Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Risk factors associated with mortality among patients on maintenance hemodialysis: The Thailand Renal Replacement Therapy registry

INTRODUCTION

End-stage kidney disease (ESKD) has been increasing in prevalence across the world, including Thailand, and patients with ESKD on hemodialysis have a high mortality risk.

METHODS

A retrospective cohort study was performed across 855 hemodialysis centers in the Thailand Renal Replacement Therapy registry. The database and mortality data were analyzed.

RESULTS

A total of 58 952 patients were included. The survival rates at 1, 3, and 5 years were 93.5%, 69.7%, and 41.2%, respectively. On multivariate analysis, factors such as aging, permanent catheter or arteriovenous graft, twice-weekly hemodialysis, low levels of urea reduction ratio, normalized protein catabolic rate, hemoglobin, transferrin saturation, serum albumin, LDL-cholesterol, intact-parathyroid hormone, uric acid, sodium, phosphate, and bicarbonate were significantly related to death.

CONCLUSION

Mortality is high in ESKD patients on hemodialysis. Age, type of vascular access, twice-weekly hemodialysis, inadequate dialysis, low protein intake, anemia, abnormal electrolytes, and bone mineral disorders are associated with all-cause mortality.

PTH may predict early mortality in incident patients on hemodialysis: results from a large cohort

PURPOSE

Parathyroid hormone (PTH) is merit as a risk factor for mortality in patients with chronic kidney disease in prevalent hemodialysis patients in a U shape. Most studies, however, do not focus on incident patients and those who died within the first 90 days of therapy. We evaluated PTH as a risk factor for mortality in a large cohort population in Brazil.

METHODS

This is an observational cohort study that included 4317 adult patients who initiated hemodialysis between July 1st, 2012 and June 30, 2017. The main outcome was all-cause mortality. Fine-gray sub-distribution hazard models were used to evaluate survival in the presence of a competing event (kidney transplant).

RESULTS

Median PTH levels of 252 (118, 479) pg/mL. There were 331 deaths during the first 90 days of therapy (6.7%), 430 in a 1-year follow-up (10.7%) and 1282 (32%) during the 5-year study period. Deaths according to PTH < 150, 150-600 and > 600 pg/mL corresponded to 38.1%, 33.0% and 28.5%, respectively (p < 0.001). In an adjusted model, patients who started dialysis with PTH < 150 pg/mL had a higher mortality risk within the first 90 days, but not in 1 year and 5 years after starting dialysis. Analyses in a subset of patients with a repeated PTH in 1 year (N = 1954) showed that although persistent PTH low levels (< 150 pg/mL) at 1 year were significantly associated with all-cause mortality, this result was not sustained after multiple adjustments.

CONCLUSION

PTH < 150 pg/mL confers a high mortality risk in the first 90 days of dialysis. If this result reflects poor nutritional conditions, it deserves further investigations.

Remaining life expectancy of Korean hemodialysis patients: how much longer can they live?

BACKGROUND

Hemodialysis (HD) patients have a higher mortality rate compared to the general population. However, no study has investigated life expectancy in Korean HD patients so far. Therefore, this study aimed to calculate the remaining life expectancy among Korean maintenance HD patients and compare it to those of the general population as well as HD patients from other countries.

METHODS

Baseline data were retrieved from HD quality assessment data from 2015. Among the patients over 30 years old who were alive at the beginning of 2016 (20,304 males and 14,264 females), a total of 22,078 (12,621 males and 9,457 females) were still alive at the end of 2021 while 12,490 (7,683 males and 4,807 females) were deceased during 6 years of follow-up. We used the life table method to calculate the expected remaining years of life in 2-year increments.

RESULTS

The remaining life expectancies for 60-year-old patients were 11.64 years for males and 14.64 years for females. The average remaining life expectancies of the HD population were only about half of the general population. Diabetic patients demonstrated shorter life expectancy compared to patients with hypertension or glomerulonephritis. The remaining life expectancy of Korean HD patients was similar to that of Japanese and was almost double that of HD patients in Western countries such as Europe and the United States.

CONCLUSION

The HD population shows a shorter life expectancy compared to the general population. Longitudinal analysis should be warranted to analyze the effect of advanced dialysis technology on improved survival rates among the HD population.

Dialysis Outcomes Across Countries and Regions: A Global Perspective From the International Society of Nephrology Global Kidney Health Atlas Study

Introduction

Kidney failure treated with hemodialysis (HD), or peritoneal dialysis (PD) is a major global health problem that is associated with increased risks of death and hospitalization. This study aimed to compare the incidence and causes of death and hospitalization during the first year of HD or PD among countries.

Methods

The third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) was conducted between June and September 2022. For this analysis, data were obtained from the cross-sectional survey of key stakeholders from ISN-affiliated countries.

Results

A total of 167 countries participated in the survey (response rate 87.4%). In 48% and 58% of countries, 1% to 10% of people treated with HD and PD died within the first year, respectively, with cardiovascular disease being the main cause. Access-related infections or treatment withdrawal owing to cost were important causes of death in low-income countries (LICs). In most countries, <30% and <20% of patients with HD and PD, respectively, required hospitalization during the first year. A greater proportion of patients with HD and PD in LICs were hospitalized in the first year than those in high-income countries (HICs). Access-related infection and cardiovascular disease were the commonest causes of hospitalization among patients with HD, whereas PD-related infection was the commonest cause in patients with PD.

Conclusion

There is significant heterogeneity in the incidence and causes of death and hospitalization in patients with kidney failure treated with dialysis. These findings highlight opportunities to improve care, especially in LICs where infectious and social factors are strong contributors to adverse outcomes.

Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial)

BACKGROUND

Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients.

METHODS

An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients).

DISCUSSION

Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.

Risk Factors for Thromboembolic Events in Patients With Dialysis-Dependent CKD: Pooled Analysis of Phase 3 Roxadustat Trials in Japan

INTRODUCTION

Thromboembolic events have occurred in clinical trials of roxadustat. This post hoc analysis explored potential factors related to thromboembolic events in dialysis-dependent patients treated with roxadustat in four phase 3 clinical trials in Japan.

METHODS

Thromboembolic events with onset before and after week 12 were evaluated. Baseline risk factors for thromboembolic events were investigated by Cox regression analyses. Nested case-control analyses using conditional logistic models with matched pairs of case-control data explored relationships between thromboembolic events and laboratory parameters.

RESULTS

Of the 444 patients, 56 thromboembolic events were observed in 44 patients during ≤ 52 weeks of treatment. The proportion of venous and arterial thromboembolic events gradually increased after week 12. Baseline risk factors included hemodialysis (vs peritoneal dialysis), advanced age (≥ 65 years), shorter dialysis vintage (< 4 months), and history of thromboembolism. The absence of concomitant intravenous or oral iron therapy (including ferric citrate) was associated with thromboembolic events before week 12 (hazard ratio 11.25; 95% confidence interval [CI] 3.36-37.71; vs presence). Case-control analysis revealed that low average transferrin saturation (< 10%; unadjusted odds ratio [OR] 6.25; 95% CI 1.52-25.62; vs ≥ 20%), high average transferrin level (≥ 2.5 g/L; unadjusted OR 4.36; 95% CI 1.23-15.39; vs < 2.0 g/L), and high average roxadustat dose (≥ 150 mg; unadjusted OR 5.95; 95% CI 1.07-33.16; vs < 50 mg) over the previous 8 weeks before the event onset were associated with thromboembolic events after week 12. However, adjustment for iron status extinguished the significant relationship between roxadustat dose and events. Multivariate case-control analysis showed that increased transferrin from baseline (≥ 1.0 g/L; adjusted OR 7.85; 95% CI 1.82-33.90; vs < 0.5 g/dL) and decreased mean corpuscular volume (< - 2 fL; adjusted OR 5.55; 95% CI 1.73-17.83; vs ≥ 0 fL) were associated with increased risk of thromboembolic events.

CONCLUSION

In addition to established risk factors, iron deficiency may be related to thromboembolic events. Graphical Abstract available for this article.

TRIAL REGISTRATION

NCT02780726, NCT02952092, NCT02780141, NCT02779764.

Predictors of functional impairment and mortality in patients on maintenance hemodialysis

INTRODUCTION

Numerous factors impact the mortality and functional abilities of patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis (MHD). We aimed to determine the mortality rate at 1 year of MHD, identify predictors of mortality, and assess functional impairments concerning activities of daily living (ADLs) and instrumental ADL (IADL).

METHODS

Our study was prospective, observational cohort study that enrolled patients receiving MHD. We collected demographic, clinical, and laboratory data. We also assessed ADLs and IADLs for daily performance.

RESULTS

Our study included 167 patients with a mean age of 51.6 ± 13.1 years, and 56.9% were male. Of these, 80 (47.9%) were diabetic, and 145 (86.8%) were hypertensive. The mortality rate after 1 year of MHD was 10.8%, and cardiovascular causes accounted for over 70% of total deaths. Sudden cardiac death was the most frequent cause (38.9%), followed by cardiogenic shock (22.2%). Older age and low parathormone levels (<300 pg/mL) were significantly associated with higher mortality rates. Mean ADL and IADL scores were 4.5 ± 1.3 and 6.3 ± 2.7, respectively. Eighteen (10.8%) and 56 (33.5%) patients had low ADL and IADL scores, respectively. Although statistically insignificant, a higher proportion of non-survivors exhibited low IADL and ADL scores. Older age, longer diabetes duration, and higher BMI levels were significantly associated with lower IADL scores.

CONCLUSIONS

Older age and suppressed PTH levels are predictors of mortality in ESRD patients receiving MHD. These patients require regular follow-ups to rule out cardiovascular morbidity. Functional impairment is prevalent but remains underdiagnosed in MHD patients. It should be monitored regularly to improve quality of life in ESRD.

