Association of Vascular Access Type with Mortality, Hospitalization, and Transfer to In-Center Hemodialysis in Patients Undergoing Home Hemodialysis

Vascular Access Considerations in Home Hemodialysis

There is a global interest in expanding home dialysis utilization among patients with ESKD. Home hemodialysis (HHD) is an appealing KRT option for this population because of its multiple clinical and quality of life benefits. Central to successful HHD is the establishment and maintenance of a functioning vascular access that serves as a patient's lifeline while on therapy. While the selection of a vascular access type is influenced by individual patient circumstances, the arteriovenous fistula is generally the preferred access method. Training patients to use their dialysis access requires attention to safety, risk management, and monitoring for complications to minimize adverse events and technique failure. Policies incorporating systematic frameworks for quality improvement and assurance, in conjunction with the measurement of metrics relating to vascular access, are tools that should be used by HHD programs to enhance the value of care delivered. In this perspective, we aim to describe what is currently known about the various vascular access options in HHD and to elucidate what needs to be taken into consideration in the selection and care of this access.

Integrated home dialysis model: facilitating home-to-home transition

Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.

Patient-Centered Home Hemodialysis: Approaches and Prescription

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.

From Home to Wearable Hemodialysis: Barriers, Progress, and Opportunities

Although the past two decades have seen substantial proportional growth of home hemodialysis in the United States, the absolute number of patients treated with home hemodialysis remains small. Currently available stationary hemodialysis devices for use in the home have inherent limitations that represent barriers for more widespread adoption by a larger proportion of individuals with kidney failure. These limitations include device weight and bulk, ergonomics considerations, technical complexity, vascular access challenges, and limited remote patient monitoring. Recent years have witnessed a resurgence in research and development of prototype wearable kidney replacement devices incorporating innovations in miniaturization, new biomaterials, and new methods for toxin clearance and dialysate regeneration. Recent work has built on five decades of incremental innovation in wearable dialysis concepts and prototypes, starting from the work by Kolff in the 1970s. Wearable dialysis devices that successfully overcome key persistent barriers to successful development and adoption of these technologies will radically reshape the landscape of kidney replacement therapies and have the potential to dramatically improve the lives of individuals living with kidney failure.

Pathways to improve nephrologist comfort in managing patients on in-center or home self-care dialysis

In end-stage kidney disease (ESKD), patient engagement and empowerment are associated with improved survival and complications. However, patients lack education and confidence to participate in self-care. The development of in center self-care hemodialysis can enable motivated patients to allocate autonomy, increase satisfaction and engagement, reduce human resource intensiveness, and cultivate a curiosity about home dialysis. In this review, we emphasize the role of education to overcome barriers to home dialysis, strategies of improving home dialysis utilization in the COVID 19 era, the significance of in-center self-care dialysis (e.g., cost containment and empowering patients), and implementation of an in-center self-care dialysis as a bridge to home hemodialysis (HHD).

Survival Analysis and Its Predictors Among Hemodialysis Patients at Saint Paul Hospital Millennium Medical College and Myungsung Christian Medical Center in Addis Ababa, Ethiopia, 2021

Background

Diabetes mellitus and hypertension are the most prominent conditions causing chronic kidney disease and eventually end-stage renal disease. Renal replacement therapy, particularly hemodialysis (HD), is the mainstay of treatment. The aim of this study is to assess the overall survival status of HD patients and potential survival predictors at Saint Paul hospital millennium medical college (SPHMMC) and Myungsung Christian Medical Center (MCM) in Addis Ababa, Ethiopia.

Methods

A retrospective cohort study was conducted on HD patients at SPHMMC and MCM general hospital from January 1, 2013 to December 30, 2020. Kaplan Meier, Log-rank, and Cox proportional regression models were used for the analysis. Estimated risks were reported as hazard ratios with 95% confidence intervals and P<0.05 was considered as having a significant association.

