulating patients with CKD diagnosed with atrial fibrillation and venous thromboembolism.

Advanced glycosylation end products as metabolic predictors of systemic pro-inflammatory and prooxidant status in patients with end-stage renal disease

Controlling systemic proinflammatory and prooxidant effectors is essential for mitigating cardiovascular risk and mortality in patients with end-stage renal disease (ESRD). However, monitoring these processes is still challenging due to the high uncertainty about their determinants and predictors. Thus, we investigated the relationship between advanced glycosylation end products (AGE), proinflammatory and prooxidant effectors in ESRD patients undergoing hemodialysis (HD). In addition to nutritional profile and dialysis efficiency, AGE, cytokines, chemokines, C-reactive protein (CRP), total (TAC) and non-protein (npAC) antioxidant capacity, lipid and protein oxidation were analyzed in blood samples from 43 HD patients. AGE, CRP, cytokines, chemokines, protein carbonyl (PCn), and malondialdehyde (MDA) were upregulated, while TAC and npAC were down-regulated in HD patients compared to heath subjects. Dialysis efficiency, TAC and npAC were reduced, while leucocytes counting, pre- and post-HD urea, TNF, IL-6, IL-10, CCL-2, MIP-1β, PCn, and MDA were increased in patients with higher AGE accumulation compared to those with lower AGE levels. Serum levels of CRP, protein carbonyl, malondialdehyde, and all cytokines and chemokines analyzed were correlated with AGE circulating levels for patients with higher AGE accumulation. AGE was inversely correlated with IL-10, TAC and npAC in patients with higher AGE accumulation. AGE exhibited predictive value (determination coefficient) to explain CRP, cytokines, chemokines, PCN, MDA, TAC and npAC variability in patients with higher AGE levels. Taken together, our findings provide evidence that AGE accumulation is associated with important proinflammatory and prooxidant effectors in patients with ESRD undergoing hemodialysis. Thus, AGE monitoring may be relevant to predict systemic inflammatory stress and the balance between oxidant and antioxidant status in these patients.

Walking Ability and Brain Natriuretic Peptide Are Highly Predictive of Kidney Transplant Waiting List Removal

Kidney transplant waitlist management is complex because waiting time is long, and the patients have significant comorbidities. Identification of patients at highest risk for waiting list removal for death and medical complications could allow better outcomes and allocation of resources.

Methods

Demographics, functional and frailty assessment' and biochemical data were retrospectively analyzed on 313 consecutive patients listed for kidney transplant. Troponin, brain natriuretic peptide, components of the Fried frailty metrics, pedometer activity, and treadmill ability were measured at the time of transplant evaluation and at subsequent re-evaluations. Cox proportional hazards models were used to identify factors associated with death or waiting list removal for medical reasons. Multivariate models were created to identify significant predictor sets.

Results

Among 249 patients removed while waitlisted, 19 (6.1%) died and 51 (16.3%) were removed for medical reasons. Mean follow-up duration was 2.3 y (±1.5 y). 417 sets of measurements were collected. Significant (P < 0.05) non-time-dependent variables associated with the composite outcome identified on univariate analysis included N-terminal probrain natriuretic peptide (BNP), treadmill ability, pedometer activity, diagnosis of diabetes and the Center of Epidemiological Studies Depression Scale question asking how many days per week could you not get going. Significant time-dependent factors included BNP, treadmill ability, Up and Go, pedometer activity, handgrip, 30 s chair sit-stand test, and age. The optimal time-dependent predictor set included BNP, treadmill ability, and patient age.

Conclusions

Changes in functional and biochemical markers are predictive of kidney waitlist removal for death and medical reasons. BNP and measures of walking ability were of particular importance.

The Role of Gastroenterologists in Preoperative Assessment and Management of Prospective Renal Transplantation Candidates

Renal transplant is the most common organ transplant worldwide, accounting for 65% of the total number of transplants. End-stage renal disease (ESRD) often has multiple significant comorbidities. Among the gastrointestinal (GI) disorders, peptic ulcer disease (PUD), cholelithiasis, and colon and liver diseases increase the risk of posttransplant morbidity. Potential renal transplantation (RT) candidates need a multidisciplinary assessment of coexisting illnesses, which may affect the perioperative risk and survival after transplantation. Successful outcome of RT depends on careful selection of the recipients by a thorough medical evaluation and screening. This review summarizes the role of gastroenterologists and hepatologists in preoperative assessment and management of renal transplant recipients.

How to cite this article

Giri S, Dash KA, Varghese J, et al. The Role of Gastroenterologists in Preoperative Assessment and Management of Prospective Renal Transplantation Candidates. Euroasian J Hepato-Gastroenterol 2023;13(1):18-25.

Characteristics and predictors of mortality on haemodialysis in Brazil: a cohort of 5,081 incident patients

Background

Although Brazil has one of the largest populations on haemodialysis (HD) in the world, data regarding patients’ characteristics and the variables associated with risk of death are scanty.

Methods

This is a retrospective analysis of all adult patients who initiated on maintenance HD at 23 dialysis centres in Brazil between 2012 and 2017. Patients were censored after 60 months of follow-up or at the end of 2019.

Results

A total of 5,081 patients were included in the analysis. The median age was 59 years, 59.4% were men, 37.5% had diabetes as the cause of kidney failure. Almost 70% had a central venous catheter (CVC) as the initial vascular access, about 60% started dialysis in the hospital, and fluid overload (FO) by bioimpedance assessment was seen in 45% of patients. The 60-month survival rate was 51.4%. In the Cox regression analysis, being older (P<0.0001), starting dialysis in the hospital (P=0.016), having diabetes as the cause of kidney failure (P=0.001), high alkaline phosphatase (P=0.005), CVC as first vascular access (P=0.023), and FO (P<0.0001) were associated with higher death risk, whereas higher body mass index (P=0.015), haemoglobin (P=0.004), transferrin saturation (P=0.002), and serum albumin (P<0.0001) were associated with better survival. The same variables, except initial CVC use (P=0.14), were associated with death risk in an analysis of subdistribution proportional hazards ratio including the competing outcomes.

Conclusions

The present study gives an overview of a large HD population in a developing country and identifies the main predictors of mortality, including some potentially modifiable ones, such as unplanned initiation of dialysis in the hospital and fluid overload.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02705-x.

Pericoronary fat attenuation index in computed tomography angiography is associated with mortality in end-stage renal disease

Background

An increased pericoronary fat attenuation index (FAI) on computed tomography angiography (CTA) is associated with increased all-cause and cardiac mortality in the general population. However, the ability of pericoronary FAI to predict long-term outcomes in chronic kidney disease (CKD) patients is unknown.

Methods

In this single-center retrospective longitudinal cohort study, we assessed the utility of CTA-based pericoronary FAI measurement to predict mortality of CKD patients, including those with end-stage renal disease (ESRD). Mapping and analysis of pericoronary FAI involved three major proximal coronary arteries. The prognostic value of pericoronary FAI for long-term mortality was assessed with multivariable Cox regression models.

Results

Among 268 CKD participants who underwent coronary CTA, 209 participants with left anterior descending artery (LAD) FAI measurements were included. The pericoronary FAI measured at the LAD was not significantly associated with adjusted risk of all-cause mortality (hazard ratio [HR], 2.08; 95% confidence interval [CI], 0.94–3.51) in any CKD group. However, ESRD patients with elevated pericoronary FAI values had a greater adjusted risk of all-cause mortality compared with the low-FAI group (HR, 2.26; 95% CI, 1.11–4.61).

Conclusion

The pericoronary FAI measured at the LAD predicted long-term mortality in patients with ESRD, which could provide an opportunity for early primary intervention in ESRD patients.

