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McGinn R, McCluskey SA, Sayed BA, Goto T, Chan CT, Murphy P. Intraoperative hemodialysis with supra- and infradiaphragmatic catheters for liver transplantation. Can J Anaesth 2024; 71:1165-1171. [PMID: 38877135 DOI: 10.1007/s12630-024-02777-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 06/16/2024] Open
Abstract
PURPOSE The benefits of intraoperative dialysis during orthotopic liver transplantation remain controversial. In patients with anuric renal failure and portopulmonary hypertension, maintaining venous return during caval clamping and unclamping along with minimizing fluid overload is critical to avoiding right ventricular strain and failure. CLINICAL FEATURES We present the case of a 54-yr-old female who underwent orthotopic liver transplantation for alcohol-related liver disease with acute decompensation including severe hepatorenal syndrome (anuric requiring dialysis), probable hepatopulmonary syndrome, moderate pulmonary hypertension (right ventricular systolic pressure, 44 mm Hg), hepatic encephalopathy (grade 2), and esophageal varices. Prior to incision, pulmonary arterial pressures were 48/28 (mean, 35) mm Hg with a central venous pressure of 30 mm Hg, cardiac output of 7.4 L·min-1, and pulmonary vascular resistance of 98 dynes·sec·cm-5. In the context of right ventricular strain and volume overload observed on transthoracic echocardiography, we inserted an additional dialysis catheter into the right femoral vein. We initiated dialysis using the two catheters as a circuit (femoral line to the dialysis machine; blood was reinjected via the subclavian line) acting as a limited venovenous bypass, allowing right ventricular offloading and hemodialysis throughout the case. We removed 4.5 L via hemodialysis during the surgery, while avoiding acidosis, hyperkalemia, and sodium shifts. The patient tolerated reperfusion adequately despite pre-existing right ventricular dilation and dysfunction. CONCLUSION We report on the use two hemodialysis catheters in a patient undergoing orthotopic liver transplantation as a circuit for simultaneous anuric hepatorenal syndrome and moderate pulmonary hypertension with right ventricular dilation and dysfunction. We believe this technique was instrumental in the patient's successful transplant.
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Affiliation(s)
- Ryan McGinn
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Blayne A Sayed
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Toru Goto
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Patricia Murphy
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth St, 3EN-464, Toronto, ON, M5G 2C4, Canada.
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Murea M, Raimann JG, Divers J, Maute H, Kovach C, Abdel-Rahman EM, Awad AS, Flythe JE, Gautam SC, Niyyar VD, Roberts GV, Jefferson NM, Shahidul I, Nwaozuru U, Foley KL, Trembath EJ, Rosales ML, Fletcher AJ, Hiba SI, Huml A, Knicely DH, Hasan I, Makadia B, Gaurav R, Lea J, Conway PT, Daugirdas JT, Kotanko P. Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial). Trials 2024; 25:424. [PMID: 38943204 PMCID: PMC11212207 DOI: 10.1186/s13063-024-08281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/20/2024] [Indexed: 07/01/2024] Open
Abstract
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.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA.
| | | | - Jasmin Divers
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Harvey Maute
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Emaad M Abdel-Rahman
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Alaa S Awad
- Division of Nephrology, University of Florida, Jacksonville, FL, USA
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Samir C Gautam
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Vandana D Niyyar
- Division of Nephrology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Glenda V Roberts
- External Relations and Patient Engagement, Division of Nephrology, Department of Medicine, Kidney Research Institute and Center for Dialysis Innovation, University of Washington, Seattle, WA, USA
| | | | - Islam Shahidul
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Ucheoma Nwaozuru
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kristie L Foley
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Alison J Fletcher
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Sheikh I Hiba
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Anne Huml
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Daphne H Knicely
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Irtiza Hasan
- Division of Nephrology, University of Florida, Jacksonville, FL, USA
| | | | - Raman Gaurav
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Janice Lea
- Division of Nephrology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Paul T Conway
- American Association of Kidney Patients, Tampa, FL, USA
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Peter Kotanko
- Department of Internal Medicine, Section on Nephrology, LLC Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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3
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Elsayed E, Farag YM, Ravi KS, Chertow GM, Mc Causland FR. Association of Changes in Vector Length with Changes in Left Ventricular Mass among Patients on Maintenance Hemodialysis: A Secondary Analysis of the Frequent Hemodialysis Network Daily Trial. KIDNEY360 2024; 5:870-876. [PMID: 38656312 PMCID: PMC11219120 DOI: 10.34067/kid.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
Key Points Bioimpedance has been proposed as an objective method to assess volume status among patients receiving maintenance hemodialysis. The Frequent Hemodialysis Network Daily Trial measured bioimpedance parameters of volume status (vector length) and cardiac magnetic resonance imaging at baseline and 12 months. We observed that changes in vector length were inversely associated with changes in left ventricular mass and volume over a 12-month period. Background Hypervolemia is thought to be a major contributor to higher left ventricular mass (LVM), a potent predictor for cardiovascular mortality among patients on maintenance hemodialysis. We hypothesized that a decrease in vector length (a bioimpedance proxy of hypervolemia) would be associated with an increase in LVM. Methods Using data from the Frequent Hemodialysis Network Daily Trial (n =160), we used linear regression to assess the association of changes in vector length from baseline to month 12 with changes in magnetic resonance imaging measures of LVM and other cardiac parameters. We adjusted models for the randomized group, baseline vector length, age, sex, race, body mass index, vascular access, dialysis vintage, history of hypertension, heart failure, and diabetes, residual kidney function, predialysis systolic BP, ultrafiltration rate, serum-dialysate sodium gradient, hemoglobin, phosphate, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, erythropoietin dose, and equilibrated Kt/V. Results The mean age of the patients was 50±13 years; 35% were female. In the fully adjusted models, a decline in vector length (per 50 Ω/m; i.e ., increase in volume) was associated with a 6.8 g (95% confidence interval [CI], −0.1 to 13.7) and 2.6 g/m2 (95% CI, −1.2 to 6.3) increase in LVM and LVM index, respectively, and an increase of 15.0 ml (95% CI, 7.5 to 22.4), 7.3 ml (95% CI, 3.0 to 12.7), 7.8 ml (95% CI, 3.0 to 12.7), and −0.9% (95% CI, −3.1 to 1.3) in left ventricular end-diastolic volume, left ventricular end-systolic volume, left ventricular stroke volume, and left ventricular ejection fraction, respectively. The lowest tertile of change in vector length (i.e ., greater increase in volume) was associated with greater increases in left ventricular end-diastolic volume and left ventricular stroke volume, versus the highest tertile. There was no evidence of heterogeneity by randomized group. Conclusions Change in vector length, a bioimpedance-derived proxy of volume status, was inversely associated with indices of LVM and volume measured by cardiac magnetic resonance imaging in patients randomized to conventional or frequent hemodialysis over 12 months.
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Affiliation(s)
- Enass Elsayed
- Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Youssef M.K. Farag
- Bayer US, LLC, Pittsburgh, Pennsylvania
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Katherine Scovner Ravi
- Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Glenn M. Chertow
- Departments of Medicine, Epidemiology and Population Health, and Health Policy, Stanford University School of Medicine, Stanford, California
| | - Finnian R. Mc Causland
- Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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4
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El Shamy O, Abra G, Chan C. Patient-Centered Home Hemodialysis: Approaches and Prescription. Clin J Am Soc Nephrol 2024; 19:517-524. [PMID: 37639246 PMCID: PMC11020435 DOI: 10.2215/cjn.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/15/2023] [Indexed: 08/29/2023]
Abstract
Writing a home hemodialysis (HD) prescription is a complex, multifactorial process that requires the incorporation of patient values, preferences, and lifestyle. Knowledge of the different options available for home HD modality (conventional, nocturnal, short daily, and alternate nightly) is also important when customizing a prescription. Finally, an understanding of the different home HD machines currently approved for use at home and their different attributes and limitations helps guide providers when formulating their prescriptions. In this review article, we set out to address these different aspects to help guide providers in providing a patient-centered home HD approach.
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Affiliation(s)
- Osama El Shamy
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Graham Abra
- Satellite Healthcare, San Jose, California
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Christopher Chan
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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5
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Chandramohan D, Rajasekaran R, Konda R, Pujari A, Avula S, Bell M, Palleti SK, Deotare A, Naik R, Bali A, Simhadri P, Arora H, Jena N. Cardiac Magnetic Resonance Imaging Findings in Patients With Chronic Kidney Disease and End-Stage Kidney Disease: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e51672. [PMID: 38313918 PMCID: PMC10838180 DOI: 10.7759/cureus.51672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/06/2024] Open
Abstract
In this systematic review and meta-analysis, we explored the utilization of cardiac magnetic resonance imaging (CMR) to detect fibrotic changes secondary to uremic cardiomyopathy during the early stages of chronic kidney disease (CKD) and in patients with end-stage kidney disease (ESKD). Uremic myocardial fibrosis can lead to arrhythmia and heart failure, and it is important to detect these changes. CMR offers a noninvasive way to characterize the severity of cardiac remodeling. A comprehensive search of multiple electronic databases was conducted. Studies were divided according to scanner field strength (1.5 or 3 Tesla). The random effects model was used to calculate the pooled mean, 95% confidence interval (CI), standard error, and standardized mean difference (SMD). The I2 statistic was used to assess the heterogeneity between study-specific estimates. The search retrieved 779 studies. From these, 20 studies met the inclusion criteria and had 642 CKD patients (mean age of 56.8 years; 65.2% males; mean estimated glomerular filtration rate (eGFR) of 33 mL/min/1.73 m2) and 658 ESKD patients on dialysis (mean age of 55.6 years; 63.3% males; mean dialysis duration of 3.47 years). CKD patients had an increased left ventricular mass index (LVMi) compared to controls, with an SMD of 0.37 (95% CI: 0.20-0.54; I2 0%; p-value <0.05). ESKD patients also had increased LVMi compared to controls, SMD 0.88 (95% CI: 0.35-1.41; I2 79.1%; p-value 0.001). Myocardial fibrosis assessment using T1 mapping showed elevated values; the SMD of native septal T1 values between CKD and controls was 1.099 (95% CI: 0.73-1.46; I2 33.6%; p-value <0.05), and the SMD of native septal T1 values between ESKD patients and controls was 1.12 (95% CI: 0.85-1.38; I2 33.69%; p-value <0.05). In conclusion, patients with CKD and ESKD with preserved left ventricular ejection fraction (LVEF) have higher LVMi and T1 values, indicating increased mass and fibrosis. T1 mapping can be used for the early detection of cardiomyopathy and as a risk stratification tool. Large, randomized trials are needed to confirm these findings and determine the effect of long-term dialysis on cardiac fibrosis.