Results

A total of 128 patients were included in the study. Median survival time was 65 months. The predominant co-morbid condition was found to be diabetes mellitus with hypertension (42%). The total risk time for these patients was 143,617 person years. The overall incidence rate of death was 2.9 per 10,000 person years (95% CI=2.2-4). Patients who developed blood stream infection were 2.98-times more likely to die than those without infection. Those using an arteriovenous fistula were 66% less likely to die than those using a central venous catheter. Additionally, patients treated in a government-owned facility were 79% less likely to die.

Conclusion

The study identified that the median survival time of 65 months was comparable with developed nations. Significant predictors of death were found to be blood stream infection and type of vascular access. Government-owned treatment facilities showed better patient survival.

Ultrasound guided cannulation of dialysis access

Vascular access is the key part of haemodialysis (HD) treatment, as this is not possible without a functioning access. The use of the arteriovenous fistula (AVF) has fewer complications, lower mortality and fewer hospital admissions compared to central venous catheter (CVC). However, although guidelines recommend AVF as the access of choice, access-related cannulation complications may lead to greater morbidity. Most guidelines recommend using Doppler ultrasound (DU) to surveil the AVF for HD, but its use must not only be limited to surveillance as it can also be used for needling. Therefore, among those techniques at our disposal today, one of the best tools for AVF needling is Doppler ultrasound (DU). Despite the lack of evidence regarding ultrasound-guided needling of AVF, it is becoming part of our usual practice arsenal in many HD centres. Its use has allowed needling results to improve and the number of complications to be reduced versus traditional ‘blind’ needling. It should be remembered that even though it is very useful for the daily work of dialysis nurses, as in the case of other techniques, it requires adequate, specialised and long-term training to acquire competence in using it. For example, it is important to learn some concepts and terminology that should be known and, at the same time, be highly familiar with different techniques available. Two types of needling techniques are described using US assistance: US-guided needling, where DU is used to make a map of the vessels which can be utilised and to mark the best site to insert the needles once the mapping is done; and real-time US-guided needling, the simultaneous manipulation of the probe and the insertion of the puncture needle through the slice plane of the ultrasound device. Regarding the real-time technique, there are two approaches: out of plane (the probe takes a transversal image of the needle) and in plane (vessel axis aligned with the probe and the needle in the same plane) To ensure successful needling and to maximise reproducibility, especially with tight deadlines and staff resources, nursing staff need to follow some important recommendations that include safety and the use of the method, both for them and the patient. In this way, ultrasound-guided needling becomes a tool with enormous potential utility, but practical training is as important as knowing the technique.

Essentials of Vascular Access for Home Hemodialysis

Hemodialysis (HD) at home has gained increasing popularity in recent years because of regulatory and financial issues. Creation and maintenance of a well-functioning, cannulatable vascular access is essential for performance of home HD (HHD). A vascular access team-based approach to creation, maintenance, and troubleshooting of vascular access can facilitate removing barriers to cannulation at home related to fear of pain and bleeding associated with large bore needles. Frequent cannulation of HD access is associated with more frequent access complications, especially infections. Thus, proper cannulation of arteriovenous access requires careful training of rope ladder and buttonhole techniques to avoid infectious and traumatic complications that can lead to dire consequences. Development of better methods of creating buttonholes and single needles for dialysis can facilitate HHD. A culture of self-cannulation at dialysis centers can also promote HHD.

Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit

A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system.

Quality Assurance and Preventing Serious Adverse Events in the Home Hemodialysis Setting

Patient safety is of the utmost importance in home hemodialysis (HHD). Recognizing that there are risks related to vascular access (both infectious and noninfectious events), dialysis water quality, and procedural-related adverse events (including arteriovenous fistula needle dislodgement or air embolism), there is a need for systematic identification and management. Although adverse events are relatively infrequent in HHD, the potential consequences of these events may include significant morbidity, HHD treatment failure, or death. Therefore, having a systematic framework to review each event, audit and retrain patient technique, disclose and discuss events with patients, home unit staff and device companies (if relevant) and determine preventative measures to avoid future adverse events, is crucial. In this review, we will describe the literature around the types and relative frequency of serious adverse events in the HHD setting and we will outline a quality assurance framework for capturing, managing, and avoiding serious adverse events. Finally, we will describe some of the novel existing approaches to preventing or addressing serious adverse events and critical knowledge gaps that should be evaluated in future study.