Anticoagulation in patients with kidney failure on dialysis: factor XI as a therapeutic target

Chronic kidney disease is present in almost 10% of the world population and is associated with excess mortality and morbidity. Reduced glomerular filtration rate and the presence and extent of proteinuria, key domains of chronic kidney disease, have both been shown to be strong and independent risk factors for cardiovascular disease. Patients with kidney failure requiring dialysis are at highest risk for cardiovascular events (e.g., stroke or myocardial infarction), and of developing chronic cardiovascular conditions, such as heart failure. Despite the high burden of cardiovascular disease, there is a paucity of evidence supporting therapies to reduce this risk. Although long-term anticoagulant treatment has the potential to prevent thromboembolism in persons with kidney failure on dialysis, this possibility remains understudied. The limited data available on anticoagulation in patients with kidney failure has focused on vitamin K antagonists or direct oral anticoagulants that inhibit thrombin or factor (F) Xa. The risk of bleeding is a major concern with these agents. However, FXI is emerging as a potential safer target for new anticoagulants because FXI plays a greater part in thrombosis than in hemostasis. In this article, we (i) explain the rationale for considering anticoagulation therapy in patients with kidney failure to reduce atherothrombotic events, (ii) highlight the limitations of current anticoagulants in this patient population, (iii) explain the potential benefits of FXI inhibitors, and (iv) summarize ongoing studies investigating FXI inhibition in patients with kidney failure on dialysis.

Cytokines and chemokines systemic levels are related to dialysis adequacy and creatinine clearance in patients with end-stage renal disease undergoing hemodialysis

Although the clearance of low-molecular weight toxins is modulated by dialysis dose, the relationship between dialysis adequacy and middle systemic inflammatory mediators is often overlooked. Thus, the relationship between dialysis adequacy, pro- and anti-inflammatory cytokines and chemokines in hemodialysis (HD) patients was investigated. Forty-eight HD patients (19 women and 25 men) were investigated. Age, body mass index, time in HD, nutritional status, Kt/V and blood biochemical parameters was similar in patients of both sexes (P > 0.05). Thus, patients were stratified by dialysis adequacy measured by Kt/V method (adequate Kt/V ≥ 1.2). Post-HD urea, creatinine, cytokines (IFN-γ, IL-4 and IL-10) and chemokines (CCL-2, CCL-5, CXCL-8 and CXCL-10) were higher in patients with Kt/V < 1.2 (P < 0.05). Kt/V exhibited significant correlation with CXCL-10/IP-10 serum levels. Positive correlation between creatinine with IFN-γ, CCL-2/MCP-1, and CXCL-10/IP-10, and negative correlation with IL-10 was identified in patients with Kt/V < 1.2 (P < 0.05). In patients with Kt/V ≥ 1.2, only IL-10 was positively and CXCL-10/IP-10 negatively correlated with creatinine levels (P < 0.05). Kt/V and creatinine levels exhibited variable predictive value (Kt/V = 27% to 37%, creatinine = 29% to 47%) to explain cytokines and chemokines circulating levels in patients with adequate and inadequate dialysis dose. Taken together, our findings provide evidence that in addition to modulating uremic toxins levels, such as urea and creatinine, dialysis dose is associated with circulating levels of inflammatory mediators. Thus, low Kt/V results and creatinine accumulation are potential indicators of the systemic inflammatory stress determined by up-regulation of proinflammatory cytokines and chemokines, and downregulation of anti-inflammatory cytokines.

Predictors of Health Deterioration Among Older New Zealanders Undergoing Dialysis: A Three-Year Accelerated Longitudinal Cohort Study

Background:

Patient involvement in dialysis decision-making is crucial, yet little is known about patient-reported outcomes over time on dialysis.

Objective:

To examine health-related outcomes over 24 and 36 months in an older cohort of dialysis patients.

Design:

The “Dialysis outcomes in those aged ≥65 years study” is a prospective longitudinal cohort study of New Zealanders with kidney failure.

Setting:

Three New Zealand nephrology units.

Patients:

Kidney failure (dialysis and predialysis) patients aged 65 or above. We have previously described outcomes after 12 months of dialysis therapy relative to baseline.

Measurements:

Patient-reported social and health factors using the SF-36, EQ-5D, and Kidney Symptom Score questionnaires.

Methods:

This article describes and compares characteristics of 120 older kidney failure patients according to whether they report “Same/better” or “Worse” health 24 and 36 months later, and identifies predictors of “worse health.” Modified Poisson regression modeling estimated relative risks (RR) of worse health.

Results:

Of 120 patients at 12 months, 47.5% had worse health or had died by 24 months. Of those surviving at 24 months (n = 80), 40% had “Worse health” or had died at 36 months. Variables independently associated with reduced risk of “Worse health” (24 months) were as follows: Māori ethnicity (RR = 0.44; 95% CI = 0.26-0.75), Pacific ethnicity (RR = 0.39; 95% CI = 0.33-0.46); greater social satisfaction (RR = 0.57; 95% CI = 0.46-0.7). Variables associated with an increased risk of “Worse health” were as follows: problems with usual activities (RR = 1.32; 95% CI = 1.04-1.37); pain or discomfort (RR = 1.48; 95% CI = 1.34, 1.63). At 36 months, lack of sense of community (RR = 1.41; 95% CI = 1.18-1.69), 2 or more comorbidities (RR = 1.21; 95% CI = 1.13-1.29), and problems with poor health (RR = 1.47; 95% CI = 1.41-1.54) were associated with “Worse health.”

Limitations:

Participant numbers restricted the number of variables able to be included in the multivariable model, and hence there may have been insufficient power to detect certain associations.

Conclusions:

In this study, the majority of older dialyzing patients report “Same/better health” at 24 and 36 months. Māori and Pacific people report better outcomes on dialysis. Social and/or clinical interventions aimed at improving social satisfaction, sense of community, and help with usual activities may impact favorably on the experiences for older dialysis patients.

Trial registration:

Australian and New Zealand clinical trials registry: ACTRN12611000024943.

End-stage kidney disease and COVID-19 in an urban safety-net hospital in Boston, Massachusetts

Introduction

End-stage kidney disease (ESKD) patients are at a high risk for Coronavirus Disease 2019 (COVID-19). In this study, we compared characteristics and outcomes of ESKD and non-ESKD patients admitted with COVID-19 to a large safety-net hospital.

Methods

We evaluated 759 adults (45 with ESKD) hospitalized with COVID-19 in Spring of 2020. We examined clinical characteristics, laboratory measures and clinical outcomes. Logistic regression analyses were performed to investigate the associations between ESKD status and outcomes.

Results

73% of ESKD and 47% of non-ESKD patients identified as Black (p = 0.002). ESKD patients were older and had higher rates of comorbidities. Admission ferritin was approximately 6-fold higher in ESKD patients. During hospitalization, the rise in white blood cell count, lactate dehydrogenase, ferritin and C-reactive protein, and the decrease in platelet count and serum albumin were all significantly greater in ESKD patients. The in-hospital mortality was higher for ESKD [18% vs. 10%; multivariable adjusted odds ratio 1.5 (95% CI, 0.48–4.70)], but this did not reach statistical significance.

Conclusions

Among hospitalized COVID-19 patients, ESKD patients had more co-morbidities and more robust inflammatory response than non-ESKD patients. The odds ratio point estimate for death was higher in ESKD patients, but the difference did not reach statistical significance.

Comorbidity burden may explain adiponectin's paradox as a marker of increased mortality risk in hemodialysis patients

Despite experimental evidence of beneficial metabolic, antiatherosclerotic and antiinflammatory effects of the 30 kDa adipokine, adiponectin, maintenance hemodialysis (MHD) patients with high adiponectin blood levels have paradoxically high mortality rates. We aimed to examine the direction of the associations between adiponectin and all-cause and cardiovascular mortality as well as with markers of oxidative stress, inflammation and nutrition in MHD patients with varying degrees of comorbidities. A cohort of 261 MHD patients (mean age 68.6 ± 13.6 years, 38.7% women), grouped according to baseline comorbidity index (CI) and serum adiponectin levels, were followed prospectively for six years. High and low concentrations were established according to median CI and adiponectin levels and cross-classified. Across the four CI-adiponectin categories, the group with low comorbidities and high adiponectin exhibited the best outcomes. Conversely, the high comorbidity group with high adiponectin levels had the lowest survival rate in both all-cause mortality (log rankχ² = 23.74, p < 0.001) and cardiovascular mortality (log rankχ² = 34.16, p < 0.001). Further data adjustment for case-mix covariates including fat mass index did not substantially affect these results. In conclusion, the direction of adiponectin’s prognostic associations in MHD patients is inverse in those with few comorbidities and direct in those with many comorbidities.