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Affiliation(s)
| | - Rhoshini Rajasekaran
- General Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, IND
| | | | - Ashwini Pujari
- Nephrology, University of Alabama at Birmingham, Birmingham, USA
| | - Sreekant Avula
- Diabetes, Endocrinology, and Metabolism, University of Minnesota, Minneapolis, USA
| | - Megan Bell
- Libraries, University of Alabama at Birmingham, Birmingham, USA
| | - Sujith K Palleti
- Nephrology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Apoorv Deotare
- Nephrology, Montgomery Kidney Specialists, Montgomery, USA
| | - Roopa Naik
- Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
- Internal Medicine/Hospital Medicine, Geisinger Health System, Wilkes-Barre, USA
| | - Atul Bali
- Internal Medicine/Nephrology, Geisinger Medical Center, Danville, USA
- Internal Medicine/Nephrology, Geisinger Health System, Wilkes-Barre, USA
- Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Prathap Simhadri
- Internal Medicine/Nephrology, AdventHealth, Florida State University College of Medicine, Daytona Beach, USA
| | - Harkesh Arora
- Hospital Medicine, Lovelace Medical Center, Albuquerque, USA
| | - Nihar Jena
- Cardiovascular Medicine, Wayne State University, Pontiac, USA
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6
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Rocco MV, Rigaud M, Ertel C, Russell G, Zemdegs J, Vecchio M. Fluid Intake Management in Maintenance Hemodialysis Using a Smartphone-Based Application: A Pilot Study. Kidney Med 2023; 5:100703. [PMID: 37663954 PMCID: PMC10470202 DOI: 10.1016/j.xkme.2023.100703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Rationale & Objective Increased interdialytic weight gain (IDWG) has been associated with increased morbidity and mortality. We evaluated the usefulness and safety of a mobile application (app) that allows patients receiving maintenance hemodialysis to self-monitor their daily fluid intake. Study Design Within group comparison before or during intervention. Setting & Participants Patients receiving maintenance hemodialysis with mean IDWG of <4%. Exposure Participants were trained to use a smartphone-based app, FiApp that allowed them to record fluid intake and compare with individual targeted daily fluid intake determined by the nephrologist. Outcomes The primary study outcome was the association between IDWG and fluid intake recorded in the FiApp. Secondary outcomes included FiApp safety and usage. Patient interviews were performed at weeks 1 and 4 to collect information regarding FiApp usability and recommendations for app improvements. Analytical Approach Mean, median, and standard deviation. Results Eighteen of 25 patients completed the full 4-week study, provided all app data, and completed 2 patient interviews. The mean 4-week IDWG during app use was similar to the baseline mean 4-week IDWG before app use; however, 61% of the participants had a decrease in IDWG when using the app compared with IDWG at baseline. Of the 18 participants who completed the study, only 1 had a mean 4-week IDWG that was 20% higher than that at baseline. The app was used on ≥80% of the days by 13 (72%) of 18 participants, and was used every day in 7 (39%) of 18 participants. The mean relationship between fluid reported in the app and fluid consumed was 40%. Limitations This safety study recruited patients who had IDWG of <4%. Conclusions A smartphone-based app can be safely used to help patients receiving maintenance hemodialysis track and control fluid intake. Motivated patients were able to decrease IDWG despite baseline IDWG being <4% of the body weight. Trial Registration NCT03759847. Plain-Language Summary Patients receiving maintenance hemodialysis struggle to limit fluid intake. Excess fluid intake can lead to adverse cardiovascular events. We developed a smartphone app to help patients receiving dialysis self-monitor their fluid intake. In this safety study in patients receiving dialysis with an interdialytic weight gain of <4% of the body weight, more than half of the patients were able to decrease their interdialytic fluid intake while using the app, and only 1 patient had an increase in interdialytic weight gain of >20% while using the app. Information gleaned from structured patient interviews will be used to refine this app.
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Affiliation(s)
- Michael V. Rocco
- Wake Forest University School of Medicine, Section on Nephrology, Winston-Salem, NC
| | | | | | - Greg Russell
- Wake Forest University School of Medicine, Department of Biostatistics and Data Science, Winston-Salem, NC
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Natale P, Ju A, Strippoli GF, Craig JC, Saglimbene VM, Unruh ML, Stallone G, Jaure A. Interventions for fatigue in people with kidney failure requiring dialysis. Cochrane Database Syst Rev 2023; 8:CD013074. [PMID: 37651553 PMCID: PMC10468823 DOI: 10.1002/14651858.cd013074.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD). OBJECTIVES We aimed to evaluate the effects of pharmacological and non-pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Studies evaluating pharmacological and non-pharmacological interventions affecting levels of fatigue or fatigue-related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue-related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered. DATA COLLECTION AND ANALYSIS Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Ninety-four studies involving 8191 randomised participants were eligible. Pharmacological and non-pharmacological interventions were compared either to placebo or control, or to another pharmacological or non-pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis-Related Fatigue scale score): SMD -1.18, 95% CI -2.04 to -0.31; I2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD -1.23, 95% CI -1.96 to -0.50; I2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD -1.06, 95% CI -1.47, -0.65; I2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD -0.64, 95% CI -1.03 to -0.25; I2 = 75%) in HD. A wide range of heterogenous interventions and fatigue-related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non-pharmacological interventions on fatigue or fatigue-related outcomes, including non-physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive-behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta-blockers, anabolic steroids, glucose-enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non-pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported. AUTHORS' CONCLUSIONS Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non-pharmacological interventions had uncertain effects on fatigue or fatigue-related outcomes in people receiving dialysis. Future adequately powered, high-quality studies are likely to change the estimated effects of interventions for fatigue and fatigue-related outcomes in people receiving dialysis.
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Affiliation(s)
- Patrizia Natale
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Angela Ju
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Giovanni Fm Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Mark L Unruh
- University of New Mexico, Department of Internal Medicine, Albuquerque, New Mexico, USA
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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8
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Mark PB, Mangion K, Rankin AJ, Rutherford E, Lang NN, Petrie MC, Stoumpos S, Patel RK. Left ventricular dysfunction with preserved ejection fraction: the most common left ventricular disorder in chronic kidney disease patients. Clin Kidney J 2022; 15:2186-2199. [PMID: 36381379 PMCID: PMC9664574 DOI: 10.1093/ckj/sfac146] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 08/25/2023] Open
Abstract
Chronic kidney disease (CKD) is a risk factor for premature cardiovascular disease. As kidney function declines, the presence of left ventricular abnormalities increases such that by the time kidney replacement therapy is required with dialysis or kidney transplantation, more than two-thirds of patients have left ventricular hypertrophy. Historically, much research in nephrology has focussed on the structural and functional aspects of cardiac disease in CKD, particularly using echocardiography to describe these abnormalities. There is a need to translate knowledge around these imaging findings to clinical outcomes such as unplanned hospital admission with heart failure and premature cardiovascular death. Left ventricular hypertrophy and cardiac fibrosis, which are common in CKD, predispose to the clinical syndrome of heart failure with preserved left ventricular ejection fraction (HFpEF). There is a bidirectional relationship between CKD and HFpEF, whereby CKD is a risk factor for HFpEF and CKD impacts outcomes for patients with HFpEF. There have been major improvements in outcomes for patients with heart failure and reduced left ventricular ejection fraction as a result of several large randomized controlled trials. Finding therapy for HFpEF has been more elusive, although recent data suggest that sodium-glucose cotransporter 2 inhibition offers a novel evidence-based class of therapy that improves outcomes in HFpEF. These observations have emerged as this class of drugs has also become the standard of care for many patients with proteinuric CKD, suggesting that there is now hope for addressing the combination of HFpEF and CKD in parallel. In this review we summarize the epidemiology, pathophysiology, diagnostic strategies and treatment of HFpEF with a focus on patients with CKD.
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Affiliation(s)
- Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alastair J Rankin
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Elaine Rutherford
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Nephrology, NHS Dumfries and Galloway, Dumfries, UK
| | - Ninian N Lang
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sokratis Stoumpos
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rajan K Patel
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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9
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Sarnak MJ, Auguste BL, Brown E, Chang AR, Chertow GM, Hannan M, Herzog CA, Nadeau-Fredette AC, Tang WHW, Wang AYM, Weiner DE, Chan CT. Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e146-e164. [PMID: 35968722 DOI: 10.1161/cir.0000000000001088] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.
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10
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Glyde M, Sutherland E, Dye L, Mitra S, Keane D. Patients' perspectives of fluid management: A multicentre comparative study of home and incentre haemodialysis. J Ren Care 2022; 49:84-92. [PMID: 35637608 DOI: 10.1111/jorc.12426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/15/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is increasing worldwide interest in person-centred care in haemodialysis and home haemodialysis (HHD). Intradialytic fluid management is a vital component of haemodialysis, and often a shared decision, yet patients' perspectives and experience of related decisions are largely unexplored. OBJECTIVES To explore the perspectives of patients receiving home or incentre haemodialysis (IHD), in relation to intradialytic fluid management. DESIGN A multicentre cross-sectional survey. PARTICIPANTS Eight hundred and thirty-nine patients receiving IHD and 99 patients receiving HHD, across six English renal units. MEASUREMENTS Self-reported measures of understanding, experiences and control of fluid management, and willingness to achieve target weight. An objective test of patients' ability to relate common signs and symptoms to fluid overload or excessive ultrafiltration. RESULTS Patients receiving HHD had greater knowledge than those receiving IHD (66.1% vs. 42.3%, p < 0.001) about causes of common signs and symptoms which remained when controlling for age, education and years since beginning haemodialysis. Patients receiving HHD felt more in control of and had greater self-reported adherence to fluid management (p < 0.01), yet knowledge gaps existed in both cohorts. CONCLUSIONS Greater patient knowledge and its practice in HHD may contribute to improved fluid balance and outcomes. Whilst patient selection may contribute towards these differences, the training patients receive when opting for HHD and subsequent experience are likely to be key contributing factors. Integrating aspects of education on fluid management from HHD training programmes should be considered in IHD, and further targeted, robust education remains an unmet need.