Complications and challenges of home hemodialysis: A historical review

Home hemodialysis (HHD) has evolved as a preferred and safe kidney replacement modality over the past six decades. Despite advances in technological aspects of HHD, potential complications still pose a challenge to health care givers, patients, and their families. In this narrative review, we describe vascular access and cannulation, anticoagulation, nutritional, residual kidney function, psychosocial, technique failure, and machine/procedural-related complications. Addressing these problems is essential for favorable patient outcomes.

The survival analysis of tunnel-cuffed central venous catheter versus arteriovenous hemodialysis access among elderly patients: A retrospective single center study

BACKGROUND

There is currently a controversy for the optimal vascular access option in the elderly, regarding their multiple comorbidities and life expectancies. Our study aimed to compare the survival of tunneled cuff venous catheter (CVC) and arteriovenous access (AV access) in elderly patients.

METHODS

A retrospective cohort study was performed by electronic medical record review. All hemodialysis patients aged 65 years and over who firstly initiated dialysis from January 1, 2012 to December 31, 2016 at Siriraj hospital, Thailand, were included. The primary outcomes are to compare a 2-year period of survival between CVC and AV access in terms of abandonment, death, and combined outcome. Propensity score covariate and Charlson Comorbidity Score (CCI) were used for multivariable analysis adjustment.

RESULTS

A total of 359 patients were included; 216 (60.2%) patients had initiated hemodialysis via CVC while the rest used AV access. The patients' average ages were 76.7 ± 7.0 and 74.0 ± 5.8 years (p-value<0.001) in the CVC and AV access group, respectively. The 2-year mortality rates of CVC and AV access groups were 24.1% and 15.4%, respectively (p-value = 0.038). Multivariable analyses showed that the adjusted hazard ratio (aHR) of combined endpoints, i.e., vascular access abandonment and death, was statistically different only in the CCI-adjusted model (aHR = 0.68, 95% CI: 0.46-0.99). Mortality from infection cause was more common in the CVC group than the AV access group.

CONCLUSION

CVC access maybe considers an alternative option for frail elderly patients. However, the patient selection is a crucial issue, given higher infection-related mortality in patients using CVC.

A Systematic Approach To Promoting Home Hemodialysis during End Stage Kidney Disease

Home dialysis has garnered much attention since the advent of the Advancing American Kidney Health initiative. For many patients and nephrologists, home dialysis and peritoneal dialysis are synonymous. However, home hemodialysis (HHD) should not be forgotten. Since 2004, HHD has grown more rapidly than other dialytic modalities. The cardinal feature of HHD is customizability of treatment intensity, which can be titrated to address the vexing problems of volume and pressure loading during interdialytic gaps and ultrafiltration intensity during each hemodialysis session. Growing HHD utilization requires commitment to introducing patients to the modality throughout the course of ESKD. In this article, we describe a set of strategies for introducing HHD concepts and equipment. First, patients initiating dialysis may attend a transitional care unit, which offers an educational program about all dialytic modalities during 3-5 weeks of in-facility hemodialysis, possibly using HHD equipment. Second, prevalent patients on hemodialysis may participate in "trial-run" programs, which allow patients to experience increased treatment frequency and HHD equipment for several weeks, but without the overt commitment of initiating HHD training. In both models, perceived barriers to HHD-including fear of equipment, anxiety about self-cannulation, catheter dependence, and the absence of a care partner-can be addressed in a supportive setting. Third, patients on peritoneal dialysis who are nearing a transition to hemodialysis may be encouraged to consider a home-to-home transition (i.e., from peritoneal dialysis to HHD). Taken together, these strategies represent a systematic approach to growing HHD utilization in multiple phenotypes of patients on dialysis. With the feature of facilitating intensive hemodialysis, HHD can be a key not only to satiating demand for home dialysis, but also to improving the health of patients on dialysis.

