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Ok E, Demirci C, Asci G, Yuksel K, Kircelli F, Koc SK, Erten S, Mahsereci E, Odabas AR, Stuard S, Maddux FW, Raimann JG, Kotanko P, Kerr PG, Chan CT. Patient Survival With Extended Home Hemodialysis Compared to In-Center Conventional Hemodialysis. Kidney Int Rep 2023; 8:2603-2615. [PMID: 38106580 PMCID: PMC10719649 DOI: 10.1016/j.ekir.2023.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction More frequent and/or longer hemodialysis (HD) has been associated with improvements in numerous clinical outcomes in patients on dialysis. Home HD (HHD), which allows more frequent and/or longer dialysis with lower cost and flexibility in treatment planning, is not widely used worldwide. Although, retrospective studies have indicated better survival with HHD, this issue remains controversial. In this multicenter study, we compared thrice-weekly extended HHD with in-center conventional HD (ICHD) in a large patient population with a long-term follow-up. Methods We matched 349 patients starting HHD between 2010 and 2014 with 1047 concurrent patients on ICHD by using propensity scores. Patients were followed-up with from their respective baseline until September 30, 2018. The primary outcome was overall survival. Secondary outcomes were technique survival; hospitalization; and changes in clinical, laboratory, and medication parameters. Results The mean duration of dialysis session was 418 ± 54 minutes in HHD and 242 ± 10 minutes in patients on ICHD. All-cause mortality rate was 3.76 and 6.27 per 100 patient-years in the HHD and the ICHD groups, respectively. In the intention-to-treat analysis, HHD was associated with a 40% lower risk for all-cause mortality than ICHD (hazard ratio [HR] = 0.60; 95% confidence interval [CI] 0.45 to 0.80; P < 0.001). In HHD, the 5-year technical survival was 86.5%. HHD treatment provided better phosphate and blood pressure (BP) control, improvements in nutrition and inflammation, and reduction in hospitalization days and medication requirement. Conclusion These results indicate that extended HHD is associated with higher survival and better outcomes compared to ICHD.
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Savoia M, Tripepi G, Goethel-Paal B, Baró Salvador ME, Ponce P, Voiculescu D, Pachmann M, Jirka T, Koc SK, Marcinkowski W, Cioffi M, Neri L, Usvyat L, Hymes JL, Maddux FW, Zoccali C, Stuard S. European Nephrologists' Attitudes toward the Application of Artificial Intelligence in Clinical Practice: A Comprehensive Survey. Blood Purif 2023; 53:80-87. [PMID: 38008072 PMCID: PMC10836740 DOI: 10.1159/000534604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/12/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION The rapid advancement of artificial intelligence and big data analytics, including descriptive, diagnostic, predictive, and prescriptive analytics, has the potential to revolutionize many areas of medicine, including nephrology and dialysis. Artificial intelligence and big data analytics can be used to analyze large amounts of patient medical records, including laboratory results and imaging studies, to improve the accuracy of diagnosis, enhance early detection, identify patterns and trends, and personalize treatment plans for patients with kidney disease. Additionally, artificial intelligence and big data analytics can be used to identify patients' treatment who are not receiving adequate care, highlighting care inefficiencies in the dialysis provider, optimizing patient outcomes, reducing healthcare costs, and consequently creating values for all the involved stakeholders. OBJECTIVES We present the results of a comprehensive survey aimed at exploring the attitudes of European physicians from eight countries working within a major hemodialysis network (Fresenius Medical Care NephroCare) toward the application of artificial intelligence in clinical practice. METHODS An electronic survey on the implementation of artificial intelligence in hemodialysis clinics was distributed to 1,067 physicians. Of the 1,067 individuals invited to participate in the study, 404 (37.9%) professionals agreed to participate in the survey. RESULTS The survey showed that a substantial proportion of respondents believe that artificial intelligence has the potential to support physicians in reducing medical malpractice or mistakes. CONCLUSION While artificial intelligence's potential benefits are recognized in reducing medical errors and improving decision-making, concerns about treatment plan consistency, personalization, privacy, and the human aspects of patient care persist. Addressing these concerns will be crucial for successfully integrating artificial intelligence solutions in nephrology practice.
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Affiliation(s)
- Matteo Savoia
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | - Giovanni Tripepi
- Clinical Epidemiology of Renal Diseases and Hypertension Unit, Consiglio Nazionale delle Ricerche Institute of Clinical Physiology, Reggio Calabria, Italy
| | | | | | - Pedro Ponce
- Fresenius Medical Care, Global Medical Office, Lisbon, Portugal
| | | | - Martin Pachmann
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | - Tomas Jirka
- Fresenius Medical Care, Global Medical Office, Praha, Czechia
| | | | | | - Mario Cioffi
- Fresenius Medical Care, Global Medical Office, Naples, Italy
| | - Luca Neri
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | - Len Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Jeffrey L Hymes
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Franklin W Maddux
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Carmine Zoccali
- Institute of Biology and Molecular Genetics (BIOGEM), Ariano Irpino, Italy
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET), Reggio Calabria, Italy
| | - Stefano Stuard
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
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Zhang H, Wang LC, Chaudhuri S, Pickering A, Usvyat L, Larkin J, Waguespack P, Kuang Z, Kooman JP, Maddux FW, Kotanko P. Real-time prediction of intradialytic hypotension using machine learning and cloud computing infrastructure. Nephrol Dial Transplant 2023:7117966. [PMID: 37055366 DOI: 10.1093/ndt/gfad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND In maintenance hemodialysis patients, intradialytic hypotension (IDH) is a frequent complication that has been associated with poor clinical outcomes. Prediction of IDH may facilitate timely interventions and eventually reduce IDH rates. METHODS We developed a machine learning model to predict IDH in in-center hemodialysis patients 15 to 75 minutes in advance. IDH was defined as systolic blood pressure (SBP) < 90 mmHg. Demographic, clinical, treatment-related, and laboratory data were retrieved from electronic health records and merged with intradialytic machine data that were sent in real-time to the cloud. For model development, dialysis sessions were randomly split into training (80%) and testing (20%) sets. The area under the receiver operating characteristic curve (AUROC) was used as a measure of model's predictive performance. RESULTS We utilized data from 693 patients who contributed 42 656 hemodialysis sessions and 355 693 intradialytic SBP measurements. IDH occurred in 16.2% of hemodialysis treatments. Our model predicted IDH 15 to 75 minutes in advance with an AUROC of 0.89. Top IDH predictors were the most recent intradialytic SBP, and IDH rate as well as mean nadir SBP of the previous 10 dialysis sessions. CONCLUSIONS Real-time prediction of IDH during an ongoing hemodialysis session is feasible and has a clinically actionable predictive performance. If and to what degree this predictive information facilitates the timely deployment of preventive interventions and translates into lower IDH rates and improved patient outcomes warrants prospective studies.
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Affiliation(s)
| | | | - Sheetal Chaudhuri
- Fresenius Medical Care, Global Medical Office, Waltham, MA, USA
- Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Len Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, MA, USA
| | - John Larkin
- Fresenius Medical Care, Global Medical Office, Waltham, MA, USA
| | - Pete Waguespack
- Fresenius Medical Care, Digital Technology & Innovation, Waltham, MA, USA
| | - Zuwen Kuang
- Fresenius Medical Care, Digital Technology & Innovation, Waltham, MA, USA
| | - Jeroen P Kooman
- Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Peter Kotanko
- Renal Research Institute, NY, NY, USA
- Icahn School of Medicine at Mount Sinai, NY, NY, USA
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ter Meulen KJ, Ye X, Wang Y, Usvyat LA, van der Sande FM, Konings CJ, Kotanko P, Kooman JP, Maddux FW. Variability of Serum Phosphate in Incident Hemodialysis Patients: Association with All-Cause Mortality. Kidney360 2023; 4:374-380. [PMID: 36918167 PMCID: PMC10103252 DOI: 10.34067/kid.0000000000000062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 12/20/2022] [Indexed: 03/15/2023]
Abstract
Key Points An increase in serum phosphate variability is an independent risk factor of mortality. The effects of a positive directional range (DR) is most pronounced in patients with high serum phosphate levels whereas the effects of a negative DR is most pronounced in patients with low serum phosphate and/or serum albumin. Background In maintenance hemodialysis (HD) patients, previous studies have shown that serum phosphate levels have a bidirectional relation to outcome. Less is known about the relation between temporal dynamics of serum phosphate in relation to outcome. We aimed to further explore the relation between serum phosphate variability and all-cause mortality. Methods All adult incident HD patients treated in US Fresenius Kidney Care clinics between January 2010 and October 2018 were included. Baseline period was defined as 6 months after initiation of HD and months 7–18 as follow-up period. All-cause mortality was recorded during the follow-up period. The primary metric of variability used was directional range (DR) that is the difference between the largest and smallest values within a time period; DR was positive when the smallest value preceded the largest and negative otherwise. Cox proportional hazards models with spline terms were applied to explore the association between phosphate, DR, and all-cause mortality. In addition, tensor product smoothing splines were computed to further elucidate the interactions of phosphate, DR, and all-cause mortality. Results We included 302,613 patients. Baseline phosphate was 5.1±1.2 mg/dl, and mean DR was +0.6±3.3 mg/dl. Across different levels of phosphate, higher levels of DR of phosphate were associated with higher risk of all-cause mortality. In patients with lower levels of phosphate and serum albumin, the effect of a negative DR was most pronounced, whereas in patients with higher phosphate levels, a positive DR was related to increased mortality. Conclusions Higher variability of serum phosphate is related to mortality at all levels of phosphate, especially in lower levels with a negative DR and in low serum albumin levels. This could possibly reflect dietary intake in patients who are already inflamed or malnourished, where a further reduction in serum phosphate should prompt for nutritional evaluation.
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Affiliation(s)
- Karlien J. ter Meulen
- Maastricht University Medical Center, Maastricht, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | - Xiaoling Ye
- Renal Research Institute, New York, New York
| | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California–Santa Barbara, Santa Barbara, California
| | - Len A. Usvyat
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | | | | | - Peter Kotanko
- Renal Research Institute, New York, New York
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Jeroen P. Kooman
- Maastricht University Medical Center, Maastricht, The Netherlands
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Blankenship DM, Usvyat L, Kraus MA, Chatoth DK, Lasky R, Turk JE, Maddux FW. Assessing the impact of transitional care units on dialysis patient outcomes: A multicenter, propensity score-matched analysis. Hemodial Int 2023; 27:165-173. [PMID: 36757059 DOI: 10.1111/hdi.13068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/28/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Inadequate predialysis care and education impacts the selection of a dialysis modality and is associated with adverse clinical outcomes. Transitional care units (TCUs) aim to meet the unmet educational needs of incident dialysis patients, but their impact beyond increasing home dialysis utilization has been incompletely characterized. METHODS This retrospective study included adults initiating in-center hemodialysis at a TCU, matched to controls (1:4) with no TCU history initiating in-center hemodialysis. Patients were followed for up to 14 months. TCUs are dedicated spaces where staff provide personalized education and as-needed adjustments to dialysis prescriptions. For many patients, therapy was initiated with four to five weekly dialysis sessions, with at least some sessions delivered by home dialysis machines. Outcomes included survival, first hospitalization, transplant waiting-list status, post-TCU dialysis modality, and vascular access type. FINDINGS The study included 724 patients initiating dialysis across 48 TCUs, with 2892 well-matched controls. At the end of 14 months, patients initiating dialysis in a TCU were significantly more likely to be referred and/or wait-listed for a kidney transplant than controls (57% vs. 42%; p < 0.0001). Initiation of dialysis at a TCU was also associated with significantly lower rates of receiving in-center hemodialysis at 14 months (74% vs. 90%; p < 0.0001) and higher rates of arteriovenous access (70% vs. 63%; p = 0.003). Although not statistically significant, TCU patients were more likely to survive and less likely to be hospitalized during follow-up than controls. DISCUSSION Although TCUs are sometimes viewed as only a means for enhancing utilization of home dialysis, patients attending TCUs exhibited more favorable outcomes across all endpoints. In addition to being 2.5-fold more likely to receive home dialysis, TCU patients were 42% more likely to be referred for transplantation. Our results support expanding utilization of TCUs for patients with inadequate predialysis support.