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Affiliation(s)
- Megan Glyde
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Ed Sutherland
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Louise Dye
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Sandip Mitra
- Department of Renal Medicine, Manchester Royal Infirmary, Manchester, UK.,Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - David Keane
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Manchester, UK
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11
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Moustafa BH, ElHatw MK, Shaheen IS. Update on Pediatric Hemodialysis Adequacy. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:323-329. [PMID: 37417185 DOI: 10.4103/1319-2442.379031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
The use of high reflux dialyzers to achieve a Kt/Vurea above 1.2 did not improve patient survival in most literature reports. After an electronic search in many sites, guidelines, systematic reviews, and review articles (cited references): We recommend (1) using the equilibrated double-pool, weekly rather than per session, Kt/Vurea, (2) Use of UF-dry weight to avoid V changes, (3) consider protein catabolic Rate (4) Use of double pool to avoid urea generation rebound effect. Beyond the urea model, other recommended parameters include the middle molecule clearance and patient clinical data as blood pressure control, normal ventricular morphology, and function, absence of anemia, bone mineral disease, vascular calcifications, good nutrition and growth, long-lasting vascular access, less intra-dialysis hypotension, fewer hospitalizations related to complications as infection, long-term patient survival with better life quality. All mentioned parameters are the good markers for adequate dialysis. Since (1) frequent short and (or) slow long dialysis sessions show better solute clearance and hemodynamic stability associated with better control of cardiovascular and bone disease, anemia, nutrition, and growth with better quality of life and survival. (2) The spare in the cost of the antihypertensive medications, erythroid-stimulating drugs, phosphate binders, and frequent hospitalization, compensates for the high dialysis cost. (3) The use of some advisable techniques can minimize access trauma; therefore, HD Model can be changeable according to each patient's clinical and biochemical follow-up dialysis adequacy progress pattern.
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Affiliation(s)
- Bahia H Moustafa
- Department of Pediatric Nephrology, Dialysis/Transplantation Unit, Faculty of Medicine, Cairo University Children Hospital, Cairo University, Cairo, Egypt
| | - Mohamad Khaled ElHatw
- Department of Pediatrics, Northern Area Armed Forces Hospital, Hafr Al Batin, Saudi Arabia
| | - Ihab S Shaheen
- Department of Pediatric Nephrology, Royal Hospital for Children, Glasgow, United Kingdom
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12
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Murea M, Flythe JE, Anjay R, Emaad ARM, Gupta N, Kovach C, Vachharajani TJ, Kalantar-Zadeh K, Casino FG, Basile C. Kidney dysfunction requiring dialysis is a heterogeneous syndrome: we should treat it like one. Curr Opin Nephrol Hypertens 2022; 31:92-99. [PMID: 34846314 DOI: 10.1097/mnh.0000000000000754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Advanced kidney failure requiring dialysis, commonly labeled end-stage kidney disease or chronic kidney disease stage 5D, is a heterogeneous syndrome -a key reason that may explain why: treating advanced kidney dysfunction is challenging and many clinical trials involving patients on dialysis have failed, thus far. Treatment with dialytic techniques - of which maintenance thrice-weekly hemodialysis is most commonly used - is broadly named kidney 'replacement' therapy, a term that casts the perception of a priori abandonment of intrinsic kidney function and subsumes patients into a single, homogeneous group. RECENT FINDINGS Patients with advanced kidney failure necessitating dialytic therapy may have ongoing endogenous kidney function, and differ in their clinical manifestations and needs. Different terminology, for example, kidney dysfunction requiring dialysis (KDRD) with stages of progressive severity could better capture the range of phenotypes of patients who require kidney 'assistance' therapy. SUMMARY Classifying patients with KDRD based on objective, quantitative levels of endogenous kidney function, as well as patient-reported symptoms and quality of life, would facilitate hemodialysis prescriptions tailored to level of kidney dysfunction, clinical needs, and personal priorities. Such classification would encourage clinicians to move toward personalized, physiological, and adaptive approach to hemodialysis therapy.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Rastogi Anjay
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Abdel-Rahman M Emaad
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Nupur Gupta
- Indiana University Health, Indianapolis, Indiana
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Tushar J Vachharajani
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti
- Dialysis Centre SM2, Policoro, Italy
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13
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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14
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Lung ultrasound guided dry-weight reduction and echocardiographic changes in clinically euvolemic hypertensive hemodialysis patients: 12-month results of a randomized controlled trial. Hellenic J Cardiol 2021; 64:1-6. [PMID: 34856379 DOI: 10.1016/j.hjc.2021.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/12/2021] [Accepted: 11/22/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) and dysfunction are highly prevalent in hemodialysis patients and independently associated with adverse outcomes. This study examines the long-term effects of dry-weight reduction with a standardized lung-ultrasound (US)-guided strategy on echocardiographic indexes of left ventricular (LV) mass and function in hemodialysis patients. METHODS Seventy-one clinically euvolemic, hemodialysis patients with hypertension were randomized to dry-weight reduction guided by pre-hemodialysis lung US (n=35) or standard-of-care treatment (n=36) and were followed-up for 12 months. Two-dimensional and tissue-Doppler echocardiography (TDI) were performed at baseline and study-end. RESULTS During follow-up, dry-weight reduction took place in more patients in the active than in the control arm of the trial (71.4% vs 22.2%; p<0.001). Left atrial (LA) surface (-1.37±4.50 vs 1.28±5.00 cm2; P=0.006) and LA volume index (-3.22±11.82 vs 4.76±12.83 ml/m2; P=0.009) decreased in the active and increased in the control group. LV end-diastolic volume (-0.94±11.45 vs 6.58±13.92 ml/m2; P=0.015) decreased only in the active group. LV mass index was unchanged in the active (134.21±44.75 vs 133.57±45.51; P=0.844) and marginally increased in the control group (134.21±40.96 vs 143.77±50.04 g/m2; P=0.089). LV E/e' wave ratio was unchanged in the active (12.45±4.69 vs 12.56±4.89; P=0.521) and increased in the usual-care group (10.91±4.97 vs12.36±6.43; P=0.003). LV systolic function did not differ among the two study arms across the trial. CONCLUSIONS Over 12 months, lung-US-guided dry-weight reduction is associated with reverse LV and LA remodeling, myocardial hypertrophy regression and improved LV diastolic filling properties.
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15
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Murea M, Deira J, Kalantar-Zadeh K, Casino FG, Basile C. The spectrum of kidney dysfunction requiring chronic dialysis therapy: Implications for clinical practice and future clinical trials. Semin Dial 2021; 35:107-116. [PMID: 34643003 DOI: 10.1111/sdi.13027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/11/2021] [Accepted: 09/22/2021] [Indexed: 12/13/2022]
Abstract
Staging to capture kidney function and pathophysiologic processes according to severity is widely used in chronic kidney disease or acute kidney injury not requiring dialysis. Yet the diagnosis of "end-stage kidney disease" (ESKD) considers patients as a single homogeneous group, with negligible kidney function, in need of kidney replacement therapy. Herein, we review the evidence behind the heterogeneous nature of ESKD and discuss potential benefits of recasting the terminology used to describe advanced kidney dysfunction from a monolithic entity to a disease with stages of ascending severity. We consider kidney assistance therapy in lieu of kidney replacement therapy to better reconcile all available types of therapy for advanced kidney failure including dietary intervention, kidney transplantation, and dialysis therapy at varied schedules. The lexicon "kidney dysfunction requiring dialysis" (KDRD) with stages of ascending severity based on levels of residual kidney function (RKF)-that is, renal urea clearance-and manifestations related to uremia, fluid status, and other abnormalities is discussed. Subtyping KDRD by levels of RKF could advance dialysis therapy as a form of kidney assistance therapy adjusted based on RKF and clinical symptoms. We focus on intermittent hemodialysis and underscore the need to personalize dialysis treatments and improve characterization of patients included in clinical trials.
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Affiliation(s)
- Mariana Murea
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy.,Dialysis Centre SM2, Policoro, Italy
| | - Carlo Basile
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
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16
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Graham-Brown MPM, March DS, Young R, Highton PJ, Young HML, Churchward DR, Dungey M, Stensel DJ, Bishop NC, Brunskill NJ, Smith AC, McCann GP, McConnachie A, Burton JO. A randomized controlled trial to investigate the effects of intra-dialytic cycling on left ventricular mass. Kidney Int 2021; 99:1478-1486. [PMID: 34023029 DOI: 10.1016/j.kint.2021.02.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 12/22/2022]
Abstract
Cardiovascular disease is the leading cause of death for patients receiving hemodialysis. Since exercise mitigates many risk factors which drive cardiovascular disease for these patients, we assessed effects of a program of intra-dialytic cycling on left ventricular mass and other prognostically relevant measures of cardiovascular disease as evaluated by cardiac MRI (the CYCLE-HD trial). This was a prospective, open-label, single-blinded cluster-randomized controlled trial powered to detect a 15g difference in left ventricular mass measured between patients undergoing a six-month program of intra-dialytic cycling (exercise group) and patients continuing usual care (control group). Pre-specified secondary outcomes included measures of myocardial fibrosis, aortic stiffness, physical functioning, quality of life and ventricular arrhythmias. Outcomes were analyzed as intention-to-treat according to a pre-specified statistical analysis plan. Initially, 130 individuals were recruited and completed baseline assessments (65 each group). Ultimately, 101 patients completed the trial protocol (50 control group and 51 exercise group). The six-month program of intra-dialytic cycling resulted in a significant reduction in left ventricular mass between groups (-11.1g; 95% confidence interval -15.79, -6.43), which remained significant on sensitivity analysis (missing data imputed) (-9.92g; 14.68, -5.16). There were significant reductions in both native T1 mapping and aortic pulse wave velocity between groups favoring the intervention. There was no increase in either ventricular ectopic beats or complex ventricular arrhythmias as a result of exercise with no significant effect on physical function or quality of life. Thus, a six-month program of intradialytic cycling reduces left ventricular mass and is safe, deliverable and well tolerated.
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Affiliation(s)
- Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - Daniel S March
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Robin Young
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Patrick J Highton
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - Hannah M L Young
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Darren R Churchward
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Maurice Dungey
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - David J Stensel
- National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - Nicolette C Bishop
- National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - Nigel J Brunskill
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK.