The effects of vascular access types on the survival and quality of life and depression in the incident hemodialysis patients

Background

Although arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD), the association between vascular access types and quality of life is not well-known. We investigated the relationships between HD vascular access types and all-cause mortality, health-related quality of life (HRQOL) and the degree of depression in a large prospective cohort.

Methods

A total of 1461 patients who newly initiated HD were included. The initial vascular access types were classified into AVF, arteriovenous graft (AVG), and central venous catheter (CVC). The primary outcomes were all-cause mortality and HRQOL and depression. The secondary outcome was all-cause hospitalization. Kidney Disease Quality of Life Short Form 36 (KDQOL-36) and Beck’s depression inventory (BDI) scores were measured to assess HRQOL and depression.

Results

Among 1461 patients, we identified 314 patients who started HD via AVF, 76 via AVG, and 1071 via CVC. In the survival analysis, patients with AVF showed significantly better survival compared with patients with other accesses (p < .001). The AVF and AVG group had higher KDQOL-36 score and lower BDI score than CVC group at 3 months and 12 months after the initiation of HD. The frequency of hospitalization was higher in patients with AVG compared to those with AVF (AVF 0.7 vs. AVG 1.1 times per year) (p = .024).

Conclusions

The patients with AVF had better survival rate and low hospitalization rate, and the patients with AVF or AVG showed both higher HRQOL and lower depression scores than those with CVC.

Point-of-care ultrasound for assessing arteriovenous fistula maturity in outpatient hemodialysis

BACKGROUND

Point-of-care ultrasound in end-stage renal disease is on the rise. Presently the decision to cannulate an arteriovenous fistula is based on its duration since surgery and physical exam. This study examines the effects of point-of-care ultrasound on decreasing the time to arteriovenous fistula cannulation, time spent with a central venous catheter, and the complications and infections that arise.

METHODS

Prospective point-of-care ultrasound patients were recruited between January 2015 and January 2018, while retrospective data (non-point-of-care ultrasound) were collected via chart review from patients who had fistula creation between November 2011 and May 2014. Patients had point-of-care ultrasound within 3 weeks after arteriovenous fistula creation and were followed for 1 year. Arteriovenous fistula cannulation was initiated when the following parameters were met: diameter > 6 mm (with no depreciable narrowing of more than 20% throughout), depth < 6 mm, and length > 6 cm. Demographic data, as well as time to cannulation and central venous catheter removal, number of infections, complications, and interventions were compared between point-of-care ultrasound and non-point-of-care ultrasound groups using unpaired t-test, chi-square, and Fisher exact test statistical analysis.

RESULTS

A total of 37 patients with new arteriovenous fistulas were followed by point-of-care ultrasound compared to 29 non-point-of-care ultrasound patients. Point-of-care ultrasound patients had earlier cannulations (35.5 vs 63.3 days, p < 0.05), shorter central venous catheter duration (68.2 vs 98.3 days, p < 0.05), and less infections (12 vs 19) without differences in complication compared to the non-point-of-care ultrasound.

CONCLUSION

Point-of-care ultrasound facilitates early and safe arteriovenous fistula cannulation leading to a reduction in central venous catheter time and risk of infection. Point-of-care ultrasound may also aid in earlier identification of complications and difficult cannulations.

Managing Kidney Failure with Home Hemodialysis

There is a resurgence in clinical adoption of home hemodialysis globally driven by several demonstrated clinical and economic advantages. Yet, the overall adoption of home hemodialysis remains under-represented in most countries. The practicality of managing ESKD with home hemodialysis is a common concern among practicing nephrologists in the United States. The primary objective of this invited feature is to deliver a practical guide to managing ESKD with home hemodialysis. We have included common clinical scenarios, clinical and infrastructure management problems, and approaches to the day-to-day management of patients undergoing home hemodialysis.

The use of nurse-administered vascular access audit in home hemodialysis patients: A quality initiative

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.

Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers

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.

