Survival trends of US dialysis patients with heart failure: 1995 to 2005

Impact of dialysis modality choice on the survival of end-stage renal disease patients with congestive heart failure in southern China: A retrospective cohort study

Background and object

Heart failure is one of the common complications in patients with end-stage renal disease (ESRD) and a major cause of death in these patients. The choice of dialysis modality for ESRD patients with congestive heart failure (CHF) is still inconclusive. The purpose of this study was to compare the prognosis of hemodialysis (HD) and peritoneal dialysis (PD) among ESRD patients with CHF and provide a basis for clinical decision-making.

Materials and methods

This was a retrospective study conducted at Guangdong Provincial Hospital of Traditional Chinese Medicine that included patients with CHF requiring long-term renal replacement therapy between January 1, 2012 and December 31, 2017. The end of follow-up was December 31, 2020. All patients were divided into HD and PD groups and sub grouped by age, and we used univariate and multifactorial Cox regression analyses to calculate the relative hazard ratios (HR) of the different dialysis types and adjusted for differences in baseline data using propensity score matching (PSM).

Result

A total of 121 patients with PD and 156 patients with HD were included in this study. Among younger ESRD patients (≤65 years of age) with CHF, the prognosis of HD was worse than that of PD [HR = 1.84, 95% confidence interval (CI) = 1.01–3.34], and this disadvantage remained significant in the fully adjusted model [sex, age at dialysis initiation, Charlson comorbidities index, body mass index, prealbumin, hemoglobin, and left ventricular ejection fraction (LVEF)] and after PSM. In the older group (>65 years of age), the prognosis of HD was better than that of PD (HR = 0.46, 95% CI = 0.25–0.85), and the protective effect remained in the fully adjusted model and after PSM. The aforementioned survival differences across the cohort were maintained in patients with preserved LVEF (>55%), but could not be reproduced in patients with reduced LVEF (≤55%).

Conclusion

In southern China, PD is a better choice for younger patients with ESRD, CHF and preserved LVEF, and HD is the better option for older patients.

Hypoalbuminaemia and One-Year Mortality in Haemodialysis Patients with Heart Failure: A Cohort Analysis

INTRODUCTION

The prevalence of chronic kidney disease (CKD) and heart failure (HF) has been rising over the past decade, with a prevalence close to 40%. Cardiovascular disease and malnutrition are common comorbidities and known risk factors for mortality in haemodialysis (HD) patients. We aimed to evaluate the one-year mortality rate after dialysis induction, and the impact of serum albumin levels on survival outcomes, in patients with CKD and HF.

METHODS

This was a retrospective analysis of patients with CKD and HF who underwent chronic HD between January 2016 and December 2019 in a tertiary-care Portuguese hospital. Variables were submitted to univariate and multivariate analysis to determine factors predictive of one-mortality after HD start.

RESULTS

In total, 204 patients were analysed (mean age 75.1 ± 10.3 years). Within the first year of HD start, 28.7% of patients died. These patients were significantly older [79.8 ± 7.2 versus 72.9 ± 10.9 years, p < 0.001; OR 1.08 (1.04-1.13), p < 0.001] and had a higher mean Charlson Index [9.0 ± 1.8 versus 8.3 ± 2.0, p = 0.015; OR 1.22 (1.04-1.44), p = 0.017], lower serum creatinine [5.1 ± 1.6 mg/dL versus 5.8 ± 2.0 mg/dL; p = 0.021; OR 0.80 (0.65-0.97), p = 0.022], lower albumin levels [3.1 ± 0.6 g/dL versus 3.4 ± 0.6 g/dL, p < 0.001; OR 0.38 (0.22-0.66), p = 0.001] and started haemodialysis with a central venous catheter more frequently [80.4% versus 66.2%, p = 0.050]. Multivariate analysis identified older age [aOR 1.07 (1.03-1.12), p = 0.002], lower serum creatinine [aOR 0.80 (0.64-0.99), p = 0.049] and lower serum albumin [aOR 0.41 (0.22-0.75), p = 0.004] as predictors of one-year mortality.