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17
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Rutherford E, Ireland S, Mangion K, Stewart GA, MacGregor MS, Roditi G, Woodward R, Gandy SJ, Houston JG, Jardine AG, Rauchhaus P, Witham MD, Mark PB, Struthers AD. A Randomized, Controlled Trial of the Effect of Allopurinol on Left Ventricular Mass Index in Hemodialysis Patients. Kidney Int Rep 2020; 6:146-155. [PMID: 33426394 PMCID: PMC7783562 DOI: 10.1016/j.ekir.2020.10.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/01/2020] [Accepted: 10/20/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Increased left ventricular mass index (LVMI) is associated with mortality in end-stage renal disease. LVMI regression may improve outcomes. Allopurinol has reduced LVMI in randomized controlled trials in chronic kidney disease, diabetes, and ischemic heart disease. This study investigated whether allopurinol would regress LVMI in hemodialysis patients. Methods This was a randomized placebo-controlled double-blind multicenter trial funded by the British Heart Foundation (PG/12/72/29743). A total of 80 patients undergoing regular maintenance hemodialysis were recruited from NHS Tayside, NHS Greater Glasgow and Clyde and NHS Ayrshire and Arran in Scotland, UK. Participants were randomly assigned on a 1:1 ratio to 12 months of therapy with allopurinol 300 mg or placebo after each dialysis session. The primary outcome was change in LVMI, as assessed by cardiac magnetic resonance imaging (CMRI) at baseline and 12 months. Secondary outcomes were change in BP, flow-mediated dilation (FMD), augmentation indices (AIx), and pulse wave velocity (PWV). Results A total of 53 patients, with a mean age of 58 years, completed the study and had CMRI follow-up data for analysis. Allopurinol did not regress LVMI (change in LVMI: placebo +3.6 ± 10.4 g/m2; allopurinol: +1.6 ± 11 g/m2; P = 0.49). Allopurinol had no demonstrable effect on BP, FMD, AIx, or PWV. Conclusion Compared with placebo, treatment with allopurinol did not regress LVMI in this trial.
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Affiliation(s)
- Elaine Rutherford
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK.,Renal & Transplant Unit, Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Sheila Ireland
- Division of Molecular & Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK
| | | | - Mark S MacGregor
- Renal Unit, Crosshouse Hospital, NHS Ayrshire & Arran, Kilmarnock, UK
| | - Giles Roditi
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK.,Department of Radiology, Glasgow Royal Infirmary, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Rosemary Woodward
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK
| | - Stephen J Gandy
- Department of Radiology, Ninewells Hospital, NHS Tayside, Dundee, UK.,Medical Physics, Ninewells Hospital, NHS Tayside, Dundee, UK
| | | | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK.,Renal & Transplant Unit, Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Petra Rauchhaus
- Tayside Clinical Trials Unit, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - Miles D Witham
- NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals Trust, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK.,Renal & Transplant Unit, Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Allan D Struthers
- Division of Molecular & Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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18
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Girsberger M, Chan CT. Retrospective single center cohort study: effect of intensive home hemodialysis on right ventricular systolic pressure and clinical outcomes. BMC Nephrol 2020; 21:508. [PMID: 33238914 PMCID: PMC7687753 DOI: 10.1186/s12882-020-02159-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 11/10/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Increased right ventricular systolic pressure (RVSP), a surrogate marker for pulmonary hypertension, is common in patients with end-stage kidney disease. Limited data suggest improvement of RVSP with intensive dialysis, but it is unknown whether these improvements translate to better clinical outcomes. METHODS We conducted a retrospective single center cohort study at the Toronto General Hospital. All patients who performed intensive home hemodialysis (IHHD) for at least a year between 1999 and 2017, and who had a baseline as well as a follow-up echocardiogram more than a year after IHHD, were included. Patients were categorized into two groups based on the RVSP at follow-up: elevated (≥ 35 mmHg) and normal RVSP. Multivariate and cox regression analyses were done to identify risk factors for elevated RVSP at follow-up and reaching the composite endpoint (death, cardiovascular hospitalization, treatment failure), respectively. RESULTS One hundred eight patients were included in the study. At baseline, 63% (68/108) of patients had normal RVSP and 37% (40/108) having elevated RVSP. After a follow-up of 4 years, 70% (76/108) patient had normal RVSP while 30% (32/108) had elevated RVSP. 8 (10%) out of the 76 patients with normal RVSP and 15 (47%) out of the 32 patients with elevated RVSP reached the composite endpoint of death, cardiovascular hospitalization or technique failure. In a multivariate analysis, age, diabetes and smoking were not associated with elevated RVSP at follow-up. Elevated RVSP at baseline was not associated with a higher likelihood in reaching the composite endpoint or mortality. CONCLUSION Mean RVSP did not increase in patients on IHHD over time, and maintenance of normal RVSP was associated with better clinical outcomes.
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Affiliation(s)
- Michael Girsberger
- Division of Nephrology, University Health Network, 200 Elizabeth Street, 8N room 846, Toronto, ON, M5G 2C4, Canada
| | - Christopher T Chan
- Division of Nephrology, University Health Network, 200 Elizabeth Street, 8N room 846, Toronto, ON, M5G 2C4, Canada.
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19
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Response to: Loutradis et al. Longer Dialysis Sessions Improve Cardiac Systolic Function by Reducing Myocardial Stunning. J Card Fail 2020; 26:1028-1029. [PMID: 32890738 DOI: 10.1016/j.cardfail.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/01/2020] [Indexed: 11/20/2022]
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20
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Roehm B, Gulati G, Weiner DE. Heart failure management in dialysis patients: Many treatment options with no clear evidence. Semin Dial 2020; 33:198-208. [PMID: 32282987 PMCID: PMC7597416 DOI: 10.1111/sdi.12878] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure with reduced ejection fraction (HFrEF) impacts approximately 20% of dialysis patients and is associated with high mortality rates. Key issues discussed in this review of HFrEF management in dialysis include dialysis modality choice, vascular access, dialysate composition, pharmacological therapies, and strategies to reduce sudden cardiac death, including the use of cardiac devices. Peritoneal dialysis and more frequent or longer duration of hemodialysis may be better tolerated due to slower ultrafiltration rates, leading to less intradialytic hypotension and better volume control; dialysate cooling and higher dialysate calcium may also have benefits. While high-quality evidence exists for many drug classes in the non-dialysis population, dialysis patients were excluded from major trials, and only limited data exist for many medications in kidney failure patients. Despite limited evidence, beta blocker and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use is common in dialysis. Similarly, devices such as implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy that have proven benefits in non-dialysis HFrEF patients have not consistently been beneficial in the limited dialysis studies. The use of leadless pacemakers and subcutaneous ICDs can mitigate future hemodialysis access limitations. Additional research is critical to address knowledge gaps in treating maintenance dialysis patients with HFrEF.
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Affiliation(s)
- Bethany Roehm
- William B. Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Gaurav Gulati
- Cardiovascular Center, Division of Cardiology, Tufts Medical Center, Boston, MA
| | - Daniel E. Weiner
- William B. Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, MA
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21
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Smyth B, Chan CT, Grieve SM, Puranik R, Zuo L, Hong D, Gray NA, De Zoysa JR, Scaria A, Gallagher M, Perkovic V, Jardine M. Predictors of Change in Left-Ventricular Structure and Function in a Trial of Extended Hours Hemodialysis. J Card Fail 2020; 26:482-491. [PMID: 32302717 DOI: 10.1016/j.cardfail.2020.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/14/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Myocardial pathology is common in patients undergoing hemodialysis. To explore the effects of differing aspects of dialysis treatment on its evolution, we examined the impact of change in markers of volume status, hemodynamics and solute clearance on left ventricular (LV) parameters in a randomized trial of extended hours dialysis. METHODS AND RESULTS A Clinical Trial of IntensiVE (ACTIVE) Dialysis randomized 200 patients undergoing hemodialysis to extended dialysis hours (≥ 24 hours/week) or standard hours (12-18 hours/week) for 12 months. In a prespecified substudy, 95 participants underwent cardiac magnetic resonance imaging (CMR) at baseline and at the study's end. Generalized linear regression was used to model the relationship between changes in LV parameters and markers of volume status (normalized ultrafiltration rate and total weekly interdialytic weight gain), hemodynamic changes (systolic and diastolic blood pressure) and solute control (urea clearance, dialysis hours and phosphate). Randomization to extended hours dialysis was not associated with change in any CMR parameter. Reduction in ultrafiltration rate was associated with reduction in LV mass index (P = 0.049) and improved ejection fraction (P = 0.024); reduction in systolic blood pressure was also associated with improvement in ejection fraction (P = 0.045); reduction in interdialytic weight gain was associated with reduced stroke volume (P = 0.038). There were no associations between change in urea clearance, phosphate or total hours per week and CMR parameters. CONCLUSIONS Reduction in ultrafiltration rate and blood pressure are associated with improved myocardial parameters in hemodialysis recipients independently of solute clearance or dialysis time. These findings underscore the importance of fluid status and related parameters as potential treatment targets in this population.
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Affiliation(s)
- Brendan Smyth
- The George Institute for Global Health and University of New South Wales, Sydney, Australia; Sydney School of Public Health, University of Sydney, Sydney, Australia; Department of Renal Medicine, St George Hospital, Sydney, Australia.
| | | | - Stuart M Grieve
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Sydney Translational Imaging Laboratory, Charles Perkins Centre, University of Sydney, Sydney, Australia; Department of Radiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Rajesh Puranik
- Specialist Magnetic Resonance Imaging, Newtown, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Li Zuo
- Peking University People's Hospital, Beijing, China
| | - Daqing Hong
- Renal Department, Sichuan Provincial People's Hospital, Chengdu, China
| | - Nicholas A Gray
- Sunshine Coast University Hospital, Birtinya, Australia; School of Health and Sport Sciences, University of the Sunshine Coast, Australia
| | - Janak R De Zoysa
- North Shore Hospital, Auckland, New Zealand; Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Anish Scaria
- The George Institute for Global Health and University of New South Wales, Sydney, Australia
| | - Martin Gallagher
- The George Institute for Global Health and University of New South Wales, Sydney, Australia; Renal Unit, Concord Repatriation General Hospital, Sydney, Australia
| | - Vlado Perkovic
- The George Institute for Global Health and University of New South Wales, Sydney, Australia
| | - Meg Jardine
- The George Institute for Global Health and University of New South Wales, Sydney, Australia; Renal Unit, Concord Repatriation General Hospital, Sydney, Australia
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Sarafidis P, Faitatzidou D, Papagianni A. Benefits and risks of frequent or longer haemodialysis: weighing the evidence. Nephrol Dial Transplant 2020; 36:gfaa023. [PMID: 32073626 DOI: 10.1093/ndt/gfaa023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Indexed: 12/28/2022] Open
Abstract
Although the ability of individuals with end-stage renal disease to maintain body homoeostasis is equally impaired during all weekdays, conventional haemodialysis (HD) treatment is scheduled thrice weekly, containing two short and one long interdialytic interval. This intermittent nature of HD and the consequent fluctuations in volume, metabolic parameters and electrolytes have long been hypothesized to predispose to complications. Large observational studies link the first weekday with an increased risk of cardiovascular morbidity and mortality. Several schemes of frequent and/or longer, home or in-centre HD have been introduced, aiming to alleviate the above risks by both increasing total dialysis duration and reducing the duration of interdialytic intervals. Observational studies in this field have non-uniform results, showing that enhanced frequency in home (but not in-centre) HD is associated with reduced mortality. Evidence from the randomized Daily and Nocturnal Trials of the Frequent HD Network suggest the opposite, showing mortality benefits with in-centre daily but not with home nocturnal dialysis. Secondary analyses of these trials indicate that daily and nocturnal schedules do not have equal effects on intermediate outcomes. Alternative schemes, such as thrice weekly in-centre nocturnal HD or every-other-day HD, seem to also offer improvements in several intermediate endpoints, but need further testing with randomized trials. This review summarizes the effects of frequent and/or longer HD methods on hard and intermediate outcomes, attempting to provide a balanced overview of the field.