Prognosis of hemodialysis patients undergoing surgery for gastric cancer: Results of a multicenter retrospective study

BACKGROUND

Little is known about the survival outcomes of and predictive factors for survival in hemodialysis patients undergoing surgery for gastric cancer.

METHODS

We performed a multicenter retrospective study from 9 institutions to investigate the survival outcomes of 75 hemodialysis patients with gastric cancer. Patient characteristics included demographic data, hemodialysis- and gastric cancer-related variables. Multivariate Cox hazards models were applied to determine independent predictors of poor overall survival and non-gastric cancer related death.

RESULTS

Stage I disease was predominant (58.7%) in our series. The overall morbidity and the 30-day mortality rates were 25.3% and 1.3%, respectively. The 5-year overall survival rates of patients with pStages I, II, III, and IV disease were 59.2%, 42.9%, 32.3%, and 0%, respectively. Eleven (14.7%) patients died of gastric cancer, whereas many more (40.0%) died owing to causes other than gastric cancer. Non-gastric cancer-related death was especially prevalent in patients with pStages I (95.2%) and II (75.0%) disease. Multivariable analysis revealed advanced age, long duration of hemodialysis (> 5 years), total gastrectomy, and pStage IV disease to be independently associated with poor overall survival. Notably, advanced age, long duration of hemodialysis, and the presence of cardiovascular disease were all independent predictors of non-gastric cancer-related death. Patients with all 3 factors had very poor survival outcomes (3-year overall survival; 14.3%).

CONCLUSION

The survival outcomes of hemodialysis patients with gastric cancer, especially those with early-stage gastric cancer, were clearly poor, largely owing to the increased risk of non-gastric cancer-related death. Preoperative comorbidities and hemodialytic features were useful for predicting long-term outcomes of this vulnerable population.

Advance care planning among African American patients on haemodialysis and their end-of-life care preferences

BACKGROUND

African Americans in the general population have been shown to be less likely than White ethnic groups to participate in advance care planning; however, advance care planning in the population receiving dialysis has not been well explored.

OBJECTIVE

We examined the prevalence of African American patients receiving haemodialysis' advance care planning discussions, and whether advance care planning impacts end-of-life care preferences.

DESIGN

In-person interviewer-administered surveys of African American patients receiving in-centre haemodialysis.

SETTING/PARTICIPANTS

About 101 participants at three large dialysis organisation units in Chicago.

OUTCOMES

Self-reported advance care planning and preferences for life-extending treatments at end-of-life.

RESULTS

Most patients (69%) report no advance care planning discussions with their healthcare providers. Nearly all patients (92%) without prior advance care planning reported their healthcare providers approached them about advance care planning. While the majority of patients indicated preference for aggressive life-extending care, prior conversations about end-of-life care wishes either with family members or a healthcare provider significantly decreased patients' likelihood of choosing aggressive life-extending care across three scenarios (all p < 0.05). Significantly more patients reported that common end-of-life scenarios related to increased dependence/disability were "not worth living through" compared with those associated with increased burden on family, decreased cognitive function, and severe pain/discomfort.

CONCLUSION

African Americans with end-stage renal disease need more frequent, culturally-sensitive advance care planning discussions. Despite a preference for aggressive life-sustaining treatments, individuals with prior advance care planning discussions were significantly less likely to support aggressive end-of-life care. End-of-life care discussions that focus on the impact of life-extending care on patients' independence could be more concordant with the values and priorities of the African American patients.

Serum trace metal association with response to erythropoiesis stimulating agents in incident and prevalent hemodialysis patients

Alterations in hemodialysis patients' serum trace metals have been documented. Early studies addressing associations levels of serum trace metals with erythropoietic responses and/or hematocrit generated mixed results. These studies were conducted prior to current approaches for erythropoiesis stimulating agent (ESA) drug dosing guidelines or without consideration of inflammation markers (e.g. hepcidin) important for regulation of iron availability. This study sought to determine if the serum trace metal concentrations of incident or chronic hemodialysis patients associated with the observed ESA response variability and with consideration to ESA dose response, hepcidin, and high sensitivity C-reactive protein levels. Inductively-coupled plasma-mass spectrometry was used to measure 14 serum trace metals in 29 incident and 79 prevalent dialysis patients recruited prospectively. We compared these data to three measures of ESA dose response, sex, and dialysis incidence versus dialysis prevalence. Hemoglobin was negatively associated with ESA dose and cadmium while positively associated with antimony, arsenic and lead. ESA dose was negatively associated with achieved hemoglobin and vanadium while positively associated with arsenic. ESA response was positively associated with arsenic. Vanadium, nickel, cadmium, and tin were increased in prevalent patients. Manganese was increased in incident patients. Vanadium, nickel, and arsenic increased with time on dialysis while manganese decreased. Changes in vanadium and manganese were largest and appeared to have some effect on anemia. Incident and prevalent patients' chromium and antimony levels exceeded established accepted upper limits of normal.

Association between Ultrafiltration Rate and Clinical Outcome Is Modified by Muscle Mass in Hemodialysis Patients

BACKGROUND

The association between ultrafiltration rate (UFR) and mortality may be affected by the muscle mass or volume status in hemodialysis (HD) patients. However, there is an absence of data regarding this association.

METHODS

We performed an observational study on patients (≥18 years old) who had been on HD for at least 3 months. A body composition monitor (BCM) was used for baseline bioimpedance analysis measurement. The primary composite outcome was defined as the time to death or the first cardiovascular event.

RESULTS

The median (interquartile range) UFR, volume excess measured by the BCM, and lean tissue index (LTI) (calculated as lean tissue mass/height2) were 11.4 (8.0-15.0) mL/h/kg, 2.4 (1.4-4.1) L, and 12.5 (10.4-14.4) kg/m2, respectively. During 284 person-years of follow-up, the primary outcome occurred in 44 of the 167 patients (26%). Higher UFR was associated with an increased outcome of death or cardiovascular event; the adjusted hazard ratio (HR) was 1.044 (95% confidence interval [CI]: 1.006-1.083). This association remained consistent even after adjusting for volume excess. However, the association between UFR and the primary outcome was modified by LTI (pinteraction = 0.027); the association was significant in patients with LTI < 12.5 kg/m2, and the HR (95% CI) was 1.050 (1.001-1.102).

CONCLUSION

Higher UFR was associated with an increased risk of a composite outcome of death or cardiovascular event regardless of volume status in HD patients. However, muscle mass may modify the association between higher UFR and increased risk of a composite outcome.

Functional dependence and the mental dimension of quality of life in Hemodialysis patients: the PROHEMO study

Background

Functional dependence is highly prevalent in maintenance hemodialysis (MHD) settings. Also, poor health-related quality of life (HRQoL) and high levels of depressive symptoms have been reported by MHD patients. We investigated associations between functional status and mental aspects of quality of life in Brazilian MHD patients.

Methods

Cross sectional study of 235 patients enrolled in two of the four participating MHD clinics of the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO) in Salvador, BA, Brazil. Data were collected from September 2016 to August 2017. The Katz’s questionnaire was used for basic activities of daily living (ADL) and the Lawton-Brody’s questionnaire for instrumental activities of daily living (IADL). ADL and IADL scores were combined to create 3 functional status groups: highly dependent (n = 47), moderately dependent (n = 109) and independent (n = 82). The validated Brazilian version of the Kidney Disease Quality of Life Short Form (KDQOL-SF) was used for scores of two distinct HRQoL measures, i.e., the mental component summary (MCS) and the 5-item mental health inventory (MHI-5). We used linear regression to estimate differences in scores with adjustment for possible confounders: months of dialysis, age, gender, other sociodemographic variables, body mass index, type of vascular access, dialysis dose by Kt/V, laboratory variables (albumin, blood hemoglobin, calcium, phosphorus, urea, creatinine and parathyroid hormone) and nine comorbid conditions.