CONCLUSION

In our cohort, older age, lower serum creatinine and lower serum albumin were independent risk factors for one-year mortality, highlighting the prognostic importance of malnutrition in patients starting chronic HD.

Race and Mortality in CKD and Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

RATIONALE & OBJECTIVES

Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy.

STUDY DESIGN

Retrospective cohort study.

SETTINGS & PARTICIPANTS

3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment.

EXPOSURE

Race.

OUTCOME

Mortality.

ANALYTIC APPROACH

Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC.

RESULTS

During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28).

LIMITATIONS

Residual confounding.

CONCLUSIONS

The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.

Therapeutic Approach to Patients with Heart Failure with Reduced Ejection Fraction and End-stage Renal Disease

BACKGROUND

Several risk factors including Ischemic heart disease, uncontrolled hypertension, high output Heart Failure (HF) from shunting through vascular hemodialysis access, and anemia, contribute to development of HF in patients with End-Stage Renal Disease (ESRD). Guidelinedirected medical and device therapy for Heart Failure with Reduced Ejection Fraction (HFrEF) has not been extensively studied and may have limited safety and efficacy in patients with ESRD.

RESULTS

Maintenance of interdialytic and intradialytic euvolemia is a key component of HF management in these patients but often difficult to achieve. Beta-blockers, especially carvedilol which is poorly dialyzed is associated with cardiovascular benefit in this population. Despite paucity of data, Angiotensin-converting Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs) when appropriately adjusted by dose and with close monitoring of serum potassium can also be administered to these patients who tolerate beta-blockers. Mineralocorticoid receptors in patients with HFrEF and ESRD have been shown to reduce mortality in a large randomized controlled trial without any significantly increased risk of hyperkalemia. Implantable Cardiac-defibrillators (ICDs) should be considered for primary prevention of sudden cardiac death in patients with HFrEF and ESRD who meet the implant indications. Furthermore in anemic iron-deficient patients, intravenous iron infusion may improve functional status. Finally, mechanical circulatory support with leftventricular assist devices may be related to increased mortality risk and the presence of ESRD poses a relative contraindication to further evaluation of these devices.

Trends in the Use of Guideline-Directed Therapies Among Dialysis Patients Hospitalized With Systolic Heart Failure: Findings From the American Heart Association Get With The Guidelines-Heart Failure Program

OBJECTIVES

The purpose of this study was to determine the temporal trends in the adherence to heart failure (HF)-related process of care measures and clinical outcomes among patients with acute decompensated HF with reduced ejection fraction (HFrEF) and end-stage renal disease (ESRD).

BACKGROUND

Previous studies have demonstrated significant underuse of evidence-based HF therapies among patients with coexisting ESRD and HFrEF. However, it is unclear if the proportional use of evidence-based medical therapies and associated clinical outcomes among these patients has changed over time.

METHODS

Get With The Guidelines-HF study participants who were admitted for acute HFrEF between January 2005 and June 2014 were stratified into 3 groups on the basis of their admission renal function: normal renal function, renal insufficiency without dialysis, and dialysis. Temporal change in proportional adherence to the HF-related process of care measures and incidence of clinical outcomes (1-year mortality, HF hospitalization, and all-cause hospitalization) during the study period was evaluated across the 3 renal function groups.

RESULTS

The study included 111,846 patients with HFrEF from 390 participating centers, of whom 19% had renal insufficiency but who did not require dialysis, and 3% were on dialysis. There was a significant temporal increase in adherence to evidence-based medical therapies (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker: p trend <0.0001, β-blockers: p trend = 0.0089; post-discharge follow-up referral: p trend <0.0001) and defect-free composite care (p trend <0.0001) among dialysis patients. An improvement in adherence to these measures was also observed among patients with normal renal function and patients with renal insufficiency without a need for dialysis. There was no significant change in cumulative incidence of clinical outcomes over time among the HF patients on dialysis.