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Affiliation(s)
- Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Danai Faitatzidou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Kalra DK, Madan N. Defined by the Company One Keeps: The Importance of Cardiac Comorbidities after Kidney Transplant Cardiac Remodeling and Outcomes. Cardiology 2020; 145:77-79. [PMID: 31914440 DOI: 10.1159/000505203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Dinesh K Kalra
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA,
| | - Nidhi Madan
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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24
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Jaroszyński A, Furmaga J, Zapolski T, Zaborowski T, Rudzki S, Dąbrowski W. The improvement of QRS-T angle as a manifestation of reverse electrical remodeling following renal transplantation in end-stage kidney disease patients on haemodialysis. BMC Nephrol 2019; 20:441. [PMID: 31791259 PMCID: PMC6889434 DOI: 10.1186/s12882-019-1624-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/13/2019] [Indexed: 01/19/2023] Open
Abstract
Background Successful renal transplantation (RT) reverses some of the cardiac changes and reduces cardiac mortality in hemodialysis (HD) patients. Widened QRS-T angle reflects both ventricular repolarization and depolarization. It is considered a sensitive and strong predictor of heart ventricular remodeling as well as a powerful and independent risk stratifier suitable in predicting cardiac events in various clinical settings. The study aimed to assess the influence of the RT on QRS-T angle and to evaluate factors influencing QRS-T changes in renal transplanted recipients (RTRs). Methods Fifty-four selected HD patients who have undergone RT were included. Blood chemistry, echocardiography, and QRS-T angle were evaluated 5 times: about 1 week, 3 months, 6 months, 1 year and 3 years after RT. Results An improvement of echocardiographic parameters was observed. The dynamics of changes in individual parameters were, however, variable. QRS-T angle correlated with echocardiographic parameters. The biphasic pattern of the decreases of QRS-T angle was observed. The first decrease took place in the third month of follow-up. The second decrease of QRS-T angle was observed after 1 year of follow-up. The QRS-T angle was higher in RTRs compared with controls during each evaluation. Multivariable analysis demonstrated that the decrease of left ventricle enddiastolic volume was an independent predictor of early QRS-T angle improvement. The increase of left ventricle ejection fraction was found to be the independent predictor of the late QRS-T angle improvement. Conclusions RT induces biphasic reverse electrical remodeling as assessed by the narrowing of QRS-T angle. Early decrease of QRS-T angle is mainly due to the normalization of volume status, whereas late decrease is associated predominantly with the improvement of cardiac contractile function.
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Affiliation(s)
- Andrzej Jaroszyński
- Institute of Medical Sciences, Jan Kochanowski University in Kielce, Al. IX Wieków Kielc 19A, 25-317, Kielce, Poland. .,Department of Family Medicine, Medical University of Lublin, Lublin, Poland.
| | - Jacek Furmaga
- Department of General and Transplant Surgery and Nutritional Treatment, Medical University of Lublin, Lublin, Poland
| | - Tomasz Zapolski
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Tomasz Zaborowski
- Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Sławomir Rudzki
- Department of General and Transplant Surgery and Nutritional Treatment, Medical University of Lublin, Lublin, Poland
| | - Wojciech Dąbrowski
- Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
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25
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Karur GR, Wald R, Goldstein MB, Wald R, Jimenez-Juan L, Kiaii M, Leipsic J, Kirpalani A, Bello O, Barthur A, Ng MY, Deva DP, Yan AT. Association between conversion to in-center nocturnal hemodialysis and right ventricular remodeling. Nephrol Dial Transplant 2019; 33:1010-1016. [PMID: 28992094 DOI: 10.1093/ndt/gfx232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/07/2017] [Indexed: 11/12/2022] Open
Abstract
Background In-center nocturnal hemodialysis (INHD) is associated with favorable left ventricular (LV) remodeling. Although right ventricular (RV) structure and function carry prognostic significance, the impact of dialysis intensification on RV is unknown. Our objectives were to evaluate changes in RV mass index (MI), end-diastolic volume index (EDVI), end-systolic volume index (ESVI) and ejection fraction (EF) after conversion to INHD and their relationship with LV remodeling. Methods Of 67 conventional hemodialysis (CHD, 4 h/session, three times/week) patients, 30 continued on CHD and 37 converted to INHD (7-8 h/session, three times/week). Cardiac magnetic resonance imaging was performed at baseline and 1 year using a standardized protocol; an experienced and blinded reader performed RV measurements. Results At 1 year there were significant reductions in RVMI {-2.1 g/m2 [95% confidence interval (CI) -3.8 to - 0.4], P = 0.017}, RVEDVI [-9.5 mL/m2 (95% CI - 16.3 to - 2.6), P = 0.008] and RVESVI [-6.2 mL/m2 (95% CI - 10.9 to - 1.6), P = 0.011] in the INHD group; no significant changes were observed in the CHD group. Between-group comparisons showed significantly greater reduction of RVESVI [-7.9 mL/m2 (95% CI - 14.9 to - 0.9), P = 0.03] in the INHD group, a nonsignificant trend toward greater reduction in RVEDVI and no significant difference in RVMI and RVEF changes. There was significant correlation between LV and RV in terms of changes in mass index (MI) (r = 0.46), EDVI (r = 0.73), ESVI (r = 0.7) and EF (r = 0.38) over 1 year (all P < 0.01). Conclusions Conversion to INHD was associated with a significant reduction of RVESVI. Temporal changes in RV mass, volume and function paralleled those of LV. Our findings support the need for larger, longer-term studies to confirm favorable RV remodeling and determine its impact on clinical outcomes.
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Affiliation(s)
- Gauri R Karur
- Department of Medical Imaging, Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ron Wald
- Division of Nephrology, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Marc B Goldstein
- Division of Nephrology, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Rachel Wald
- University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Jimenez-Juan
- University of Toronto, Toronto, Ontario, Canada.,Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathon Leipsic
- Department of Radiology and Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anish Kirpalani
- Department of Medical Imaging, Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Olugbenga Bello
- Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ashita Barthur
- Department of Medical Imaging, Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ming-Yen Ng
- University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Djeven P Deva
- Department of Medical Imaging, Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Yan
- University of Toronto, Toronto, Ontario, Canada.,Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
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26
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Samanta R, Chan C, Chauhan VS. Arrhythmias and Sudden Cardiac Death in End Stage Renal Disease: Epidemiology, Risk Factors, and Management. Can J Cardiol 2019; 35:1228-1240. [DOI: 10.1016/j.cjca.2019.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/23/2019] [Accepted: 05/07/2019] [Indexed: 11/17/2022] Open
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Cardiorenal Interactions Revisited: How to Improve Heart Failure Outcomes in Patients With Chronic Kidney Disease. Curr Heart Fail Rep 2019; 15:307-314. [PMID: 30123941 DOI: 10.1007/s11897-018-0406-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF THE REVIEW To summarize current advances in the understanding and management of heart failure (HF) in patients with advanced chronic kidney disease (CKD). RECENT FINDINGS Diagnosis of HF and treatment of congestion are crucial in the management of patients with advanced CKD to reduce symptoms, preserve organ function, and improve outcomes. Echocardiography and cardiovascular biomarkers may help to differentiate cardiac from non-cardiac components of overhydration. Renal replacement therapy or ultrafiltration may be required to treat congestion. Furthermore, patients with advanced CKD are frequently undertreated with disease-modifying HF therapies, but the use of beta-blockers and ACEi should be considered under close monitoring of kidney function and serum potassium. The use of the new oral potassium binders may translate into improved outcomes. The treatment of HF in patients with advanced CKD requires a multi-disciplinary approach. New diagnostic and therapeutic strategies are under evaluation and may contribute to improved outcomes.
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Abstract
Conventional hemodialysis is associated with high morbidity and mortality rates, as well as a reduced quality of life. There is a growing interest in the provision of more intensive hemodialysis, due to associated benefits in terms of reduced cardiovascular morbidity, better regulation of mineral metabolism, as well as its impact on quality of life measures, fertility, and sleep. Nocturnal hemodialysis, both in center and at home, allows the delivery of more intensive hemodialysis. This review discusses the benefits of nocturnal hemodialysis and evaluates the evidence based on available literature.
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29
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Girsberger M, Thenganatt J, Chan CT. Correction of pulmonary hypertension with intensive hemodialysis: A case report. Hemodial Int 2019; 23:E49-E52. [DOI: 10.1111/hdi.12691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/06/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - John Thenganatt
- Division of RespirologyUniversity Health Network Toronto Canada
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30
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Dhruve M, Faratro R, D'Gama C, Fung S, Arustei D, Wong E, Chan CT. The use of nurse-administered vascular access audit in home hemodialysis patients: A quality initiative. Hemodial Int 2019; 23:133-138. [PMID: 30734988 DOI: 10.1111/hdi.12708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 08/08/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Vascular access complications are associated with increased morbidity and mortality in home hemodialysis (HHD). Nurse-administered vascular access checklist is a feasible quality improvement strategy aimed to lower HHD access errors. METHODS We conducted a prospective quality improvement initiative for consecutive HHD patients between April 2013 and December 2016 at the Toronto General Hospital. Vascular access audits were administered every 6 months during clinic visits and during retraining sessions after an infection. We aimed to (1) determine whether prospective serial administration of vascular audit will decrease in the number of errors performed by the patient and (2) to determine whether there is an association between the number of errors and vascular access related infection. FINDINGS A total of 370 audits were performed on 122 patients with a mean HHD vintage of 6.7 (0.8-19.5) years. The mean number of errors per patient decreased from 1.24 ± 1.75 (baseline) to 0.33 ± 0.49 (last follow-up), P < 0.001. Among patients who had serial vascular access audits performed, there was a significant decrease in median number of errors (baseline median 1, [0-2] end of study median 0, [0-1] P = 0.01). Patients performing buttonhole cannulation made most proportion of errors as compared to CVC, 54% vs. 40% (P = 0.01) respectively; and as compared to rope ladder cannulation 54% vs. 37% (P = 0.008). We were unable to demonstrate an association between the change in patient reported errors and vascular access related infection. DISCUSSION Vascular access audit is a feasible quality initiative, which leads to a decrease in the number of patient reported errors in vascular access. The longitudinal clinical sequelae of this strategy warrants further examination.