Results

Mean age was 51.2 ± 12.4 yr (median age = 51.0 yr), 59.1% were male, 93.2% were non-White. The prevalence of self-reported functional status differed by age: 54.4% for age < 45 yr, 67.8% for age 45–60 yr and 73.9% for age ≥ 60 yr. Using functionally independent as reference, lower scores were observed for highly dependent patients in MCS (difference: -4.69, 95% CI: -8.09, -0.29) and MHI-5 (difference: -5.97, 95% CI: -8.09, -1.29) patients. These differences changed slightly with extensive adjustments for covariates.

Conclusions

Our results call attention to a high prevalence of functional dependence in younger and older MHD patients. The results suggest that the lower self-reported mental quality of life in functionally dependent MHD patients cannot be explained by differences in age and comorbidities.

Risk Prediction for Early Chronic Kidney Disease: Results from an Adult Health Examination Program of 19,270 Individuals

Developing effective risk prediction models is a cost-effective approach to predicting complications of chronic kidney disease (CKD) and mortality rates; however, there is inadequate evidence to support screening for CKD. In this study, four data mining algorithms, including a classification and regression tree, a C4.5 decision tree, a linear discriminant analysis, and an extreme learning machine, are used to predict early CKD. The study includes datasets from 19,270 patients, provided by an adult health examination program from 32 chain clinics and three special physical examination centers, between 2015 and 2019. There were 11 independent variables, and the glomerular filtration rate (GFR) was used as the predictive variable. The C4.5 decision tree algorithm outperformed the three comparison models for predicting early CKD based on accuracy, sensitivity, specificity, and area under the curve metrics. It is, therefore, a promising method for early CKD prediction. The experimental results showed that Urine protein and creatinine ratio (UPCR), Proteinuria (PRO), Red blood cells (RBC), Glucose Fasting (GLU), Triglycerides (TG), Total Cholesterol (T-CHO), age, and gender are important risk factors. CKD care is closely related to primary care level and is recognized as a healthcare priority in national strategy. The proposed risk prediction models can support the important influence of personality and health examination representations in predicting early CKD.

International and multicenter real-world study of sorafenib-treated patients with hepatocellular carcinoma under dialysis

BACKGROUND & AIMS

Information on safety and efficacy of systemic treatment in patients with hepatocellular carcinoma (HCC) under dialysis are limited due to patient exclusion from clinical trials. Thus, we aimed to evaluate the rate, prevalence, tolerability, and outcome of sorafenib in this population.

METHODS

We report a multicenter study comprising patients from Latin America and Europe. Patients treated with sorafenib were enrolled; demographics, dose modifications, adverse events (AEs), treatment duration, and outcome of patients undergoing dialysis were recorded.

RESULTS

As of March 2018, 6156 HCC patients were treated in 44 centres and 22 patients were concomitantly under dialysis (0.36%). The median age was 65.5 years, 40.9% had hepatitis C, 75% had Child-Pugh A, and 85% were Barcelona Clinic Liver Cancer-C. The median time to first dose modification, treatment duration and overall survival rate were 2.4 months (interquartile ranges [IQR], 0.8-3.8), 10.8 months (IQR, 4.5-16.9), and 17.5 months (95% CI, 7.2-24.5), respectively. Seventeen patients required at least 1 dose modification. The main causes of first dose modification were asthenia/worsening of Eastern Cooperative Oncology Group-Performance Status and diarrhoea. At the time of death or last follow-up, four patients were still on treatment and 18 had discontinued sorafenib: 14 were due to tumour progression, 2 were sorafenib-related, and 2 were non-sorafenib-related AE.

CONCLUSIONS

The outcomes observed in this cohort seem comparable to those in the non-dialysis population. Thus, to the best of our knowledge, this is the largest and most informative dataset regarding systemic treatment outcomes in HCC patients undergoing dialysis.

Risk Factors Before Dialysis Predominate as Mortality Predictors in Diabetic Maintenance Dialysis patients

Diabetic patients undergoing maintenance dialysis (MD) have a particularly high mortality rate. Many of the risk factors for mortality have been identified in diabetics who die before reaching end stage renal disease (ESRD), i.e. before dialysis (BD). In addition, many risk factors for mortality have been identified in diabetics after dialysis onset (AD). However, whether in the BD period there are long-term risk factors for AD mortality in diabetics is unknown. We therefore investigated a new concept, i.e. that clinical and biochemical risk factors during the BD stage affect long-term AD mortality. We performed a population based retrospective cohort study, in diabetic CKD patients in a single center in south Israel who initiated MD between the years 2003 and 2015. Clinical and biochemical data 12 months BD and 6 months AD were collected and evaluated for association with mortality AD using Cox’s proportional-hazards model. BD parameters that were found to be significant were adjusted for significant parameters AD, thus generating a “combined” regression model in order to isolate the contribution of BD factors on long term mortality. Six hundred and fifty two diabetic MD patients were included in the final analysis. Four independent BD parameters were found in the multivariate model to significantly predict AD mortality: age, BMI (inversely), pulse pressure (U-shaped) and cardiovascular comorbidity. AD independent risk factors for mortality were age, BMI (inversely) and albumin (inversely). Of note, BD factors remained dominantly significant even after additionally adjusting for AD factors. No association was found between either BD HbA1C levels or BD proteinuria and AD mortality. In diabetics who reach ESRD, BD parameters can predict long term AD mortality. Thus, some of the factors affecting the poor survival of diabetic MD patients appear to begin already in the BD period.

The prognostic impact of cirrhosis on patients receiving maintenance haemodialysis

BACKGROUND

Further study is needed on the prognostic impact of cirrhosis on haemodialysis patients.

AIM

To evaluate cirrhosis' impact according to severity on survival and to provide therapeutic guidelines for haemodialysis cirrhotic patients.

METHODS

Patients with end-stage renal failure treated with haemodialysis were included retrospectively from 01/01/2000 to 31/12/2004 and prospectively from 01/01/2005 to 31/12/2014 in our French Region. Clinical data, presence of cirrhosis and its severity were recorded at the beginning of haemodialysis. The primary endpoint was 2-year survival.

RESULTS

Seven thousand three hundred and fifty-four patients (96%) without cirrhosis and 304 patients (4%) with cirrhosis were included. Two-year survival in noncirrhotic patients was higher than in cirrhotic patients (71.7% vs 54.4%, P < 0.0001). Patients with decompensated cirrhosis had a worse 2-year outcome (44.1%) as compared to compensated cirrhotic (62.8%, P = 0.002) and noncirrhotic patients (71.7%, P < 0.0001). Compensated and decompensated cirrhosis were independent predictive factors of 2-year mortality. In sensitivity analysis restricted to cirrhotic patients, 2-year survival of Child-Pugh A patients was higher than in Child-Pugh B and C patients (65.5% vs 27.7% vs 0%, P < 0.0001). Development of predictive models based either on severity scores (MELD and Child-Pugh) and extrahepatic comorbidities allowed correct classification of around 70% of patients in terms of mortality and may help to better stratify mortality risk in this population.

CONCLUSIONS

Cirrhosis is independently associated with mortality in haemodialysis patients. Patients with severe cirrhosis have a poor 2-year outcome. Severity of cirrhosis and presence of extrahepatic comorbidities should be considered when deciding to initiate renal replacement therapy.

Polyvascular disease in patients with myocardial infarction and chronic kidney disease

Aim. To study polyvascular disease in patients with myocardial infarction (MI) and chronic kidney disease (CKD). Materials and methods. A total of 954 patients older than 18 years old with ST-segment elevation MI (STEMI) up to 24 hours of pain onset were included in the study. Clinical and demographic data were collected for all patients, including physical examination, 16-lead electrocardiogram recording, echocardiography, laboratory assessment with the measurements of cardiospecific enzymes and serum creatinine. Glomerular filtration rate (GFR) was estimated according to the CKD-EPI equation. Of them, 771 (81%) underwent coronary angiography, duplex scanning of the brachiocephalic (BCA) and lower extremity arteries (LEA). Patients with stage 1-4 CKD diagnosed according to the criteria provided by the Russian Society of Nephrologists were allocated into a separate group (n=281; 36.5%). CKD stages were determined with the level of GFR. Patients with stage 5 CKD were excluded from the study. Renal dysfunction was defined as the presence of an estimated GFR less than 60 ml/min/1.73 m2. Results and discussion. The results of the study indicate a high prevalence of PolyVD in patients with CKD. Every second patient had LEA stenosis (p

Approaches for patients with very high MELD scores

In the era of the "sickest first" policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. LT is still the only curative treatment in this population. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in "too sick to transplant" patients. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Despite this, the performance of scores based on these variables is still insufficient. Consideration of a patient's comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. So far, local expertise remains the last safeguard to LT. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. The absence of "definitive" contraindications and the control of "dynamic" contraindications allow a "transplantation window" to be defined. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes.