Geriatric Nutritional Risk Index and First-Year Mortality in Incident Hemodialysis Patients

OBJECTIVE

The Geriatric Nutritional Risk Index is a simple nutritional screening method, and this study aimed to investigate the association between the initial Geriatric Nutritional Risk Index and all-cause mortality in incident patients in the first year after the initiation of hemodialysis.

MATERIALS AND METHODS

This study is a retrospective cohort study and used the Korean Renal Data System database. Patients who were eligible for Geriatric Nutritional Risk Index assessment and underwent hemodialysis from January 2016 to December 2019 were included. The primary outcome was all-cause mortality, and outcome evaluation was performed in December 2020. A Cox proportional hazard model was used to analyze the association between the Geriatric Nutritional Risk Index and mortality.

RESULTS

A total of 10,545 patients were included, and the mean age was 63.9 ± 3.7 years. The patients were divided into four groups by the quartile of the Geriatric Nutritional Risk Index with a mean value of 96.2 ± 8.2. During the study period, 545 (5.2%) deaths occurred. The surviving patients had higher Geriatric Nutritional Risk Index values than ones who died in the first year of hemodialysis initiation (96.6 ± 7.5 vs. 88.2 ± 9.3, p < 0.001). Quartile 1 (Geriatric Nutritional Risk Index < 91.8) showed a significantly increased risk of all-cause (Hazard Ratio: 2.56; 95% Confidence Interval: 2.13-3.09; p < 0.001) and cardiovascular mortality (Hazard Ratio: 22.29; 95% Confidence Interval: 1.71- 3.08; p < 0.001) at the first year in comparison with Quartile 4 (Geriatric Nutritional Risk Index ≥ 101.3). In areas under the receiver-operating characteristic curves of all-cause mortality, the Geriatric Nutritional Risk Index model improved predictive values, compared to the baseline model. The area with the Geriatric Nutritional Risk Index model was significantly higher than the one with a model including albumin or body mass index (p < 0.001).

CONCLUSIONS

These findings suggest that a low Geriatric Nutritional Risk Index (<91.8) is associated with first-year all-cause and cardiovascular mortality in patients who start hemodialysis and may be a useful and reproducible tool for assessing prognoses in this population.

Glasgow prognostic score as an outcome predictor for patients initiating hemodialysis

INTRODUCTION

This retrospective study examined the relationship between the Glasgow Prognostic Score (GPS) at hemodialysis (HD) initiation and overall/cardiovascular mortality.

METHODS

A total of 264 patients starting HD between 2014 and 2015 at a single center were studied. Follow-up persisted until therapy change, death, or study end (December 31, 2021), with a median of 6.8 years.

RESULTS

Patients with a higher GPS more frequently had emergent HD initiation and showed increased eGFR at initiation. During follow-up, 60% of patients died, with cardiovascular disease being the leading cause. Univariate analysis revealed a significant difference in median survival time across GPS classes. Cox proportional hazard models confirmed a significant association between GPS and mortality.

CONCLUSIONS

We report a significant association between GPS at HD initiation and mortality. GPS may prove useful as a prognostic tool for identifying high-risk patients, underscoring the need for future research to validate these findings and explore the potential of GPS-based interventions.

Intradialytic Hypotension and Mortality in Adolescents and Young Adults With Kidney Failure Receiving Maintenance Hemodialysis

Rationale & Objective

Intradialytic hypotension (IDH) is associated with mortality in adults with kidney failure requiring hemodialysis (HD); however, large-scale pediatric studies are lacking. Moreover, there is no evidence-based consensus definition of IDH in pediatric literature. We aimed to examine the association of commonly used definitions of IDH with mortality in adolescents and young adults.

Study Design

This was a retrospective observational cohort study.

Setting & Participants

In total, 1,199 adolescents and young adults (N = 320, aged 10-18 years and N = 879, aged 19-21 years) who initiated HD in a large dialysis organization were included.

Exposures

This study used different definitions of IDH.

Outcome

The study outcome was 2-year all-cause mortality.

Analytical Approach

Several definitions of IDH were selected a priori based on a literature review. Patients were classified as having IDH if it was present in at least 30% of HD treatments during the first 90 days after dialysis initiation. Cox proportional hazards regression was used to test whether IDH associated with 2-year all-cause mortality.

Results

Over a 2-year follow-up period, 54 (4.5%) patients died. Dependent on its definition, IDH was present in 2.9%-61.1% of patients. After the multivariable adjustment for sociodemographic and clinical characteristics, we found no association of IDH with mortality. Results were consistent across subgroups stratified by age (aged <18 and 19-21 years) and predialysis systolic blood pressure (<120, 120-150, and >150 mm Hg). We also examined IDH as occurring in <5%, 5%-29%, 30%-50%, and >50% of baseline treatments, and did not find a dose-response association with mortality (P > 0.05).

Limitations

Owing to low event rates, our current sample size may have been too small to detect a difference in mortality.

Conclusions

Our study found that IDH was not associated with mortality in adolescents and young adults.

Importance of dialysis specialists in early mortality in elderly hemodialysis patients: a multicenter retrospective cohort study

The early mortality rate in elderly patients undergoing hemodialysis is more than twice that in young patients, requiring more specialized healthcare. We investigated whether the number of professional dialysis specialists affected early mortality in elderly patients undergoing hemodialysis. This multicenter retrospective cohort study analyzed data from 1860 patients aged ≥ 70 years who started hemodialysis between January 2010 and December 2017. Study regions included Seoul, Gyeonggi-do, Gangwon-do, Daejeon/Chungcheong-do, Daegu/Gyeongsangbuk-do, and Busan/Ulsan/Gyeongsangnam-do. The number of patients undergoing hemodialysis per dialysis specialist was calculated using registered data from each hemodialysis center. Early mortality was defined as death within 6 months of hemodialysis initiation. Gangwon-do (28.3%) and Seoul (14.5%) showed the highest and lowest early mortality rate, respectively. Similarly, Gangwon-do (64.6) and Seoul (43.9) had the highest and lowest number of patients per dialysis specialist, respectively. Relatively consistent results were observed for the regional rankings of early mortality rate and number of patients per dialysis specialist. Multivariate Cox regression analysis-adjusted for previously known significant risk factors-revealed that the number of patients per dialysis specialist was an independent risk factor for early mortality (hazard ratio: 1.031, p < 0.001). This study underscores the growing need for dialysis specialists for elderly hemodialysis patients in Korea.

Long-term Patiromer Use and Outcomes Among US Veterans With Hyperkalemia and CKD: A Propensity-Matched Cohort Study

Rationale & Objective

Patiromer is a potassium binder approved for the long-term management of hyperkalemia. Although patiromer use among patients with advanced chronic kidney disease (CKD) has been shown to reduce the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, it remains unclear whether patiromer can improve clinical outcomes. The aim of this study was to examine the association of long-term patiromer use with clinical outcomes among hyperkalemic patients with CKD.

Study Design

This was a longitudinal observational study.

Setting & Participants

We evaluated a national cohort of 854,217 US Veterans who had at least 1 serum potassium measurement of ≥5.1 mEq/L and were treated at US Department of Veterans Affairs health care facilities between January 2016 and September 2019.

Exposure

The exposure was long-term patiromer use.

Outcomes

The outcomes were as follows: (1) composite endpoint of kidney failure with replacement therapy (KFRT) or all-cause death and (2) all-cause death including the post-KFRT period.

Analytical Approach

Cox proportional Fine-Gray subdistribution hazard models were used in a propensity-matched cohort.

Results

Among 2,004 patients who ever used patiromer during the study period (0.2% of the cohort), 666 met the criteria for long-term patiromer use. We matched 308 long-term patiromer users to 308 nonusers based on propensity scores. The median estimated glomerular filtration rate was 23.5 mL/min/1.73m2, and the median potassium level was 5.2 mEq/L. Approximately 45% were on renin-angiotensin system inhibitor(s) at baseline. During follow-up, 93 patients developed KFRT, and 134 patients died. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome (HR, 0.74; 95% CI, 0.53-1.01; P = 0.06) and a 41% lower risk of all-cause mortality (HR, 0.59; 95% CI, 0.41-0.84; P = 0.003).

Limitations

The study cohort included mostly male veterans with relatively short follow-up periods.

Conclusions

Long-term patiromer use was associated with a lower risk of all-cause mortality among patients with CKD and hyperkalemia. Long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD.

Plain-Language Summary

Hyperkalemia is a common complication of chronic kidney disease (CKD) and can result in the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, a cornerstone of CKD management. Patiromer is a new potassium binder approved for the long-term management of hyperkalemia, but it remains unclear whether patiromer can improve clinical outcomes. We examined a cohort of US Veterans with hyperkalemia between January 2016 and September 2019 and found that patiromer use was uncommon for treating hyperkalemia during this study period. We then matched 308 long-term patiromer users and 308 nonusers based on propensity scores. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome and a 41% lower risk of all-cause mortality. These findings indicate that long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD.

Advanced Image-Guided Percutaneous Technique Versus Advanced Laparoscopic Surgical Technique for Peritoneal Dialysis Catheter Placement

Rationale & Objective

Timely placement of a functional peritoneal dialysis (PD) catheter is crucial to long-term PD success. Advanced image-guided percutaneous and advanced laparoscopic techniques both represent best practice catheter placement options. Advanced image-guided percutaneous is a minimally invasive procedure that does not require general anesthesia.

Study Design

Retrospective cohort study comparing time from referral to procedure, complication rate, and 1-year catheter survival between placement techniques.

Setting & Participants

Patients who had advanced laparoscopic or advanced image-guided percutaneous PD catheter placement from January 1, 2011 to December 31, 2013 in an integrated Northern California health care delivery system.

Exposure

PD catheter placement using advanced laparoscopic or advanced image-guided percutaneous techniques.