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Affiliation(s)
- Miten Dhruve
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rose Faratro
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Celine D'Gama
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Stella Fung
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Daniela Arustei
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Elizabeth Wong
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christopher T Chan
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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31
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Alaiti MA, Goud A, Ramani G, Bagchi S, Al-Kindi S, Sawicki S, Longenecker C, Jenkins T, Pauza D, Park M, McComsey G, Simonetti O, Hoit B, Rajagopalan S. Design of the exercise MRI evaluation of HIV-pulmonary arterial hypertension longitudinal determinants (EXALTED) trial. J Cardiovasc Med (Hagerstown) 2018; 18:888-896. [PMID: 28937582 DOI: 10.2459/jcm.0000000000000575] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a potentially serious cause of dyspnea and exercise limitation in patients with HIV infection. In this trial, we propose using exercise MRI in conjunction with cardiopulmonary testing to delineate PAH from other causes of cardiovascular dysfunction, identify individuals with exercise-induced PAH who are at high risk of developing resting PAH, and provide longitudinal estimates of progression of PAH and right ventricular function. METHODS In this prospective observational study, HIV patients with dyspnea and exercise limitation in the absence of identifiable causes and those who meet the inclusion criteria will be enrolled based on resting pulmonary artery pressure (≤ or >40 mmHg) on a screening echocardiogram and exercise limitation on the Modified Medical Research Council dyspnea scale. Patients without evidence of resting PAH will be enrolled into both rest and exercise MRI and cardiopulmonary testing protocol, whereas patients with evidence of PAH on resting echocardiograms will undergo only resting cardiac MRI studies to evaluate right ventricular function and fibrosis. Both patient subgroups will be followed for 24 months to obtain longitudinal progression of the disease. In a sub-study, we will further analyze inflammatory variables that may predict these changes, thus allowing early identification of these patients. IMPLICATIONS AND CONCLUSIONS This trial will be the first study to provide an understanding of the mechanisms underpinning the functional deterioration of the right ventricle in patients with HIV and will impart insight into the immune mediators of PAH progression and right ventricular functional deterioration in patients with HIV-PAH.
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Affiliation(s)
- Mohamad Amer Alaiti
- aDivision of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio bDivision of Cardiovascular Medicine, University of Maryland Baltimore, Maryland cDivision of Infectious Diseases and Institute of Human Virology dHouston Methodist DeBakey Heart & Vascular Center, Houston, Texas eDivision of Infectious Disease, Cleveland Medical Center, Cleveland, Ohio fThe Ohio State University, Columbus, Ohio, USA
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Ward FL, Faratro R, McQuillan RF. Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers. Semin Dial 2018; 31:449-454. [PMID: 29750827 DOI: 10.1111/sdi.12708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with end-stage kidney disease who are considering home hemodialysis (HHD) face the challenge of learning to self-cannulate their arteriovenous access. Current practice discourages the use of tunneled central venous catheters, with recent indications that self-cannulating patients have superior outcomes. Patient-level barriers do not appear to preclude a successful HHD program and should not be viewed as insurmountable by healthcare staff or patients. The healthcare team must address patient fears while instructing the patient to perform self-cannulation safely. Identification and understanding of the barriers perceived by the patient will allow the patient and healthcare team work collaboratively, toward the goal of independence with self-cannulation both during initial training and follow-up care. The aim of this review was to provide a practical resource to aid in the identification and resolution of these patient-level barriers, with the overall goal of improving the patient experience and medical outcomes in home hemodialysis programs.
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Affiliation(s)
- Frank L Ward
- Department of Nephrology, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Rose Faratro
- Department of Nephrology, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Rory F McQuillan
- Department of Nephrology, University Health Network, Toronto General Hospital, Toronto, ON, Canada
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33
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Assessment of right ventricular dysfunction in end-stage renal disease patients on maintenance haemodialysis by cardiac magnetic resonance imaging. Eur J Radiol 2018; 102:89-94. [DOI: 10.1016/j.ejrad.2018.02.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 02/23/2018] [Accepted: 02/28/2018] [Indexed: 11/19/2022]
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34
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Lin TT, Yang WS, Hsieh MY, Wu CC, Lin LY. Deterioration of Deceleration Capacity of Heart Rate is Associated with Left Ventricular Hypertrophy in End-Stage Renal Disease Population. ACTA CARDIOLOGICA SINICA 2018; 34:242-250. [PMID: 29844645 PMCID: PMC5968340 DOI: 10.6515/acs.201805_34(3).20180202a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) is prevalent in patients with end-stage renal disease (ESRD), and may be secondary to arterial stiffness and volume overload. It is unclear whether LVH is caused by autonomic nerve dysregulation (AND), a frequent condition in patients with ESRD that is characterized by sympathetic hyperactivity and vagal withdrawal. We hypothesized that AND estimated by heart rate variability (HRV) may be associated with LVH in patients with ESRD. METHODS We prospectively enrolled patients with ESRD undergoing hemodialysis. Cardiac function and LVH were assessed using echocardiography according to the recommendations of the American Society of Echocardiography. Holter recordings were used to quantify HRV and deceleration capacity (DC). Dataon comorbidities and medications, and serum markers were obtained. Logistic regression analysis was performed. RESULTS Among the 281 included patients, 63% had LVH. The patients with LVH were older, had more comorbidities and advanced diastolic dysfunction than those without LVH. The root mean square of successive differences (rMSSD) (9.10 ± 5.44 versus 13.25 ± 8.61; p = 0.004) and DC (2.08 ± 1.90 versus 3.89 ± 1.45; p = 0.021) were lower in the patients with LVH than that in those without LVH. Multivariate regression analysis showed that hypertension, asymmetrical dimethylarginine (ADMA), advanced diastolic dysfunction grade, rMSSD, and DC were independently associated with LVH. Among these variables, DC and ADMA showed the highest diagnostic value for LVH with areas under curves of 0.701 and 0.751, respectively. CONCLUSIONS AND is independently associated with LVH in patients with ESRD.
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Affiliation(s)
- Ting-Tse Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu;
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Department of Internal Medicine, National Taiwan University College of Medicine, Taipei
| | - Wei-Shun Yang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu
| | - Mu-Yang Hsieh
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu;
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Department of Internal Medicine, National Taiwan University College of Medicine, Taipei
| | - Chih-Chen Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu
| | - Lian-Yu Lin
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei;
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Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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35
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Loutradis C, Sarafidis PA, Papadopoulos CE, Papagianni A, Zoccali C. The Ebb and Flow of Echocardiographic Cardiac Function Parameters in Relationship to Hemodialysis Treatment in Patients with ESRD. J Am Soc Nephrol 2018; 29:1372-1381. [PMID: 29592914 PMCID: PMC5967760 DOI: 10.1681/asn.2017101102] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular disease is the leading cause of mortality in patients receiving hemodialysis. Cardiovascular events in these patients demonstrate a day-of-week pattern; i.e., they occur more commonly during the last day of the long interdialytic interval and the first session of the week. The hemodialysis process causes acute decreases in cardiac chamber size and pulmonary circulation loading and acute diastolic dysfunction, possibly through myocardial stunning and other non-myocardial-related mechanisms; systolic function, in contrast, is largely unchanged. During interdialytic intervals volume overload, acid-base, and electrolyte shifts, as well as arterial and myocardial wall changes, result in dilatation of right cardiac chambers and pulmonary circulation overload. Recent studies suggest that these alterations are more extended during the long interdialytic interval or the first dialysis session of the week and are associated with excess volume overload or removal, respectively, thus adding a mechanism for the day-of-week pattern of mortality in patients receiving hemodialysis. This review summarizes the existing data from echocardiographic studies of cardiac morphology and function during the hemodialysis session, as well as during the interdialytic intervals.
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Affiliation(s)
| | | | - Christodoulos E Papadopoulos
- 3rd Department of Cardiology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; and
| | | | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
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Rutherford E, Mark PB. What happens to the heart in chronic kidney disease? J R Coll Physicians Edinb 2018; 47:76-82. [PMID: 28569289 DOI: 10.4997/jrcpe.2017.117] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Cardiovascular disease is common in patients with chronic kidney disease. The increased risk of cardiovascular disease seen in this population is attributable to both traditional and novel vascular risk factors. Risk of sudden cardiac or arrhythmogenic death is greatly exaggerated in chronic kidney disease, particularly in patients with end stage renal disease where the risk is roughly 20 times that of the general population. The reasons for this increased risk are not entirely understood and while atherosclerosis is accelerated in the presence of chronic kidney disease, premature myocardial infarction does not solely account for the excess risk. Recent work demonstrates that the structure and function of the heart starts to alter early in chronic kidney disease, independent of other risk factors. The implications of cardiac remodelling and hypertrophy may predispose chronic kidney disease patients to heart failure, arrhythmia and myocardial ischaemia. Further research is needed to minimise cardiovascular risk associated with structural and functional heart disease associated with chronic kidney disease.
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Affiliation(s)
- E Rutherford
- P Mark, BHF Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK,
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Mangion K, McDowell K, Mark PB, Rutherford E. Characterizing Cardiac Involvement in Chronic Kidney Disease Using CMR-a Systematic Review. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018; 11:2. [PMID: 29497467 PMCID: PMC5818546 DOI: 10.1007/s12410-018-9441-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW The aim of the review was to identify and describe recent advances (over the last 3 years) in cardiac magnetic resonance (CMR) imaging in patients with chronic kidney disease (CKD). We conducted a literature review in line with current guidelines. RECENT FINDINGS The authors identified 22 studies. Patients with CKD had left ventricular global and regional dysfunction and adverse remodeling. Stress testing with CMR revealed a reduced stress-response in CKD patients. Native T1 relaxation times (as a surrogate markers of fibrosis) are elevated in CKD patients, proportional to disease duration. Patients with CKD have reduced strain magnitudes and reduced aortic distensibility. SUMMARY CMR has diagnostic utility to identify and characterize cardiac involvement in this patient group. A number of papers have described novel findings over the last 3 years, suggesting that CMR has potential to become more widely used in studies in this patient group.