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Affiliation(s)
| | - Len Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Michael A Kraus
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Dinesh K Chatoth
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Rachel Lasky
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Joseph E Turk
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Franklin W Maddux
- Fresenius Medical Care AG & Co. KGaA, Global Medical Office, Bad Homburg, Germany
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Blankenship DM, Usvyat L, Lasky R, Maddux FW. COVID-19 vaccination status impact on mortality in end-stage kidney disease. Hemodial Int 2023; 27:197-199. [PMID: 36747493 DOI: 10.1111/hdi.13072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 11/06/2022] [Accepted: 01/19/2023] [Indexed: 02/08/2023]
Affiliation(s)
| | - Len Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Rachel Lasky
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Franklin W Maddux
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
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Novakivskyy V, Shurduk R, Grin I, Tkachenko T, Pavlenko N, Hrynevych A, Hymes JL, Maddux FW, Stuard S. War in Ukraine and dialysis treatment: human suffering and organizational challenges. Clin Kidney J 2023; 16:676-683. [PMID: 37007698 PMCID: PMC10061431 DOI: 10.1093/ckj/sfad003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Indexed: 01/09/2023] Open
Abstract
Abstract
In January 2021, there were 9,648 patients in Ukraine on kidney replacement therapy, including 8,717 on extracorporeal therapies and 931 on peritoneal dialysis. On 24 February 2022, foreign troops entered the territory of Ukraine. Before the war, the Fresenius Medical Care dialysis network in Ukraine operated three medical centres. These medical centres provided haemodialysis therapy to 349 end stage kidney disease patients. In addition, Fresenius Medical Care Ukraine delivered medical supplies to almost all regions of Ukraine. Even though Fresenius Medical Care's share of end stage kidney disease patients on dialysis is small, a brief narrative account of the managerial challenges that Fresenius Medical Care Ukraine and the clinical directors of the Fresenius Medical Care centres had to face, as well as the suffering of the dialysis population, is a useful testimony of the burden imposed by war on these frail, high-risk patients dependent on a complex technology such as dialysis. The war in Ukraine is causing immense suffering for the dialysis population of this country and has called for heroic efforts from the dialysis personnel. The experience of a small dialysis network treating a minority of dialysis patients in Ukraine is described. Guaranteeing dialysis treatment has been and remains an enormous challenge in Ukraine and we are confident that the generosity and the courage of Ukrainian dialysis staff and international aid will help to mitigate this tragic suffering.
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Guinsburg AM, Jiao Y, Bessone MID, Monaghan CK, Magalhães B, Kraus MA, Kotanko P, Hymes JL, Kossmann RJ, Berbessi JC, Maddux FW, Usvyat LA, Larkin JW. Predictors of shorter- and longer-term mortality after COVID-19 presentation among dialysis patients: parallel use of machine learning models in Latin and North American countries. BMC Nephrol 2022; 23:340. [PMID: 36273142 PMCID: PMC9587666 DOI: 10.1186/s12882-022-02961-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 10/04/2022] [Indexed: 11/21/2022] Open
Abstract
Background We developed machine learning models to understand the predictors of shorter-, intermediate-, and longer-term mortality among hemodialysis (HD) patients affected by COVID-19 in four countries in the Americas. Methods We used data from adult HD patients treated at regional institutions of a global provider in Latin America (LatAm) and North America who contracted COVID-19 in 2020 before SARS-CoV-2 vaccines were available. Using 93 commonly captured variables, we developed machine learning models that predicted the likelihood of death overall, as well as during 0–14, 15–30, > 30 days after COVID-19 presentation and identified the importance of predictors. XGBoost models were built in parallel using the same programming with a 60%:20%:20% random split for training, validation, & testing data for the datasets from LatAm (Argentina, Columbia, Ecuador) and North America (United States) countries. Results Among HD patients with COVID-19, 28.8% (1,001/3,473) died in LatAm and 20.5% (4,426/21,624) died in North America. Mortality occurred earlier in LatAm versus North America; 15.0% and 7.3% of patients died within 0–14 days, 7.9% and 4.6% of patients died within 15–30 days, and 5.9% and 8.6% of patients died > 30 days after COVID-19 presentation, respectively. Area under curve ranged from 0.73 to 0.83 across prediction models in both regions. Top predictors of death after COVID-19 consistently included older age, longer vintage, markers of poor nutrition and more inflammation in both regions at all timepoints. Unique patient attributes (higher BMI, male sex) were top predictors of mortality during 0–14 and 15–30 days after COVID-19, yet not mortality > 30 days after presentation. Conclusions Findings showed distinct profiles of mortality in COVID-19 in LatAm and North America throughout 2020. Mortality rate was higher within 0–14 and 15–30 days after COVID-19 in LatAm, while mortality rate was higher in North America > 30 days after presentation. Nonetheless, a remarkable proportion of HD patients died > 30 days after COVID-19 presentation in both regions. We were able to develop a series of suitable prognostic prediction models and establish the top predictors of death in COVID-19 during shorter-, intermediate-, and longer-term follow up periods. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02961-x.
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Affiliation(s)
| | - Yue Jiao
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
| | | | - Caitlin K Monaghan
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
| | | | | | - Peter Kotanko
- Renal Research Institute, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jeffrey L Hymes
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
| | | | | | - Franklin W Maddux
- Fresenius Medical Care AG & Co. KGaA, Global Medical Office, Bad Homburg, Germany
| | - Len A Usvyat
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
| | - John W Larkin
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA.
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Chaudhuri S, Han H, Monaghan C, Larkin J, Waguespack P, Shulman B, Kuang Z, Bellamkonda S, Brzozowski J, Hymes J, Black M, Kotanko P, Kooman JP, Maddux FW, Usvyat L. Real-time prediction of intradialytic relative blood volume: a proof-of-concept for integrated cloud computing infrastructure. BMC Nephrol 2021; 22:274. [PMID: 34372809 PMCID: PMC8351092 DOI: 10.1186/s12882-021-02481-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inadequate refilling from extravascular compartments during hemodialysis can lead to intradialytic symptoms, such as hypotension, nausea, vomiting, and cramping/myalgia. Relative blood volume (RBV) plays an important role in adapting the ultrafiltration rate which in turn has a positive effect on intradialytic symptoms. It has been clinically challenging to identify changes RBV in real time to proactively intervene and reduce potential negative consequences of volume depletion. Leveraging advanced technologies to process large volumes of dialysis and machine data in real time and developing prediction models using machine learning (ML) is critical in identifying these signals. METHOD We conducted a proof-of-concept analysis to retrospectively assess near real-time dialysis treatment data from in-center patients in six clinics using Optical Sensing Device (OSD), during December 2018 to August 2019. The goal of this analysis was to use real-time OSD data to predict if a patient's relative blood volume (RBV) decreases at a rate of at least - 6.5 % per hour within the next 15 min during a dialysis treatment, based on 10-second windows of data in the previous 15 min. A dashboard application was constructed to demonstrate how reporting structures may be developed to alert clinicians in real time of at-risk cases. Data was derived from three sources: (1) OSDs, (2) hemodialysis machines, and (3) patient electronic health records. RESULTS Treatment data from 616 in-center dialysis patients in the six clinics was curated into a big data store and fed into a Machine Learning (ML) model developed and deployed within the cloud. The threshold for classifying observations as positive or negative was set at 0.08. Precision for the model at this threshold was 0.33 and recall was 0.94. The area under the receiver operating curve (AUROC) for the ML model was 0.89 using test data. CONCLUSIONS The findings from our proof-of concept analysis demonstrate the design of a cloud-based framework that can be used for making real-time predictions of events during dialysis treatments. Making real-time predictions has the potential to assist clinicians at the point of care during hemodialysis.
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Affiliation(s)
- Sheetal Chaudhuri
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA. .,Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Hao Han
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
| | - Caitlin Monaghan
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
| | - John Larkin
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
| | | | - Brian Shulman
- Fresenius Medical Care North America, Waltham, MA, USA
| | - Zuwen Kuang
- Fresenius Medical Care North America, Waltham, MA, USA
| | | | - Jane Brzozowski
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
| | - Jeffrey Hymes
- Fresenius Medical Care North America, Waltham, MA, USA
| | - Mike Black
- Fresenius Medical Care North America, Waltham, MA, USA
| | - Peter Kotanko
- Renal Research Institute, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeroen P Kooman
- Maastricht University Medical Center, Maastricht, The Netherlands
| | - Franklin W Maddux
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
| | - Len Usvyat
- Fresenius Medical Care, Global Medical Office, 920 Winter Street, Waltham, MA, 02451, USA
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Chaudhuri S, Han H, Usvyat L, Jiao Y, Sweet D, Vinson A, Johnstone Steinberg S, Maddux D, Belmonte K, Brzozowski J, Bucci B, Kotanko P, Wang Y, Kooman JP, Maddux FW, Larkin J. Machine learning directed interventions associate with decreased hospitalization rates in hemodialysis patients. Int J Med Inform 2021; 153:104541. [PMID: 34343957 DOI: 10.1016/j.ijmedinf.2021.104541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/14/2021] [Accepted: 06/29/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND An integrated kidney disease company uses machine learning (ML) models that predict the 12-month risk of an outpatient hemodialysis (HD) patient having multiple hospitalizations to assist with directing personalized interdisciplinary interventions in a Dialysis Hospitalization Reduction Program (DHRP). We investigated the impact of risk directed interventions in the DHRP on clinic-wide hospitalization rates. METHODS We compared the hospital admission and day rates per-patient-year (ppy) from all hemodialysis patients in 54 DHRP and 54 control clinics identified by propensity score matching at baseline in 2015 and at the end of the pilot in 2018. We also used paired T test to compare the between group difference of annual hospitalization rate and hospitalization days rates at baseline and end of the pilot. RESULTS The between group difference in annual hospital admission and day rates was similar at baseline (2015) with a mean difference between DHRP versus control clinics of -0.008 ± 0.09 ppy and -0.05 ± 0.96 ppy respectively. The between group difference in hospital admission and day rates became more distinct at the end of follow up (2018) favoring DHRP clinics with the mean difference being -0.155 ± 0.38 ppy and -0.97 ± 2.78 ppy respectively. A paired t-test showed the change in the between group difference in hospital admission and day rates from baseline to the end of the follow up was statistically significant (t-value = 2.73, p-value < 0.01) and (t-value = 2.29, p-value = 0.02) respectively. CONCLUSIONS These findings suggest ML model-based risk-directed interdisciplinary team interventions associate with lower hospitalization rates and hospital day rate in HD patients, compared to controls.
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Affiliation(s)
- Sheetal Chaudhuri
- Fresenius Medical Care, Global Medical Office, Waltham, United States; Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hao Han
- Fresenius Medical Care, Global Medical Office, Waltham, United States
| | - Len Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, United States
| | - Yue Jiao
- Fresenius Medical Care, Global Medical Office, Waltham, United States
| | - David Sweet
- Fresenius Medical Care North America, Waltham, United States
| | - Allison Vinson
- Fresenius Medical Care North America, Waltham, United States
| | | | - Dugan Maddux
- Fresenius Medical Care North America, Waltham, United States
| | | | - Jane Brzozowski
- Fresenius Medical Care, Global Medical Office, Waltham, United States
| | - Brad Bucci
- Fresenius Medical Care North America, Waltham, United States
| | - Peter Kotanko
- Renal Research Institute, NY, United States; Icahn School of Medicine at Mount Sinai, New York, United States
| | - Yuedong Wang
- University of California, Santa Barbara, United States
| | - Jeroen P Kooman
- Maastricht University Medical Center, Maastricht, The Netherlands
| | - Franklin W Maddux
- Fresenius Medical Care, Global Medical Office, Waltham, United States
| | - John Larkin
- Fresenius Medical Care, Global Medical Office, Waltham, United States.
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11
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Zhang H, Preciado P, Wang Y, Meyring-Wosten A, Raimann JG, Kooman JP, van der Sande FM, Usvyat LA, Maddux D, Maddux FW, Kotanko P. Association of all-cause mortality with pre-dialysis systolic blood pressure and its peridialytic change in chronic hemodialysis patients. Nephrol Dial Transplant 2021; 35:1602-1608. [PMID: 32003794 PMCID: PMC7473807 DOI: 10.1093/ndt/gfz289] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 11/25/2019] [Indexed: 12/31/2022] Open
Abstract
Background Pre-dialysis systolic blood pressure (pre-HD SBP) and peridialytic SBP change have been associated with morbidity and mortality among hemodialysis (HD) patients in previous studies, but the nature of their interaction is not well understood. Methods We analyzed pre-HD SBP and peridialytic SBP change (calculated as post-HD SBP minus pre-HD SBP) between January 2001 and December 2012 in HD patients treated in US Fresenius Medical Care facilities. The baseline period was defined as Months 4–6 after HD initiation, and all-cause mortality was noted during follow-up. Only patients who survived baseline and had no missing covariates were included. Censoring events were renal transplantation, modality change or study end. We fitted a Cox proportional hazard model with a bivariate spline functions for the primary predictors (pre-HD SBP and peridialytic SBP change) with adjustment for age, gender, race, diabetes, access-type, relative interdialytic weight gain, body mass index, albumin, equilibrated normalized protein catabolic rate and ultrafiltration rate. Results A total of 172 199 patients were included. Mean age was 62.1 years, 61.6% were white and 55% were male. During a median follow-up of 25.0 months, 73 529 patients (42.7%) died. We found that a peridialytic SBP rise combined with high pre-HD SBP was associated with higher mortality. In contrast, when concurrent with low pre-HD SBP, a peridialytic SBP rise was associated with better survival. Conclusion The association of pre-HD and peridialytic SBP change with mortality is complex. Our findings call for a joint, not isolated, interpretation of pre-HD SBP and peridialytic SBP change.