Outcomes

One-year PD catheter survival; major, minor, and infectious complications; time from referral to PD catheter placement; and procedure time.

Analytical Approach

Wilcoxon rank sum tests to compare referral and procedure times; χ2/Fisher exact tests to compare complications; and modified least-squares regression to compare adjusted 1-year catheter survival between PD placement techniques.

Results

We identified 191 and 238 PD catheters placed through advanced image-guided percutaneous and advanced laparoscopic techniques, respectively. Adjusted 1-year PD catheter survival was 80% (95% CI, 74%-87%) using advanced image-guided percutaneous technique vs 91% (87%-96%) using advanced laparoscopic technique (P = 0.01). Major complications were <1% in both groups. Minor and infectious complications were 45.6% and 38.7% in advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P = 0.01). Median days from referral to procedure were 12 and 33 for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P < 0.001). Median procedure time was 30 and 44.5 minutes for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P < 0.001).

Limitations

Retrospective study with practice preference influenced by timing, local expertise, and resources.

Conclusions

Both advanced image-guided percutaneous and advanced laparoscopic techniques reported rare major complications and demonstrated excellent (advanced laparoscopic) and acceptable (advanced image-guided percutaneous) 1-year PD catheter survival. For patients referred for PD catheter placement at centers where advanced laparoscopic resources or expertise remain limited, the advanced image-guided percutaneous technique can provide a complementary and timely option to support the utilization of PD.

Plain-Language Summary

Peritoneal dialysis is a preferred dialysis modality for many patients. However, the lack of available skilled surgeons can limit the placement of the peritoneal dialysis catheter in a timely manner. In the past decade, interventional radiology has developed expertise in placing peritoneal dialysis catheters. Using data from an integrated health care system, we compared the outcome of peritoneal dialysis catheters placed using laparoscopic surgery and interventional radiology techniques. Our results showed excellent 1-year patency of peritoneal dialysis catheters placed using laparoscopic surgery, whereas interventional radiology placement of catheters had lower but acceptable 1-year patency survival, based on best practice guideline criteria. Hence, interventional radiology placement of peritoneal dialysis catheters may be a viable alternative when laparoscopic surgery is not available or feasible.

Catheter Event Rates in Medical Compared to Surgical Peritoneal Dialysis Catheter Insertion

Introduction

How patient, center, and insertion technique factors interact needs to be understood when designing peritoneal dialysis (PD) catheter insertion pathways.

Methods

We undertook a prospective cohort study in 44 UK centers enrolling participants planned for first catheter insertion. Sequences of regressions were used to describe the associations linking patient and dialysis unit-level characteristics with catheter insertion technique and their impact on the occurrence of catheter-related events in the first year (catheter-related infection, hospitalization, and removal). Factors associated with catheter events were incorporated into a multistate model comparing the rates of catheter events between medical and surgical insertion alongside treatment modality transitions and mortality.

Results

Of 784 first catheter insertions, 466 (59%) had a catheter event in the first year and 61.2% of transitions onto hemodialysis (HD) were immediately preceded by a catheter event. Catheter malfunction was less but infection was more common with surgical compared with medical insertions. Participants at centers with fewer late presenters and more new dialysis patients starting PD, had a lower probability of a catheter event. Adjusting for these factors, the hazard ratio for a catheter event following insertion (medical vs. surgical) was 0.70 (95% confidence interval [CI] 0.43 to 1.13), and once established on PD 0.77 (0.62 to 0.96).

Conclusion

Offering both medical and surgical techniques is associated with lower catheter event rates and keeps people on PD for longer.

Associations between abrupt transition, dialysis-requiring AKI, and early mortality in ESKD among U.S. veterans

BACKGROUND

Mortality is high within the first few months of starting chronic dialysis. Pre-ESKD trajectory of kidney function has been shown to be predictive of early death after dialysis initiation. We aim to better understand how two key aspects of pre-dialysis kidney function-an abrupt transition pattern and an episode of dialysis-requiring AKI (AKI-D) leading directly to ESKD-are associated with early mortality after dialysis initiation.

METHODS

We extracted national data from U.S. Veterans Health Administration cross-linked with the United States Renal Data System (USRDS) to identify patients who initiated hemodialysis during 2009-2013. We defined abrupt transition as having a mean outpatient eGFR ≥ 30 ml/min/1.73m2 within 1 year prior to ESKD. AKI-D was identified using inpatient serum creatinine measurements (serum Cr increase by at least 50% from baseline) along with billing codes for inpatient receipt of dialysis for AKI within 30 days prior to the ESKD start date. We used multivariable proportional hazards models to examine the association between patterns of kidney function prior to ESKD and all-cause mortality within 90 days after ESKD.

RESULTS

Twenty-two thousand eight hundred fifteen patients were identified in the final analytic cohort of Veterans who initiated hemodialysis and entered the USRDS. We defined five patterns of kidney function decline. Most (68%) patients (N = 15,484) did not have abrupt transition and did not suffer an episode of AKI-D prior to ESKD (reference group). The remaining groups had abrupt transition, AKI-D, or both. Patients who had an abrupt transition with (N = 503) or without (N = 3611) AKI-D had the highest risk of early mortality after ESKD onset after adjustment for demographics and comorbidities (adjusted HR 2.10, 95% CI 1.66-2.65 for abrupt transition with AKI-D; adjusted HR 2.10, 95% CI 1.90-2.33 for abrupt transition without AKI-D). In contrast, patients who experienced AKI-D without an abrupt transition pattern (N =  2141 had only a modestly higher risk of early death (adjusted HR 1.19, 95% CI 1.01-1.40).

CONCLUSIONS

An abrupt decline in kidney function within 1 year prior to ESKD occurred in nearly 1 in 5 incident hemodialysis patients (18%) in this national cohort of Veterans and was strongly associated with higher early mortality after ESKD onset.

Concordance indices with left-truncated and right-censored data

In the context of time-to-event analysis, a primary objective is to model the risk of experiencing a particular event in relation to a set of observed predictors. The Concordance Index (C-Index) is a statistic frequently used in practice to assess how well such models discriminate between various risk levels in a population. However, the properties of conventional C-Index estimators when applied to left-truncated time-to-event data have not been well studied, despite the fact that left-truncation is commonly encountered in observational studies. We show that the limiting values of the conventional C-Index estimators depend on the underlying distribution of truncation times, which is similar to the situation with right-censoring as discussed in Uno et al. (2011) [On the C-statistics for evaluating overall adequacy of risk prediction procedures with censored survival data. Statistics in Medicine 30(10), 1105-1117]. We develop a new C-Index estimator based on inverse probability weighting (IPW) that corrects for this limitation, and we generalize this estimator to settings with left-truncated and right-censored data. The proposed IPW estimators are highly robust to the underlying truncation distribution and often outperform the conventional methods in terms of bias, mean squared error, and coverage probability. We apply these estimators to evaluate a predictive survival model for mortality among patients with end-stage renal disease.

Survival in hemodialysis in Brazil according to the source of payment for the treatment: Public Healthcare System (SUS) versus private insurance

INTRODUCTION

Brazil has the largest public and universal healthcare system in the world, but little is known about the outcomes of patients on hemodialysis (HD) in the country according to the source of funding for the treatment.

OBJECTIVE

To compare the profile and survival of patients under HD treatment funded by the Public Healthcare System (SUS) to those with private insurance.

METHODS

Retrospective analysis of adults undergoing HD between 2012 and 2017 in 21 dialysis centers in Brazil that provided both by the SUS and private health insurance. Participants, regardless of the paying source, received similar dialysis treatment. Data were censored after 60 months of follow-up or at the end of 2019.

RESULTS

4,945 patients were included, 59.7% of which were financed by the SUS. Patients financed by SUS, compared to those with private insurance, were younger (58 vs. 60 years; p < 0.0001) and with a lower prevalence of diabetes (35.8% vs. 40.9%; p < 0.0001). The 60-month survival rates in these groups were 51.1% and 52.1%, respectively (p = 0.85). In the analysis of the subdistribution proportional hazard ratio by the Fine-Gray model, including adjustment for concurrent outcomes, a significant increase in the risk ratio for death was found (1.22 [95% confidence interval 1.04 to 1.43]) in patients with treatment funded by the SUS.

CONCLUSIONS

Patients on HD with treatment funded by the SUS have a higher adjusted risk of death when compared to those with private insurance, despite similar dialysis treatment. Factors not directly related to dialysis therapy could explain this difference.

The benefit of planned dialysis to early survival on hemodialysis versus peritoneal dialysis: a nationwide prospective multicenter study in Korea

Optimal preparation is recommended for patients with advanced chronic kidney disease to minimize complications during dialysis initiation. This study evaluated the effects of planned dialysis initiation on survival in patients undergoing incident hemodialysis and peritoneal dialysis. Patients newly diagnosed with end-stage kidney disease who started dialysis were enrolled in a multicenter prospective cohort study in Korea. Planned dialysis was defined as dialysis therapy initiated with permanent access and maintenance of the initial dialysis modality. A total of 2892 patients were followed up for a mean duration of 71.9 ± 36.7 months and 1280 (44.3%) patients initiated planned dialysis. The planned dialysis group showed lower mortality than the unplanned dialysis group during the 1st and 2nd years after dialysis initiation (1st year: adjusted hazard ratio [aHR] 0.51; 95% confidence interval [CI] 0.37-0.72; P < 0.001; 2nd year: aHR 0.71; 95% CI 0.52-0.98, P = 0.037). However, 2 years after dialysis initiation, mortality did not differ between the groups. Planned dialysis showed a better early survival rate in hemodialysis patients, but not in peritoneal dialysis patients. Particularly, infection-related mortality was reduced only in patients undergoing hemodialysis with planned dialysis initiation. Planned dialysis has survival benefits over unplanned dialysis in the first 2 years after dialysis initiation, especially in patients undergoing hemodialysis. It improved infection-related mortality during the early dialysis period.