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Affiliation(s)
- Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, BHF Building, 126 University Place, Glasgow, G12 8TA UK
| | - Kirsty McDowell
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, BHF Building, 126 University Place, Glasgow, G12 8TA UK
| | - Patrick B. Mark
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, BHF Building, 126 University Place, Glasgow, G12 8TA UK
- Glasgow Renal & Transplant Unit, NHS Greater Glasgow & Clyde, Queen Elizabeth University Hospital, Glasgow, UK
| | - Elaine Rutherford
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, BHF Building, 126 University Place, Glasgow, G12 8TA UK
- Glasgow Renal & Transplant Unit, NHS Greater Glasgow & Clyde, Queen Elizabeth University Hospital, Glasgow, UK
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Ren H, Gong D, He X, Jia F, He Q, Xu B, Liu Z. Evaluation of Intradialytic Hypertension Using Bioelectrical Impedance Combined With Echocardiography in Maintenance Hemodialysis Patients. Ther Apher Dial 2017; 22:22-30. [PMID: 29214739 DOI: 10.1111/1744-9987.12605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/11/2017] [Accepted: 07/17/2017] [Indexed: 01/06/2023]
Abstract
Although intra-dialytic hypertension (IDH) has been noted in clinical settings for many years, its pathogenesis remains unclear. In this cross-sectional study, we analyzed IDH incidence in our center and the correlation between postdialysis volume state and IDH. One hundred thirty-one maintenance hemodialysis (MHD) patients were enrolled in our study, and bioelectrical impedance (BIA) and echocardiography (ECG) were recorded. In addition, demographic data were collected, and laboratory examinations were conducted. The patients were grouped into four groups according to the change in systolic blood pressure (SBP) between predialysis and postdialysis. The incidence of IDH was 10.7%. The proportion of extracellular water to total body weight (ECW/TW), as evaluated by BIA, was significantly higher in the IDH group than in the other three groups both in pre-and post-dialysis. In particular, postdialysis SBP was highest in the highest tertile interval of ECW/TW. In addition, among the four groups, left ventricular volume (LVV) was highest in the IDH group. Binary logistic analyses revealed that predialysis SBP, postdialysis ECW/TW and LVV were independent risk factors of intradialytic hypertension. When predicting IDH, the AUC of the ROC curve was higher for ECW/TW combined with LVV (0.752, 95% CI 0.613-0.896) than for either LVV or ECW/TW alone. Our study further showed that post-dialysis volume expansion is an important factor for the development of IDH.
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Affiliation(s)
- Hongqi Ren
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Clinical School of Second Military Medical University, Nanjing University School of Medicine, Nanjing, China.,Department of Nephrology, Huaihai Hospital affiliated with Xuzhou Medical University, Xuzhou, China
| | - Dehua Gong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Clinical School of Second Military Medical University, Nanjing University School of Medicine, Nanjing, China
| | - Xu He
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Clinical School of Second Military Medical University, Nanjing University School of Medicine, Nanjing, China
| | - Fengyu Jia
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Clinical School of Second Military Medical University, Nanjing University School of Medicine, Nanjing, China
| | - Qunpeng He
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Clinical School of Second Military Medical University, Nanjing University School of Medicine, Nanjing, China
| | - Bin Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Clinical School of Second Military Medical University, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Clinical School of Second Military Medical University, Nanjing University School of Medicine, Nanjing, China
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Tuegel C, Bansal N. Heart failure in patients with kidney disease. Heart 2017; 103:1848-1853. [PMID: 28716974 DOI: 10.1136/heartjnl-2016-310794] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/22/2017] [Accepted: 05/23/2017] [Indexed: 01/24/2023] Open
Abstract
Heart failure (HF) is a leading cause of morbidity and mortality in patients with chronic kidney disease (CKD), and the population of CKD patients with concurrent HF continues to grow. The accurate diagnosis of HF is challenging in patients with CKD in part due to a lack of validated imaging and biomarkers specifically in this population. The pathophysiology between the heart and the kidneys is complex and bidirectional. Patients with CKD have greater prevalence of traditional HF risk factors as well as unique kidney-specific risk factors including malnutrition, acid-base alterations, uraemic toxins, bone mineral changes, anemia and myocardial stunning. These risk factors also contribute to the decline of kidney function seen in patients with subclinical and clinical HF. More targeted HF therapies may improve outcomes in patients with kidney disease as current HF therapies are underutilised in this population. Further work is also needed to develop novel HF therapies for the CKD population.
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Affiliation(s)
- Courtney Tuegel
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Nisha Bansal
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
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Banshodani M, Kawanishi H, Fukuma S, Moriishi M, Shintaku S, Tsuchiya S. The impact of hemodialysis schedules on the day of the week of hospitalization for cardiovascular and infectious diseases, over a period of 20 years. PLoS One 2017; 12:e0180577. [PMID: 28700621 PMCID: PMC5503277 DOI: 10.1371/journal.pone.0180577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 06/16/2017] [Indexed: 01/11/2023] Open
Abstract
There have been no studies as yet that have evaluated how hemodialysis (HD) schedules affect the day of the week of hospitalization for cardiovascular diseases (CVDs) and infectious diseases (IDs), over a period of time. Herein, we performed a retrospective observational cohort study (1995–2014) evaluating 11,111 hospitalizations in 1,953 patients with end-stage renal disease, receiving HD 3 times a week (following either a Monday-Wednesday-Friday [MWF] schedule or a Tuesday-Thursday-Saturday [TTS] schedule) or receiving frequent HD (FHD) at least 4 times a week. Overall, hospitalization rates for CVDs and IDs were the highest on Monday in the MWF schedule and Tuesday in the TTS schedule compared to the average rates for all the days of the week. When generalized estimating equations (GEEs) were used in conjunction with robust variance estimators of each type of CVD, the risk for pulmonary edema was found to be significantly higher on Sunday and Monday in the MWF schedule and Monday and Tuesday in the TTS schedule. For both cerebrovascular and ischemic heart disease, the risks were significantly higher on Tuesday in the MWF schedule and Wednesday in the TTS schedule. Moreover, there were significant differences in the day of the week risks among the various CVD types. On trend analysis, the overall hospitalization rate for CVDs on the first HD day did not decrease (P = 0.2); however, the hospitalization rate for IDs on the first HD day significantly decreased (P = 0.02) over a span of 20 years. When GEEs were used in the case of FHD patients with severe heart failure, the hospitalization rate on the first HD day (Monday) significantly decreased after FHD initiation (P = 0.04). It was found that HD schedules affected the day of the week of hospitalization for CVDs. FHD may lower the day of the week risk.
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Affiliation(s)
- Masataka Banshodani
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Hideki Kawanishi
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
- Faculty of Medicine, Hiroshima University, Hiroshima, Japan
- * E-mail:
| | - Shingo Fukuma
- Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Misaki Moriishi
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Sadanori Shintaku
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Shinichiro Tsuchiya
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
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Jardine MJ, Zuo L, Gray NA, de Zoysa JR, Chan CT, Gallagher MP, Monaghan H, Grieve SM, Puranik R, Lin H, Eris JM, Zhang L, Xu J, Howard K, Lo S, Cass A, Perkovic V. A Trial of Extending Hemodialysis Hours and Quality of Life. J Am Soc Nephrol 2017; 28:1898-1911. [PMID: 28151412 PMCID: PMC5461782 DOI: 10.1681/asn.2015111225] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 11/28/2016] [Indexed: 02/05/2023] Open
Abstract
The relationship between increased hemodialysis hours and patient outcomes remains unclear. We randomized (1:1) 200 adult recipients of standard maintenance hemodialysis from in-center and home-based hemodialysis programs to extended weekly (≥24 hours) or standard (target 12-15 hours, maximum 18 hours) hemodialysis hours for 12 months. The primary outcome was change in quality of life from baseline assessed by the EuroQol 5 dimension instrument (3 level) (EQ-5D). Secondary outcomes included medication usage, clinical laboratory values, vascular access events, and change in left ventricular mass index. At 12 months, median weekly hemodialysis hours were 24.0 (interquartile range, 23.6-24.0) and 12.0 (interquartile range, 12.0-16.0) in the extended and standard groups, respectively. Change in EQ-5D score at study end did not differ between groups (mean difference, 0.04 [95% confidence interval, -0.03 to 0.11]; P=0.29). Extended hours were associated with lower phosphate and potassium levels and higher hemoglobin levels. Blood pressure (BP) did not differ between groups at study end. Extended hours were associated with fewer BP-lowering agents and phosphate-binding medications, but were not associated with erythropoietin dosing. In a substudy with 95 patients, we detected no difference between groups in left ventricular mass index (mean difference, -6.0 [95% confidence interval, -14.8 to 2.7] g/m2; P=0.18). Five deaths occurred in the extended group and two in the standard group (P=0.44); two participants in each group withdrew consent. Similar numbers of patients experienced vascular access events in the two groups. Thus, extending weekly hemodialysis hours did not alter overall EQ-5D quality of life score, but was associated with improvement in some laboratory parameters and reductions in medication burden. (Clinicaltrials.gov identifier: NCT00649298).
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Affiliation(s)
- Meg J Jardine
- The George Institute for Global Health,
- Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, Australia
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Nicholas A Gray
- Department of Renal Medicine, Nambour General Hospital, Nambour, Australia
- Sunshine Coast Clinical School, The University of Queensland, Brisbane, Australia
| | - Janak R de Zoysa
- Department of Nephrology, North Shore Hospital, University of Auckland, Auckland, New Zealand
| | | | | | | | - Stuart M Grieve
- Sydney Translational Imaging Laboratory, Charles Perkins Centre, Sydney Medical School, and
- Departments of Radiology, Cardiology, and
| | - Rajesh Puranik
- Sunshine Coast Clinical School, The University of Queensland, Brisbane, Australia
- Specialist Magnetic Resonance Imaging, Newtown, Australia
| | - Hongli Lin
- First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Josette M Eris
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Jinsheng Xu
- Fourth Hospital Affiliated to Hebei Medical University, Shijiazhuang, China
| | - Kirsten Howard
- School of Public Health, University of Sydney, Sydney, Australia
- Institute for Choice, University of South Australia, Sydney, Australia
| | | | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia; and
| | - Vlado Perkovic
- The George Institute for Global Health
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
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Perl J, Dember LM, Bargman JM, Browne T, Charytan DM, Flythe JE, Hickson LJ, Hung AM, Jadoul M, Lee TC, Meyer KB, Moradi H, Shafi T, Teitelbaum I, Wong LP, Chan CT. The Use of a Multidimensional Measure of Dialysis Adequacy-Moving beyond Small Solute Kinetics. Clin J Am Soc Nephrol 2017; 12:839-847. [PMID: 28314806 PMCID: PMC5477210 DOI: 10.2215/cjn.08460816] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. Small solute removal, exemplified by Kt/Vurea, has been broadly applied as a means to quantify the dose of thrice weekly hemodialysis. Yet, the reliance on small solute clearances alone as a measure of dialysis adequacy fails fully to quantify the intended clinical effects of dialysis therapy. This review aims to (1) understand the strengths and limitations of small solute kinetics as a surrogate marker of dialysis dose, and (2) present the prospect of a more comprehensive construct for dialysis dose, one that considers more broadly the goals of ESRD care to maximize both quality of life and survival. On behalf of the American Society of Nephrology Dialysis Advisory Group, we propose the need to ascertain the validity and utility of a multidimensional measure that moves beyond small solute kinetics alone to quantify optimal dialysis derived from both patient-reported and comprehensive clinical and dialysis-related measures.