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Affiliation(s)
- Hanjie Zhang
- Research Department, Renal Research Institute, New York, NY, USA
| | | | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California at Santa Barbara, CA, USA
| | | | - Jochen G Raimann
- Research Department, Renal Research Institute, New York, NY, USA
| | - Jeroen P Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frank M van der Sande
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | | | - Peter Kotanko
- Research Department, Renal Research Institute, New York, NY, USA.,Department of Medicine and Nephrology, Icahn School of Medicine at Mount Sinai New York, NY, USA
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12
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Han M, Ye X, Rao S, Williams S, Thijssen S, Hymes J, Maddux FW, Kotanko P. Hepatitis B Vaccination Response in Hemodialysis Patients: The Impact of Dialysis Shift. Blood Purif 2021; 50:628-635. [PMID: 33508838 DOI: 10.1159/000513154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Hepatitis B (HB) vaccination in hemodialysis patients is important as they are at a higher risk of contracting HB. However, hemodialysis patients have a lower HB seroconversion rate than their healthy counterparts. As better sleep has been associated with better seroconversion in healthy populations and early hemodialysis start has been linked to significant sleep-wake disturbances in hemodialysis patients, we examined if hemodialysis treatment start time is associated with HB vaccination response. METHODS Demographics, standard-of-care clinical, laboratory, and treatment parameters, dialysis shift data, HB antigen status, HB vaccination status, and HB titers were collected from hemodialysis patients in Fresenius clinics from January 2010 to December 2015. Patients in our analysis received 90% of dialysis treatments either before or after 8:30 a.m., were negative for HB antigen, and received a complete series of HB vaccination (Engerix B® or Recombivax HB™). Univariate and multivariate regression models examined whether dialysis start time is a predictor of HB vaccination response. RESULTS Patients were 65 years old, 57% male, and had a HD vintage of 10 months. Patients whose dialysis treatments started before 8:30 a.m. were more likely to be younger, male, and have a greater dialysis vintage. Patients receiving Engerix B® and starting dialysis before 8:30 a.m. had a significantly higher seroconversion rate compared to patients who started dialysis after 8:30 a.m. Early dialysis start was a significant predictor of seroconversion in univariate and multivariate regression including male gender, but not in multivariate regression including age, neutrophil-to-lymphocyte ratio, and vintage. CONCLUSION While better sleep following vaccination is associated with seroconversion in the general population, this is not the case in hemodialysis patients after multivariate adjustment. In the context of end-stage kidney disease, early dialysis start is not a significant predictor of HB vaccination response. The association between objectively measured postvaccination sleep duration and seroconversion rate should be investigated.
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Affiliation(s)
- Maggie Han
- Renal Research Institute, New York, New York, USA,
| | - Xiaoling Ye
- Renal Research Institute, New York, New York, USA
| | - Sharon Rao
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | | | | | - Jeffrey Hymes
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Franklin W Maddux
- Fresenius Medical Care Management AG, Bad Homburg, Bad Homburg, Germany
| | - Peter Kotanko
- Renal Research Institute, New York, New York, USA.,Icahn School of Medicine, New York, New York, USA
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13
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Olaniran KO, Eneanya ND, Zhao SH, Ofsthun NJ, Maddux FW, Thadhani RI, Dalrymple LS, Nigwekar SU. Mortality and Hospitalizations among Sickle Cell Disease Patients with End-Stage Kidney Disease Initiating Dialysis. Am J Nephrol 2021; 51:995-1003. [PMID: 33486484 DOI: 10.1159/000513012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/10/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) is the most common inherited hematological disorder and a well-described risk factor for end-stage kidney disease (ESKD). Mortality and hospitalizations among patients with SCD who develop ESKD remain understudied. Furthermore, prior studies focused only on SCD patients where ESKD was caused by SCD. We aimed to describe mortality and hospitalization risk in all SCD patients initiating dialysis and explore risk factors for mortality and hospitalization. METHODS We performed a national observational cohort study of African American ESKD patients initiating dialysis (2000-2014) in facilities affiliated with a large dialysis provider. SCD was identified by diagnosis codes and matched to a reference population (non-SCD) by age, sex, dialysis initiation year, and geographic region of care. Sensitivity analyses were conducted by restricting to patients where SCD was recorded as the cause of ESKD. RESULTS We identified 504 SCD patients (mean age: 47 ± 14 years; 48% females) and 1,425 reference patients (mean age: 46 ± 14 years; 49% females). The median follow-up was 2.4 (IQR 1.0-4.5) years. Compared to the reference, SCD was associated with higher mortality risk (hazard ratio 1.66; 95% confidence interval [CI]: 1.36-2.03) and higher hospitalization rates (incidence rate ratio 2.12; 95% CI: 1.88-2.38) in multivariable analyses. Exploratory multivariable mortality risk models showed the largest mortality risk attenuation with the addition of time-varying hemoglobin and high-dose erythropoietin, but the association of SCD with mortality remained significant. Sensitivity analyses (restricted to ESKD caused by SCD) also showed significant associations between SCD and mortality and hospitalizations, but with larger effect estimates. High-dose erythropoietin was associated with the highest risk for mortality and hospitalization in SCD. CONCLUSIONS Among ESKD patients, SCD is associated with a higher risk for mortality and hospitalization, particularly in patients where SCD is identified as the cause of ESKD.
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Affiliation(s)
- Kabir O Olaniran
- Division of Nephrology, Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA,
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sophia H Zhao
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Norma J Ofsthun
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Franklin W Maddux
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
- Fresenius Medical Care AG & Co, KGaA, Bad Homburg, Germany
| | - Ravi I Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Mass General Brigham, Boston, Massachusetts, USA
| | | | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Monaghan CK, Larkin JW, Chaudhuri S, Han H, Jiao Y, Bermudez KM, Weinhandl ED, Dahne-Steuber IA, Belmonte K, Neri L, Kotanko P, Kooman JP, Hymes JL, Kossmann RJ, Usvyat LA, Maddux FW. Machine Learning for Prediction of Patients on Hemodialysis with an Undetected SARS-CoV-2 Infection. Kidney360 2021; 2:456-468. [PMID: 35369017 PMCID: PMC8786002 DOI: 10.34067/kid.0003802020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 01/12/2021] [Indexed: 02/04/2023]
Abstract
Background We developed a machine learning (ML) model that predicts the risk of a patient on hemodialysis (HD) having an undetected SARS-CoV-2 infection that is identified after the following ≥3 days. Methods As part of a healthcare operations effort, we used patient data from a national network of dialysis clinics (February-September 2020) to develop an ML model (XGBoost) that uses 81 variables to predict the likelihood of an adult patient on HD having an undetected SARS-CoV-2 infection that is identified in the subsequent ≥3 days. We used a 60%:20%:20% randomized split of COVID-19-positive samples for the training, validation, and testing datasets. Results We used a select cohort of 40,490 patients on HD to build the ML model (11,166 patients who were COVID-19 positive and 29,324 patients who were unaffected controls). The prevalence of COVID-19 in the cohort (28% COVID-19 positive) was by design higher than the HD population. The prevalence of COVID-19 was set to 10% in the testing dataset to estimate the prevalence observed in the national HD population. The threshold for classifying observations as positive or negative was set at 0.80 to minimize false positives. Precision for the model was 0.52, the recall was 0.07, and the lift was 5.3 in the testing dataset. Area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC) for the model was 0.68 and 0.24 in the testing dataset, respectively. Top predictors of a patient on HD having a SARS-CoV-2 infection were the change in interdialytic weight gain from the previous month, mean pre-HD body temperature in the prior week, and the change in post-HD heart rate from the previous month. Conclusions The developed ML model appears suitable for predicting patients on HD at risk of having COVID-19 at least 3 days before there would be a clinical suspicion of the disease.
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Affiliation(s)
| | - John W. Larkin
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - Sheetal Chaudhuri
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts,Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hao Han
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - Yue Jiao
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | | | - Eric D. Weinhandl
- Fresenius Medical Care North America, Medical Office, Waltham, Massachusetts
| | | | - Kathleen Belmonte
- Nursing & Clinical Services, Fresenius Kidney Care, Waltham, Massachusetts
| | - Luca Neri
- Fresenius Medical Care Deutschland GmbH, EMEA Medical Office, Bad Homburg, Germany
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, New York,Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeroen P. Kooman
- Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jeffrey L. Hymes
- Fresenius Medical Care North America, Medical Office, Waltham, Massachusetts
| | - Robert J. Kossmann
- Fresenius Medical Care North America, Medical Office, Waltham, Massachusetts
| | - Len A. Usvyat
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts
| | - Franklin W. Maddux
- Fresenius Medical Care AG & Co. KGaA, Global Medical Office, Bad Homburg, Germany
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15
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Chaudhuri S, Long A, Zhang H, Monaghan C, Larkin JW, Kotanko P, Kalaskar S, Kooman JP, van der Sande FM, Maddux FW, Usvyat LA. Artificial intelligence enabled applications in kidney disease. Semin Dial 2021; 34:5-16. [PMID: 32924202 PMCID: PMC7891588 DOI: 10.1111/sdi.12915] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Artificial intelligence (AI) is considered as the next natural progression of traditional statistical techniques. Advances in analytical methods and infrastructure enable AI to be applied in health care. While AI applications are relatively common in fields like ophthalmology and cardiology, its use is scarcely reported in nephrology. We present the current status of AI in research toward kidney disease and discuss future pathways for AI. The clinical applications of AI in progression to end-stage kidney disease and dialysis can be broadly subdivided into three main topics: (a) predicting events in the future such as mortality and hospitalization; (b) providing treatment and decision aids such as automating drug prescription; and (c) identifying patterns such as phenotypical clusters and arteriovenous fistula aneurysm. At present, the use of prediction models in treating patients with kidney disease is still in its infancy and further evidence is needed to identify its relative value. Policies and regulations need to be addressed before implementing AI solutions at the point of care in clinics. AI is not anticipated to replace the nephrologists' medical decision-making, but instead assist them in providing optimal personalized care for their patients.
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Affiliation(s)
- Sheetal Chaudhuri
- Maastricht University Medical CenterMaastrichtThe Netherlands
- Fresenius Medical CareWalthamMAUSA
| | | | | | | | | | - Peter Kotanko
- Renal Research InstituteNew YorkNYUSA
- Icahn School of Medicine at Mount SinaiNew YorkNYUSA
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16
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Guedes M, Pecoits-Filho R, Leme JEG, Jiao Y, Raimann JG, Wang Y, Kotanko P, de Moraes TP, Thadhani R, Maddux FW, Usvyat LA, Larkin JW. Impacts of dialysis adequacy and intradialytic hypotension on changes in dialysis recovery time. BMC Nephrol 2020; 21:529. [PMID: 33287719 PMCID: PMC7720452 DOI: 10.1186/s12882-020-02187-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 11/25/2020] [Indexed: 11/22/2022] Open
Abstract
Background Dialysis recovery time (DRT) surveys capture the perceived time after HD to return to performing regular activities. Prior studies suggest the majority of HD patients report a DRT > 2 h. However, the profiles of and modifiable dialysis practices associated with changes in DRT relative to the start of dialysis are unknown. We hypothesized hemodialysis (HD) dose and rates of intradialytic hypotension (IDH) would associate with changes in DRT in the first years after initiating dialysis. Methods We analyzed data from adult HD patients who responded to a DRT survey ≤180 days from first date of dialysis (FDD) during 2014 to 2017. DRT survey was administered with annual KDQOL survey. DRT survey asks: “How long does it take you to be able to return to your normal activities after your dialysis treatment?” Answers are: < 0.5, 0.5-to-1, 1-to-2, 2-to-4, or > 4 h. An adjusted logistic regression model computed odds ratio for a change to a longer DRT (increase above DRT > 2 h) in reference to a change to a shorter DRT (decrease below DRT < 2 h, or from DRT > 4 h). Changes in DRT were calculated from incident (≤180 days FDD) to first prevalent (> 365-to- ≤ 545 days FDD) and second prevalent (> 730-to- ≤ 910 days FDD) years. Results Among 98,616 incident HD patients (age 62.6 ± 14.4 years, 57.8% male) who responded to DRT survey, a higher spKt/V in the incident period was associated with 13.5% (OR = 0.865; 95%CI 0.801-to-0.935) lower risk of a change to a longer DRT in the first-prevalent year. A higher number of HD treatments with IDH episodes per month in the incident period was associated with a 0.8% (OR = 1.008; 95%CI 1.001-to-1.015) and 1.6% (OR = 1.016; 95%CI 1.006-to-1.027) higher probability of a change to a longer DRT in the first- and second-prevalent years, respectively. Consistently, an increased in incidence of IDH episodes/months was associated to a change to a longer DRT over time. Conclusions Incident patients who had higher spKt/V and less sessions with IDH episodes had a lower likelihood of changing to a longer DRT in first year of HD. Dose optimization strategies with cardiac stability in fluid removal should be tested. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02187-9.
