1
|
Liu KH, Chang WH, Lai ECC, Tsai PC, Hsu B, Yang YH, Lin WR, Huang TS, Su FY, Chiang JH, Li CY, Tsai YS, Sung JM. Ambient temperature and the occurrence of intradialytic hypotension in patients receiving hemodialysis. Clin Kidney J 2024; 17:sfad304. [PMID: 38213491 PMCID: PMC10783262 DOI: 10.1093/ckj/sfad304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Indexed: 01/13/2024] Open
Abstract
Background Intradialytic hypotension (IDH) is a common hemodialysis complication causing adverse outcomes. Despite the well-documented associations of ambient temperatures with fluid removal and pre-dialysis blood pressure (BP), the relationship between ambient temperature and IDH has not been adequately studied. Methods We conducted a cohort study at a tertiary hospital in southern Taiwan between 1 January 2016 and 31 October 2021. The 24-h pre-hemodialysis mean ambient temperature was determined using hourly readings from the weather station closest to each patient's residence. IDH was defined using Fall40 [systolic BP (SBP) drop of ≥40 mmHg] or Nadir90/100 (SBP <100 if pre-dialysis SBP was ≥160, or SBP <90 mmHg). Multivariate logistic regression with generalizing estimating equations and mediation analysis were utilized. Results The study examined 110 400 hemodialysis sessions from 182 patients, finding an IDH prevalence of 11.8% and 10.4% as per the Fall40 and Nadir90/100 criteria, respectively. It revealed a reverse J-shaped relationship between ambient temperature and IDH, with a turning point around 27°C. For temperatures under 27°C, a 4°C drop significantly increased the odds ratio of IDH to 1.292 [95% confidence interval (CI) 1.228 to 1.358] and 1.207 (95% CI 1.149 to 1.268) under the Fall40 and Nadir90/100 definitions, respectively. Lower ambient temperatures correlated with higher ultrafiltration, accounting for about 23% of the increased IDH risk. Stratified seasonal analysis indicated that this relationship was consistent in spring, autumn and winter. Conclusion Lower ambient temperature is significantly associated with an increased risk of IDH below the threshold of 27°C, irrespective of the IDH definition. This study provides further insight into environmental risk factors for IDH in patients undergoing hemodialysis.
Collapse
Affiliation(s)
- Kuan-Hung Liu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Hsiang Chang
- Department of Food Safety/ Hygiene and Risk Management, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Research Center of Environmental Trace Toxic Substances, National Cheng Kung University, Tainan, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Chen Tsai
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Bin Hsu
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Hsuan Yang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tzu-Shan Huang
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Fang-Yi Su
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Hsien Chiang
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Yau-Sheng Tsai
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Junne-Ming Sung
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
2
|
Canney M, Clark EG. Risk-Based Thresholds for Hemodialysis Ultrafiltration Rates: A Warning Signal or a Call to Action? Clin J Am Soc Nephrol 2023; 18:693-695. [PMID: 37163611 PMCID: PMC10278854 DOI: 10.2215/cjn.0000000000000181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- Mark Canney
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
3
|
Navarrete JE, Rajabalan A, Cobb J, Lea JP. Proportion of Hemodialysis Treatments with High Ultrafiltration Rate and the Association with Mortality. KIDNEY360 2022; 3:1359-1366. [PMID: 36176655 PMCID: PMC9416834 DOI: 10.34067/kid.0001322022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/02/2022] [Indexed: 01/11/2023]
Abstract
Background Rapid fluid removal during hemodialysis has been associated with increased mortality. The limit of ultrafiltration rate (UFR) monitored by the Centers for Medicare & Medicaid Services is 13 ml/kg per hour. It is not clear if the proportion of treatments with high UFR is associated with higher mortality. We examined the association of proportion of dialysis treatments with high UFR and mortality in end stage kidney failure patients receiving hemodialysis. Methods This was a retrospective study of incident patients initiating hemodialysis between January 1, 2010, and December 31, 2019, at Emory dialysis centers. The proportion of treatments with high UFR (>13 ml/kg per hour) per patient was calculated using data from the initial 3 months of dialysis therapy. Patients were categorized on the basis of quartiles of proportion of dialysis sessions with high UFR. Risk of death and survival probabilities were calculated and compared for all quartiles. Results Of 1050 patients eligible, the median age was 59 years, 56% were men, and 91% were Black. The median UFR was 6.5 ml/kg per hour, and the proportion of sessions with high UFR was 5%. Thirty-one percent of patients never experienced high UFR. Being a man, younger age, shorter duration of hemodialysis sessions, lower weight, diabetic status, higher albumin, and history of heart failure were associated with a higher proportion of sessions with high UFR. Patients in the higher quartile (26% dialysis with high UFR, average UFR 9.8 ml/kg per hour, median survival of 5.6 years) had a higher risk of death (adjusted hazard ratio 1.54; 95% CI, 1.13 to 2.10) compared with those in the lower quartile (0% dialysis with high UFR, average UFR 4.7 ml/kg per hour, median survival 8.8 years). Conclusions Patients on hemodialysis who did not experience frequent episodes of elevated UFR during the first 3 months of their dialysis tenure had a significantly lower risk of death compared with patients with frequent episodes of high UFR.