Assessing the impact of transitional care units on dialysis patient outcomes: A multicenter, propensity score-matched analysis

INTRODUCTION

Inadequate predialysis care and education impacts the selection of a dialysis modality and is associated with adverse clinical outcomes. Transitional care units (TCUs) aim to meet the unmet educational needs of incident dialysis patients, but their impact beyond increasing home dialysis utilization has been incompletely characterized.

METHODS

This retrospective study included adults initiating in-center hemodialysis at a TCU, matched to controls (1:4) with no TCU history initiating in-center hemodialysis. Patients were followed for up to 14 months. TCUs are dedicated spaces where staff provide personalized education and as-needed adjustments to dialysis prescriptions. For many patients, therapy was initiated with four to five weekly dialysis sessions, with at least some sessions delivered by home dialysis machines. Outcomes included survival, first hospitalization, transplant waiting-list status, post-TCU dialysis modality, and vascular access type.

FINDINGS

The study included 724 patients initiating dialysis across 48 TCUs, with 2892 well-matched controls. At the end of 14 months, patients initiating dialysis in a TCU were significantly more likely to be referred and/or wait-listed for a kidney transplant than controls (57% vs. 42%; p < 0.0001). Initiation of dialysis at a TCU was also associated with significantly lower rates of receiving in-center hemodialysis at 14 months (74% vs. 90%; p < 0.0001) and higher rates of arteriovenous access (70% vs. 63%; p = 0.003). Although not statistically significant, TCU patients were more likely to survive and less likely to be hospitalized during follow-up than controls.

DISCUSSION

Although TCUs are sometimes viewed as only a means for enhancing utilization of home dialysis, patients attending TCUs exhibited more favorable outcomes across all endpoints. In addition to being 2.5-fold more likely to receive home dialysis, TCU patients were 42% more likely to be referred for transplantation. Our results support expanding utilization of TCUs for patients with inadequate predialysis support.

Sobrevida na hemodiálise no Brasil de acordo com a fonte pagadora do tratamento: Sistema Único de Saúde versus convênio privado

Resumo Introdução: O Brasil possui o maior sistema público e universal de saúde do mundo, mas pouco se sabe sobre os desfechos dos pacientes em hemodiálise (HD) no país de acordo com a fonte de financiamento do tratamento. Objetivo: Comparar o perfil e a sobrevida dos pacientes que têm o tratamento de HD custeado pelo Sistema Único de Saúde (SUS) com aqueles com convênio privado. Métodos: Análise retrospectiva dos adultos incidentes em HD entre 2012 e 2017 em 21 centros de diálise no Brasil que atendiam tanto pelo SUS quanto por convênios privados. Os participantes, independentemente da fonte pagadora, receberam tratamento dialítico semelhante. Os dados foram censurados com 60 meses de acompanhamento ou ao final de 2019. Resultados: Foram incluídos 4945 pacientes, sendo 59,7% financiados pelo SUS. Os pacientes financiados pelo SUS, em comparação aos que tinham convênio privado, eram mais jovens (58 vs 60 anos; p < 0,0001) e com menor prevalência de diabetes (35,8% vs 40,9%; p < 0,0001). As taxas de sobrevida, em 60 meses nesses grupos foram de 51,1% e 52,1%, respectivamente (p = 0,85). Na análise da razão de risco proporcional de subdistribuição pelo modelo de Fine-Gray, incluindo ajuste para desfechos concorrentes, foi encontrado um aumento significativo na razão de risco para morte (1,22 [intervalo de confiança de 95% 1,04 a 1,43]) nos pacientes com tratamento custeado pelo SUS. Conclusões: Pacientes em HD com tratamento custeado pelo SUS têm um risco ajustado de morte mais elevado do que aqueles com convênio privado, apesar do tratamento dialítico semelhante. Fatores não relacionados diretamente à terapia dialítica poderiam justificar esta diferença.

Managing Transition between dialysis modalities: a call for Integrated care In Dialysis Units

Summary Patients with chronic kidney disease have three main possible groups of dialysis techniques: in-center hemodialysis, peritoneal dialysis, and home hemodialysis. Home dialysis techniques have been associated with clinical outcomes that are equivalent and sometimes superior to those of in-center hemodialysisTransitions between treatment modalities are crucial moments. Transition periods are known as periods of disruption in the patient’s life associated with major complications, greater vulnerability, greater mortality, and direct implications for quality of life. Currently, it is imperative to offer a personalized treatment adapted to the patient and adjusted over time.An integrated treatment unit with all dialysis treatments and a multidisciplinary team can improve results by establishing a life plan, promoting health education, medical and psychosocial stabilization, and the reinforcement of health self-care. These units will result in gains for the patient’s journey and will encourage home treatments and better transitions.Peritoneal dialysis as the initial treatment modality seems appropriate for many reasons and the limitations of the technique are largely overcome by the advantages (namely autonomy, preservation of veins, and preservation of residual renal function).The transition after peritoneal dialysis can (and should) be carried out with the primacy of home treatments. Assisted dialysis must be considered and countries must organize themselves to provide an assisted dialysis program with paid caregivers.The anticipation of the transition is essential to improve outcomes, although there are no predictive models that have high accuracy; this is particularly important in the transition to hemodialysis (at home or in-center) in order to plan autologous access that allows a smooth transition.

Biphasic Dynamics of Inflammatory Markers Following Hemodialysis Initiation: Results From the International MONitoring Dialysis Outcome Initiative

Introduction

Inflammation is highly prevalent among patients with end-stage kidney disease and is associated with adverse outcomes. We aimed to investigate longitudinal changes in inflammatory markers in a diverse international incident hemodialysis patient population.

Methods

The MONitoring Dialysis Outcomes (MONDO) Consortium encompasses hemodialysis databases from 31 countries in Europe, North America, South America, and Asia. The MONDO database was queried for inflammatory markers (total white blood cell count [WBC], neutrophil count, lymphocyte count, serum albumin, and C-reactive protein [CRP]) and hemoglobin levels in incident hemodialysis patients. Laboratory parameters were measured every month. Patients were stratified by survival time (≤6 months, >6 to 12 months, >12 to 18 months, >18 to 24 months, >24 to 30 months, >30 to 36 months, and >36 months) following dialysis initiation. We used cubic B-spline basis function to evaluate temporal changes in inflammatory parameters in relationship with patient survival.

Results

We studied 18,726 incident hemodialysis patients. Their age at dialysis initiation was 71.3 ± 11.9 years; 10,802 (58%) were males. Within the first 6 months, 2068 (11%) patients died, and 12,295 patients (67%) survived >36 months (survivor cohort). Hemodialysis patients who died showed a distinct biphasic pattern of change in inflammatory markers where an initial decline of inflammation was followed by a rapid rise that was consistently evident approximately 6 months before death. This pattern was similar in all patients who died and was consistent across the survival time intervals. In contrast, in the survivor cohort, we observed initial decline of inflammation followed by sustained low levels of inflammatory biomarkers.

Conclusion

Our international study of incident hemodialysis patients highlights a temporal relationship between serial measurements of inflammatory markers and patient survival. This finding may inform the development of prognostic models, such as the integration of dynamic changes in inflammatory markers for individual risk profiling and guiding preventive and therapeutic interventions.

Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease

Chronic kidney disease (CKD) and kidney failure are global health problems associated with morbidity, mortality and healthcare costs, with unequal access to kidney replacement therapy between countries. The diversity of guidelines concerning referral from primary care to a specialist nephrologist determines different outcomes around the world among patients with CKD where several guidelines recommend referral when the glomerular filtration rate (GFR) is <30 mL/min/1.73 m2 regardless of age. Additionally, fixed non-age-adapted diagnostic criteria for CKD that do not distinguish correctly between normal kidney senescence and true kidney disease can lead to overdiagnosis of CKD in the elderly and underdiagnosis of CKD in young patients and contributes to the unfair referral of CKD patients to a kidney specialist. Non-age-adapted recommendations contribute to unnecessary referral in the very elderly with a mild disease where the risk of death consistently exceeds the risk of progression to kidney failure and ignore the possibility of effective interventions of a young patient with long life expectancy. The opportunity of mitigating CKD progression and cardiovascular complications in young patients with early stages of CKD is a task entrusted to primary care providers who are possibly unable to optimally accomplish guideline-directed medical therapy for this purpose. The shortage in the nephrology workforce has classically led to focused referral on advanced CKD stages preparing for kidney replacement, but the need for hasty referral to a nephrologist because of the urgent requirement for kidney replacement therapy in advanced CKD is still observed and changes are required to move toward reducing the kidney failure burden. The Kidney Failure Risk Equation (KFRE) is a novel tool that can guide wiser nephrology referrals and impact patients.

Postoperative mortality in patients with end-stage renal disease according to the use of sugammadex: a single-center retrospective propensity score matched study

BACKGROUND

Clearance of the sugammadex-rocuronium complex is limited to renal excretion. There are restrictions on the use of sugammadex in patients with severe renal impairment. A paucity of data supports the clinical safety of sugammadex in patients with renal impairment. We analyzed mortality after using sugammadex in patients with end-stage renal disease to establish evidence of safety for sugammadex.

METHODS

We retrospectively collected the medical records of 2,134 patients with end-stage renal disease who were dependent on hemodialysis and underwent surgery under general anesthesia between January 2018 and December 2019. Propensity score matching was used. The primary outcome was the 30-day mortality rate, and secondary outcomes were the 1-year mortality rate and causes of death.