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Affiliation(s)
- Murilo Guedes
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Juliana El Ghoz Leme
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Yue Jiao
- Global Medical Office, Fresenius Medical Care, 920 Winter Street, Waltham, MA, 02451, USA
| | | | - Yuedong Wang
- University of California Santa Barbara, Santa Barbara, CA, USA
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Franklin W Maddux
- Global Medical Office, Fresenius Medical Care, 920 Winter Street, Waltham, MA, 02451, USA
| | - Len A Usvyat
- Global Medical Office, Fresenius Medical Care, 920 Winter Street, Waltham, MA, 02451, USA
| | - John W Larkin
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil. .,Global Medical Office, Fresenius Medical Care, 920 Winter Street, Waltham, MA, 02451, USA.
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17
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Hippen BE, Reed AI, Ketchersid T, Maddux FW. Implications of the Advancing American Kidney Health Initiative for kidney transplant centers. Am J Transplant 2020; 20:1244-1250. [PMID: 31561276 DOI: 10.1111/ajt.15619] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 09/09/2019] [Accepted: 09/21/2019] [Indexed: 01/25/2023]
Abstract
The announcement of the Advancing American Kidney Health (AAKH) Initiative on July 10, 2019 was met with a mix of excitement and trepidation, befitting a proposed radical reconfiguration of the delivery of kidney disease care. Aspiring to reduce the incidence of end-stage renal disease, increase the prevalence of home dialysis, and double the number of organs available for transplant, the AAKH payment models primarily focus on incenting behaviors of general nephrologists, though actualizing positive incentives will require the active cooperation of dialysis providers and transplant centers. Here, we review the AAKH initiatives' potential impact on all stakeholders and opine on financial and regulatory pressures on kidney transplant programs, outlining areas of uncertainty and concern, and suggest key points of reflection for clinical and administrative leaders of kidney transplant centers weighing participation in any of the voluntary payment models.
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Affiliation(s)
| | - Alan I Reed
- University of Iowa Organ Transplant Center, Iowa City, Iowa
| | - Terry Ketchersid
- Integrated Care Group, Fresenius Medical Care, North America, Waltham, Massachusetts
| | - Franklin W Maddux
- Global Medical Office, Fresenius Medical Care AG & Co., KGaA, Waltham, Massachusetts
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18
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Sawin DA, Ma L, Stennett A, Ofsthun N, Himmele R, Kossmann RJ, Maddux FW. Phosphates in medications: Impact on dialysis patients
. Clin Nephrol 2020; 93:163-171. [PMID: 32049627 PMCID: PMC7264818 DOI: 10.5414/cn109853] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 03/13/2020] [Indexed: 12/12/2022] Open
Abstract
Maintaining phosphorus balance in in-center hemodialysis (ICHD) patients is problematic despite recommended dietary restriction, dialysis, and phosphate binder use. Rarely is P content in prescribed medications considered, but this source should raise concern. Data was obtained from the Fresenius Kidney Care (FKC) electronic data warehouse Knowledge Center and MedReview-eRx accessed Surescripts, housing > 80% of US-filled prescriptions. Adult FKC ICHD patients prescribed ≥ 1 medication in the MedReview-eRx database were analyzed (695,759 prescriptions). Information collected included medication dose, dose unit, dose timing, strength, start and stop dates, refills, demographic information, admission history, and modality type. Numbers of patients, prescriptions by individual medication, and drug class were then analyzed. Medications prescribed > 100 times were reported. Median doses/day (number of tablets) were calculated for each medication (open order on randomly selected day). Phosphate content of medications taken in FKC clinics was assessed using routinely used pharmacology references, and potential resulting phosphate and pill burden were also calculated. The top five prescribed drug classes in FKC dialysis patients were calcium-channel blockers (22%), proton pump inhibitors (PPIs; 18%), acetaminophen-opioid (AO; 13%), angiotensin-converting enzyme inhibitors (ACEi; 10%), and α2-agonists (9%). The maximum phosphate added for different medications varied by manufacturer. For instance, at median daily doses, phosphate contributions from the top five medications prescribed were 112 mg for amlodipine, 116.2 mg from lisinopril, 6.7 mg from clonidine, 0 mg from acetaminophen, and 200 mg for omeprazole. Prescribing these together could increase the daily phosphate load by 428 mg, forcing the patient to exceed the recommended daily intake (RDI) with food and drink. Phosphate content in medications prescribed to HD patients can substantially contribute to the daily phosphate load and, in combination, may even exceed the daily recommended dietary phosphate intake. Healthcare providers should monitor all medications containing phosphate prescribed in order to minimize risk of uncontrolled hyperphosphatemia and poor adherence.
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Affiliation(s)
- Dixie-Ann Sawin
- Fresenius Medical Care North America, Renal Therapies Group, and
| | - Lin Ma
- Fresenius Kidney Care, Waltham, MA, USA
| | | | | | - Rainer Himmele
- Fresenius Medical Care North America, Renal Therapies Group, and
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19
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Chaudhuri S, Han H, Muchiutti C, Ryter J, Reviriego-Mendoza M, Maddux D, Larkin JW, Usvyat LA, Chatoth D, Kooman JP, Maddux FW. Remote Treatment Monitoring on Hospitalization and Technique Failure Rates in Peritoneal Dialysis Patients. Kidney360 2020; 1:191-202. [PMID: 35368632 PMCID: PMC8809254 DOI: 10.34067/kid.0000302019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/28/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND An integrated kidney disease healthcare company implemented a peritoneal dialysis (PD) remote treatment monitoring (RTM) application in 2016. We assessed if RTM utilization associates with hospitalization and technique failure rates. METHODS We used data from adult (age ≥18 years) patients on PD treated from October 2016 through May 2019 who registered online for the RTM. Patients were classified by RTM use during a 30-day baseline after registration. Groups were: nonusers (never entered data), moderate users (entered one to 15 treatments), and frequent users (entered >15 treatments). We compared hospital admission/day and sustained technique failure (required >6 consecutive weeks of hemodialysis) rates over 3, 6, 9, and 12 months of follow-up using Poisson and Cox models adjusted for patient/clinical characteristics. RESULTS Among 6343 patients, 65% were nonusers, 11% were moderate users, and 25% were frequent users. Incidence rate of hospital admission was 22% (incidence rate ratio [IRR]=0.78; P=0.002), 24% (IRR=0.76; P<0.001), 23% (IRR=0.77; P≤0.001), and 26% (IRR=0.74; P≤0.001) lower in frequent users after 3, 6, 9, and 12 months, respectively, versus nonusers. Incidence rate of hospital days was 38% (IRR=0.62; P=0.013), 35% (IRR=0.65; P=0.001), 34% (IRR=0.66; P≤0.001), and 32% (IRR=0.68; P<0.001) lower in frequent users after 3, 6, 9, and 12 months, respectively, versus nonusers. Sustained technique failure risk at 3, 6, 9, and 12 months was 33% (hazard ratio [HR]=0.67; P=0.020), 31% (HR=0.69; P=0.003), 31% (HR=0.69; P=0.001), and 27% (HR=0.73; P=0.001) lower, respectively, in frequent users versus nonusers. Among a subgroup of survivors of the 12-month follow-up, sustained technique failure risk was 26% (HR=0.74; P=0.023) and 21% (HR=0.79; P=0.054) lower after 9 and 12 months, respectively, in frequent users versus nonusers. CONCLUSIONS Our findings suggest frequent use of an RTM application associates with less hospital admissions, shorter hospital length of stay, and lower technique failure rates. Adoption of RTM applications may have the potential to improve timely identification/intervention of complications.
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Affiliation(s)
- Sheetal Chaudhuri
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
- Maastricht University Medical Center, Maastricht, The Netherlands; and
| | - Hao Han
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | | | - Jessica Ryter
- Fresenius Medical Care North America, Waltham, Massachusetts
| | | | - Dugan Maddux
- Fresenius Medical Care North America, Waltham, Massachusetts
| | - John W. Larkin
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | - Len A. Usvyat
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | - Dinesh Chatoth
- Fresenius Medical Care North America, Waltham, Massachusetts
| | - Jeroen P. Kooman
- Maastricht University Medical Center, Maastricht, The Netherlands; and
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Thadhani RI, Rosen S, Ofsthun NJ, Usvyat LA, Dalrymple LS, Maddux FW, Hymes JL. Conversion from Intravenous Vitamin D Analogs to Oral Calcitriol in Patients Receiving Maintenance Hemodialysis. Clin J Am Soc Nephrol 2020; 15:384-391. [PMID: 32111702 PMCID: PMC7057297 DOI: 10.2215/cjn.07960719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In the United States, intravenous vitamin D analogs are the first-line therapy for management of secondary hyperparathyroidism in hemodialysis patients. Outside the United States, oral calcitriol (1,25-dihydroxyvitamin D3) is routinely used. We examined standard laboratory parameters of patients on in-center hemodialysis receiving intravenous vitamin D who switched to oral calcitriol. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study of adult patients treated within Fresenius Kidney Care clinics. During a 6-month period (December 2013 to May 2014), we identified patients on an intravenous vitamin D analog (doxercalciferol or paricalcitol) who switched to oral calcitriol and matched them to patients receiving an intravenous vitamin D analog. Mean serum calcium, phosphate, and intact parathyroid hormone (iPTH) concentrations were examined for up to 12 months of follow-up. We used Poisson and Cox proportional hazards regression models to examine hospitalization and survival rates. The primary analysis was conducted as intention-to-treat; secondary analyses included an as-treated evaluation. RESULTS A total of 2280 patients who switched to oral calcitriol were matched to 2280 patients receiving intravenous vitamin D. Compared with patients on intravenous vitamin D, mean calcium and phosphate levels in the oral calcitriol group were lower after the change to oral calcitriol. In contrast, iPTH levels were higher in the oral calcitriol group. At 12 months, the percentage of patients with composite laboratories in target range (calcium <10 mg/dl, phosphate 3.0-5.5 mg/dl, and iPTH 150-600 pg/ml) were comparable between groups (45% versus 45%; P=0.96). Hospital admissions, length of hospital stay, and survival were comparable between groups. An as-treated analysis and excluding those receiving cinacalcet did not reveal significant between-group differences. CONCLUSIONS Among patients receiving in-center hemodialysis who were switched to oral calcitriol versus those on an intravenous vitamin D analog, the aggregate of all mineral and bone laboratory parameters in range was largely similar between groups.
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Affiliation(s)
- Ravi I Thadhani
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sophia Rosen
- Fresenius Medical Care North America, Waltham, Massachusetts; and
| | - Norma J Ofsthun
- Fresenius Medical Care North America, Waltham, Massachusetts; and
| | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, Massachusetts; and
| | | | | | - Jeffrey L Hymes
- Fresenius Medical Care North America, Waltham, Massachusetts; and
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Weller RB, Wang Y, He J, Maddux FW, Usvyat L, Zhang H, Feelisch M, Kotanko P. Does Incident Solar Ultraviolet Radiation Lower Blood Pressure? J Am Heart Assoc 2020; 9:e013837. [PMID: 32106744 PMCID: PMC7335547 DOI: 10.1161/jaha.119.013837] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/12/2019] [Indexed: 12/21/2022]
Abstract
Background Hypertension remains a leading global cause for premature death and disease. Most treatment guidelines emphasize the importance of risk factors, but not all are known, modifiable, or easily avoided. Population blood pressure correlates with latitude and is lower in summer than winter. Seasonal variations in sunlight exposure account for these differences, with temperature believed to be the main contributor. Recent research indicates that UV light enhances nitric oxide availability by mobilizing storage forms in the skin, suggesting incident solar UV radiation may lower blood pressure. We tested this hypothesis by exploring the association between environmental UV exposure and systolic blood pressure (SBP) in a large cohort of chronic hemodialysis patients in whom SBP is determined regularly. Methods and Results We studied 342 457 patients (36% black, 64% white) at 2178 US dialysis centers over 3 years. Incident UV radiation and temperature data for each clinic location were retrieved from the National Oceanic and Atmospheric Administration database. Linear mixed effects models with adjustment for ambient temperature, sex/age, body mass index, serum Na+/K+ and other covariates were fitted to each location and combined estimates of associations calculated using the DerSimonian and Laird procedure. Pre-dialysis SBP varied by season and was ≈4 mm Hg higher in black patients. Temperature, UVA and UVB were all linearly and inversely associated with SBP. This relationship remained statistically significant after correcting for temperature. Conclusions In hemodialysis patients, in addition to environmental temperature, incident solar UV radiation is associated with lower SBP. This raises the possibility that insufficient sunlight is a new risk factor for hypertension, perhaps even in the general population.