There's no place like home: 35-year patient survival on home hemodialysis

The vast majority of maintenance dialysis patients suffer from poor long-term survival rates and lower levels of health-related quality of life. However, home hemodialysis is a historically significant dialysis modality that has been associated with favorable outcomes as well as greater patient autonomy and control, yet only represents a small minority of the total dialysis performed in the United States. Some potential disadvantages of home hemodialysis include vascular access complications, infection-related hospitalizations, patient fatigue, and attrition. In addition, current barriers and challenges in expanding the utilization of this modality include limited patient and provider education and technical expertise. Here we report a 65-year old male with end-stage renal disease due to Alport's syndrome who has undergone 35 years of uninterrupted thrice-weekly home hemodialysis (ie, every Sunday, Tuesday, and Thursday evening, each session lasting 3 to 3¼ hours in length) using a conventional hemodialysis machine who has maintained a high functional status allowing him to work 6-8 hours per day. The patient has been able to liberalize his dietary and fluid intake while only requiring 3-4 liters of ultrafiltration per treatment, despite having absence of residual kidney function. Through this case of extraordinary longevity and outcomes after 35 years of dialysis and a review of the literature, we illustrate the history of home hemodialysis, its significant clinical and psychosocial advantages, as well as the barriers that hinder its widespread adaptation.

Relative risk of home hemodialysis attrition in patients using a telehealth platform

INTRODUCTION

Home hemodialysis (HHD) facilitates increased treatment frequency, which may improve patient outcomes. However, attrition due to technique failure limits the clinical effectiveness of the modality. Nx2me Connected Health is a telehealth platform that enables ongoing assessment of HHD patients using NxStage equipment, and that may reduce patient burden. We aimed to assess whether use of Nx2me was associated with risk of HHD attrition.

METHODS

We compared risks of all-cause attrition, dialysis cessation (i.e., death or transplant), and technique failure in Nx2me users and matched control patients, using a retrospective cohort study. We also compared the likelihood of HHD training graduation in patients who initiated use of Nx2me during training with the likelihood in matched control patients. Matching factors included date of HHD initiation, NxStage treatment duration at initiation of follow-up, and prescribed treatment frequency. We used stratified Fine-Gray and Cox regression to compare risks, with adjustment for demographic factors and vascular access modality, and stratification by matched cluster.

FINDINGS

We identified 606 Nx2me users; 49.5% initiated use of Nx2me in <3 months after initiation of HHD with NxStage equipment. Adjusted hazard ratios (AHRs) of all-cause attrition, dialysis cessation, and technique failure were 0.80 (95% confidence interval, 0.68-0.95), 1.10 (0.86-1.41), and 0.71 (0.57-0.87), respectively, for Nx2me users vs. matched controls. AHRs were similar in patients who initiated use of Nx2me in <3 months after initiation of HHD. The AHR of HHD training graduation was 1.61 (1.10-2.36) in patients who initiated use of Nx2me within 2 weeks of training initiation vs. matched controls.

DISCUSSION

Use of Nx2me was associated with lower risk of all-cause attrition, lower risk of technique failure, and higher likelihood of HHD training graduation. Further studies are needed to identify the mechanisms by which use of a telehealth platform may improve clinical outcomes and reduce patient burden.

End-stage renal disease: a risk factor of deep neck infection - a nationwide follow-up study in Taiwan

BACKGROUND

Uremia is likely a risk factor for deep neck infection (DNI). However, only a few relevant cases have been reported, and evidence sufficient to support this hypothesis is lacking. The aim of the study is to investigate the effects of end-stage renal disease (ESRD) on DNI.

METHODS

We used the database of the Registry for Catastrophic Illness Patients (RFCIP), a subset of the National Health Insurance Research Database (NHIRD) in Taiwan, to conduct a retrospective follow-up study. Between 1997 and 2013, a total of 157,340 patients in Taiwan with ESRD who received dialysis were registered in the RFCIP, whom were matched with a database consisting of 1,000,000 randomly selected patients who represented the national population, to conduct the follow-up study for investigating the incidence of DNI in the ESRD and control cohorts.