Collapse
Affiliation(s)
- José E. Navarrete
- Emory University School of Medicine, Renal Division, Atlanta, Georgia
| | - Ajai Rajabalan
- Emory University School of Medicine, Renal Division, Atlanta, Georgia
| | - Jason Cobb
- Emory University School of Medicine, Renal Division, Atlanta, Georgia
| | - Janice P. Lea
- Emory University School of Medicine, Renal Division, Atlanta, Georgia
| |
Collapse
|
4
|
Bellin EY, Hellebrand AM, Kaplan SM, Ledvina JG, Markis WT, Levin NW, Kaufman AM. Epidemiology of nursing home dialysis patients-A hidden population. Hemodial Int 2021; 25:548-559. [PMID: 34132036 PMCID: PMC8596662 DOI: 10.1111/hdi.12943] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/11/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
Introduction Dialysis patients are often discharged from hospitals to skilled nursing facilities (SNFs), but little has been published about their natural history. Methods Using electronic medical record data, we conducted a retrospective cohort study of nursing home patients treated with in‐SNF hemodialysis from January 1, 2018 through June 20, 2020 within a dialysis organization across eight states. A dialytic episode began with the first in‐SNF dialysis and was ended by hospitalization, death, transfer, or cessation of treatment. The clinical characteristics and natural history of these patients and their dialytic episodes are described. Findings Four thousand five hundred and ten patients experienced 9274 dialytic episodes. Dialytic episodes had a median duration of 18 days (IQR: 8–38) and were terminated by a hospitalization n = 5747 (62%), transfer n = 2638 (28%), death n = 568 (6%), dialysis withdrawal n = 129 (1.4%), recovered function n = 2 (0.02%), or other cause n = 6 (0.06%). Increased patient mortality was associated with advancing age, low serum creatinine, albumin, or sodium, and low pre‐dialytic systolic blood pressure (sBP). U‐shaped relationships to mortality were observed for intradialytic hypotension frequency and for post‐ > pre‐hemodialysis sBP frequency. Prescription of dialysis five times weekly in the first 2 weeks was associated with better survival in the first 90 days (HR 0.77, CI 0.62–0.96; p < 0.02). Discussion Provision of in‐SNF dialysis by an external dialysis organization enables discharge from the acute care setting for appropriate treatment with increased nursing contact time in an otherwise under‐resourced environment. SNF ESRD patient clinical characteristics and outcomes are extensively characterized for the first time.
Collapse
Affiliation(s)
- Eran Y Bellin
- Departments of Epidemiology & Population Health and Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | | | | | - Nathan W Levin
- Internal Medicine, Mount Sinai Icahn School of Medicine, New York, New York, USA
| | | |
Collapse
|
5
|
Chanliau J, Durand PY. Lowering dialysis sessions duration may be dangerous. BULLETIN DE LA DIALYSE À DOMICILE 2021. [DOI: 10.25796/bdd.v4i1.60263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Dialysis session in less duration - either to give a better quality of life for the patient or to optimize the organization the dialysis institution - may have bad repercussions on the quality of the treatment and therefore the quality of life of the patient.
According to the result of the publications listed in this work, we conclude that it is necessary to perform either longer sessions or more frequent treatments to limit the interval time between two sessions.
As this is difficult to perform by the providers, we recommend to develop home dialysis to obtain the best result.
Collapse
|
6
|
Blum D, Thomas A, Harris C, Hingwala J, Beaubien-Souligny W, Silver SA. An Environmental Scan of Canadian Quality Metrics for Patients on In-Center Hemodialysis. Can J Kidney Health Dis 2020; 7:2054358120975314. [PMID: 33343910 PMCID: PMC7727051 DOI: 10.1177/2054358120975314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/24/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Quality metrics or indicators help guide quality improvement work by reporting on measurable aspects of health care upon which improvement efforts can focus. For recipients of in-center hemodialysis (ICHD) in Canada, it is unclear what ICHD quality indicators exist and whether they adequately cover different domains of health care quality. Objectives: To identify and evaluate current Canadian ICHD quality metrics to document a starting point for future collaborations and standardization of quality improvement in Canada. Design: Environmental scan of quality metrics in ICHD, and subsequent indicator evaluation using a modified Delphi approach. Setting: Canadian ICHD units. Participants: Sixteen-member pan-Canadian working group with expertise in ICHD and quality improvement. Measurements: We classified the existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks. Methods: Each metric was rated by a 5-person subcommittee using a modified Delphi approach based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for additional comments. Results: We identified 27 metrics that are tracked across 8 provinces, with only 9 (33%) tracked by multiple provinces (ie, more than 1 province). We rated 9 metrics (33%) as “necessary” to distinguish high-quality from low-quality care, of which only 2 were tracked by multiple provinces (proportion of patients by primary access and rate of vascular access-related bloodstream infections). Most (16/27, 59%) indicators assessed the IOM domains of safe or effective care, and none of the “necessary” indicators measured the IOM domains of timely, patient-centered, or equitable care. Limitations: The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals, with more representation from academic sites. Conclusions: Quality indicators in Canada mainly focus on safe and effective care, with little provincial overlap. These results highlight current gaps in quality of care measurement for ICHD, and this initial work should provide programs with a starting point to combine highly rated indicators with newly developed indicators into a concise balanced scorecard that supports quality improvement initiatives across all aspects of ICHD care. Trial Registration: not applicable.