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Affiliation(s)
- Richard B. Weller
- Center for Inflammation ResearchUniversity of EdinburghUnited Kingdom
| | - Yuedong Wang
- Department of Statistics & Applied ProbabilityUniversity of California ‐ Santa BarbaraSanta BarbaraCA
| | - Jingyi He
- Department of Statistics & Applied ProbabilityUniversity of California ‐ Santa BarbaraSanta BarbaraCA
| | | | - Len Usvyat
- Integrated Care AnalyticsFresenius Medical Care North AmericaWalthamMA
| | | | - Martin Feelisch
- Clinical & Experimental SciencesFaculty of Medicine, and Institute for Life SciencesSouthampton General HospitalUniversity of SouthamptonUnited Kingdom
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22
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Abstract
Recent developments in US kidney‐related healthcare policy have made chronic kidney disease (CKD) a societal focus in the United States. In the biggest policy change since the 1972 Social Security Amendments that extended Medicare coverage to patients with kidney failure regardless of age, a 2019 presidential executive order pledged to reduce end‐stage kidney disease, slow CKD progression, increase kidney transplants, and focus on home dialysis care. This manuscript seeks to outline key factors that can enable this milestone moment to evolve a policy framework that improves the health of society while being economically sustainable. Understanding the sociohistorical context of healthcare policy and the related lessons learned demonstrates that policy must take a broader view of the societal and system wide factors that affect chronic illness. Addressing the full breadth of the CKD epidemic requires looking at factors from both inside and outside traditional medical‐pathophysiological environments, including social determinants of health. This more fulsome insight will enable policy to better align the broad range of people and organizations who are working to combat the disease. By creating patient‐centered policy that both evolves with the speed of innovation and addresses root causes of CKD instead of narrowly focusing on symptoms or comorbidities alone, leaders in the public square have an historic opportunity to thoughtfully create the common ground of a lasting policy legacy that improves society's health today and for generations to come.
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Wong MM, Thijssen S, Wang Y, Usvyat LA, Xiao Q, Kotanko P, Maddux FW. Prediction of Mortality and Hospitalization Risk Using Nutritional Indicators and Their Changes Over Time in a Large Prevalent Hemodialysis Cohort. J Ren Nutr 2020; 30:69-78. [DOI: 10.1053/j.jrn.2019.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/10/2019] [Accepted: 01/21/2019] [Indexed: 01/01/2023] Open
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Ye X, Kooman JP, van der Sande FM, Raimann JG, Usvyat LA, Wang Y, Maddux FW, Kotanko P. Relationship between serum phosphate levels and survival in chronic hemodialysis patients: interactions with age, malnutrition and inflammation. Clin Kidney J 2019; 14:348-357. [PMID: 33564438 PMCID: PMC7857835 DOI: 10.1093/ckj/sfz143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/10/2019] [Indexed: 12/14/2022] Open
Abstract
Background Evidence indicates that the inverse relationships between phosphate levels and mortality maybe modified by age. Furthermore, malnutrition and inflammation could strengthen the risk associated with phosphate abnormalities. This study aimed to assess the associations between phosphate levels and mortality while accounting for the interactions with age and parameters associated with malnutrition and inflammation in hemodialysis (HD) patients. Methods Adult HD patients (n = 245 853) treated in Fresenius Medical Care North America clinics from January 2010 to October 2018 were enrolled. Baseline was defined as Months 4-6 on dialysis, with the subsequent 12 months as the follow-up period. Univariate and multivariate Cox proportional hazard models with spline terms were applied to study the nonlinear relationships between serum phosphate levels and mortality. The interactions of phosphate levels with albumin, creatinine, normalized protein catabolic rate (nPCR) and neutrophil-lymphocyte ratio (NLR) were assessed with smoothing spline analysis of variance Cox proportional hazard models. Results Older patients tended to have lower levels of serum phosphate, albumin, creatinine and nPCR. Additionally, both low (<4.0 mg/dL) and high (>5.5 mg/dL) phosphate levels were associated with higher risk of mortality across all age strata. The U-shaped relationships between phosphate levels and outcome persisted even for patients with low or high levels of serum albumin, creatinine, nPCR and NLR, respectively. Conclusion The consistent U-shaped relationships between serum phosphate and mortality across age strata and levels of inflammatory and nutritional status should prompt the search for underlying causes and potentially nutritional intervention in clinical practice.
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Affiliation(s)
- Xiaoling Ye
- Research Department, Renal Research Institute, New York, NY, USA
| | - Jeroen P Kooman
- Nephrology Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Frank M van der Sande
- Nephrology Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jochen G Raimann
- Research Department, Renal Research Institute, New York, NY, USA
| | - Len A Usvyat
- Research Department, Renal Research Institute, New York, NY, USA.,Global Medical Office, Fresenius Medical Care, Waltham, MA, USA
| | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California-Santa Barbara, Santa Barbara, CA, USA
| | | | - Peter Kotanko
- Research Department, Renal Research Institute, New York, NY, USA.,Department of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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26
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Hecking M, Moissl U, Genser B, Rayner H, Dasgupta I, Stuard S, Stopper A, Chazot C, Maddux FW, Canaud B, Port FK, Zoccali C, Wabel P. Greater fluid overload and lower interdialytic weight gain are independently associated with mortality in a large international hemodialysis population. Nephrol Dial Transplant 2019; 33:1832-1842. [PMID: 29688512 PMCID: PMC6168737 DOI: 10.1093/ndt/gfy083] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/02/2018] [Indexed: 11/12/2022] Open
Abstract
Background Fluid overload and interdialytic weight gain (IDWG) are discrete components of the dynamic fluid balance in haemodialysis patients. We aimed to disentangle their relationship, and the prognostic importance of two clinically distinct, bioimpedance spectroscopy (BIS)-derived measures, pre-dialysis and post-dialysis fluid overload (FOpre and FOpost) versus IDWG. Methods We conducted a retrospective cohort study on 38 614 incident patients with one or more BIS measurement within 90 days of haemodialysis initiation (1 October 2010 through 28 February 2015). We used fractional polynomial regression to determine the association pattern between FOpre, FOpost and IDWG, and multivariate adjusted Cox models with FO and/or IDWG as longitudinal and time-varying predictors to determine all-cause mortality risk. Results In analyses using 1-month averages, patients in quartiles 3 and 4 (Q3 and Q4) of FO had an incrementally higher adjusted mortality risk compared with reference Q2, and patients in Q1 of IDWG had higher adjusted mortality compared with Q2. The highest adjusted mortality risk was observed for patients in Q4 of FOpre combined with Q1 of IDWG [hazard ratio (HR) = 2.66 (95% confidence interval 2.21-3.20), compared with FOpre-Q2/IDWG-Q2 (reference)]. Using longitudinal means of FO and IDWG only slightly altered all HRs. IDWG associated positively with FOpre, but negatively with FOpost, suggesting a link with post-dialysis extracellular volume depletion. Conclusions FOpre and FOpost were consistently positive risk factors for mortality. Low IDWG was associated with short-term mortality, suggesting perhaps an effect of protein-energy wasting. FOpost reflected the volume status without IDWG, which implies that this fluid marker is clinically most intuitive and may be best suited to guide volume management in haemodialysis patients.
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Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Ulrich Moissl
- Fresenius Medical Care, Research and Development, Bad Homburg, Germany
| | - Bernd Genser
- Mannheim Institute of Public Health, Social and Preventive Medicine, University of Heidelberg, Heidelberg, Germany.,BGStats Consulting, Vienna, Austria
| | - Hugh Rayner
- Heart of England, NHS Foundation Trust, Birmingham, UK
| | | | - Stefano Stuard
- Fresenius Medical Care, Research and Development, Bad Homburg, Germany
| | - Andrea Stopper
- Fresenius Medical Care, Region EMEALA, Bad Homburg, Germany
| | - Charles Chazot
- NephroCare Tassin-Charcot, Lyon, France.,F-CRIN INI-CRT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | | | - Bernard Canaud
- Fresenius Medical Care, Region EMEALA, Bad Homburg, Germany
| | | | - Carmine Zoccali
- National Research Council of Italy (CNR-IFC), Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Peter Wabel
- Fresenius Medical Care, Research and Development, Bad Homburg, Germany
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27
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Dember LM, Lacson E, Brunelli SM, Hsu JY, Cheung AK, Daugirdas JT, Greene T, Kovesdy CP, Miskulin DC, Thadhani RI, Winkelmayer WC, Ellenberg SS, Cifelli D, Madigan R, Young A, Angeletti M, Wingard RL, Kahn C, Nissenson AR, Maddux FW, Abbott KC, Landis JR. The TiME Trial: A Fully Embedded, Cluster-Randomized, Pragmatic Trial of Hemodialysis Session Duration. J Am Soc Nephrol 2019; 30:890-903. [PMID: 31000566 DOI: 10.1681/asn.2018090945] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 02/11/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Data from clinical trials to inform practice in maintenance hemodialysis are limited. Incorporating randomized trials into dialysis clinical care delivery should help generate practice-guiding evidence, but the feasibility of this approach has not been established. METHODS To develop approaches for embedding trials into routine delivery of maintenance hemodialysis, we performed a cluster-randomized, pragmatic trial demonstration project, the Time to Reduce Mortality in ESRD (TiME) trial, evaluating effects of session duration on mortality (primary outcome) and hospitalization rate. Dialysis facilities randomized to the intervention adopted a default session duration ≥4.25 hours (255 minutes) for incident patients; those randomized to usual care had no trial-driven approach to session duration. Implementation was highly centralized, with no on-site research personnel and complete reliance on clinically acquired data. We used multiple strategies to engage facility personnel and participating patients. RESULTS The trial enrolled 7035 incident patients from 266 dialysis units. We discontinued the trial at a median follow-up of 1.1 years because of an inadequate between-group difference in session duration. For the primary analysis population (participants with estimated body water ≤42.5 L), mean session duration was 216 minutes for the intervention group and 207 minutes for the usual care group. We found no reduction in mortality or hospitalization rate for the intervention versus usual care. CONCLUSIONS Although a highly pragmatic design allowed efficient enrollment, data acquisition, and monitoring, intervention uptake was insufficient to determine whether longer hemodialysis sessions improve outcomes. More effective strategies for engaging clinical personnel and patients are likely required to evaluate clinical trial interventions that are fully embedded in care delivery.
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Affiliation(s)
- Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, .,Department of Biostatistics, Epidemiology, and Informatics
| | - Eduardo Lacson
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | | | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics, and
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Tom Greene
- Departments of Population Health Science and Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Dana C Miskulin
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Ravi I Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts.,Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Denise Cifelli
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosemary Madigan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Young
- DaVita Clinical Research, Minneapolis, Minnesota
| | - Michael Angeletti
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Rebecca L Wingard
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Christina Kahn
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Allen R Nissenson
- DaVita Kidney Care, El Segundo, California.,David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; and
| | - Franklin W Maddux
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Kevin C Abbott
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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Abstract
Consistent with the increase of precision medicine, the care of patients with end-stage kidney disease (ESKD) requiring maintenance dialysis therapy should evolve to become more personalized. Precise and personalized care is nuanced and informed by a number of factors including an individual's needs and preferences, disease progression, and response to and tolerance of treatments. Technology can support the delivery of more precise and personalized care through multiple mechanisms, including more accurate and real-time assessments of key care elements, enhanced treatment monitoring, and remote monitoring of home dialysis therapies. Data from health care and non-health care sources and advanced analytical methods such as machine learning can be used to create novel insights, and large volumes of data can be integrated to support clinical decisions. Health care models continue to evolve and the opportunities and need for novel care approaches supported by technology and health informatics continue to expand as the delivery and organization of health care changes. Ultimately, precise personalized care for ESKD, including dialysis therapy, will become more feasible as the biological, social, and environmental determinants of health are more broadly understood and as advances in science, engineering, and information management create the means to provide truly precise care for ESKD.