Declining comorbidity-adjusted mortality rates in English patients receiving maintenance renal replacement therapy

We aimed to compare long-term mortality trends in end-stage renal disease versus general population controls after accounting for differences in age, sex and comorbidity. Cohorts of 45,000 patients starting maintenance renal replacement therapy (RRT) and 5.3 million hospital controls were identified from two large electronic hospital inpatient data sets: the Oxford Record Linkage Study (1965-1999) and all-England Hospital Episode Statistics (2000-2011). All-cause and cause-specific three-year mortality rates for both populations were calculated using Poisson regression and standardized to the age, sex, and comorbidity structure of an average 1970-2008 RRT population. The median age at initiation of RRT in 1970-1990 was 49 years, increasing to 61 years by 2006-2008. Over that period, there were increases in the prevalence of vascular disease (from 10.0 to 25.2%) and diabetes (from 6.7 to 33.9%). After accounting for age, sex and comorbidity differences, standardized three-year all-cause mortality rates in treated patients with end-stage renal disease between 1970 and 2011 fell by about one-half (relative decline 51%, 95% confidence interval 41-60%) steeper than the one-third decline (34%, 31-36%) observed in the general population. Declines in three-year mortality rates were evident among those who received a kidney transplant and those who remained on dialysis, and among those with and without diabetes. These data suggest that the full extent of mortality rate declines among RRT patients since 1970 is only apparent when changes in comorbidity over time are taken into account, and that mortality rates in RRT patients appear to have declined faster than in the general population.

Unfavorable effects of history of volume overload and late referral to a nephrologist on mortality in patients initiating dialysis: a multicenter prospective cohort study in Japan

BACKGROUND

Patients with late referral and positive history of volume overload may have a poor prognosis after initiating dialysis due to insufficient and/or inadequate management of complications of renal failure and the lack of better dialysis preparation. Little is known about the influence of the relationship between history of volume overload and late referral on prognosis.

METHODS

We analyzed 1475 patients who had initiated dialysis for the first time from October 2011 to September 2013. late referral was defined as referral to a nephrologist < 3 months before dialysis initiation. The major outcomes were all-cause death and deaths due to cardiovascular diseases (CVD). The impact of late referral and history of volume overload on all-cause mortality was assessed by Cox proportional hazards models.

RESULTS

Among 1475 patients, the mean patient age was 67.5 years. During the median follow-up of 2.2 years, 260 deaths occurred; 99 were due to CVD. Cox proportional hazards models demonstrated that late referral (adjusted hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.00-1.82) and history of volume overload (adjusted HR, 1.39; 95% CI, 1.06-1.81) were risk factors for all-cause mortality. Furthermore, late referral coexisting was associated with a history of volume overload increased mortality (adjusted HR, 2.10; 95% CI, 1.39-3.16 versus absence of late referral without history of volume overload) after adjusting for age, sex, diabetes, atherosclerotic disease, and laboratory values.

CONCLUSIONS

Both late referral and history of volume overload were associated with increased risks of all-cause mortality.

TRIAL REGISTRATION

University Hospital Medical Information Network (UMIN000007096). Registered 18 January 2012, retrospectively registered. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000008349 .

A mixed-methods investigation of incident Hemodialysis access in a safety-net population

Background

Despite improved health outcomes associated with arteriovenous fistulas, 80% of Americans initiate hemodialysis using a catheter, influenced by low socioeconomic status among other factors. Risk factors for incident catheter use in safety-net populations are unknown. Our objective was to identify factors associated with incident catheter use among hemodialysis patients at one safety-net hospital, with a goal of informing fistula placement initiatives targeted at safety-net populations more generally.

Methods

We performed a retrospective review of all incident hemodialysis patients at a single urban safety-net hospital from January 1, 2010 - December 31, 2015 (n = 241), as well as semi-structured interviews with a multi-lingual convenience sample of patients (n = 10) from this cohort. The primary outcome was incident vascular access modality. Multivariable logistic regression was used to identify factors associated with incident catheter use. Interview transcripts were coded using a directed content analysis framework based on a model describing barriers to healthcare access.

Results

Subjects were 61.8% male, racially/ethnically diverse (19.5% white, 29.5% black, 28.6% Hispanic, 17.4% Asian), with a mean age of 52.4 years. Eighty-eight percent initiated hemodialysis using a catheter. In multivariable analysis, longer duration of nephrology care was associated with decreased catheter use (>12 months vs. 0–6 months: adjusted Odds Ratio [aOR] 0.07, 95% CI 0.02–0.23, p < 0.001), whereas uninsured status increased odds of catheter use (aOR 3.96, 1.23–12.76, p = 0.02). There was a decrease in catheter use after vascular surgery services became available in-hospital (OR 0.40, 95% CI 0.16–0.98, p = 0.04), however this association was not significant in multivariable analysis (aOR 0.48, 0.17–1.36, p = 0.17). During interviews, patients cited emotional responses to disease, lack of social and financial resources, and limited health knowledge as barriers to obtaining fistula surgery.

Conclusions

The rate of catheter use in this urban safety-net population is above the national average. Access to health insurance, early referrals to nephrology, and provision of in-hospital vascular surgery should be prioritized in the safety-net. Additionally, services that support patients’ emotional and learning needs may decrease delays in fistula placement.

Predictors of Health Deterioration Among Older Adults After 12 Months of Dialysis Therapy: A Longitudinal Cohort Study From New Zealand

BACKGROUND

Involving patients in dialysis decision making is crucial, yet little is known about patient-reported experiences and patient-reported outcomes of dialysis.

STUDY DESIGN

A prospective longitudinal cohort study of older patients receiving long-term dialysis. Predictors of worse health status were assessed using modified Poisson regression analysis.

SETTING & PARTICIPANTS

150 New Zealanders 65 years or older with end-stage kidney disease dialyzing at 1 of 3 nephrology centers.

PREDICTORS

Patient-reported social and health characteristics based on the 36-Item Short Form Health Survey, EQ-5D, and Kidney Symptom Score questionnaires and clinical information from health records.

OUTCOMES

Health status after 12 months of follow-up.

RESULTS

35% of study participants had reported worse health or had died at 12 months. Baseline variables independently associated with reduced risk for worse health status were Pacific ethnicity (relative risk [RR], 0.63; 95% CI, 0.53-0.72), greater bother on the Kidney Symptom Score (RR, 0.78; 95% CI, 0.62-0.97), and dialyzing at home with either home hemodialysis (RR, 0.55; 95% CI, 0.36-0.83) or peritoneal dialysis (RR, 0.86; 95% CI, 0.79-0.93). Baseline variables independently associated with increased risk were greater social dissatisfaction (RR, 1.66; 95% CI, 1.27-2.17), lower sense of community (RR, 1.70; 95% CI, 1.09-2.64), comorbid conditions (RR, 1.70; 95% CI, 1.09-2.64), EQ-5D anxiety/depression (RR, 1.61; 95% CI, 1.07-2.42); poor/fair overall general health (RR, 1.60; 95% CI, 1.37-1.85), and longer time on dialysis therapy (RR, 1.03; 95% CI, 1.00-1.05).

LIMITATIONS

Small sample size restricted study power.

CONCLUSIONS

Most older dialyzing patients studied reported same/better health 12 months later. Home-based dialysis, regardless of whether hemodialysis or peritoneal dialysis, was associated with reduced risk for worse health, and older Pacific People reported better outcomes on dialysis therapy. Social and/or clinical interventions aimed at improving social satisfaction, sense of community, and reducing anxiety/depression may favorably affect the experiences of older patients receiving long-term dialysis.