Collapse
Affiliation(s)
- Daniel Blum
- Division of Nephrology, Jewish General Hospital, Montreal, QC, Canada
- Daniel Blum, Division of Nephrology, Jewish General Hospital, 3755 Cote Sainte Catherine, D-070, Montreal, QC, Canada H3T 1E2.
| | - Alison Thomas
- Division of Nephrology, St. Michael’s Hospital, Toronto, ON, Canada
| | - Claire Harris
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Jay Hingwala
- Division of Nephrology, University of Manitoba, Winnipeg, Canada
| | | | - Samuel A. Silver
- Division of Nephrology, Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
| |
Collapse
|
7
|
Terner Z, Long A, Reviriego-Mendoza M, Larkin JW, Usvyat LA, Kotanko P, Maddux FW, Wang Y. Seasonal and Secular Trends of Cardiovascular, Nutritional, and Inflammatory Markers in Patients on Hemodialysis. KIDNEY360 2020; 1:93-105. [PMID: 35372910 PMCID: PMC8809101 DOI: 10.34067/kid.0000352019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/13/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND All life on earth has adapted to the effects of changing seasons. The general and ESKD populations exhibit seasonal rhythms in physiology and outcomes. The ESKD population also shows secular trends over calendar time that can convolute the influences of seasonal variations. We conducted an analysis that simultaneously considered both seasonality and calendar time to isolate these trends for cardiovascular, nutrition, and inflammation markers. METHODS We used data from adult patients on hemodialysis (HD) in the United States from 2010 through 2014. An additive model accounted for variations over both calendar time and time on dialysis. Calendar time trends were decomposed into seasonal and secular trends. Bootstrap procedures and likelihood ratio methods tested if seasonal and secular variations exist. RESULTS We analyzed data from 354,176 patients on HD at 2436 clinics. Patients were 59±15 years old, 57% were men, and 61% had diabetes. Isolated average secular trends showed decreases in pre-HD systolic BP (pre-SBP) of 2.6 mm Hg (95% CI, 2.4 to 2.8) and interdialytic weight gain (IDWG) of 0.35 kg (95% CI, 0.33 to 0.36) yet increases in post-HD weight of 2.76 kg (95% CI, 2.58 to 2.97). We found independent seasonal variations of 3.3 mm Hg (95% CI, 3.1 to 3.5) for pre-SBP, 0.19 kg (95% CI, 0.17 to 0.20) for IDWG, and 0.62 kg (95% CI, 0.46 to 0.79) for post-HD weight as well as 0.12 L (95% CI, 0.11 to 0.14) for ultrafiltration volume, 0.41 ml/kg per hour (95% CI, 0.37 to 0.45) for ultrafiltration rates, and 3.30 (95% CI, 2.90 to 3.77) hospital days per patient year, which were higher in winter versus summer. CONCLUSIONS Patients on HD show marked seasonal variability of key indicators. Secular trends indicate decreasing BP and IDWG and increasing post-HD weight. These methods will be of importance for independently determining seasonal and secular trends in future assessments of population health.
Collapse
Affiliation(s)
- Zachary Terner
- Department of Statistics and Applied Probability, University of California-Santa Barbara, Santa Barbara, California
| | - Andrew Long
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | | | - John W. Larkin
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | - Len A. Usvyat
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, New York; and
- Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York
| | | | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California-Santa Barbara, Santa Barbara, California
| |
Collapse
|
8
|
Alvarez L, Brown D, Hu D, Chertow GM, Vassalotti JA, Prichard S. Intradialytic Symptoms and Recovery Time in Patients on Thrice-Weekly In-Center Hemodialysis: A Cross-sectional Online Survey. Kidney Med 2019; 2:125-130. [PMID: 32734233 PMCID: PMC7380355 DOI: 10.1016/j.xkme.2019.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Rationale & Objective Patients experience various symptoms during hemodialysis. We aimed to assess the frequency and severity of symptoms during hemodialysis and whether intradialytic symptoms are associated with recovery time postdialysis. Study Design An online questionnaire was sent to 10,000 patients in a National Kidney Foundation database. Setting & Participants Adult patients receiving in-center hemodialysis 3 times weekly for 3 or more months. Exposure Online questionnaire. Analytic Approach Tabulation of frequency and severity of events and recovery time as percent of respondents, construction of a total symptom score, followed by rank correlation analysis of symptom characteristics with total recovery time. Outcomes Patient-reported intradialytic symptoms and recovery time postdialysis. Results 359 patients met screening criteria and completed the questionnaire. Mean age was 62.5 ± 13.8 years, 207 (58%) were men, 74 (21%) were black/African American, 132 (37%) had diabetes, 252 (70%) had hypertension, and 102 (28%) had a history of myocardial infarction, heart surgery, or stent placement. 311 (87%) patients had symptoms during dialysis in the previous week, with mean severity of 2.7 (range for each symptom, 1-5). The most common symptoms were fatigue/feeling washed out (62%), cramps (44%), and symptoms of low blood pressure (42%). Median time to recovery was 3 (range, 0-24) hours, and this correlated with the incidence and severity of intradialytic symptoms (P < 0.0001). 40% of patients had time to recovery times of 4 hours or longer. 1 in 3 patients reported having stopped dialysis early for intradialytic symptoms and 6% reported skipping dialysis at least once because of intradialytic symptoms. Limitations Recall-based self-reported data with a relatively low response rate. Conclusions A majority of patients receiving in-center hemodialysis experience symptoms such as feeling washed out, fatigue, and cramping; these may be severe and are correlated with longer recovery time following hemodialysis, as well as shortened and skipped hemodialysis sessions.