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Affiliation(s)
- Len Usvyat
- Medical Office, Fresenius Medical Care North America, Waltham, MA..
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29
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Eneanya ND, Maddux DW, Reviriego-Mendoza MM, Larkin JW, Usvyat LA, van der Sande FM, Kooman JP, Maddux FW. Longitudinal patterns of health-related quality of life and dialysis modality: a national cohort study. BMC Nephrol 2019; 20:7. [PMID: 30621634 PMCID: PMC6325821 DOI: 10.1186/s12882-018-1198-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 12/28/2018] [Indexed: 12/18/2022] Open
Abstract
Background Health-related quality of life (HrQoL) varies among dialysis patients. However, little is known about the association of dialysis modality with HrQoL over time. We describe longitudinal patterns of HrQoL among chronic dialysis patients by treatment modality. Methods National retrospective cohort study of adult patients who initiated in-center dialysis or a home modality (peritoneal or home hemodialysis) between 1/2013 and 6/2015. Patients remained on the same modality for the first 120 days of the first two years. HrQoL was assessed by the Kidney Disease and Quality of Life-36 (KDQOL) survey in the first 120 days of the first two years after dialysis initiation. Home modality patients were matched to in-center patients in a 1:5 fashion. Results In-center (n=4234) and home modality (n=880) patients had similar demographic and clinical characteristics. In-center dialysis patients had lower mean KDQOL scores across several domains compared to home modality patients. For patients who remained on the same modality, there was no change in HrQoL. However, there were trends towards clinically meaningful changes in several aspects of HrQoL for patients who switched modalities. Specifically, physical functioning decreased for patients who switched from home to in-center dialysis (p< 0.05). Conclusions Among a national cohort of chronic dialysis patients, there was a trend towards different patterns of HrQoL life that were only observed among patients who changed modality. Patients who switched from home to in-center modalities had significant lower physical functioning over time. Providers and patients should be mindful of HrQoL changes that may occur with dialysis modality change. Electronic supplementary material The online version of this article (10.1186/s12882-018-1198-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, 307 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
| | | | | | - John W Larkin
- Fresenius Medical Care North America, Waltham, MA, USA
| | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, MA, USA
| | - Frank M van der Sande
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Jeroen P Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
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30
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Li NC, Thadhani RI, Reviriego-Mendoza M, Larkin JW, Maddux FW, Ofsthun NJ. Association of Smoking Status With Mortality and Hospitalization in Hemodialysis Patients. Am J Kidney Dis 2018; 72:673-681. [DOI: 10.1053/j.ajkd.2018.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/01/2018] [Indexed: 11/11/2022]
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31
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Barzel E, Larkin JW, Marcus A, Reviriego-Mendoza MM, Usvyat LA, Sor M, Maddux FW. Tract dilation to salvage failing buttonholes in arteriovenous dialysis fistulae. J Vasc Access 2018; 20:290-300. [PMID: 30319008 DOI: 10.1177/1129729818804996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Hemodialysis patients with an arteriovenous fistula can use buttonhole techniques for cannulation. Although buttonholes generally work well, patients may report difficult and painful cannulation, and buttonholes may fail over time. We aimed to assess the effectiveness of tract dilation in treatment of failing buttonholes. METHODS We retrospectively analyzed data from patients treated with buttonhole tract dilation at an outpatient vascular access center between January 2013 and August 2015. RESULTS Data from 23 patients were analyzed. There were 51 tract dilation procedures during 36 encounters for failing arteriovenous fistula buttonhole tract(s). The technical success rate for established tract dilation with "blunt-recanalization" was 90% (n = 46). The five remaining buttonholes had "sharp-recanalization" to create and dilate new tract through the buttonhole. For 46 buttonholes treated with "blunt-recanalization," there was an 85% clinical success rate at one week (39 buttonholes), and one was lost to follow-up; there was a 70% clinical success rate after one month (32 buttonholes). In the five buttonholes with "sharp-recanalization," there was only one clinical success with p < 0.05 for difference in success rate compared to "blunt-recanalization" at both one week and one month. There was one complication from "sharp-recanalization" requiring abandonment of the buttonhole tract. DISCUSSION Buttonhole tract dilation is a useful method to treat difficult cannulation and painful cannulation and has the potential to extend the life of failing buttonholes.
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Affiliation(s)
- Eyal Barzel
- 1 Azura Vascular Care, Malvern, PA, USA.,2 American Access Care of New Jersey, Cherry Hill, NJ, USA
| | - John W Larkin
- 3 Fresenius Medical Care North America, Waltham, MA, USA
| | - Allen Marcus
- 1 Azura Vascular Care, Malvern, PA, USA.,2 American Access Care of New Jersey, Cherry Hill, NJ, USA
| | | | - Len A Usvyat
- 3 Fresenius Medical Care North America, Waltham, MA, USA
| | - Murat Sor
- 1 Azura Vascular Care, Malvern, PA, USA
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Maddux DW, Usvyat LA, Blanchard T, Jiao Y, Kotanko P, van der Sande FM, Kooman JP, Maddux FW. TRANSITION PERIOD CLINICAL TRAJECTORIES FOR PD VERSUS HD STARTERS. Perit Dial Int 2018; 39:42-50. [PMID: 30257998 DOI: 10.3747/pdi.2017.00252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 05/29/2018] [Accepted: 06/02/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Peritoneal dialysis (PD) starters generally have a better outcome compared with hemodialysis (HD) starters, perhaps related to treatment characteristics or case mix. We previously showed that pre- and post-dialysis start clinical parameter trajectories are related to outcomes. The aim of this study was to investigate these trajectories in PD and HD starters. METHODS This retrospective observational study analyzing data from the Fresenius Medical Care-chronic kidney disease (CKD) Registry from January 2009 to March 2018 examines trends in key clinical parameters through the transition period covering 12 months before to 12 months after dialysis start in 8,088 HD and 1,015 PD starters. RESULTS Hemodialysis starters differed from PD starters by a significantly greater decline in estimated glomerular filtration rate (eGFR) slope (-0.64 vs -0.45 mL/min/1.73 m2/month) before and higher eGFR (9.85 vs 7.84 mL/min/1.73 m2) at dialysis start. Relatedly, differences in phosphorus (0.07 vs 0.05 mg/dL/month) and hemoglobin (-0.08 vs -0.01 g/dL/month) slopes before the transition to dialysis therapy were observed. After dialysis start, HD starters experienced a greater increase in albumin (0.01 vs 0 g/dL/month) whereas PD starters experienced a decline in serum sodium and higher white blood cell counts compared with HD starters. CONCLUSION For nephrology practice CKD patients, HD and PD starters appear clinically comparable in the year before dialysis start although HD starters exhibit a more rapid pre-dialytic eGFR decline. Ideally, studies comparing incident HD and PD outcomes should also consider CKD eGFR trajectories. In the first dialysis year, divergence occurs in albumin, white blood cell count, sodium and hemoglobin trends, which may be partly treatment-related.
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Affiliation(s)
- Dugan W Maddux
- Medical Office, Fresenius Medical Care North America, Waltham, United States
| | - Len A Usvyat
- Medical Office, Fresenius Medical Care North America, Waltham, United States
| | - Thomas Blanchard
- Medical Office, Fresenius Medical Care North America, Waltham, United States
| | - Yue Jiao
- Medical Office, Fresenius Medical Care North America, Waltham, United States
| | - Peter Kotanko
- Nephrology, Renal Research Institute, NY, United States
| | - Frank M van der Sande
- Internal Medicine and Nephrology , Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Franklin W Maddux
- Medical Office, Fresenius Medical Care North America, Waltham, United States
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Thadhani R, Guilatco R, Hymes J, Maddux FW, Ahuja A. Switching from Epoetin Alfa (Epogen®) to Epoetin Alfa-Epbx (RetacritTM) Using a Specified Dosing Algorithm: A Randomized, Non-Inferiority Study in Adults on Hemodialysis. Am J Nephrol 2018; 48:214-224. [PMID: 30196301 PMCID: PMC6214608 DOI: 10.1159/000492621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/01/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND For patients with anemia undergoing hemodialysis, erythropoiesis-stimulating agents (ESAs) are typically dosed via precise algorithms. Using one such algorithm, we assessed the maintenance of hemoglobin levels in patients switched from epoetin alfa reference product (Epogen®) to epoetin alfa-epbx (RetacritTM; a biosimilar to US-licensed Epogen®/Procrit®). METHODS This randomized, open-label, non-inferiority study was conducted at Fresenius Medical Care North America (FMCNA) hemodialysis centers. Patients with anemia and chronic kidney disease undergoing maintenance hemodialysis and receiving routine intravenous (IV) Epogen® were randomized 1: 1 to switch to IV RetacritTM or continue standard-of-care (Epogen®) for 24 weeks, using analogous versions of the FMCNA ESA-dosing algorithm. The primary endpoint was the proportion of time patients' hemoglobin was 9-11 g/dL during weeks 17-24. RESULTS Of 432 randomized patients, 418 received treatment (RetacritTM, n = 212; standard-of-care, n = 206) and comprised the full analysis set. A similar proportion of patients discontinued from each arm. The proportion of time patients' hemoglobin was within the target range was 61.9% (95% CI 57.5-66.2) in the RetacritTM arm and 63.3% (95% CI 58.7-67.7) in the standard-of-care arm. The difference in proportions between treatment arms was -1.4% (95% CI -7.6 to 4.9), and the lower bound of the confidence interval was within the pre-specified non-inferiority margin of -12.5%. There was no statistically significant difference between arms in the mean change from baseline in the weekly mean ESA dose during weeks 17-24, and no clinically relevant differences in safety outcomes. CONCLUSIONS Switching to RetacritTM was non-inferior to continuing -Epogen® in maintaining hemoglobin levels in patients receiving hemodialysis, when both ESAs were dosed using a specified algorithm (ClinicalTrials.gov, NCT02504294).
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Affiliation(s)
- Ravi Thadhani
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ruffy Guilatco
- Pfizer Essential Health, Clinical Development and Medical Affairs, Pfizer Inc., Makati City, Philippines
| | - Jeffrey Hymes
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | | | - Ajay Ahuja
- Pfizer Essential Health, Clinical Development and Medical Affairs, Pfizer Inc., Lake Forest, Illinois, USA
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Mathew RO, Bangalore S, Sidhu MS, Fleg JL, Maddux FW. Increasing inclusion of patients with advanced chronic kidney disease in cardiovascular clinical trials. Kidney Int 2018; 93:787-788. [DOI: 10.1016/j.kint.2017.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 10/17/2022]
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McDougall KA, Larkin JW, Wingard RL, Jiao Y, Rosen S, Ma L, Usvyat LA, Maddux FW. Depressive affect in incident hemodialysis patients. Clin Kidney J 2018; 11:123-129. [PMID: 29423211 PMCID: PMC5798120 DOI: 10.1093/ckj/sfx054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/15/2017] [Indexed: 11/22/2022] Open
Abstract
Background The prevalence of depressive affect is not well defined in the incident hemodialysis (HD) population. We investigated the prevalence of and associated risk factors and hospitalization rates for depressive affect in incident HD patients. Methods We performed a prospective investigation using the Patient Health Questionnaire 2 (PHQ2) depressive affect assessment. From January to July of 2013 at 108 in-center clinics randomly selected across tertiles of baseline quality measures, we contacted 577 and 543 patients by telephone for depressive affect screening. PHQ2 test scores range from 0 to 6 (scores ≥3 suggest the presence of depressive affect). The prevalence of depressive affect was measured at 1–30 and 121–150 days after initiating HD; depressive affect risk factors and hospitalization rates by depressive affect status at 1–30 days after starting HD were computed. Results Of 1120 contacted patients, 340 completed the PHQ2. In patients screened at 1–30 or 121–150 days after starting HD, depressive affect prevalence was 20.2% and 18.5%, respectively (unpaired t-test, P = 0.7). In 35 patients screened at both time points, there were trends for lower prevalence of depressive affect at the end of incident HD, with 20.0% and 5.7% of patients positive for depressive affect at 1–30 and 121–150 days, respectively (paired t-test, P = 0.1). Hospitalization rates were higher in patients with depressive affect during the first 30 days, exhibiting 1.5 more admissions (P < 0.001) and 10.5 additional hospital days (P = 0.008) per patient-year. Females were at higher risk for depressive affect at 1–30 days (P = 0.01). Conclusions The prevalence of depressive affect in HD patients is high throughout the incident period. Rates of hospital admissions and hospital days are increased in incident HD patients with depressive affect.