Development and Validation of the Modified Charlson Comorbidity Index in Incident Peritoneal Dialysis Patients: A National Population-Based Approach

Background

The utility of applying the Charlson comorbidity index (CCI) to peritoneal dialysis (PD) patients is disputed because the relative weight of each comorbidity in PD patients may be different from those in other chronic diseases. We aimed to develop and validate a modified CCI in incident PD patients (mCCI-IPD) for better risk stratification and prediction of mortality.

Methods

The mCCI-IPD was developed using data from all Korean adult incident PD patients between 2005 and 2008 ( n = 7,606). Multivariate Cox regression was used to determine new weights for the individual comorbidities in the CCI. The prognostic performance of the mCCI-IPD was validated in an independent cohort ( n = 664) through c-statistics and continuous net reclassification improvement (cNRI).

Results

A total of 75.5% of the patients in the development cohort had 1 or more comorbidities. The Cox proportional hazards model provided reassigned severity weights for the 11 comorbidities that significantly predicted mortality. In the validation cohort, the CCI and mCCI-IPD scores were both correlated with survival and showed no differences in their c-statistics. However, multivariate analyses using cNRI revealed that the mCCI-IPD provided a 38.2% improvement in mortality risk assessment compared with the CCI (95% confidence interval [CI], 15.3 – 61.0; p < 0.001). These significant reclassification improvements were observed consistently in subjects with events (cNRIEvent, 28.2% [95% CI, 6.9 – 49.5; p = 0.009]) and without events (cNRINon-event, 10.0% [95% CI, 1.7 – 18.2; p = 0.019]).

Conclusions

Compared with the CCI, the mCCI-IPD showed better performance in mortality prediction for incident PD patients. Therefore, this tool may be used as a preferred index for statistical analysis and clinical decision-making.

The burden of comorbidity in people with chronic kidney disease stage 3: a cohort study

BACKGROUND

Multimorbidity is a growing concern for healthcare systems, with many countries experiencing demographic transition to older population profiles. Chronic kidney disease (CKD) is common but often considered in isolation. The extent and prognostic significance of its comorbidities is not well understood. This study aimed to assess the extent and prognostic significance of 11 comorbidities in people with CKD stage 3.

METHODS

A prospective cohort of 1741 people with CKD stage 3 was recruited from primary care between August 2008 and March 2010. Participants underwent medical history, clinical assessment, blood and urine sampling. Comorbidity was defined by self-reported doctor-diagnosed condition, disease-specific medication or blood results (hemoglobin), and treatment burden as number of ongoing medications. Logistic regression was used to identify associations with greater treatment burden (taking >5 medications) and greater multimorbidity (3 or more comorbidities). Kaplan Meier plots and multivariate Cox proportional hazards models were used to investigate associations between multimorbidity and all-cause mortality.

RESULTS

One thousand seven hundred forty-one people were recruited, mean age 72.9 +/-9 years. Mean baseline eGFR was 52 ml/min/1.73 m(2). Only 78/1741 (4 %) had no comorbidities, 453/1741 (26 %) had one, 508/1741 (29 %) had two and 702/1741 (40 %) had >2. Hypertension was common (88 %), 30 % had 'painful condition', 24 % anemia, 23 %, ischaemic heart disease, 17 % diabetes and 12 % thyroid disorders. Median medication use was 5 medications (interquartile range 3-8) and increased with degree of comorbidity. Greater treatment burden and multimorbidity were independently associated with age, smoking, increasing body mass index and decreasing eGFR. Treatment burden was also independently associated with lower education status. After median 3.6 years follow-up, 175/1741 (10 %) died. Greater multimorbidity was independently associated with mortality (hazard ratio 2.81 (95 % confidence intervals 1.72-4.58), p < 0.001) for 3 or more comorbidities vs 0 or 1).

CONCLUSIONS

Isolated CKD was rare and multimorbidity the norm in this cohort of people with moderate CKD. Increasing multimorbidity was associated with greater medication burden and poorer survival. CKD management should include consideration of comorbidities.

Survival after parathyroidectomy in chronic hemodialysis patients with severe secondary hyperparathyroidism

INTRODUCTION

The life for end-stage renal disease patients has remarkably improved in the last years. Although mineral and bone disorders remain as unsolved complication, in severe secondary hyperparathyroidism (sHPT), the ultimate treatment is parathyroidectomy (PTX). It is an old treatment, but there are still insufficient data regarding survival after PTX. The study goals were to compare 2-year mortality and morbidity after PTX in surgically versus medically treated sHPT and to compare the efficacy and safety in subtotal versus total PTX in a cohort of patients receiving hemodialysis (HD).

METHODS

This prospective, longitudinal study was carried out on a cohort of chronic HD patients with severe sHPT (iPTH over 700 pg/ml). Among the overall HD population, 26 patients underwent PTX. This group was compared to a control group treated with specific drugs. Laboratory parameters, specific symptoms and mortality were registered after 24 months of follow-up for each group. The subgroups of subtotal and total PTX patients were also compared.

RESULTS

All average values of mineral markers were significantly reduced after PTX, as a proof that surgical treatment was effective. The reduction in mineral markers and the improvement in symptoms and mortality rates were similar after total and subtotal PTX. Bone pain was significantly lower in patients after PTX than in those drug treated (p = 0.0005), but not muscle weakness and itching. Survival at 2 years was better in patients surgically treated (PTX) despite significantly higher mean baseline values of iPTH, Ca and ALP compared to patients medically treated (p = 0.03).

CONCLUSIONS

We compared clinical and laboratory outcomes in HD patients with severe sHPT. Mortality, bone pain and mineral markers were improved by PTX. Total and subtotal PTX had similar clinical outcomes.

Comorbidity burden at dialysis initiation and mortality: A cohort study

Background

A high level of comorbidity at dialysis initiation is associated with an increased risk of death. However, contemporary assessments of the validity and prognostic value of comorbidity indices are lacking.

Objectives

To assess the validity of two comorbidity indices and to determine if a high degree of comorbidity is associated with mortality among dialysis patients.

Design

Cohort study.

Setting

QEII Health Sciences Centre (Halifax, Nova Scotia, Canada).

Patients

Incident, chronic dialysis patients between 01 Jan 2006 and 01 Jul 2013.

Measurements

Exposure: The Charlson Comorbidity Index (CCI) and End-Stage Renal Disease Comorbidity Index (ESRD-CI) were used to classify individual comorbid conditions into an overall score. Comorbidities were classified using patient charts and electronic records.

Outcome: All-cause mortality.

Confounders: Patient demographics, dialysis access, cause of ESRD and baseline laboratory data.

Methods

Regression coefficients were estimated on the CCI and ESRD-CI. Discrimination for death was assessed using Harrell’s c-index. Adjusted Cox proportional hazard models were used to calculate relative hazards and 95 % confidence intervals for each category of the CCI and ESRD-CI.

Results

The cohort consisted of 771 ESRD patients from 01 Jan 2006 to 01 Jul 2013. Most were male (62 %) and Caucasian (91 %). The cohort had a high proportion of diabetes (48 %), history of previous myocardial infarction (31 %) and heart failure (22 %). Regression coefficients on the CCI and ESRD-CI were 0.55 and 0.52, respectively. The c-index, for the prediction of death, was 0.61 for the CCI and 0.63 for the ESRD-CI. ESRD-CI scores of 4, 5 and ≥6 were associated with a similar mortality risk (adjusted relative hazard of 1.95, 1.89 and 1.99, respectively). There was a small increased mortality risk for CCI scores of 4, 5 and ≥6 (adjusted relative hazard of 1.86, 2.38 and 2.71, respectively).

Limitations

Classification of comorbidities for each patient was determined by clinical impression.

Conclusions

The CCI and ESRD-CI have a limited ability to discriminate mortality risk for incident dialysis patients. Acknowledging the frequency with which they are used, this study emphasizes the need to re-examine the usefulness of previously derived comorbidity indices in contemporary dialysis cohorts.

Importance of simultaneous evaluation of multiple risk factors for hemodialysis patients' mortality and development of a novel index: dialysis outcomes and practice patterns study

BACKGROUND

For hemodialysis (HD) patients, many risk factors for death are associated with each other intricately. However, they are often considered separately in clinical settings. We evaluated the maintenance HD patients' risk of death within one year from multiple risk factors simultaneously considering their interrelationships using a novel index (survival index, SI) for HD patients in the United States developed using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS).