Collapse
Affiliation(s)
| | | | - Dean Hu
- Outset Medical Inc, San Jose, CA
| | | | - Joseph A Vassalotti
- Icahn School of Medicine at Mount Sinai, New York, NY.,National Kidney Foundation, Inc, New York, NY
| | | |
Collapse
|
9
|
Effects of hemodialysis on blood volume, macro- and microvascular function. Microvasc Res 2019; 129:103958. [PMID: 31734376 DOI: 10.1016/j.mvr.2019.103958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 11/11/2019] [Accepted: 11/13/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vascular dysfunction is considered to spur the progression of cardiovascular disease in hemodialysis (HD) patients. Whether the HD procedure itself contributes to vascular dysfunction remains incompletely investigated. The present study sought to comprehensively assess the effects of HD on arterial and venous function along with concomitant changes in blood volume (BV). METHODS AND RESULTS We determined BV with high-precision, automated carbon monoxide-rebreathing, arterial stiffness using applanation tonometry and intrinsic microvascular function via retinal vessel analysis prior to and after conventional 4-hour HD in fasting-controlled conditions in 10 patients. All HD patients were non-smokers and non-obese (body mass index = 22.8 ± 2.8 m·kg-2). Hypertension (70%), coronary artery disease (40%) and diabetes mellitus (20%) were the most prevalent comorbidities. Prior to HD, all patients presented with hypervolemia (+2208 ± 1213 ml). HD decreased body weight (-1.72 ± 1.25 kg, P = 0.002) and plasma volume (-689 ± 566 ml, P = 0.004), while hematocrit (Hct) was concomitantly increased (+4.8 ± 4.5%, P = 0.009). HD did not affect large elastic artery stiffness, as determined by carotid-femoral pulse wave velocity (P = 0.448) and carotid distensibility (P = 0.562). In contrast, flicker light-induced retinal venular dilation was reduced by three-fourths after HD (-2.4 ± 1.7%, P = 0.039), in parallel to increased retinal venular diameter (+11.2 ± 4.9 μm, P = 0.002). In regression analyses, a negative association was observed between HD-induced changes in Hct and retinal venular dilation (r ≥ -0.89, P ≤ 0.045). CONCLUSION Conventional HD resulting in substantial plasma volume removal do not alter large artery elastic properties, whereas intrinsic microvascular venular dilator function is markedly impaired, an effect directly associated with the increase in hemoconcentration.
Collapse
|
10
|
Dekker M, Konings C, Canaud B, Carioni P, Guinsburg A, Madero M, van der Net J, Raimann J, van der Sande F, Stuard S, Usvyat L, Wang Y, Xu X, Kotanko P, Kooman J. Pre-dialysis fluid status, pre-dialysis systolic blood pressure and outcome in prevalent haemodialysis patients: results of an international cohort study on behalf of the MONDO initiative. Nephrol Dial Transplant 2019; 33:2027-2034. [PMID: 29718469 DOI: 10.1093/ndt/gfy095] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/06/2018] [Indexed: 11/12/2022] Open
Abstract
Background Pre-dialysis fluid overload (FO) associates with mortality and causes elevated pre-dialysis systolic blood pressure (pre-SBP). However, low pre-SBP is associated with increased mortality in haemodialysis patients. The objective of this study was to investigate the interaction between pre-dialysis fluid status (FS) and pre-SBP in association with mortality. Methods We included all patients from the international Monitoring Dialysis Outcome Initiative (MONDO) database with a pre-dialysis multifrequency bioimpedance spectroscopy measurement in the year 2011. We used all parameters available during a 90-day baseline period. All-cause mortality was recorded during 1-year follow-up. Associations with outcome were assessed with Cox models and a smoothing spline Cox analysis. Results We included 8883 patients. In patients with pre-dialysis FO (>+1.1 to +2.5 L), pre-SBP <110 mmHg was associated with an increased risk of death {hazard ratio (HR) 1.52 [95% confidence interval (CI) 1.06-2.17]}. An increased risk of death was also associated with pre-dialysis fluid depletion (FD; <-1.1 L) combined with a pre-SBP <140 mmHg. In normovolemic (NV) patients, low pre-SBP <110 mmHg was associated with better survival [HR 0.46 (95% CI 0.23-0.91)]. Also, post-dialysis FD associated with a survival benefit. Results were similar when inflammation was present. Only high ultrafiltration rate could not explain the higher mortality rates observed. Conclusion The relation between pre-SBP and outcome is dependent on pre-dialysis FS. Low pre-SBP appears to be disadvantageous in patients with FO or FD, but not in NV patients. Post-dialysis FD was found to associate with improved survival. Therefore, we suggest interpreting pre-SBP levels in the context of FS and not as an isolated marker.
Collapse
Affiliation(s)
- Marijke Dekker
- Department of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Internal Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Constantijn Konings
- Department of Internal Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | | | | | - Magdalena Madero
- Department of Nephrology, National Heart Institute, Mexico City, Mexico
| | - Jeroen van der Net
- Department of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Frank van der Sande
- Department of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Len Usvyat
- Renal Research Institute, New York, NY, USA.,Fresenius Medical Care North America, Waltham, MA, USA
| | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California-Santa Barbara, Santa Barbara, CA, USA
| | - Xiaoqi Xu
- Department of Nephrology, Fresenius Medical Care Asia Pacific and
| | - Peter Kotanko
- Renal Research Institute, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeroen Kooman
- Department of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
11
|
Deng Y, Liu H, Lin N, Ma L, Fu W. Influence of dry weight reduction on anemia in patients undergoing hemodialysis. J Int Med Res 2019; 47:5536-5547. [PMID: 31530055 PMCID: PMC6862877 DOI: 10.1177/0300060519872048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Volume load in patients undergoing hemodialysis correlates with renal anemia, with reductions in volume load significantly improving hemoglobin levels. We performed a prospective controlled study to assess the effect of post-dialysis dry weight reduction, resulting from the gradual enhancement of ultrafiltration, on renal anemia in this patient population. Methods Sixty-four patients with renal anemia on maintenance hemodialysis were randomized to an ultrafiltration group, in which dry weight was gradually reduced by slightly increasing the ultrafiltration volume while maintaining routine hemodialysis, and a control group, in which patients underwent conventional dialysis while routine ultrafiltration was maintained. After 28 weeks, post-dialysis weight and levels of hematocrit, hemoglobin, C-reactive protein, serum albumin, serum ferritin, and transferrin saturation were compared. Results All parameters were similar at baseline between the two groups and remained unchanged at week 28 in the control group compared with baseline. In contrast, the ultrafiltration group showed a significant reduction in post-dialysis weight and C-reactive protein concentration and a significant increase in hematocrit, hemoglobin, albumin, serum ferritin, and transferrin saturation. Conclusions Dry weight reduction resulting from enhanced ultrafiltration may improve renal anemia in patients undergoing hemodialysis.