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Affiliation(s)
- Kathryn A McDougall
- Clinical Innovation Initiatives, Fresenius Medical Care North America, Waltham, MA 02451
| | - John W Larkin
- Integrated Care Analytics, Fresenius Medical Care North America, Waltham, MA 02451
| | - Rebecca L Wingard
- Clinical Innovation Initiatives, Fresenius Medical Care North America, Waltham, MA 02451
| | - Yue Jiao
- Integrated Care Analytics, Fresenius Medical Care North America, Waltham, MA 02451
| | - Sophia Rosen
- Integrated Care Analytics, Fresenius Medical Care North America, Waltham, MA 02451
| | - Lin Ma
- Reporting and Algorithms, Fresenius Medical Care North America, Waltham, MA 02451
| | - Len A Usvyat
- Integrated Care Analytics, Fresenius Medical Care North America, Waltham, MA 02451
| | - Franklin W Maddux
- Clinical and Scientific Affairs, Fresenius Medical Care North America, Waltham, MA 02451
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Maddux D, Usvyat LA, Xu D, Wang Y, Kotanko P, van der Sande FM, Kooman JP, Maddux FW. The Association of Weekly pre-Hemodialysis Systolic Blood Pressure and Following Week Mortality. Kidney Blood Press Res 2018; 43:88-97. [PMID: 29414829 DOI: 10.1159/000487105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 01/25/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Few studies examine the impact of systolic blood pressure (SBP) on mortality in the incident hemodialysis (HD) period, and throughout the first HD year. This large retrospective observational study analyzes the impact of "current" and cumulative low preSBP <110 mmHg (L), and variations in preSBP on short-term (1 week) mortality over the first HD year. METHODS Weekly mean preSBP for HD weeks 1 to 51 was categorized into L or high preSBP>=110 mmHg (H) for each patient. A generalized linear model (GLM) was used to compute the probability of death in the following week. The model includes age, gender, race and three preSBP-related parameters: (a) percent of prior weeks with L preSBP; (b) percent of prior weeks with switching between L to H; (c) "current" week's preSBP as a binary variable. Separate models were constructed that include demographics and BP-related parameters (a), (b), and (c) separately. RESULTS In a model combining (a), (b), and (c) above, "current" week L preSBP is associated with increased odds ratio for following week mortality throughout the first HD year. The percent of prior week's L and more switching between L and H are less significantly associated with short-term mortality. In models including (a), (b), and (c) separately, "current" L preSBP is associated with higher mortality. CONCLUSION This study confirms an association of L preSBP with increased short-term mortality which is maintained over the first HD year. Percent of L preSBP in prior weeks, switching between L and H, and "current" week L are all associated with short-term mortality risk, but "current" week L preSBP is most significant.
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Affiliation(s)
- Dugan Maddux
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Danqing Xu
- University of California at Santa Barbara, Santa Barbara, California, USA
| | - Yuedong Wang
- University of California at Santa Barbara, Santa Barbara, California, USA
| | | | | | - Jeroen P Kooman
- Maastricht University Medical Centre, Maastricht, the Netherlands
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Han M, Ye X, Preciado P, Williams S, Campos I, Bonner M, Young C, Marsh D, Larkin JW, Usvyat LA, Maddux FW, Pecoits-Filho R, Kotanko P. Relationships between Neighborhood Walkability and Objectively Measured Physical Activity Levels in Hemodialysis Patients. Blood Purif 2018; 45:236-244. [PMID: 29478044 DOI: 10.1159/000485161] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Neighborhood walkability is associated with indicators of health in the general population. We explored the association between neighborhood walkability and daily steps in hemodialysis (HD) patients. METHODS We measured daily steps over 5 weeks using Fitbit Flex (Fitbit, San Francisco, CA, USA) and retrieved Walk Score® (WS) data by patient's home ZIP code (www.walkscore.com; 0 = poorest walkability; 100 = greatest walkability). RESULTS HD patients took a mean of 6,393 ± 3,550 steps/day (n = 46). Median WS of the neighborhood where they resided was 28. Patients in an above-median WS (n = 27) neighborhood took significantly more daily steps compared to those (n = 19) in a below-median WS neighborhood (7,514 ± 3,900 vs. 4,800 ± 2,228 steps/day; p < 0.001, t test). Daily steps and WS were directly correlated (R = 0.425; p = 0.0032, parametric test; R = 0.359, p = 0.0143, non-parametric test). CONCLUSION This is the first study conducted among HD patients to indicate a direct relationship between neighborhood walkability and the actual steps taken. These results should be considered when designing initiatives to increase and improvise exercise routines in HD populations.
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Affiliation(s)
- Maggie Han
- Renal Research Institute, New York, New York, USA
| | - Xiaoling Ye
- Renal Research Institute, New York, New York, USA
| | | | | | | | | | | | | | - John W Larkin
- Pontificia Universidade Catolica do Parana, Curitiba, Brazil.,Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | | | | | - Peter Kotanko
- Renal Research Institute, New York, New York, USA.,Icahn School of Medicine, New York, New York, USA
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Hippen BE, Maddux FW. Integrating kidney transplantation into value-based care for people with renal failure. Am J Transplant 2018; 18:43-52. [PMID: 28898574 DOI: 10.1111/ajt.14454] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/05/2017] [Accepted: 07/29/2017] [Indexed: 01/25/2023]
Abstract
Healthcare reimbursement is increasingly tied to value instead of volume, with special attention paid to resource-intensive populations such as patients with renal disease. To this end, Medicare has sponsored pilot projects to encourage providers to develop care coordination and population health management strategies to provide quality care while reducing resource utilization. In this Personal Viewpoint essay, we argue in favor of expanding one such pilot project-the Comprehensive ESRD Care (CEC) initiative-to include patients with advanced chronic kidney disease and kidney transplant recipients. The implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) offers a time-sensitive incentive for transplant centers in particular to align with extant CECs. An "expanded" CEC model proffers opportunity for robust cooperation between general nephrology practices, dialysis providers, and transplant centers to develop care coordination strategies for all patients with renal disease, realign incentives for all clinical stakeholders to increase kidney transplantation rates, and reduce total costs of care.
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Affiliation(s)
- Franklin W Maddux
- Medical Office, Fresenius Medical Care North America, Waltham, Massachusetts
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Maddux DW, Usvyat LA, Ketchersid T, Jiao Y, Blanchard TC, Kotanko P, van der Sande FM, Kooman JP, Maddux FW. Clinical parameters before and after the transition to dialysis. Hemodial Int 2017; 22:235-244. [PMID: 29149476 DOI: 10.1111/hdi.12603] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The transition from pre-dialysis chronic kidney disease (CKD) to post-dialysis start is a critical period associated with high patient mortality and increased hospital admissions. Little is known about the trends of key clinical and laboratory parameters through this time of transition to start dialysis. METHODS De-identified data including demographics, vital signs, lab results, and eGFR from the Fresenius Medical Care-CKD Registry were analyzed to determine trends in clinical and laboratory parameters through the time of transition from 12 months pre-dialysis start to 12 months post-dialysis start. Trends in key clinical and laboratory parameters associated with cardiovascular, nutritional, mineral metabolism and inflammatory domains were examined in association with the transition to dialysis start and first year dialysis survival. FINDINGS All parameters show divergence for patients who survive vs. do not survive the first year of dialysis. Of note, during pre-dialysis CKD the absolute systolic blood pressure (SBP) level is lower and the slope for SBP decline is significantly steeper for patients who do not survive the first year on dialysis. DISCUSSION This study uniquely demonstrates the trajectories of key parameters though the transition from pre-dialysis to post-dialysis start. Significant differences are noted in the pre-dialysis period for patients who survive vs. those who do not survive the first year of dialysis. Early recognition of adverse trends in the pre-dialysis period may create opportunity to intervene to improve early dialysis outcomes.
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Affiliation(s)
- Dugan W Maddux
- Medical Office, Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Len A Usvyat
- Medical Office, Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Terry Ketchersid
- Medical Office, Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Yue Jiao
- Medical Office, Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Tommy C Blanchard
- Medical Office, Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, New York, USA
| | - Frank M van der Sande
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jeroen P Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Franklin W Maddux
- Medical Office, Fresenius Medical Care North America, Waltham, Massachusetts, USA
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Ye X, Dekker MJE, Maddux FW, Kotanko P, Konings CJAM, Raimann JG, van der Sande FM, Usvyat LA, Kooman JP, Thijssen S. Dynamics of Nutritional Competence in the Last Year Before Death in a Large Cohort of US Hemodialysis Patients. J Ren Nutr 2017; 27:412-420. [PMID: 28943158 DOI: 10.1053/j.jrn.2017.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/02/2017] [Accepted: 06/14/2017] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES Recently, a new Nutritional Competence Score (NCS) has been shown to associate with hospitalization and outcome in hemodialysis patients. The aim of this study was to investigate the dynamics, the individual components, and the impact of hospitalizations of this score's trajectory in the year before death. In addition, we investigated whether dynamics in the NCS add additional independent prognostic value over a single cross-sectional assessment. DESIGN We included all Fresenius Medical Care North America patients who initiated hemodialysis between January 1, 2006, and December 31, 2011 with data on all 5 NCS components (serum albumin, creatinine, phosphate, equilibrated normalized protein catabolic rate, and interdialytic weight gain) in at least 1 month. NCS was quantified monthly, and trajectories were compared between nonsurvivors and survivors across different dialysis vintage strata. Survivors and nonsurvivors were matched by dialysis vintage. The association of baseline NCS and NCS dynamics with mortality risk were assessed with Cox proportional hazards models. RESULTS In this cohort of 110,794 patients, we found that across all vintage groups, NCS was lower in patients who died than in survivors. NCS was found to significantly decline before death, whereas survivors showed no decline in NCS. The rate of NCS decline before death was not materially influenced by hospitalization in the months before death. Cox models showed that NCS dynamics over time carry significant predictive power above a cross-sectional NCS assessment. CONCLUSIONS There are distinct differences in NCS values and their trajectories between patients who die and vintage-matched controls. These differences may be able to be exploited for implementation of a routine, prospective monitoring tool for early detection of patients at increased risk of death. Prospective studies are required to validate such an approach.
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Affiliation(s)
- Xiaoling Ye
- Renal Research Institute, New York, New York.
| | - Marijke J E Dekker
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Peter Kotanko
- Renal Research Institute, New York, New York; Icahn School of Medicine at Mount Sinai, New York, New York
| | - Constantijn J A M Konings
- Department of Internal Medicine, Division of Nephrology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | - Frank M van der Sande
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, Massachusetts
| | - Jeroen P Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
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Smith WB, Gibson S, Newman GE, Hendon KS, Askelson M, Zhao J, Hantash J, Flanagan B, Larkin JW, Usvyat LA, Thadhani RI, Maddux FW. The dynamics of the metabolism of acetate and bicarbonate associated with use of hemodialysates in the ABChD trial: a phase IV, prospective, single center, single blind, randomized, cross-over, two week investigation. BMC Nephrol 2017; 18:273. [PMID: 28851317 PMCID: PMC5576126 DOI: 10.1186/s12882-017-0683-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 08/04/2017] [Indexed: 11/17/2022] Open
Abstract
Background In the United States, hemodialysis (HD) is generally performed via a bicarbonate dialysate. It is not known if small amounts of acid used in dialysate to buffer the bicarbonate can meaningfully contribute to overall buffering administered during HD. We aimed to investigate the metabolism of acetate with use of two different acid buffer concentrates and determine if it effects blood bicarbonate concentrations in HD patients. Methods The Acid-Base Composition with use of hemoDialysates (ABChD) trial was a Phase IV, prospective, single blind, randomized, cross-over, 2 week investigation of peridialytic dynamics of acetate and bicarbonate associated with use of acid buffer concentrates. Eleven prevalent HD patients participated from November 2014 to February 2015. Patients received two HD treatments, with NaturaLyte® and GranuFlo® acid concentrates containing 4 and 8 mEq/L of acetate, respectively. Dialysate order was chosen in a random fashion. The endpoint was to characterize the dynamics of acetate received and metabolized during hemodialysis, and how it effects overall bicarbonate concentrations in the blood and dialysate. Acetate and bicarbonate concentrations were assessed before, at 8 time points during, and 6 time points after the completion of HD. Results Data from 20 HD treatments for 11 patients (10 NaturaLyte® and 10 GranuFlo®) was analyzed. Cumulative trajectories of arterialized acetate were unique between NaturaLyte® and GranuFlo® (p = 0.003), yet individual time points demonstrated overlap without remarkable differences. Arterialized and venous blood bicarbonate concentrations were similar at HD initiation, but by 240 min into dialysis, mean arterialized bicarbonate concentrations were 30.2 (SD ± 4.16) mEq/L in GranuFlo® and 28.8 (SD ± 4.26) mEq/L in NaturaLyte®. Regardless of acid buffer concentrate, arterial blood bicarbonate was primarily dictated by the prescribed bicarbonate level. Subjects tolerated HD with both acid buffer concentrates without experiencing any related adverse events. Conclusions A small fraction of acetate was delivered to HD patients with use of NaturaLyte® and GranuFlo® acid buffers; the majority of acetate received was observed to be rapidly metabolized and cleared from the circulation. Blood bicarbonate concentrations appear to be determined mainly by the prescribed concentration of bicarbonate. Trial registration This trial was registered on ClinicalTrials.gov on 11 Dec 2014 (NCT02334267). Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0683-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- William B Smith
- Volunteer Research Group and New Orleans Center for Clinical Research at the University of Tennessee Medical Center, 1928 Alcoa Highway, Suite 107, Knoxville, TN, 37920, USA.