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Affiliation(s)
- Jeffrey Perl
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Ross BA, Wald R, Goldstein MB, Yuen DA, Leipsic J, Kiaii M, Rathe A, Deva DP, Kirpalani A, Bello OO, Graham JJ, Leong-Poi H, Connelly KA, Yan AT. Relationships Between Left Ventricular Structure and Function According to Cardiac MRI and Cardiac Biomarkers in End-Stage Renal Disease. Can J Cardiol 2017; 33:501-507. [DOI: 10.1016/j.cjca.2016.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/12/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022] Open
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Liu F, Sun Y, Xu T, Sun L, Liu L, Sun W, Feng X, Ma J, Wang L, Yao L. Effect of Nocturnal Hemodialysis versus Conventional Hemodialysis on End-Stage Renal Disease: A Meta-Analysis and Systematic Review. PLoS One 2017; 12:e0169203. [PMID: 28107451 PMCID: PMC5249197 DOI: 10.1371/journal.pone.0169203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 12/12/2016] [Indexed: 12/20/2022] Open
Abstract
Objectives The purpose of this study is to assess the efficacy and safety of nocturnal hemodialysis on end-stage renal disease (ESRD) patients. Methods We searched Medline, EmBase, and the Cochrance Central Register of Controlled Trials for studies up to January 2016. Analysis was done to compare variant outcomes of different hemodialysis schedules, including mortality, cardiovascular-associated variables, uremia-associated variables, quality of life (QOL), side-effects, and drug usage. Results We collected and analyzed the results of 28 studies involving 22,508 patients in our meta-analysis. The mortality results in this meta-analysis indicated that the nocturnal hemodialysis (NHD) group was not significantly different from conventional hemodialysis (CHD) group (Mortality: OR: 0.75; 95% confidence intervals (CIs): 0.52 to 1.10; p = 0.145), but the CHD group had significantly fewer number of hospitalizations than the NHD group (OR: 1.54; 95%CI: 1.32 to 1.79; p<0.001). NHD was superior to CHD for cardiovascular-associated (left ventricular hypertrophy [LVH]: SMD: -0.39; 95%CI: -0.68 to -0.10; p = 0.009, left ventricular hypertrophy index [LVHI]: SMD: -0.64; 95%CI: -0.83 to -0.46; p<0.001) and uremia-associated intervention results (Serum albumin: SMD: 0.89; 95%CI: 0.41 to 1.36; p<0.001). For the assessment of quality of life, NHD treatment significantly improved the patients’ QOL only for SF36-Physical Components Summary (SMD: 0.43; 95%CI: 0.26 to 0.60; p<0.001). NHD intervention was relatively better than CHD for anti-hypertensive drug usage (SMD: -0.48; 95%CI: -0.91 to -0.05; p = 0.005), and there was no difference between groups in our side-effects assessment. Conclusion NHD and CHD performed similarly in terms of ESRD patients’ mortality and side-effects. NHD was superior to CHD for cardiovascular-associated and uremia-associated results, QOL, and drug usage; for number of hospitalizations, CHD was relatively better than NHD.
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Affiliation(s)
- Fangjie Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yiting Sun
- Department of Clinical Medicine, China Medical University, Shenyang, Liaoning, China
| | - Tianhua Xu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Li Sun
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Linlin Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wei Sun
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xin Feng
- Blood Purification Center, Liaoning Electric Power Center Hospital, Shenyang, Liaoning, China
| | - Jianfei Ma
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Lining Wang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
- * E-mail:
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Poon CK, Chan CT. Home hemodialysis associated infection-The “Achilles' Heel” of intensive hemodialysis. Hemodial Int 2016; 21:155-160. [PMID: 27781373 DOI: 10.1111/hdi.12508] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Clara K. Poon
- Division of Nephrology; University Health Network; Toronto Ontario Canada
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Research cardiac magnetic resonance imaging in end stage renal disease - incidence, significance and implications of unexpected incidental findings. Eur Radiol 2016; 27:315-324. [PMID: 27053260 PMCID: PMC5127861 DOI: 10.1007/s00330-016-4288-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/04/2016] [Accepted: 02/08/2016] [Indexed: 01/19/2023]
Abstract
Objectives Left ventricular mass (LVM) at cardiac magnetic resonance imaging (CMR) is a frequent end point in clinical trials in nephrology. Trial participants with end stage renal disease (ESRD) may have a greater frequency of incidental findings (IF). We retrospectively investigated prevalence of IF in previous research CMR and reviewed their subsequent impact on participants. Methods Between 2002 and 2006, 161 ESRD patients underwent CMR in a transplant assessment study. Images were used to assess LV mass and function. In the current study a radiologist reviewed the scans for IF. Review of patient records determined the subsequent clinical significance of IF. Results There were 150 IF in 95 study participants. Eighty-four (56 %) were new diagnoses. One hundred and two were non-cardiac. Fifteen were suspicious of malignancy. There was a clinically significant IF for 14.9 % of the participants. In six cases earlier identification of an IF may have improved quality of life or survival. Conclusions Without radiology support clinically important IF may be missed on CMR. Patients undergoing CMR in trials should be counselled about the frequency and implications of IF. Patients with ESRD have a higher prevalence of IF than reported in other populations. Nephrology studies require mechanisms for radiologist reporting and strategies for dealing with IF. Key Points • Incidental findings on research cardiac magnetic resonance imaging can have significant consequences. • We considered incidental findings in historical renal cardiac resonance imaging clinical trials. • Incidental findings are common and important in the chronic kidney disease population. • Without radiology support, clinically significant incidental findings may be missed on imaging. • Study protocols, approvals and consent processes should take account of possible findings.
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47
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Chan CT, Mok MM. In Search of the True Effect of Home Intensive Hemodialysis. Am J Kidney Dis 2016; 67:539-41. [DOI: 10.1053/j.ajkd.2015.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 11/11/2022]
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Weinhandl ED, Gilbertson DT, Collins AJ. Mortality, Hospitalization, and Technique Failure in Daily Home Hemodialysis and Matched Peritoneal Dialysis Patients: A Matched Cohort Study. Am J Kidney Dis 2016; 67:98-110. [DOI: 10.1053/j.ajkd.2015.07.014] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 07/06/2015] [Indexed: 11/11/2022]
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Dey V, Hair M, So B, Spalding EM. Thrice-Weekly Nocturnal In-Centre Haemodiafiltration: A 2-Year Experience. NEPHRON EXTRA 2015; 5:50-7. [PMID: 26557842 PMCID: PMC4592506 DOI: 10.1159/000436982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Adequate control of plasma phosphate without phosphate binders is difficult to achieve on a thrice-weekly haemodialysis schedule. The use of quotidian nocturnal dialysis is effective but not practical in the in-centre setting. This quality improvement project was set up as an exercise allowing the evaluation of small-solute clearance by combining convection with extended-hour dialysis in a thrice-weekly hospital setting. Methods A single-centred, prospective analysis of patients' electronic records was performed from August 2012 to July 2014. The duration of haemodiafiltration was increased from a median of 4.5 to 8 h. Dialysis adequacy, biochemical parameters and medications were reviewed on a monthly basis. A reduction in plasma phosphate was anticipated, so all phosphate binders were stopped. Results Since inception, 14 patients have participated with over 2,000 sessions of dialysis. The pre-dialysis phosphate level fell from a mean of 1.52 ± 0.4 to 1.06 ± 0.1 mmol/l (p < 0.05). The average binder intake of 3.26 ± 2.6 tablets was eliminated. A normal plasma phosphate range has been maintained with increased dietary phosphate intake and no requirement for intradialytic phosphate supplementation. Conclusion Phosphate control can be achieved without the need for binders or supplementation on a thrice-weekly in-centre haemodiafiltration program.
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Affiliation(s)
- Vishal Dey
- John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock, UK
| | - Mario Hair
- John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock, UK
| | - Beng So
- John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock, UK
| | - Elaine M Spalding
- John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock, UK
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Chertow GM, Levin NW, Beck GJ, Daugirdas JT, Eggers PW, Kliger AS, Larive B, Rocco MV, Greene T. Long-Term Effects of Frequent In-Center Hemodialysis. J Am Soc Nephrol 2015; 27:1830-6. [PMID: 26467779 DOI: 10.1681/asn.2015040426] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 09/15/2015] [Indexed: 11/03/2022] Open
Abstract
The Frequent Hemodialysis Network Daily Trial randomized 245 patients to receive six (frequent) or three (conventional) in-center hemodialysis sessions per week for 12 months. As reported previously, frequent in-center hemodialysis yielded favorable effects on the coprimary composite outcomes of death or change in left ventricular mass and death or change in self-reported physical health. Here, we determined the long-term effects of the 12-month frequent in-center hemodialysis intervention. We determined the vital status of patients over a median of 3.6 years (10%-90% range, 1.5-5.3 years) after randomization. Using an intention to treat analysis, we compared the mortality hazard in randomized groups. In a subset of patients from both groups, we reassessed left ventricular mass and self-reported physical health a year or more after completion of the intervention; 20 of 125 patients (16%) randomized to frequent hemodialysis died during the combined trial and post-trial observation periods in contrast to 34 of 120 patients (28%) randomized to conventional hemodialysis. The relative mortality hazard for frequent versus conventional hemodialysis was 0.54 (95% confidence interval, 0.31 to 0.93); with censoring of time after kidney transplantation, the relative hazard was 0.56 (95% confidence interval, 0.32 to 0.99). Bayesian analysis suggested a relatively high probability of clinically significant benefit and a very low probability of harm with frequent hemodialysis. In conclusion, a 12-month frequent in-center hemodialysis intervention significantly reduced long-term mortality, suggesting that frequent hemodialysis may benefit selected patients with ESRD.
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Affiliation(s)
- Glenn M Chertow
- Department of Medicine, Stanford University, Palo Alto, California;
| | | | | | | | - Paul W Eggers
- National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | | | | | | | - Tom Greene
- Cleveland Clinic Foundation, Cleveland, Ohio; University of Utah, Salt Lake City, Utah
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