RESULTS

In the ESRD group, 280 DNIs were identified with an incidence rate of 43 per 100,000 person-years. In the comparison group, 194 DNIs were identified with an incidence rate of 20 per 100,000 person-years. The incidence rate ratio was 2.16 (p < 0.001). Kaplan-Meier analysis indicated that the ESRD group had a significantly higher cumulative incidence of DNI (p < 0.001). According to Cox regression analysis, the hazard ratio of ESRD for DNI was 2.23 (p < 0.001). The therapeutic methods (non-surgery and surgery), performance of tracheostomy, duration of hospitalization did not differ significantly between the two groups, except more ESRD-DNI patients were admitted to intensive care units. The mortality rate of patients with DNI in the ESRD group was significantly higher than that in the control group (8.6% for ESRD vs 3.6% for control, p = 0.032). Furthermore, the Kaplan-Meier analysis demonstrated a poorer survival outcome in the ESRD group (p = 0.029). However, the individual survival outcomes following non-surgical and surgical therapies in the ESRD group did not differ significantly (p = 0.31).

CONCLUSIONS

ESRD is a predisposing factor for DNI, increasing its risk by twofold. In the patients with ESRD, DNI was not associated with higher rates of surgical debridement, tracheostomy, and mediastinal complications or longer hospital stays; however, it was associated with poorer survival outcomes, regardless of the therapeutic method.

Nutritional Predictors of Mortality in Long Term Hemodialysis Patients

Serum albumin had been noted to be a predictor of mortality in hemodialysis (HD) patients. Normalized protein catabolic rate (nPCR) less than 0.8 or greater than 1.4 g/kg/d was also associated with greater mortality. There was no previous study to show the effectiveness of combination of serum albumin and nPCR to predict the mortality in chronic HD patients. Eight hundred and sixty-six patients were divided into 4 groups according to their nPCR and serum albumin levels. Biochemical, and hematological parameters were recorded. The associations between groups, variables mentioned above and mortality were analyzed. Multivariate Cox regression analysis showed that age, diabetes mellitus, fistula as blood access, nPCR <1.2 g/kg/day combined with albumin <4 (Group A), nPCR ≧ 1.2 g/kg/day combined with albumin <4 g/dL (Group B) (nPCR ≧ 1.2 g/kg/day combined with Albumin ≧ 4 g/dL as reference group), non-anuria, hemoglobin, creatinine, and log (high sensitivity C reactive protein) were correlated with 36 months mortality. Group A and group B patients had higher 36 months cardiovascular (CV) and infection related mortality rates as compared with group D patients. In conclusion, Group A and Group B patients had significantly higher rate of all-cause, CV and infection related mortality.

Timely Referral to Outpatient Nephrology Care Slows Progression and Reduces Treatment Costs of Chronic Kidney Diseases

Introduction

We present a new approach to evaluate the importance of ambulatory nephrology care in patients with chronic kidney disease (CKD).

Methods

An anonymized health claims database of German insurance companies was searched in a retrospective analysis for patients with CKD using the codes of the International Classification of Diseases, 10th German modification. A total of 105,219 patients with CKD were identified. Patients were assigned to the group "timely referral," when nephrology care was present in the starting year 2009, or initiated during the following 3 years in CKD1-4. Using frequency matching for age and gender, 21,024 of the late referral group were matched with the equal number of patients in the timely referral group. Hospital admission rates, total treatment costs, and kidney function (change in CKD stages, start of dialysis, mortality) were documented each year during the 4-year follow-up.

Results

Hospital admission rates (110%-186%) and total treatment costs (119%-160%) were significantly higher (P < 0.03) in late referral compared with timely referral. In the timely referral group, significantly more patients did not change their CKD stage (65%-72.9% vs. 52%-64.6%, P < 0.05) compared with late referral. Starting in CKD3 more patients tended to start dialysis in 1 year in timely referral (1.9 ± 0.6 vs. 1.0 ± 0.4, P = 0.1). In contrast, death rates were significantly higher in the late referral group (18.8 ± 1.8% vs. 6.7 ± 0.4%, P = 0.0001).

Discussion

Timely referral to outpatient nephrology care is associated with slowed disease progression, less hospital admissions, reduced total treatment costs, and improved survival in patients with CKD.