RESULTS

A total of 2,039 patients were included in the study. Sugammadex was administered as a reversal agent for rocuronium in 806 (39.5%) patients; the remaining 1,233 (60.5%) patients did not receive sugammadex. After matching, 1,594 patients were analyzed; 28 (3.5%) of the 797 patients administered sugammadex, and 28 (3.5%) of the 797 patients without sugammadex, died within 30 days after surgery (P > 0.99); 38 (4.8%) of the 797 patients administered sugammadex, and 45 (5.7%) of the 797 patients without sugammadex, died within 1 year after surgery (P = 0.499). No significant differences in the causes of 30-day mortality were observed between the two groups after matching (P = 0.860).

CONCLUSIONS

In this retrospective study, sugammadex did not increase the 30-day and 1-year mortality rate after surgery in end-stage renal disease patients.

Initiation of Dialysis Is Associated With Impaired Cardiovascular Functional Capacity

Background The transition to dialysis period carries a substantial increased cardiovascular risk in patients with chronic kidney disease. Despite this, alterations in cardiovascular functional capacity during this transition are largely unknown. The present study therefore sought to assess ventilatory exercise response measures in patients within 1 year of initiating dialysis. Methods and Results We conducted a cross-sectional study of 241 patients with chronic kidney disease stage 5 from the CAPER (Cardiopulmonary Exercise Testing in Renal Failure) study and from the intradialytic low-frequency electrical muscle stimulation pilot randomized controlled trial cohorts. Patients underwent cardiopulmonary exercise testing and echocardiography. Of the 241 patients (age, 48.9 [15.0] years; 154 [63.9%] men), 42 were predialytic (mean estimated glomerular filtration rate, 14 mL·min-1·1.73 m-2), 54 had a dialysis vintage ≤12 months, and 145 had a dialysis vintage >12 months. Dialysis vintage ≤12 months exhibited a significantly impaired cardiovascular functional capacity, as assessed by oxygen uptake at peak exercise (18.7 [5.8] mL·min-1·kg-1) compared with predialysis (22.7 [5.2] mL·min-1·kg-1; P<0.001). Dialysis vintage ≤12 months also exhibited reduced peak workload, impaired peak heart rate, reduced circulatory power, and increased left ventricular mass index (P<0.05 for all) compared with predialysis. After excluding those with prior kidney transplant, dialysis vintage >12 months exhibited a lower oxygen uptake at peak exercise (17.0 [4.9] mL·min-1·kg-1) compared with dialysis vintage ≤12 months (18.9 [5.9] mL·min-1·kg-1; P=0.033). Conclusions Initiating dialysis is associated with a significant impairment in oxygen uptake at peak exercise and overall decrements in ventilatory and hemodynamic exercise responses that predispose patients to functional dependence. The magnitude of these changes is comparable to the differences between low-risk New York Heart Association class I and higher-risk New York Heart Association class II to IV heart failure.

Screening of malnutrition with malnutrition inflammation score and geriatric nutritional risk index in hemodialysis patients

BACKGROUND AND AIMS

Screening malnutrition, which is the most common complication in hemodialysis patients, is extremely important for these patients. Malnutrition inflammation score (MIS) and geriatric nutritional risk index (GNRI) are malnutrition screening tests used in hemodialysis patients in recent years. The purposes of this study are to evaluate the nutritional status of hemodialysis patients with different screening tests and to determine the cutoff values for this disease-specific MIS and GNRI.

METHODS

The study was conducted with 194 adult patients including 98 males and 96 females whose mean age was 53.1 ± 10.96. Subjective global assessment (SGA) and MIS tests were applied, and the GNRI value was calculated for screening malnutrition. MIS and GNRI cutoff values were obtained by adopting the SGA scores as a standard and drawing a receiver operating characteristic curve. The tatistical Package for the Social Sciences-22.0 package program was used in the analysis.

RESULTS

According to SGA, 70.7% of the patients were nourished, 21.1% were mildly-moderately malnourished, and 8.2% were found to be severely malnourished. The optimal cutoff value predicted for malnutrition was 6.5 points (94.7% sensitivity and 98.5% specificity) for MIS and 86.0 points (64.9% sensitivity and 62.8% specificity) for GNRI. Based on these cutoff values, 28.9% of the patients were determined to be malnourished according to MIS and 45.4% according to GNRI.

CONCLUSION

In conclusion, screening tests are very important in the early identification of malnutrition in hemodialysis patients. This study was conducted to evaluate the malnutrition of hemodialysis patients with different screening tests. At the end of the study, the availability of MIS was found to be high in detecting malnutrition in hemodialysis patients because of its high accuracy and sensitivity of MIS. The cutoff points we identified for both MIS and GNRI are thought to facilitate the determination of malnutrition.

Renal function and mortality in patients with atrial fibrillation

AIM

The aim of this study is to examine the association of the presence of chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) values with mortality in patients with atrial fibrillation.

METHODS

This posthoc analysis of a randomized controlled trial consisted of hospitalized patients with atrial fibrillation who were followed up for a median of 2.7 years after discharge. Kaplan-Meier curves, multivariate Cox-regression and spline curves were utilized to assess the association of CKD, CKD stages 2-5 according to the KDOQI guidelines, and the continuum of eGFR values with the primary outcome of all-cause death, and the secondary outcome of cardiovascular mortality.

RESULTS

Out of 1064 hospitalized patients with atrial fibrillation, 465 (43.7%) had comorbid CKD. The presence of CKD was associated with an increased risk for both all-cause and cardiovascular mortality following hospitalization [adjusted hazard ratio (aHR): 1.60; 95% confidence intervals (95% CIs): 1.25-2.05 and aHR: 1.74; 95% CI: 1.30-2.33, respectively]. The aHRs for all-cause mortality in CKD stages 2-5, as compared with CKD stage 1 were 2.18, 2.62, 4.20 and 3.38, respectively (all P < 0.05). In spline curve analyses, eGFR values lower than 50 ml/min/1.73 m2 were independent predictors of higher all-cause and cardiovascular mortality.

CONCLUSION

In recently hospitalized patients with atrial fibrillation, the presence of CKD was independently associated with decreased survival, which was significant across CKD stages 2-5, as compared with CKD stage 1. Values of eGFR lower than 50 ml/min/1.73 m2 were incrementally associated with worse prognosis.

Efficacy and Safety of Daprodustat for Treatment of Anemia of Chronic Kidney Disease in Incident Dialysis Patients: A Randomized Clinical Trial

IMPORTANCE

Daprodustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor, is being evaluated as an oral alternative to conventional erythropoiesis-stimulating agent (ESA) therapy. Few studies of anemia treatment in an incident dialysis (ID) population have been reported.

OBJECTIVE

To evaluate the efficacy and safety of daprodustat vs darbepoetin alfa in treating anemia of chronic kidney disease in ID patients.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, randomized, open-label clinical trial was conducted from May 11, 2017, through September 24, 2020, in 90 centers across 14 countries. Patients with advanced CKD were eligible if they planned to start dialysis within 6 weeks from screening or had started and received hemodialysis (HD) or peritoneal dialysis (PD) within 90 days before randomization, had a screening hemoglobin (Hb) concentration of 8.0 to 10.5 g/dL (to convert to grams per liter, multiply by 10) and a randomization Hb of 8.0 to 11.0 g/dL, were ESA-naive or had received limited ESA treatment, and were iron-replete.

INTERVENTIONS

Randomized 1:1 to daprodustat or darbepoetin alfa.

MAIN OUTCOMES AND MEASURES

The primary analysis in the intent-to-treat population evaluated the mean change in Hb concentration from baseline to evaluation period (weeks 28-52) to assess noninferiority of daprodustat vs darbepoetin alfa (noninferiority margin, -0.75 g/dL). The mean monthly intravenous (IV) iron dose from baseline to week 52 was the principal secondary end point. Rates of treatment-emergent and serious adverse events (AEs) were also compared between treatment groups to assess safety and tolerability.

RESULTS

A total of 312 patients (median [IQR] age, 55 [45-65] years; 194 [62%] male) were randomized to either daprodustat (157 patients; median [IQR] age, 52.0 [45-63] years; 96 [61%] male) or darbepoetin alfa (155 patients; median [IQR] age, 56.0 [45-67] years; 98 [63%] male); 306 patients (98%) completed the trial. The mean (SD) Hb concentration during the evaluation period was 10.5 (1.0) g/dL for the daprodustat and 10.6 (0.9) g/dL for the darbepoetin alfa group, with an adjusted mean treatment difference of -0.10 g/dL (95% CI, -0.34 to 0.14 g/dL), indicating noninferiority. There was a reduction in mean monthly IV iron use from baseline to week 52 in both treatment groups; however, daprodustat was not superior compared with darbepoetin alfa in reducing monthly IV iron use (adjusted mean treatment difference, 19.4 mg [95% CI, -11.0 to 49.9 mg]). Adverse event rates were 76% for daprodustat vs 72% for darbepoetin alfa.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that daprodustat was noninferior to darbepoetin alfa in treating anemia of CKD and may represent a potential oral alternative to a conventional ESA in the ID population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03029208.

The impact of quality of life measured by WHOQOL-BREF on mortality in maintenance hemodialysis patients: a single center retrospective cross-sectional study

BACKGRUOUND

Several previous studies have reported that quality of life (QoL) in hemodialysis patients affects mortality. However, the 36-item Short Form Health Survey, which has been used mainly in previous studies, is complicated in terms of questionnaire composition and interpretation. This study aimed to identify the impact of QoL on mortality in hemodialysis patients using an easier and simpler diagnostic tool.

METHODS

This retrospective study included 160 hemodialysis patients. QoL was evaluated using the World Health Organization Quality of Life Questionnaire-Brief version (WHOQOL-BREF). Psychosocial factors were evaluated using the Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support, Montreal Cognitive Assessment, and Pittsburgh Sleep Quality Index. We also evaluated medical factors, such as dialysis adequacy and laboratory results.