CONCLUSIONS

In a large contemporary cohort of HFrEF patients with ESRD, adherence to the HF process of care measures has improved significantly over the past 10 years. Unlike patients with normal renal function, there was no significant change in 1-year clinical outcomes over time among HF patients on dialysis.

Prevalence and variation of Chronic Kidney Disease in the Irish health system: initial findings from the National Kidney Disease Surveillance Programme

BACKGROUND

Chronic Kidney Disease (CKD) is a major non-communicable chronic disease that is associated with adverse clinical and economic outcomes. Passive surveillance systems are likely to improve efforts for prevention of chronic kidney disease (CKD) and inform national service planning. This study was conducted to determine the overall prevalence of CKD in the Irish health system, assess period trends and explore patterns of variation as part of a novel surveillance initiative.

METHODS

We identified 207, 336 adult patients, age 18 and over, with serum creatinine measurements recorded from a provincial database between 2005-2011 in the Northwest of Ireland. Estimated glomerular filtration rates (eGFR) were determined using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation from standardized creatinine measurements and the presence of CKD was defined as eGFR<60 ml/min per 1.73 m2. Age and sex-specific prevalence estimates were determined for each group while generalized estimating equations (GEE) and multivariable logistic regression were used to explore associations using adjusted odds ratios (AOR) and 95% confidence intervals (95% CI).

RESULTS

The prevalence of CKD in the health system was 11.8% (95% CI 11.8-12.1); 10.9% in men (10.7-11.1) and 12.6% in women (12.4-12.8). This corresponded to a detection rate of 4.5% (5.1% in women and 3.9% in men). The prevalence of CKD was significantly higher in women than in men (12.6% versus 10.9%, P<0.001), older age groups, and among patients with a history of Acute Kidney Injury (AKI) than without (45.2% versus 10.7%, P<0.0001). Multivariable analysis identified advancing age, female gender, location of medical supervision, county of residence, and AKI as significant determinants of prevalence.

CONCLUSION

The prevalence of CKD in the Irish health system is 11.8% corresponding to a detection rate of 4.5% in the general population. Demographic, geographic factors and acute kidney injury episodes are important determinants of disease burden. Passive surveillance of CKD is both feasible and desirable within the Irish health system, and offers huge opportunities for targeted prevention programmes and improved clinical outcomes.

Blood pressure and cardiovascular mortality in dialysis patients with left ventricular systolic dysfunction

BACKGROUND

In patients chronically treated with hemodialysis, the prevalence of heart failure is high with a consequently poor prognosis. The role played by blood pressure (BP) on cardiovascular (CV) mortality of these patients has not been clearly defined.

METHODS

In this follow-up study, we investigated the relationship of pre- and postdialysis measurements of BP with CV and all-cause mortality in a cohort of 557 dialysis patients with a left ventricular (LV) ejection fraction <50%.

RESULTS

During the follow-up (mean = 21.6 ± 8.8 months), 179 deaths were recorded. Ninety-eight patients died from CV causes. By the Cox multivariable analysis, we constructed a predictive model of CV mortality including age, duration on dialysis, diabetes, serum albumin, diffusive dialysis technique, predialysis mean arterial pressure (MAP) (hazard ratio (HR) = 0.978; 95% confidence interval (CI) = 0.956-0.999), and postdialysis MAP (HR = 1.035; 95% CI = 1.010-1.061). The relationship with mortality was inverse for predialysis MAP and direct for postdialysis MAP. In a subsequent analysis, we found that pre- and postdialysis systolic BP, but not diastolic BP, were predictive of CV mortality. Predialysis MAP was in a direct relationship with body mass index. Postdialysis MAP had an inverse relationship with weight loss during dialysis session.

CONCLUSIONS

CV mortality in dialysis patients with LV dysfunction is associated with both pre- and postdialysis BP interacting in a complex relationship. Nutritional state and fluid balance and removal are possible clues to this relationship.