METHODS

We analyzed data from 3899 and 3765 patients to develop and validate SI, respectively. To predict death within one year, candidate models were developed using logistic regression models. The final model was determined by comparing the accuracy among the models for the prediction of deaths.

RESULTS

The model included age; body mass index; serum creatinine, albumin, total cholesterol and phosphorus levels; history of cardiovascular diseases; and arteriovenous fistula use. SI showed a higher accuracy in predicting death (c-statistic, 0.739) than geriatric nutritional risk index (0.647) and serum albumin level (0.637). The probability of death predicted on the basis of SI matched the observed number of deaths. Cox proportional hazard models for time-dependent SI showed that patients with low SI had a higher risk of death than patients with high SI [reference, Group 4 (26.1≤SI)]; Group 1 (SI<12.7), adjusted hazard ratio, 7.97 (95% CI, 5.02, 12.65); Group 2 (12.7≤SI<19.0), 3.18 (95% CI, 1.96, 5.16); Group 3 (19.0≤SI<26.1), 2.20 (95% CI, 1.33, 3.66).

CONCLUSION

Results of this study suggest that the simultaneous evaluation of multiple risk factors can more accurately assess patients' prognosis and identify patients at an increased risk of death than single factors.

Recalibration and validation of the Charlson comorbidity index in Korean incident hemodialysis patients

BACKGROUND

Weights assigned to comorbidities to predict mortality may vary based on the type of index disease and advances in the management of comorbidities. We aimed to develop a modified Charlson comorbidity index (CCI) in incident hemodialysis patients (mCCI-IHD), thereby improving risk stratification for mortality.

METHODS

Data on 24,738 Koreans who received their first hemodialysis treatment between 2005 and 2008 were obtained from the Korean Health Insurance dataset. The mCCI-IHD score were calculated by summing up the weights which were assigned to individual comorbidities according to their relative prognostic significance determined by multivariate Cox proportional hazards model. The modified index was validated in an independent nationwide prospective cohort (n=1,100).

RESULTS

The Cox proportional hazards model revealed that all comorbidities in the CCI except ulcers significantly predicted mortality. Thus, the mCCI-IHD included 14 comorbidities with re-assigned severity weights. In the validation cohort, both the CCI and the mCCI-IHD were correlated with mortality. However, the mCCI-IHD showed modest but significant increases in c statistics compared with the CCI at 6 months and 1 year. The analyses using continuous net reclassification improvement revealed that the mCCI-IHD improved net mortality risk reclassification by 24.6% (95% CI, 2.5-46.7; P=0.03), 26.2% (95% CI, 1.0-51.4; P=0.04) and 42.8% (95% CI, 4.9-80.8; P=0.03) with respect to the CCI at 6 months and 1 and 2 years, respectively.

CONCLUSIONS

The mCCI-IHD facilitates better risk stratification for mortality in incident hemodialysis patients compared with the CCI, suggesting that it may be a preferred index for use in clinical practice and the statistical analysis of epidemiological studies.

Development and validation of a predictive mortality risk score from a European hemodialysis cohort

Although mortality risk scores for chronic hemodialysis (HD) patients should have an important role in clinical decision-making, those currently available have limited applicability, robustness, and generalizability. Here we applied a modified Framingham Heart Study approach to derive 1- and 2-year all-cause mortality risk scores using a 11,508 European incident HD patient database (AROii) recruited between 2007 and 2009. This scoring model was validated externally using similar-sized Dialysis Outcomes and Practice Patterns Survey (DOPPS) data. For AROii, the observed 1- and 2-year mortality rates were 13.0 (95% confidence interval (CI; 12.3–13.8)) and 11.2 (10.4–12.1)/100 patient years, respectively. Increasing age, low body mass index, history of cardiovascular disease or cancer, and use of a vascular access catheter during baseline were consistent predictors of mortality. Among baseline laboratory markers, hemoglobin, ferritin, C-reactive protein, serum albumin, and creatinine predicted death within 1 and 2 years. When applied to the DOPPS population, the predictive risk score models were highly discriminatory, and generalizability remained high when restricted by incidence/prevalence and geographic location (C-statistics 0.68–0.79). This new model offers improved predictive power over age/comorbidity-based models and also predicted early mortality (C-statistic 0.71). Our new model delivers a robust and reproducible mortality risk score, based on readily available clinical and laboratory data.

Improving Geographic Equity in Kidney Transplantation Using Alternative Kidney Sharing and Optimization Modeling

The national demand for kidney transplantation far outweighs the supply of kidney organs. Currently, a patient's ability to receive a kidney transplant varies depending on where he or she seeks transplantation. This reality is in direct conflict with a federal mandate from the Department of Health and Human Services. We analyze current kidney allocation and develop an alternative kidney sharing strategy using a multiperiod linear optimization model, KSHARE. KSHARE aims to improve geographic equity in kidney transplantation while also respecting transplant system constraints and priorities. KSHARE is tested against actual 2000–2009 kidney allocation using Organ Procurement and Transplant Network data. Geographic equity is represented by minimizing the range in kidney transplant rates around local areas of the country. In 2009, less than 25% of standard criteria donor kidneys were allocated beyond the local area of procurement, and Donor Service Area kidney transplantation rates varied from 3.0% to 30.0%, for an overall range of 27.0%. Given optimal sharing of kidneys within 600 miles of procurement for 2000–2009, kidney transplant rates vary from 5.0% to 12.5% around the country for an overall kidney transplant range of 7.5%. Nationally sharing kidneys optimally between local areas only further decreases the transplant rate range by 1.7%. Enhancing the practice of sharing kidneys by the KSHARE model may increase geographic equity in kidney transplantation.

The extent and predictors of waiting time geographic disparity in kidney transplantation in the United States

BACKGROUND

Waiting time to deceased donor kidney transplant varies greatly across the United States. This variation violates the final rule, a federal mandate, which demands geographic equity in organ allocation for transplantation.

METHODS

Retrospective analysis of the United States Renal Data System and United Network for Organ Sharing database from 2000 to 2009. Median waiting time was calculated for each of the 58 donor service areas (DSA) in the United States. Multivariate regression was performed to identify DSA predictors for long waiting times to kidney transplantation.

RESULTS

The median waiting time varied between the 58 DSAs from 0.61 to 4.57 years, ranging from 0.59 to 5.17 years for standard criteria donor kidneys and 0.41 to 4.69 years for expanded criteria donor kidneys. The disparity in waiting time between the DSAs grew from 3.26 years (range, 0.41-3.67) in 2000 to 4.72 years (range, 0.50-5.22) in 2009. In DSAs with longer waiting times, there were significantly more patients suffering from end-stage renal disease and more patients listed for kidney transplant, lower kidney procurement rates, and higher transplant center competition. Patients were more likely black, sensitized, with lower educational attainment and less likely to waitlist outside of their DSA of residence. Donor organs used in DSAs with long waiting times were more likely hepatitis C positive and had a higher kidney donor profile index. Graft and patient survival at 5 years was worse for deceased donor kidney transplant, but rates for living donor kidney transplant were higher.

CONCLUSION

Our analysis demonstrates significant and worsening geographic disparity in waiting time for kidney transplant across the DSAs. Increase in living donor kidney transplant and use of marginal organs has not mitigated the disparity. Changes to the kidney allocation system might be required to resolve this extensive geographic disparity in kidney allocation.

Disparities in symptom burden and renal transplant eligibility: a pilot study

BACKGROUND

Patients with end-stage renal disease (ESRD) on hemodialysis (HD) suffer from a high symptom burden. However, there is significant heterogeneity within the HD population; certain subgroups, such as the elderly, may experience disproportionate symptom burden.

OBJECTIVES

The study's objective was to propose a category of HD patients at elevated risk for symptom burden (those patients who are not transplant candidates) and to compare symptomatology among transplant ineligible versus eligible HD patients.

DESIGN

This was a cross-sectional study.

SETTING/SUBJECTS

English-speaking, cognitively intact patients receiving HD and who were either transplant eligible (n=25) or ineligible (n=32) were recruited from two urban HD units serving patients in the greater New York City region.