RESULTS

The mean hemodialysis vintage was 70.7±38.0 months. The proportion of patients who were elderly was higher in the mortality group than in the surviving group, and the Charlson Comorbidity Index score was also higher in the former group. Of the four domains of the WHOQOL-BREF, the physical health and psychological scores of the mortality group were significantly lower than those of the survival group. When the score in the physical health domain or psychological domain was ≤10, the 10-year mortality rate after hemodialysis initiation increased by approximately 2.3- and 2-fold, respectively.

CONCLUSION

QoL may have a significant effect on mortality in patients undergoing hemodialysis. The WHOQOL-BREF is an instrument that can measure QoL relatively easily and can be used to improve the long-term prognosis of patients undergoing hemodialysis.

Allogeneic adipose tissue-derived stem cells ELIXCYTE® in chronic kidney disease: A phase I study assessing safety and clinical feasibility

The purpose of this phase I clinical trial is to assess the safety and tolerability of allogeneic adipose tissue‐derived stem cells (ADSCs) among chronic kidney disease (CKD) patients. 12 eligible CKD patients with an estimated glomerular filtration rate (eGFR) of 15–44 ml/min/1.73 m² received one dose of intravenous allogeneic ADSCs (ELIXCYTE^®), as 3 groups: 3 low dose (6.4 × 10⁷ cells in total of 8 ml), 3 middle dose (19.2 × 10⁷ cells in total of 24 ml) and 6 high dose (32.0 × 10⁷ cells in total of 40 ml) of ELIXCYTE^® and evaluated after 48 weeks. Primary endpoint was the safety profiles in terms of incidence of adverse events (AEs) and serious adverse event (SAE). Two subjects in high dose group experienced a total of 2 treatment‐related AEs which are Grade 1 slow speech and Grade 1 bradyphrenia after the infusion. One subject in middle dose group experienced an SAE unlikely related to treatment, grade 2 proteinuria. No fatal AE was reported in this study. An increase in eGFR was observed in 7 out of 12 subjects (58%) at Week 24 and in 6 of 12 subjects (50%) by Week 48. By Week 24, an increase in eGFR by more than 20% among all CKD patients with baseline eGFR ≧ 30 ml/min/1.73 m² as compared to only 2 subjects in baseline eGFR < 30 ml/min/1.73 m² group. No significant reduction in proteinuria was noted among all subjects. This phase I trial demonstrated single‐dose intravenous ELIXCYTE was well tolerated in moderate‐to‐severe CKD patients and its preliminary efficacy warrants future studies.

Temporal changes and risk factors for death from early withdrawal within 12 months of dialysis initiation-a cohort study

BACKGROUND

Mortality risk is high soon after dialysis initiation in patients with kidney failure, and dialysis withdrawal is a major cause of early mortality, attributed to psychosocial or medical reasons. The temporal trends and risk factors associated with cause-specific early dialysis withdrawal within 12 months of dialysis initiation remain uncertain.

METHODS

Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the temporal trends and risk factors associated with mortality attributed to early psychosocial and medical withdrawals in incident adult dialysis patients in Australia between 2005 and 2018 using adjusted competing risk analyses.

RESULTS

Of 32 274 incident dialysis patients, 3390 (11%) experienced death within 12 months post-dialysis initiation. Of these, 1225 (36%) were attributed to dialysis withdrawal, with 484 (14%) psychosocial withdrawals and 741 (22%) medical withdrawals. These patterns remained unchanged over the past two decades. Factors associated with increased risk of death from early psychosocial and medical withdrawals were older age, dialysis via central venous catheter, late referral and the presence of cerebrovascular disease; obesity and Asian ethnicity were associated with decreased risk. Risk factors associated with early psychosocial withdrawals were underweight and higher socioeconomic status. Presence of peripheral vascular disease, chronic lung disease and cancers were associated with early medical withdrawals.

CONCLUSIONS

Death from dialysis withdrawal accounted for >30% of early deaths in kidney failure patients initiated on dialysis and remained unchanged over the past two decades. Several shared risk factors were observed between mortality attributed to early psychosocial and medical withdrawals.

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.

Epidemiology of haemodialysis outcomes

Haemodialysis (HD) is the commonest form of kidney replacement therapy in the world, accounting for approximately 69% of all kidney replacement therapy and 89% of all dialysis. Over the last six decades since the inception of HD, dialysis technology and patient access to the therapy have advanced considerably, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes vary widely across the world and, overall, the rates of impaired quality of life, morbidity and mortality are high. Cardiovascular disease affects more than two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality. In addition, patients on HD have high symptom loads and are often under considerable financial strain. Despite the many advances in HD technology and delivery systems that have been achieved since the treatment was first developed, poor outcomes among patients receiving HD remain a major public health concern. Understanding the epidemiology of HD outcomes, why they might vary across different populations and how they might be improved is therefore crucial, although this goal is hampered by the considerable heterogeneity in the monitoring and reporting of these outcomes across settings.

This Review examines the epidemiology of haemodialysis outcomes — clinical, patient-reported and surrogate outcomes — across world regions and populations, including vulnerable individuals. The authors also discuss the current status of monitoring and reporting of haemodialysis outcomes and potential strategies for improvement.

Nearly 4 million people in the world are living on kidney replacement therapy (KRT), and haemodialysis (HD) remains the commonest form of KRT, accounting for approximately 69% of all KRT and 89% of all dialysis.

Dialysis technology and patient access to KRT have advanced substantially since the 1960s, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes continue to vary widely across countries, particularly among disadvantaged populations (including Indigenous peoples, women and people at the extremes of age).

Cardiovascular disease affects over two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality; mortality among patients on HD is significantly higher than that of their counterparts in the general population, and treated kidney failure has a higher mortality than many types of cancer. Patients on HD also experience high burdens of symptoms, poor quality of life and financial difficulties.

Careful monitoring of the outcomes of patients on HD is essential to develop effective strategies for risk reduction. Outcome measures are highly variable across regions, countries, centres and segments of the population. Establishing kidney registries that collect a variety of clinical and patient-reported outcomes using harmonized definitions is therefore crucial.

Evaluation of HD outcomes should include the impact on family and friends, and personal finances, and should examine inequities in disadvantaged populations, who comprise a large proportion of the HD population.

Early steps to kidney transplantation among persons with HIV and end-stage renal disease in ESRD network 6

INTRODUCTION

End-stage renal disease is a significant cause of morbidity and mortality in persons with HIV (PWH). Limited data exist on access to kidney transplantation for this population.

METHODS

A dataset inclusive of incident dialysis patients between 2012 and 2016 with follow-up through December 2017 that identifies PWH and the general dialysis population of Network 6 (Georgia, North Carolina, South Carolina) was created through merging the United States Renal Data System with the southeastern early transplant access registry. Early steps to kidney transplantation and patient and dialysis facility-level characteristics that serve as barriers to transplantation were described.

RESULTS

Twenty-three thousand four hundred fourteen patients were identified; 469 were PWH. Compared to non-HIV individuals, PWH were younger (49 vs. 58 years, p < 0.001), predominantly Black (87% vs. 56% p < 0.001) and male (72% vs. 56% p < 0.001). PWH were less likely to be referred to kidney transplant within 1 year of starting dialysis (36% vs. 41% p < 0.001) and waitlisted within 1 year of evaluation-start (14% vs. 30%, p = 0.05). PWH (vs. non-PWH) waited longer for referral, evaluation-start, and waitlisting and in multivariable analysis; HIV positivity was associated with a lower probability of referral (hazard ratios [HR]: 0.70; 95% confidence intervals [CIs]: 0.62-0.80), evaluation (HR 0.66; 95% CI: 0.55-0.80), and waitlisting (HR 0.29; 95% CI: 0.20-0.41).

CONCLUSIONS

Targeted interventions are needed to improve access to kidney transplants, particularly in waitlisting, for PWH.

Epidemiology of cardiovascular death in kidney failure: An Australian and New Zealand cohort study using data linkage

Aim

Cardiovascular mortality risk evolves over the lifespan of kidney failure (KF), as patients develop comorbid disease and transition between treatment modalities. Absolute cardiovascular death rates would help inform clinical practice and health‐care provision, but are not well understood across a continuum of dialysis and transplant states. We aimed to characterize cardiovascular death across the natural history of KF using a lifespan approach.

Methods

We performed a population‐based cohort study of incident patients commencing kidney replacement therapy in Australia and New Zealand. Cardiovascular deaths were identified using data linkage to national death registers. We estimated the probability of death and kidney transplant using multi‐state models, and calculated rates of graft failure and cardiovascular death across demographic factors and comorbidities.

Results

Among 60 823 incident patients followed over 381 874 person‐years, 25% (8492) of deaths were from cardiovascular disease. At 15 years from treatment initiation, patients had a 15.2% probability of cardiovascular death without being transplanted, but only 2.3% probability of cardiovascular death post‐transplant. Females had a 3% lower probability of cardiovascular death at 15 years (15.3% vs. 18.6%) but 4% higher probability of non‐cardiovascular death (54.5% vs. 50.8%). Within the first year of dialysis, cardiovascular mortality peaked in the second month and showed little improvement across treatment era.

Conclusion

Despite improvements over time, cardiovascular death remains common in KF, particularly among the dialysis population and in the first few months of treatment. Multi‐state models can provide absolute measures of cardiovascular mortality across both dialysis and transplant states.

In this population‐based cohort study using multi‐state models (alive without kidney transplant [KT], CV death without KT, non‐CV death without KT, alive after first KT, CV death after first KT and non‐CV death after first KT), the probability of CV death was higher in non‐KT than KT patients at 15 years from treatment. In patients on dialysis, CV mortality was highest from the second month after commencing dialysis and remained high thereafter. Thus, the use of multi‐state models provides helpful information on impacts of different treatments with respect to serious outcomes.