Collapse
Affiliation(s)
- Yinghui Deng
- Department of Nephrology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Hua Liu
- Department of Nephrology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Na Lin
- Department of Nephrology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Lina Ma
- Department of Geriatrics, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Wenjing Fu
- Department of Nephrology, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Wenjing Fu, Department of Nephrology, Xuan Wu Hospital, Capital Medical University, #45 Changchun Street, Xicheng District, Beijing 100053, China.
| |
Collapse
|
12
|
Abohtyra R, Chait Y, Germain MJ, Hollot CV, Horowitz J. Individualization of Ultrafiltration in Hemodialysis. IEEE Trans Biomed Eng 2018; 66:2174-2181. [PMID: 30530307 DOI: 10.1109/tbme.2018.2884931] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES There are approximately 660 000 end-stage renal disease patients in the USA, with hemodialysis (HD) the primary form of treatment. High ultrafiltration rates (UFRs) are associated with intradialytic hypotension, a complication associated with adverse clinical outcomes including mortality. Individualized UFR profiles could reduce the incidence of intradialytic hypotension. METHODS The patient's fluid dynamics during HD is described by a nonlinear model comprising intravascular and interstitial pools, whose parameters are given by the patient's estimated nominal parameter values with uncertainty ranges; the output measurement is hematocrit. We design UFR profiles that minimize the maximal UFR needed to remove a prescribed volume of fluid within a set time, with hematocrit not exceeding a specified time-varying critical profile. RESULTS We present a novel approach to design individualized UFR profiles, and give theoretical results guaranteeing that the system remains within a predefined physiologically plausible region and does not exceed a specified time-invariant critical hematocrit level for all parameters in the uncertainty ranges. We test the performance of our design using a real patient data example. The designed UFR maintains the system below a time-varying critical hematocrit profile in the example. CONCLUSION Theoretical results and simulations show that our designed UFR profiles can remove the target amount of fluid in a given time period while keeping the hematocrit below a specified critical profile. SIGNIFICANCE Individualization of UFR profiles is now feasible using current HD technology and may reduce the incidence of intradialytic hypotension.
Collapse
|
13
|
|
14
|
Murugan R, Balakumar V, Kerti SJ, Priyanka P, Chang CCH, Clermont G, Bellomo R, Palevsky PM, Kellum JA. Net ultrafiltration intensity and mortality in critically ill patients with fluid overload. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:223. [PMID: 30244678 PMCID: PMC6151928 DOI: 10.1186/s13054-018-2163-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although net ultrafiltration (UFNET) is frequently used for treatment of fluid overload in critically ill patients with acute kidney injury, the optimal intensity of UFNET is unclear. Among critically ill patients with fluid overload receiving renal replacement therapy (RRT), we examined the association between UFNET intensity and risk-adjusted 1-year mortality. METHODS We selected patients with fluid overload ≥ 5% of body weight prior to initiation of RRT from a large academic medical center ICU dataset. UFNET intensity was calculated as the net volume of fluid ultrafiltered per day from initiation of either continuous or intermittent RRT until the end of ICU stay adjusted for patient hospital admission body weight. We stratified UFNET as low (≤ 20 ml/kg/day), moderate (> 20 to ≤ 25 ml/kg/day) or high (> 25 ml/kg/day) intensity. We adjusted for age, sex, body mass index, race, surgery, baseline estimated glomerular filtration rate, oliguria, first RRT modality, pre-RRT fluid balance, duration of RRT, time to RRT initiation from ICU admission, APACHE III score, mechanical ventilation use, suspected sepsis, mean arterial pressure on day 1 of RRT, cumulative fluid balance during RRT and cumulative vasopressor dose during RRT. We fitted logistic regression for 1-year mortality, Gray's survival model and propensity matching to account for indication bias. RESULTS Of 1075 patients, the distribution of high, moderate and low-intensity UFNET groups was 40.4%, 15.2% and 44.2% and 1-year mortality was 59.4% vs 60.2% vs 69.7%, respectively (p = 0.003). Using logistic regression, high-intensity compared with low-intensity UFNET was associated with lower mortality (adjusted odds ratio 0.61, 95% CI 0.41-0.93, p = 0.02). Using Gray's model, high UFNET was associated with decreased mortality up to 39 days after ICU admission (adjusted hazard ratio range 0.50-0.73). After combining low and moderate-intensity UFNET groups (n = 258) and propensity matching with the high-intensity group (n = 258), UFNET intensity > 25 ml/kg/day compared with ≤ 25 ml/kg/day was associated with lower mortality (57% vs 67.8%, p = 0.01). Findings were robust to several sensitivity analyses. CONCLUSIONS Among critically ill patients with ≥ 5% fluid overload and receiving RRT, UFNET intensity > 25 ml/kg/day compared with ≤ 20 ml/kg/day was associated with lower 1-year risk-adjusted mortality. Whether tolerating intensive UFNET is just a marker for recovery or a mediator requires further research.