| | - Sandy Gibson
- Volunteer Research Group and New Orleans Center for Clinical Research at the University of Tennessee Medical Center, 1928 Alcoa Highway, Suite 107, Knoxville, TN, 37920, USA
| | - George E Newman
- Knoxville Kidney Center, PLLC, 320 Park 40 N Blvd, Knoxville, TN, 37923, USA
| | - Kendra S Hendon
- Knoxville Kidney Center, PLLC, 320 Park 40 N Blvd, Knoxville, TN, 37923, USA
| | | | - James Zhao
- EDETEK, 500 College Road East, Suite 200, Princeton, NJ, 08540, USA
| | - Jamil Hantash
- Tandem Labs, 115 Silvia Street, West Trenton, NJ, 08628, USA
| | - Brigid Flanagan
- Frenova Renal Research, 920 Winter Street, Waltham, MA, 02451, USA
| | - John W Larkin
- Fresenius Medical Care North America, 920 Winter Street, Waltham, MA, 02451, USA
| | - Len A Usvyat
- Fresenius Medical Care North America, 920 Winter Street, Waltham, MA, 02451, USA
| | - Ravi I Thadhani
- Massachusetts General Hospital Division of Nephrology, 55 Fruit Street #1008, Boston, MA, 02114, USA
| | - Franklin W Maddux
- Fresenius Medical Care North America, 920 Winter Street, Waltham, MA, 02451, USA
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Nissenson AR, Maddux FW. Nephrologists and Integrated Kidney Disease Care: Roles and Skills Essential for Nephrologists for Future Success. Am J Kidney Dis 2017; 70:132-138. [DOI: 10.1053/j.ajkd.2017.02.372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 02/21/2017] [Indexed: 11/11/2022]
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Larkin JW, Reviriego-Mendoza MM, Usvyat LA, Kotanko P, Maddux FW. To cool, or too cool: Is reducing dialysate temperature the optimal approach to preventing intradialytic hypotension? Semin Dial 2017; 30:501-508. [DOI: 10.1111/sdi.12628] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Len A. Usvyat
- Fresenius Medical Care North America; Waltham MA USA
| | - Peter Kotanko
- Renal Research Institute; New York NY USA
- Icahn School of Medicine at Mount Sinai; New York NY USA
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Wingard RL, McDougall K, Axley B, Howard A, O''Keefe C, Armistead N, Lynch JR, Rosen S, Usvyat L, Maddux FW. Right TraC™ Post-Hospitalization Care Transitions Program to Reduce Readmissions for Hemodialysis Patients. Am J Nephrol 2017; 45:532-539. [PMID: 28531888 DOI: 10.1159/000477325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/25/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hemodialysis (HD) patients have high hospitalization rates. This nonrandomized trial tested the effect of a bundle of renal-specific "Right TraC™" strategies on 30-day all-cause readmission rates and, secondarily, 90-day readmissions and overall admissions among HD patients. METHODS Twenty-six Fresenius clinics in West Virginia, Ohio, and Kentucky participated in the interventions. Eighteen matched clinics served as controls; intervention clinics also served as their own controls. We deployed the intervention in 3 incremental phases focused on patient information exchange, post-hospital follow-up, and telephonic case management. Thirty-day hospital readmissions per patient year (ppy) were calculated by dividing the total number of readmissions within 30 days of index admission by the total number of patient-years in baseline (2012) and remeasurement (2014) periods. We also compared readmission rates from 2010 to 2015. We used repeated measures Poisson regression to compare outcomes between groups and time periods. RESULTS From 2012 to 2014, 30-day all-cause readmissions ppy declined for Right TraC clinics (from 0.88 to 0.66 [p < 0.001]; for controls, from 0.73 to 0.61 [p = 0.16]). Difference in change between groups was nonsignificant (p = 0.26). Overall admissions ppy declined: for Right TraC clinics from 2.51 to 1.97 (p < 0.001); for controls from 2.14 to1.92 (p = 0.21); difference in change between groups was significant (p = 0.01). For 2010, 2011, and 2012, Right TraC clinic 30-day readmissions ppy were unchanged: 0.89, 1.00, 0.88 (p = 0.61 and p = 0.49); they declined to 0.66 (p < 0.001) in 2014 (intervention year); rose to 0.70 (p = 0.06) in 2015 (interventions discontinued). CONCLUSION We conclude that Right TraC interventions may have been helpful in reducing hospital readmission rates.
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Roberts-Clary S, Larkin JW, Matzke GR, Rosen S, Revirieqo-Mendoza MM, Fox T, Usvyat LA, Hymes JL, Ketchersid TL, Maddux FW. Improvements in MBD lab outcomes associated with improved pharmaceutical care in hemodialysis patients. Nephrol News Issues 2017; 31:26-32. [PMID: 30351586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
End stage renal disease (ESRD) patients require a large number of medications and are known to have high rates of nonadherence. It is estimated that >50% of ESRD patients do not take their phosphate binders as prescribed. The renal pharmacy FreseniusRx provides coordinated ESRD medication delivery and adherence support for enrolled patients. We investigated whether coordinated pharmacy care of mineral and bone disorder (MBD) therapies is associated with improvements in laboratory. outcomes. We used data from hemodialysis patients treated at Fresenius Medical Care North America (FMCNA) clinics from February 2014 to January 2015. We included patients who were residing in a state with >100 patients in the FMCNA network, not in a nursing home, and prescribed a phosphate binder and/or calcimimetic. We found 15,287 pharmacy patients who met the study criteria. Concurrent control patients not in the pharmacy were matched to pharmacy patients on a monthly basis that was based off the first date of receipt of therapy from FreseniusRx using 1:1 nearest neighbor matching on the logit of the propensity score for an array of clinical and non-clinical parameters. Logistic regression was used to measure the association between pharmacy care and patients achieving their laboratory goals for phosphorus (PO4) and intact parathyroid hormone (iPTH), and combined goals for total calcium (Ca), PO4, and iPTH. We analyzed data from 30,574 patients (15,287 pharmacy and control). In unadjusted and adjusted analyses, we consistently observed that pharmacy patients were more likely to achieve their MBD laboratory goals as compared to controls. In an adjusted analysis, we found pharmacy patients were more likely to achieve their MBD laboratory targets at 3, 6, 9, and 12 months for PO4 (11.1%, 10.5%, 11.8% and 12.7% respectively), iPTH (8.9%, 17.5%, 23.4% and 27.9% respectively) and combined goals for Ca, PO4, and. iPTH (12.1%, 13.4%, 16.7% and 21.2% respectivelv) versus controls (n<0.01 for all comparisons). These findings indicate that coordinated pharmaceutical care may be associated with improvements in patients achieving their MBD laboratory goals.
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Karaboyas A, Zee J, Brunelli SM, Usvyat LA, Weiner DE, Maddux FW, Nissenson AR, Jadoul M, Locatelli F, Winkelmayer WC, Port FK, Robinson BM, Tentori F. Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2016; 69:266-277. [PMID: 27866964 DOI: 10.1053/j.ajkd.2016.09.015] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 09/08/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Sudden death is a leading cause of death in patients on maintenance hemodialysis therapy. During hemodialysis sessions, the gradient between serum and dialysate levels results in rapid electrolyte shifts, which may contribute to arrhythmias and sudden death. Controversies exist about the optimal electrolyte concentration in the dialysate; specifically, it is unclear whether patient outcomes differ among those treated with a dialysate potassium concentration of 3 mEq/L compared to 2 mEq/L. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 55,183 patients from 20 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 1 to 5 (1996-2015). PREDICTOR Dialysate potassium concentration at study entry. OUTCOMES Cox regression was used to estimate the association between dialysate potassium concentration and both all-cause mortality and an arrhythmia composite outcome (arrhythmia-related hospitalization or sudden death), adjusting for potential confounders. RESULTS During a median follow-up of 16.5 months, 24% of patients died and 7% had an arrhythmia composite outcome. No meaningful difference in clinical outcomes was observed for patients treated with a dialysate potassium concentration of 3 versus 2 mEq/L (adjusted HRs were 0.96 [95% CI, 0.91-1.01] for mortality and 0.98 [95% CI, 0.88-1.08] for arrhythmia composite). Results were similar across predialysis serum potassium levels. As in prior studies, higher serum potassium level was associated with adverse outcomes. However, dialysate potassium concentration had only minimal impact on serum potassium level measured predialysis (+0.09 [95% CI, 0.05-0.14] mEq/L serum potassium per 1 mEq/L greater dialysate potassium concentration). LIMITATIONS Data were not available for delivered (vs prescribed) dialysate potassium concentration and postdialysis serum potassium level; possible unmeasured confounding. CONCLUSIONS In combination, these results suggest that approaches other than altering dialysate potassium concentration (eg, education on dietary potassium sources and prescription of potassium-binding medications) may merit further attention to reduce risks associated with high serum potassium levels.
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Affiliation(s)
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, MA
| | | | | | - Allen R Nissenson
- DaVita Healthcare Partners, Inc, El Segundo, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Michel Jadoul
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Friedrich K Port
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI; Vanderbilt University, Nashville, TN
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Nigwekar SU, Zhao S, Wenger J, Hymes JL, Maddux FW, Thadhani RI, Chan KE. A Nationally Representative Study of Calcific Uremic Arteriolopathy Risk Factors. J Am Soc Nephrol 2016; 27:3421-3429. [PMID: 27080977 PMCID: PMC5084892 DOI: 10.1681/asn.2015091065] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 03/14/2016] [Indexed: 11/03/2022] Open
Abstract
Accurate identification of risk factors for calcific uremic arteriolopathy (CUA) is necessary to develop preventive strategies for this morbid disease. We investigated whether baseline factors recorded at hemodialysis initiation would identify patients at risk for future CUA in a matched case-control study using data from a large dialysis organization. Hemodialysis patients with newly diagnosed CUA (n=1030) between January 1, 2010, and December 31, 2014, were matched by age, sex, and race in a 1:2 ratio to hemodialysis patients without CUA (n=2060). Mean ages for patients and controls were 54 and 55 years, respectively; 67% of participants were women and 49% were white. Median duration between hemodialysis initiation and subsequent CUA development was 925 days (interquartile range, 273-2185 days). In multivariable conditional logistic regression analyses, diabetes mellitus; higher body mass index; higher levels of serum calcium, phosphorous, and parathyroid hormone; and nutritional vitamin D, cinacalcet, and warfarin treatments were associated with increased odds of subsequent CUA development. Compared with patients with diabetes receiving no insulin injections, those receiving insulin injections had a dose-response increase in the odds of CUA involving lower abdomen and/or upper thigh areas (odds ratio, 1.49; 95% confidence interval, 1.03 to 2.51 for one or two injections per day; odds ratio, 1.88; 95% confidence interval, 1.30 to 3.43 for 3 injections per day; odds ratio, 3.74; 95% confidence interval, 2.28 to 6.25 for more than three injections per day), suggesting a dose-effect relationship between recurrent skin trauma and CUA risk. The presence of risk factors months to years before CUA development observed in this study will direct the design of preventive strategies and inform CUA pathobiology.
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Affiliation(s)
- Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts;
| | - Sophia Zhao
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Julia Wenger
- Division of Nephrology, University of North Carolina Kidney Center, Chapel Hill, North Carolina; and
| | - Jeffrey L Hymes
- Medical office, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Franklin W Maddux
- Medical office, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Ravi I Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kevin E Chan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Medical office, Fresenius Medical Care North America, Waltham, Massachusetts
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Zhang H, Wang Y, Raimann JG, Usvyat L, Kooman JP, van der Sande FM, Kotanko P, Maddux FW. SP461SEASONALITY OF HEMODYNAMIC PARAMETERS IN HEMODIALYSIS PATIENTS. Nephrol Dial Transplant 2016. [DOI: 10.1093/ndt/gfw172.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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