Early Change in Platelet Count and MPV Levels of Patients Who Received Hemodialysis for the First Time: Mogadishu Somalia Experience

INTRODUCTION

Mean platelet volume (MPV) is a marker used to assess the platelet' size and is also an indicator of platelet reactivity and prothrombotic status.

OBJECTIVE

In this study, we aimed to determine the relationship between MPV and biochemical parameters in patients who had received hemodialysis (HD) for the first time and then in respect of those same patients after their fourth HD.

METHOD

151 HD patients were enrolled in this study. Patients were eligible for inclusion if they had received their first HD session during this study protocol. Prehemodialysis blood samples were taken. Most laboratory values, including mean platelet volume (MPV) level and platelets (PLT) count, were measured before the first HD and after the fourth HD session for each patient.

RESULTS

Among the patients in our study, the mean age profile of the male patients (n = 103; 68.2%) was found to be higher than that of the female patients (n = 48; 31.8%) (53.62 ± 18.19 vs. 46.17 ± 17.9 years) (p = 0.019).In the patients' laboratory results after the fourth HD session, MPV, MPV/Plt, and Na values had increased to those after the first HD session (p < 0.001). When age and gender status were taken into account, the level of weak positive correlation with white blood cell count (WBC), neutrophil, and red cell distribution width (RDW) was found, while the weak negative correlation with platelet to lymphocyte ratio (PLR) was found (p < 0.001).

CONCLUSIONS

In our study, we found that increase in MPV and MPV/PLT levels was significant in the fourth HD session of patients with CKD. It is also debatable that there are findings indicating an increase in platelet reactivity in the first weeks of the onset of HD. This could be an early indicator of the early prevention of cardiovascular diseases.

Urgent Start Peritoneal Dialysis: A Population-Based Cohort Study,

Rationale & Objective

It is a common practice to start patients in urgent need of dialysis on hemodialysis via a central venous catheter. Because central venous catheter use is associated with increased risk of infections, hospitalizations, and mortality, urgent start peritoneal dialysis (PD) increasingly represents a viable alternative. This study aimed to examine clinical outcomes, complications, mortality, and modality retention in patients who initiated urgent start PD.

Study Design

Retrospective cohort study.

Setting and Participants

Eighty-four adult members of a large integrated health care system who initiated urgent start PD between January 1, 2011, and December 31, 2014.

Exposure

Urgent start PD.

Outcomes

Retention rates at 30, 90, and 365 days; time to the development of noninfectious and infectious complications, modality failure, and all-cause mortality.

Analytical Approach

Cumulative incidence of all-cause mortality was estimated using the Kaplan-Meier method. Retention rates for PD were computed using binomial proportions.

Results

Occurrence of major complications was less than 5%. Catheter malfunction occurred in 6% of cases; of those, catheter patency could be established in 80%. Infectious complications occurred in 20% of patients who initiated PD and included peritonitis and exit site infections. At 365 days after initiation, the cumulative incidence of all-cause mortality was 9.7% (95% CI, 4.7%-19.4%). PD retention rates were 98.8%, 91.3%, and 80.0% at 30 days, 90 days, and 1 year, respectively.

Limitations

Retrospective cohort design, a well-matched comparable group of urgent start hemodialysis patients could not be identified, small number of patients in a single integrated health care system, uncertain or limited generalizability of findings to other health care systems.

Conclusions

At 1 year after initiation, patients who initiated urgent start PD had high survival and modality retention rates. In unplanned initiation of dialysis, urgent start PD is a viable and sustainable option and should be considered in selected patients to optimize care.

Quality assuring early dialysis care: evaluating rates of death and recovery within 90 days of first dialysis using the UK Renal Registry

Background

Kidney disease registries typically report populations incident to kidney replacement therapy (KRT) after excluding reversible disease. Registry-based audit and quality assurance is thus based on populations depleted of those with the highest early mortality. It is now mandatory for UK kidney units to report all recipients of dialysis, both acute and chronic. This work presents 90-day survival and recovery outcomes for all reported adults.

Methods

Seventy adult centres reporting to the UK Renal Registry were included. Those assessed as underreporting death and recovery were excluded. Survival was evaluated using a Kaplan–Meier estimator. Cox regression was used to describe hazard ratios (HRs) for age, sex and acute/chronic dialysis coding on day 1. Analysis of all-cause 90-day mortality with recovery as a competing risk is presented.

Results

Twenty-four centres were assessed as underreporting, with rates of death/recovery below the 99.7th centile. Of 5784 dialysis starters in the remaining 46 centres, 2163 (37.4%) were coded as receiving acute dialysis on day 1. Ninety days after starting, 3860 (66.7%) of all starters were receiving KRT, 1157 (20.0%) were alive having stopped, 716 (12.4%) were dead and 51 (0.9%) were lost to follow-up. Mortality was higher among those coded as receiving acute dialysis on day 1 (HR 4.88, P &lt; 0.001). The sub-HR for recovery among those coded as receiving acute compared with chronic dialysis was 56.14 (P &lt; 0.001).

Conclusions

Death and recovery rates are substantially higher than reported in conventional incident populations. This work highlights a vulnerable subgroup of patients largely overlooked by most national quality assurance systems.

Smoothing transition to dialysis to improve early outcomes after dialysis initiation among old and frail adults-a narrative review

The number of patients ≥65 years of age suffering from advanced chronic kidney disease and transitioning to end-stage kidney disease (ESKD) is increasing. However, elderly patients often have poor outcomes once haemodialysis is initiated, including high mortality within the first year as well as fast cognitive and functional decline and diminished quality of life. The question is how we can smooth this transition to ESKD in older patients who also exhibit much higher proportions of frailty when compared with community-dwelling non-dialysis older adults and who are generally more vulnerable to invasive treatment such as kidney replacement therapy. To avoid early death and poor quality of life, a carefully prepared smooth transition should precede the initiation of treatment. This involves pre-dialysis physical and educational care, as well as mental and psychosocial preparedness of the patient to enable an informed and shared decision about the individual choice of treatment modality. Communication between a healthcare professional and patient plays a pivotal role but can be challenging given the high rate of cognitive impairment in this particular population. In order to practise patient-centred care, adapting treatment tailored to the individual patient should include comprehensive conservative care. However, structured treatment pathways including multidisciplinary teams for such conservative care are still rare and may be difficult to establish outside of large cities. Generally, geriatric nephrology misses data on the comparative effectiveness of different treatment modalities in this population of old and very old age on which to base recommendations and decisions.

Predictors of Mortality within 24 Months of Initial Arteriovenous Access Creation

INTRODUCTION

End Stage Renal Disease is increasingly common, with approximately 785,880 patients currently dialysis dependent in the United States. 86% of these patients utilize hemodialysis. Arteriovenous (AV) access with either a fistula or graft is preferred over a catheter due to lowered complication risk. The purpose of this paper is to identify mid- term predictors of mortality to guide the type of AV access in patients with suboptimal cephalic veins.

METHODS

This is a retrospective review of patient characteristics at the time of initial AV access placement. All patients receiving first time AV access were reviewed. Mortality data was found via electronic medical records review, social security death index review, and internet search. Patients in whom mortality data could not be found were excluded from the final analysis. Univariate analysis using Chi-Squared testing and Student T-Test was performed. Binary logistic regression analysis was also performed for multivariate investigation.

RESULTS

A total of 176 patients underwent first time AV access during the study period. Two year mortality data was available for 149 of these patients. Mortality occurred within 2 years for 27% of patients. Advanced age (70 vs. 61, P < 0.01), arrhythmia (48% vs. 24%, P < 0.01), abnormal EKG (36% vs.14%, P < 0.01), CHF (47% vs. 24%, P < 0.01), white, non-Hispanic race (51% vs. 22%, P < 0.01) and history of smoking (48% vs. 15%, P < 0.01) were statistically significant univariate predictors of 2-year mortality. Advanced age, white race and smoking were multivariate predictors with smoking having the largest impact (multivariate adjusted OR 11.8, P < 0.001).

CONCLUSIONS

History of tobacco smoking has a profoundly negative effect on two year survival in patients undergoing initial AV access. Absence of smoking history provides significant 2-year mortality protection and thorough attempt at autologous AVF creation should be made in these patients. Cardiac disease and advanced age continue to be lead predictors of mortality in ESRD patients.

A Step Closer to the "Fourth 90": A Practical Narrative Review of Diagnosis and Management of Nutritional Issues of People Living with HIV

The quality of life of people living with HIV (PLWH) has remarkably increased thanks to the introduction of combined antiretroviral therapy. Still, PLWH are exposed to an increased risk of cardiovascular diseases, diabetes, chronic kidney disease, and liver disease. Hence, the purpose of this review is to summarize the current knowledge about diagnosis and nutritional management with specific indication of macro and micronutrients intake for the main comorbidities of PLWH. In fact, a prompt diagnosis and management of lifestyle behaviors are fundamental steps to reach the "fourth 90". To achieve an early diagnosis of these comorbidities, clinicians have at their disposal algorithms such as the Framingham Score to assess cardiovascular risk; transient elastography and liver biopsy to detect NAFLD and NASH; and markers such as the oral glucose tolerance test and GFR to identify glucose impairment and renal failure, respectively. Furthermore, maintenance of ideal body weight is the goal for reducing cardiovascular risk and to improve diabetes, steatosis and fibrosis; while Mediterranean and low-carbohydrate diets are the dietetic approaches proposed for cardioprotective effects and for glycemic control, respectively. Conversely, diet management of chronic kidney disease requires different nutritional assessment, especially regarding protein intake, according to disease stage and eventually concomitant diabetes.