Collapse
Affiliation(s)
- Raghavan Murugan
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Critical Care Medicine, and Clinical & Translational Science, University of Pittsburgh, Suite 220, Room 206, 3347 Forbes Avenue, Pittsburgh, PA, 15261, USA.
| | - Vikram Balakumar
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Samantha J Kerti
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Priyanka Priyanka
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chung-Chou H Chang
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gilles Clermont
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Heidelberg, VIC, Australia
| | - Paul M Palevsky
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
15
|
Gosmanova EO, Kovesdy CP. Patient-Centered Approach for Hypertension Management in End-Stage Kidney Disease: Art or Science? Semin Nephrol 2018; 38:355-368. [PMID: 30082056 DOI: 10.1016/j.semnephrol.2018.05.006] [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: 10/28/2022]
Abstract
Hypertension is present in most patients with end-stage kidney disease initiating dialysis and management of hypertension is a routine but challenging task in everyday dialysis care. End-stage kidney disease patients are uniquely heterogeneous individuals with significant variations in demographic characteristics, functional capacity, and presence of concomitant comorbid conditions and their severity. Therefore, these patients require personalized approaches in addressing not only hypertension but related illnesses, while also accounting for overall prognosis and projected longevity. There are only limited clinical trial data to guide individualized blood pressure management and current guidelines are based predominantly on observational evidence and expert opinions. Inthis review, we reflect on the shortcomings of peridialytic blood pressure recordings and discuss an important paradigm shift toward using out-of-dialysis blood pressure for evaluating hypertension control and for making treatment decisions. In addition, we provide our personal view on blood pressure goals and summarize nonpharmacologic and pharmacologic treatment options for individualized management of hypertension in end-stage kidney disease.
Collapse
Affiliation(s)
- Elvira O Gosmanova
- Nephrology Section, Stratton VA Medical Center, Albany, NY.; Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of TennesseeHealth Science Center, Memphis, TN.; Nephrology Section, Memphis VA Medical Center, Memphis, TN..
| |
Collapse
|
16
|
Plantinga LC, Masud T, Lea JP, Burkart JM, O'Donnell CM, Jaar BG. Post-hospitalization dialysis facility processes of care and hospital readmissions among hemodialysis patients: a retrospective cohort study. BMC Nephrol 2018; 19:186. [PMID: 30064380 PMCID: PMC6069998 DOI: 10.1186/s12882-018-0983-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/16/2018] [Indexed: 11/17/2022] Open
Abstract
Background Both dialysis facilities and hospitals are accountable for 30-day hospital readmissions among U.S. hemodialysis patients. We examined the association of post-hospitalization processes of care at hemodialysis facilities with pulmonary edema-related and other readmissions. Methods In a retrospective cohort comprised of electronic medical record (EMR) data linked with national registry data, we identified unique patient index admissions (n = 1056; 2/1/10–7/31/15) that were followed by ≥3 in-center hemodialysis sessions within 10 days, among patients treated at 19 Southeastern dialysis facilities. Indicators of processes of care were defined as present vs. absent in the dialysis facility EMR. Readmissions were defined as admissions within 30 days of the index discharge; pulmonary edema-related vs. other readmissions defined by discharge codes for pulmonary edema, fluid overload, and/or congestive heart failure. Multinomial logistic regression to estimate odds ratios (ORs) for pulmonary edema-related and other vs. no readmissions. Results Overall, 17.7% of patients were readmitted, and 8.0% had pulmonary edema-related readmissions (44.9% of all readmissions). Documentation of the index admission (OR = 2.03, 95% CI 1.07–3.85), congestive heart failure (OR = 1.87, 95% CI 1.07–3.27), and home medications stopped (OR = 1.81, 95% CI 1.08–3.05) or changed (OR = 1.69, 95% CI 1.06–2.70) in the EMR post-hospitalization were all associated with higher risk of pulmonary edema-related vs. no readmission; lower post-dialysis weight (by ≥0.5 kg) after vs. before hospitalization was associated with 40% lower risk (OR = 0.60, 95% CI 0.37–0.96). Conclusions Our results suggest that some interventions performed at the dialysis facility in the post-hospitalization period may be associated with reduced readmission risk, while others may provide a potential existing means of identifying patients at higher risk for readmissions, to whom such interventions could be efficiently targeted. Electronic supplementary material The online version of this article (10.1186/s12882-018-0983-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Laura C Plantinga
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA. .,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
| | - Tahsin Masud
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Janice P Lea
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - John M Burkart
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - Bernard G Jaar
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Nephrology Center of Maryland, Baltimore, MD, USA
| |
Collapse
|
17
|
Erickson KF, Qureshi S, Winkelmayer WC. The Role of Big Data in the Development and Evaluation of US Dialysis Care. Am J Kidney Dis 2018; 72:560-568. [PMID: 29921451 DOI: 10.1053/j.ajkd.2018.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/07/2018] [Indexed: 11/11/2022]
Abstract
Rapid growth in electronic communications and digitalization, combined with advances in data management, analysis, and storage, have led to an era of "Big Data." The Social Security Amendments of 1972 turned end-stage renal disease (ESRD) care into a single-payer system for most patients requiring dialysis in the United States. As a result, there are few areas of medicine that have been as influenced by Big Data as dialysis care, for which Medicare's large administrative data sets have had a central role in the evaluation and development of public policy for several decades. In the 1970/1980s, Medicare data helped identify concerning trends in costs, access to dialysis care, and quality of care delivered. As the research community and policymakers made Medicare's administrative data increasingly accessible for investigation, analyses of Medicare claims have had a large role in facilitating policy synthesis and refinement. Efforts to address the skyrocketing cost of injectable drugs in the 1990s and 2000s exemplify this expanded role of Big Data. Although there are opportunities for large government and nongovernmental administrative data sets to continue serving a critical role in the evaluation and development of ESRD policies, it is important to understand challenges and limitations associated with their use.