MEASUREMENTS

In-person interviews were conducted to ascertain participants' symptom burden using the Dialysis Symptom Index (DSI), perceived symptom bother and attribution (whether the symptom was perceived to be related to HD treatment), and quality of life using the SF-36. Participants' medical records were reviewed to collect demographic and clinical data.

RESULTS

Transplant ineligible (versus eligible) patients reported an average of 13.9±4.6 symptoms versus 9.2±4.4 symptoms (p<0.01); these differences persisted after adjustment for multiple factors. A greater proportion of transplant ineligible (versus eligible) patients attributed their symptoms to HD and were more likely to report greater bother on account of the symptoms. Quality of life was also significantly lower in the transplant ineligible group.

CONCLUSIONS

Among HD patients, transplant eligibility is associated with symptom burden. Our pilot data suggest that consideration be given to employing transplant status as a method of identifying HD patients at risk for greater symptom burden and targeting them for palliative interventions.

Frailty as a novel predictor of mortality and hospitalization in individuals of all ages undergoing hemodialysis

OBJECTIVES

To quantify the prevalence of frailty in adults of all ages undergoing chronic hemodialysis, its relationship to comorbidity and disability, and its association with adverse outcomes of mortality and hospitalization.

DESIGN

Prospective cohort study.

SETTING

Single hemodialysis center in Baltimore, Maryland.

PARTICIPANTS

One hundred forty-six individuals undergoing hemodialysis enrolled between January 2009 and March 2010 and followed through August 2012.

MEASUREMENTS

Frailty, comorbidity, and disability on enrollment in the study and subsequent mortality and hospitalizations.

RESULTS

At enrollment, 50.0% of older (≥ 65) and 35.4% of younger (<65) individuals undergoing hemodialysis were frail; 35.9% and 29.3%, respectively, were intermediately frail. Three-year mortality was 16.2% for nonfrail, 34.4% for intermediately frail, and 40.2% for frail participants. Intermediate frailty and frailty were associated with a 2.7 times (95% confidence interval (CI) = 1.02-7.07, P = .046) and 2.6 times (95% CI = 1.04-6.49, P = .04) greater risk of death independent of age, sex, comorbidity, and disability. In the year after enrollment, median number of hospitalizations was 1 (interquartile range 0-3). The proportion with two or more hospitalizations was 28.2% for nonfrail, 25.5% for intermediately frail, and 42.6% for frail participants. Although intermediate frailty was not associated with number of hospitalizations (relative risk = 0.76, 95% CI = 0.49-1.16, P = .21), frailty was associated with 1.4 times (95% CI = 1.00-2.03, P = .049) more hospitalizations independent of age, sex, comorbidity, and disability. The association between frailty and mortality (interaction P = .64) and hospitalizations (P = .14) did not differ between older and younger participants.

CONCLUSIONS

Adults of all ages undergoing hemodialysis have a high prevalence of frailty, more than five times as high as community-dwelling older adults. In this population, regardless of age, frailty is a strong, independent predictor of mortality and number of hospitalizations.

Major bleeding events and risk stratification of antithrombotic agents in hemodialysis: results from the DOPPS

Benefits and risks of antithrombotic agents remain unclear in the hemodialysis population. To help clarify this we determined variation in antithrombotic agent use, rates of major bleeding events, and factors predictive of stroke and bleeding in 48,144 patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases I-IV. Antithrombotic agents including oral anticoagulants (OACs), aspirin (ASA), and anti-platelet agents (APAs) were recorded along with comorbidities at study entry, and clinical events including hospitalization due to bleeding were then collected every 4 months. There was wide variation in OAC (0.3-18%), APA (3-25%), and ASA use (8-36%), and major bleeding rates (0.05-0.22 events/year) among countries. All-cause mortality, cardiovascular mortality, and bleeding events requiring hospitalization were elevated in patients prescribed OACs across adjusted models. The CHADS2 score predicted the risk of stroke in atrial fibrillation patients. Gastrointestinal bleeding in the past 12 months was highly predictive of major bleeding events; for patients with previous gastrointestinal bleeding, the rate of bleeding exceeded the rate of stroke by at least twofold across all categories of CHADS2 score, including patients at high stroke risk. Appropriate risk stratification and a cautious approach should be considered before OAC use in the dialysis population.

Predicting mortality of incident dialysis patients in Taiwan--a longitudinal population-based study

Background

Comorbid conditions are highly prevalent among patients with end-stage renal disease (ESRD) and index score is a predictor of mortality in dialysis patients. The aim of this study is to perform a population-based cohort study to investigate the survival rate by age and Charlson comorbidity index (CCI) in incident dialysis patients.

Methods

Using the catastrophic illness registration of the Taiwan National Health Insurance Research Database for all patients from 1 January 1998 to 31 December 2008, individuals newly diagnosed with ESRD and receiving dialysis for more than 90 days were eligible for our study. Individuals younger than 18 years or renal transplantation patients either before or after dialysis were excluded. We calculated the CCI, age-weighted CCI by Deyo-Charlson method according to ICD-9 code and categorized CCI into six groups as index scores <3, 4–6, 7–9, 10–12, 13–15, >15. Cox regression models were used to analyze the association between age, CCI and survival, and the risk markers of survival.

Results

There were 79,645 incident dialysis patients, whose mean age (± SD) was 60.96 (±13.92) years; 51.43% of patients were women and 51.2% were diabetic. In cox proportional hazard models and stratifying by age, older patients had significantly higher mortality than younger patients. The mortality risk was higher in persons with higher CCI as compared with low CCI. Mortality increased steadily with higher age or comorbidity both for unadjusted and for adjusted models. For all age groups, mortality rates increased in different CCI groups with the highest rates occurring in the oldest age groups.

Conclusions

Age and CCI are both strong predictors of survival in Taiwan. The older age or higher comorbidity index in incident dialysis patient is associated with lower long-term survival rates. These population-based estimates may assist clinicians who make decisions when patients need long-term dialysis.

A randomized controlled trial of intensive periodontal therapy on metabolic and inflammatory markers in patients With ESRD: results of an exploratory study

BACKGROUND

Periodontitis is a novel risk factor for inflammation and cardiovascular disease in the dialysis population. Limited information exists about the impact of periodontal therapy in patients receiving dialysis.

STUDY DESIGN

Randomized controlled trial to assess feasibility and gather preliminary data.

SETTING & PARTICIPANTS

Dialysis patients with moderate/severe chronic periodontitis.

INTERVENTION

Intensive treatment, consisting of scaling and root planing, extraction of hopeless teeth, and placement of local-delivery antibiotics, was performed at the baseline visit for treatment-group patients and after study completion for control-group patients.

OUTCOMES

Outcomes were feasibility (screening, recruitment, enrollment, adverse events, and study withdrawal/completion), clinical periodontal parameters (probing depth, clinical attachment level, bleeding on probing, gingival index, and plaque index), and serum albumin and interleukin 6 levels at 3 and 6 months postintervention.

RESULTS

342 dialysis patients were approached for participation: 53 were randomly assigned, with 26 participants assigned to immediate treatment and 27 assigned to a control arm for treatment after 6 months. 51 patients completed baseline appointments; 46 were available for 3-month follow-up, 45 were available for 6-month follow-up examinations, and 43 completed all visits. At 3 months, there was a statistically significant improvement for the treatment group compared to the control group for 3 periodontal parameters: mean probing depth (P = 0.008), extent of probing depth ≥4 mm (P = 0.02), and extent of gingival index ≥1 (P = 0.01). However, by 6 months, the difference between groups was no longer present for any variable except probing depth ≥4 mm (P = 0.04). There was no significant difference between groups for serum albumin or high-sensitivity interleukin 6 level at any time when adjusted for body mass index, diabetic status, and plaque index.

LIMITATIONS

Small sample size and relatively healthy population, imbalance in diabetes.

CONCLUSIONS

This small trial demonstrates successful cooperation between dentists and nephrologists and successful recruitment, treatment, and retention of dialysis patients with periodontitis. Larger studies with longer follow-up are needed to determine whether treatment can improve markers of inflammation and morbidity.