Gender Disparities in Vascular Access and One-Year Mortality among Incident Hemodialysis Patients: An Epidemiological Study in Lazio Region, Italy

(1) Background: Interest in gender disparities in epidemiology, clinical features, prognosis and health care in chronic kidney disease patients is increasing. Aims of the study were to evaluate the association between gender and vascular access (arteriovenous fistula (AVF) or central venous catheter (CVC)) used at the start of hemodialysis (HD) and to investigate the association between gender and 1-year mortality. (2) Methods: The study includes 9068 adult chronic HD patients (64.7% males) registered in the Lazio Regional Dialysis Register (January 2008–December 2018). Multivariable logistic regression models were used to investigate the associations between gender and type of vascular access (AVF vs. CVC) and between gender and 1-year mortality. Interactions between gender and socio-demographic and clinical variables were tested adding the interaction terms in the final model. (3) Results: Females were older, had lower educational level and lower rate of self-sufficiency compared to males. Overall, CVC was used in 51.2% of patients. Females were less likely to use AVF for HD initiation than males. 1354 out of 8215 (16.5%) individuals died at the end of the follow-up period. Interaction term between gender and vascular access was significant in the adjusted model. From stratified analyses by vascular access, OR female vs. male (AVF) = 0.65; 95% CI 0.48–0.87 and OR female vs. male (CVC) = 0.88; 95% CI 0.75–1.04 were found. (4) Conclusions: This prospective population-based cohort study in a large Italian Region showed that in females starting chronic HD AVF was less common respect to men. The better 1-year survival of females is more evident among those women with AVF. Reducing gender disparity in access to AVF represents a key point in the management of HD patients.

The dialysis facility levels and sizes are associated with outcomes of incident hemodialysis patients

The outcomes of patients with incident kidney failure who start hemodialysis are influenced by several factors. Whether hemodialysis facility characteristics are associated with patient outcomes is unclear. We included adults diagnosed as having kidney failure requiring hemodialysis during January 1, 2001 to December 31, 2013 from the Taiwan National Health Insurance Research Database to perform this retrospective cohort study. The exposures included different sizes and levels of hemodialysis facilities. The outcomes were all-cause mortality, cardiovascular death, infection-related death, hospitalization, and kidney transplantation. During 2001-2013, we identified 74,406 patients and divided them in to three groups according to the facilities where they receive hemodialysis: medical center (n = 8263), non-center hospital (n = 40,008), and clinic (n = 26,135). The multivariable Cox model demonstrated that a larger facility size was associated with a low mortality risk (hazard ratio [HR] 0.991, 95% confidence interval [95% CI] 0.984-0.998; every 20 beds per facility). Compared with medical centers, patients in non-center hospitals and clinics had higher mortality risks (HR 1.13, 95% CI 1.09-1.17 and HR 1.11, 95% CI 1.06-1.15, respectively). Patients in medical centers and non-center hospitals had higher risk of hospitalization (subdistribution HR [SHR] 1.11, 95% CI 1.10-1.12 and SHR 1.22, 95% CI 1.21-1.23, respectively). Patients in medical centers had the highest rate of kidney transplantation among the three groups. In patients with incident kidney failure, a larger hemodialysis facility size was associated with lower mortality. Overall, medical center patients had a lower mortality rate and higher transplantation rate, whereas clinic patients had a lower hospitalization risk.

A maintenance hemodialysis mortality prediction model based on anomaly detection using longitudinal hemodialysis data

BACKGROUND

Most end-stage renal disease patients rely on hemodialysis (HD) to maintain their life, and they face a serious financial burden and high risk of mortality. Due to the current situation of the health care system in China, a large number of patients on HD are lost to follow-up, making the identification of patients with high mortality risks an intractable problem.

OBJECTIVE

This paper aims to propose a maintenance HD mortality prediction approach using longitudinal HD data under the situation of data imbalance caused by follow-up losses.

METHODS

A long short-term memory autoencoder (LSTM AE) based model is proposed to capture the physical condition changes of HD patients and distinguish between surviving and nonsurviving patients. The approach adopts anomaly detection theory, using only the surviving samples in the model training and identifying dead samples based on autoencoder reconstruction errors. The data are from a Chinese hospital electronic health record system between July 30, 2007, and August 25, 2016, and 36/72/108 continuous HD sessions were used to predict mortality within prediction windows of 90/180/365 days. Furthermore, the model performance is compared to that of logistic regression, support vector machine, random forest, LSTM classifier, isolation forest, and stacked autoencoder models.

RESULTS

Data for 1200 patients (survival: 1055, death: 145) were used to predict mortality during the next 90 days using 36 continuous HD sessions. The area under the PR curve for the LSTM AE was 0.57, the Recall_macro was 0.86, and the F1-score_macro was 0.87, outperforming the other models. Upon varying the observation window or prediction window length, LSTM AE continued to outperform the other models. According to the variable importance analysis, the dialysis session length was the feature that contributed the most to the prediction model.

CONCLUSIONS

The proposed approach was able to detect patients on maintenance HD with high mortality risk from an imbalanced dataset using anomaly detection theory and leveraging longitudinal HD data.

Improvements in six aspects of quality of care of incident hemodialysis patients - a real-world experience

Background

The transition from chronic kidney disease stage 5 to initiation of hemodialysis has gained increased attention in recent years as this period is one of high risk for patients with an annual mortality rate exceeding 20%. Morbidity and mortality in incident hemodialysis patients are partially attributed to failure to attain guideline-based targets. This study focuses on improvements in six aspects of quality of dialysis care (adequacy, anemia, nutrition, chronic kidney disease-mineral bone disorder (CKD-MBD), blood pressure and vascular access) aligning with KDIGO guidelines, during the first 6 months of hemodialysis.

Methods

We analyzed patient demographics, practice patterns and laboratory data in all 3 462 patients (mean age 65.9 years, 41% females) on hemodialysis (incident <90 days on hemodialysis, n=603, prevalent ≥90 days on hemodialysis, mean 55 months, n=2 859) from all 56 DaVita centers in Poland (51 centers) and Portugal (5 centers). 80% of patients had hemodialysis and 20% hemodiafiltration. Statistical analyses included unpaired and paired Students t-test, Chi-2 analyses, McNemar test and logistic regression analysis.

Results

Incident patients had lower Kt/V (1.4 vs 1.7, p<0.001), lower serum albumin (37 vs 40 g/l, p=0.001), lower Hb (9.9 vs 11.0 g/dl, p<0.001), lower TSAT (26 vs 31%, p<0.001), lower iPTH (372 vs 496 pg/ml, p<0.001), more often a central venous catheter (68 vs 26%, p<0.001), less often an AV fistula (34 vs 70 %, p<0.001) compared with all prevalent patients. Significantly more prevalent patients achieved international treatment targets.

Improvements in quality of care was also analyzed in a subgroup of 258 incident patients who were followed prospectively for 6 months. We observed significant improvements in Kt/V (p<0.001), albumin (p<0.001), Hb (p<0.001) transferrin saturation (TSAT, p<0.001), iPTH (p=0.005) and an increased use of AV fistula (p<0.001). Furthermore, logistic regression analyses identified treatment time and TSAT as major factors influencing the attainment of adequacy and anemia treatment targets.

Conclusion

This large real-world European multicenter analysis of representative incident hemodialysis patients indicates that the use of medical protocols and medical targets assures significant improvements in quality of care, which may correspond to better outcomes. A selection bias of survivors with less comorbidities in prevalent patients may have influenced the results.

Shared decision-making in hemodialysis vascular access practice

Shared decision-making (SDM) is a process of collaborative deliberation in the dyadic patient-physician interaction whereby physicians inform the patients about the pros and cons of all available treatment options and reach an agreement with the patients on their preferred treatment plan. In hemodialysis vascular access practice, SDM advocates a deliberative approach based on the existence of reasonable alternatives-that is, arteriovenous fistula, arteriovenous graft, and central venous catheter-so that patients are able to form and share preferences about access options. In spite of its ethical imperative, SDM is not broadly applied in hemodialysis vascular access planning. Physicians and surgeons commonly deliver prescriptive fistula-centered recommendations concerning the approach to vascular access care. This paternalistic approach has been shaped by directions from long-held clinical practice guidelines and is reinforced by financial payment models linked with the prevalence of arteriovenous fistula in patients on hemodialysis. Awareness is growing that what may have initially seemed a medically and surgically appropriate approach might not always be focused on each individual's goals of care. Clinician's recommendations for vascular access often do not sufficiently consider the uncertainty surrounding the potential benefits of the decision or the cumulative impact of the decision on patient's quality of life. In the evolving health care landscape, it is time for the practice of hemodialysis vascular access to shift from a hierarchical doctor-patient approach to patient-centered care. In this article we review the current state of vascular access practice, present arguments why SDM is necessary in vascular access planning, review barriers and potential solutions to SDM implementation, and discuss future research contingent on an effective system of physician-patient participative decision-making in hemodialysis vascular access practice.

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.

New Frontiers in Vascular Access Practice: From Standardized to Patient-tailored Care and Shared Decision Making

Vascular access planning is critical in the management of patients with advanced kidney disease who elect for hemodialysis for RRT. Policies put in place more than two decades ago attempted to standardize vascular access care around the model of optimal, namely arteriovenous fistula, and least preferred, namely central venous catheter, type of access. This homogenized approach to vascular access care emerged ineffective in the increasingly heterogeneous and complex dialysis population. The most recent vascular access guidelines acknowledge the limitations of standardized care and encourage tailoring vascular access care on the basis of patient and disease characteristics. In this article, we discuss available literature in support of patient-tailored access care on the basis of differences in vascular access outcomes by biologic and social factors-age, sex, and race. Further, we draw attention to the overlooked dimension of patient-reported preferences and shared decision making in the practice of vascular access planning. We discuss milestones to overcome as requisite steps to implement effective shared decision making in vascular access care. Finally, we take into consideration local practice cofactors as major players in vascular access fate. We conclude that a personalized approach to hemodialysis vascular access will require dynamic care specifically relevant to the individual on the basis of biologic factors, fluctuating clinical needs, values, and preferences.