Collapse
Affiliation(s)
- Kevin F Erickson
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, TX; Baker Institute for Public Policy, Rice University, Houston, TX.
| | - Samaya Qureshi
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| |
Collapse
|
18
|
Slinin Y, Babu M, Ishani A. Ultrafiltration rate in conventional hemodialysis: Where are the limits and what are the consequences? Semin Dial 2018; 31:544-550. [PMID: 29885084 DOI: 10.1111/sdi.12717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ultrafiltration rate (UFR) has attracted attention as a modifiable aspect of volume management. OBJECTIVE The objective of this review is to summarize the evidence that links UFR to patient outcomes and discuss UFR cut-offs proposed, and discuss possible consequences of adapting UFR as a quality metric. RESULTS Higher UFRs has been associated with younger age, longer dialysis vintage, greater prevalence of comorbidities, higher Kt/V, lower weight, greater interdialytic weight gain, lower residual renal function, and shorter treatment times. Many of the characteristics associated with high UFRs have also been independently associated with poor patient outcomes. Four observational studies have assessed the association between UFR and patient mortality. All of them reported an association between higher UFR and greater patient mortality, though the studies differed in their definition of UFR, follow-up, and adjustment for confounding. Evidence for the association between higher UFR and potential mediations of the mortality association, such as interdialytic hypotension, cardiac remodeling, and cardiovascular events was less consistent. There was a graded association between higher UFRs and all-cause mortality; no definitive cut-off for acceptable UFR can be established based on the current evidence. Targeting UFR in isolation might result in volume expansion and worsening patient outcomes. Residual confounding likely contributed to the findings of the observational studies. No randomized controlled trials addressed the questions. CONCLUSION Evidence supporting UFR limits is weak and confounded. Randomized controlled trials are needed before UFR can be used as a quality of care indicator.
Collapse
Affiliation(s)
- Yelena Slinin
- Veterans Administration Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Megha Babu
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Areef Ishani
- Veterans Administration Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
19
|
Plantinga LC, Lynch RJ, Patzer RE, Pastan SO, Bowling CB. Association of Serious Fall Injuries among United States End Stage Kidney Disease Patients with Access to Kidney Transplantation. Clin J Am Soc Nephrol 2018; 13:628-637. [PMID: 29511059 PMCID: PMC5969463 DOI: 10.2215/cjn.10330917] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 12/18/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Serious fall injuries in the setting of ESKD may be associated with poor access to kidney transplant. We explored the burden of serious fall injuries among patients on dialysis and patients on the deceased donor waitlist and the associations of these fall injuries with waitlisting and transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our analytic cohorts for the outcomes of (1) waitlisting and (2) transplantation included United States adults ages 18-80 years old who (1) initiated dialysis (n=183,047) and (2) were waitlisted for the first time (n=37,752) in 2010-2013. Serious fall injuries were determined by diagnostic codes for falls plus injury (fracture, joint dislocation, or head trauma) in inpatient and emergency department claims; the first serious fall injury after cohort entry was included as a time-varying exposure. Follow-up ended at the specified outcome, death, or the last date of follow-up (September 30, 2014). We used multivariable Cox proportional hazards models to determine the independent associations between serious fall injury and waitlisting or transplantation. RESULTS Overall, 2-year cumulative incidence of serious fall injury was 6% among patients on incident dialysis; with adjustment, patients who had serious fall injuries were 61% less likely to be waitlisted than patients who did not (hazard ratio, 0.39; 95% confidence interval, 0.35 to 0.44). Among incident waitlisted patients (4% 2-year cumulative incidence), those with serious fall injuries were 29% less likely than their counterparts to be subsequently transplanted (hazard ratio, 0.71; 95% confidence interval, 0.63 to 0.80). CONCLUSIONS Serious fall injuries among United States patients on dialysis are associated with substantially lower likelihood of waitlisting for and receipt of a kidney transplant.
Collapse
Affiliation(s)
| | | | | | | | - C. Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina; and
- Department of Medicine, Duke University, Durham, North Carolina
| |
Collapse
|
20
|
Abstract
PURPOSE OF REVIEW Volume management in hemodialysis patients is often challenging. Assessing volume status and deciding how much fluid to remove during hemodialysis, the so-called ultrafiltration rate (UFR), has remained a conundrum. RECENT FINDINGS To date there is no objective assessment tool to determine the needed UFR during each hemodialysis session. Higher volume overload or higher UFR is associated with poor outcomes including worse mortality and unfavorable clinical outcomes. We suggest combined use of the following criteria to determine UFR or post-dialysis target dry weight: pre-hemodialysis blood pressure and its intradialytic changes, muscle cramps, dyspnea from pulmonary vascular congestion, peripheral edema, tachycardia or palpitation, headache or lightheadedness, perspiration, and post-dialysis fatigue. Restricting fluid and salt intake-and high-dose loop diuretic use in cases of residual kidney function-can be helpful in controlling fluid gains. More frequent and more severe hypotensive episodes are associated with poor outcomes including higher death risk.
Collapse
Affiliation(s)
- Jason A Chou
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Division of Nephrology, Department of Medicine, University of California, Irvine, School of Medicine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.
- Division of Nephrology, Department of Medicine, University of California, Irvine, School of Medicine, Orange, CA, USA.
- Fielding School of Public Health at UCLA, Los Angeles, CA, USA.
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA.
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology & Hypertension, University of California Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400-ZOT: 4088, Orange, CA, 92868-3217, USA.
| |
Collapse
|
21
|
Pirkle JL, Comeau ME, Langefeld CD, Russell GB, Balderston SS, Freedman BI, Burkart JM. Effects of weight-based ultrafiltration rate limits on intradialytic hypotension in hemodialysis. Hemodial Int 2017. [PMID: 28643378 DOI: 10.1111/hdi.12578] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION High ultrafiltration (UF) rates can result in intradialytic hypotension and are associated with increased mortality. The effects of a weight-based UF rate limit on intradialytic hypotension and the potential for unwanted fluid weight gain and hospitalizations for volume overload are unknown. METHODS This retrospective cohort study examined 123 in-center hemodialysis patients at one facility who transitioned to 13 mL/kg/h maximum UF rates. Patients were studied for an 8 week UF rate limit exposure period and compared to the 8-week period immediately prior, during which the cohort served as its own historical control. The primary outcomes were frequency of intradialytic hypotension events and percentage of treatments with a hypotension event. FINDINGS The delivered UF rate was lower during the exposure compared to the baseline period (mean UF rate 7.90 ± 4.45 mL/kg/h vs. 8.92 ± 5.64 mL/kg/h; P = 0.0005). The risk of intradialytic hypotension was decreased during the exposure compared to baseline period (event rate per treatment 0.0569 vs. 0.0719, OR 0.78 [95% CI 0.62-1.00]; P = 0.0474), as was the risk of having a treatment with a hypotension event (percentage of treatments with event 5.2% vs. 6.8%, OR 0.75 [95% CI 0.58-0.96]; P = 0.0217). Subgroup analyses demonstrated that these findings were attributable to patients with high baseline UF rates. Statistically significant differences in all-cause or volume overload-related hospitalization were not observed during the exposure period. DISCUSSION A weight-based UF rate limit of 13 mL/kg/h was associated with a decrease in the rate of intradialytic hypotension events among in-center hemodialysis patients.
Collapse
Affiliation(s)
- James L Pirkle
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mary E Comeau
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Carl D Langefeld
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gregory B Russell
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - John M Burkart
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
22
|
Target weight achievement and ultrafiltration rate thresholds: potential patient implications. BMC Nephrol 2017; 18:185. [PMID: 28578687 PMCID: PMC5457585 DOI: 10.1186/s12882-017-0595-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 05/18/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Higher ultrafiltration (UF) rates and extracellular hypo- and hypervolemia are associated with adverse outcomes among maintenance hemodialysis patients. The Centers for Medicare and Medicaid Services recently considered UF rate and target weight achievement measures for ESRD Quality Incentive Program inclusion. The dual measures were intended to promote balance between too aggressive and too conservative fluid removal. The National Quality Forum endorsed the UF rate measure but not the target weight measure. We examined the proposed target weight measure and quantified weight gains if UF rate thresholds were applied without treatment time (TT) extension or interdialytic weight gain (IDWG) reduction. METHODS Data were taken from the 2012 database of a large dialysis organization. Analyses considered 152,196 United States hemodialysis patients. We described monthly patient and dialysis facility target weight achievement patterns and examined differences in patient characteristics across target weight achievement status and differences in facilities across target weight measure scores. We computed the cumulative, theoretical 1-month fluid-related weight gain that would occur if UF rates were capped at 13 mL/h/kg without concurrent TT extension or IDWG reduction. RESULTS Target weight achievement patterns were stable over the year. Patients who did not achieve target weight (post-dialysis weight ≥ 1 kg above or below target weight) tended to be younger, black and dialyze via catheter, and had shorter dialysis vintage, greater body weight, higher UF rate and more missed treatments compared with patients who achieved target weight. Facilities had, on average, 27.1 ± 9.7% of patients with average post-dialysis weight ≥ 1 kg above or below the prescribed target weight. In adjusted analyses, facilities located in the midwest and south and facilities with higher proportions of black and Hispanic patients and higher proportions of patients with shorter TTs were more likely to have unfavorable facility target weight measure scores. Without TT extension or IDWG reduction, UF rate threshold (13 mL/h/kg) implementation led to an average theoretical 1-month, fluid-related weight gain of 1.4 ± 3.0 kg. CONCLUSIONS Target weight achievement patterns vary across clinical subgroups. Implementation of a maximum UF rate threshold without adequate attention to extracellular volume status may lead to fluid-related weight gain.
Collapse
|
23
|
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.
Collapse
Affiliation(s)
- Jeffrey Perl
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Weiner DE, Lacson E. Fluid First or Not So Fast: Ultrafiltration Rate and the ESRD Quality Incentive Program. Clin J Am Soc Nephrol 2016; 11:1330-1332. [PMID: 27335125 PMCID: PMC4974881 DOI: 10.2215/cjn.05840616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Daniel E Weiner
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | | |
Collapse
|