Impact of Prior Abdominal Procedures on Peritoneal Dialysis Catheter Outcomes: Findings From the North American Peritoneal Dialysis Catheter Registry

RATIONALE & OBJECTIVE

A history of prior abdominal procedures may influence the likelihood of referral for peritoneal dialysis (PD) catheter insertion. To guide clinical decision making in this population, this study examined the association between prior abdominal procedures and outcomes in patients undergoing PD catheter insertion.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Adults undergoing their first PD catheter insertion between November 1, 2011 and November 1, 2020, at 11 institutions in Canada and the US participating in the International Society for Peritoneal Dialysis (ISPD) North American Catheter Registry.

EXPOSURE

Prior abdominal procedure(s), defined as any procedure that enters the peritoneal cavity.

OUTCOMES

Primary outcome: time to the first of abandonment of the PD catheter, or interruption/termination of PD.

SECONDARY OUTCOMES

rates of emergency room visits, hospitalizations, and procedures.

ANALYTICAL APPROACH

Cumulative incidence curves were used to describe the risk over time and an adjusted Cox proportional hazards model was used to estimate the association between the exposure and primary outcome. Models for count data were used to estimate the associations between the exposure and secondary outcomes.

RESULTS

A total of 855 patients met the inclusion criteria. Thirty-one percent had a history of a prior abdominal procedure and 20% experienced at least one PD catheter-related complication that led to the primary outcome. Prior abdominal procedures were not associated with an increased risk of the primary outcome [Adjusted HR 1.12 (95% CI 0.68-1.84)]. Upper abdominal procedures were associated with a higher adjusted hazard of the primary outcome, but there was no dose-response relationship concerning the number of procedures. There was no association between prior abdominal procedures and other secondary outcomes.

LIMITATIONS

Observational study and cohort limited to sample of patients felt to be potential candidates for PD catheter insertion.

CONCLUSION

A history of prior abdominal procedure(s) does not appear to influence catheter outcomes following PD catheter insertion. Such a history should not be a contraindication to peritoneal dialysis.

The paradox of haemodialysis: the lived experience of the clocked treatment of chronic illness

Studies exploring the relationship between time and chronic illness have generally focused on measurable aspects of time, also known as linear time. Linear time follows a predictable, sequential order of past, present and future; measured using a clock and predicated on normative assumptions. Sociological concepts addressing lifecourse disruption following diagnosis of chronic illness have served to enhance the understanding of lived experience. To understand the nuanced relationship between time and chronic illness, however, requires further exploration. Here, we show how the implicit assumptions of linear time meet in tension with the lived experience of chronic illness. We draw on interviews and photovoice work with people with end-stage kidney disease in receipt of in-centre-daytime haemodialysis to show how the clocked treatment of chronic illness disrupts experiences of time. Drawing on concepts of 'crip' and 'chronic' time we argue that clocked treatment and the lived experience of chronic illness converge at a paradox whereby clocked treatment allows for the continuation of linear time yet limits freedom. We use the concept of 'crip time' to challenge the normative assumptions implicit within linear concepts of time and argue that the understanding of chronic illness and its treatment would benefit from a 'cripped' starting point.

Humoral immunity trends in a hemodialysis cohort following SARS-CoV-2 mRNA booster: A cohort study

Background and Aims

Patients with end stage kidney disease on hemodialysis are vulnerable to SARS-CoV-2 infection. Current guidelines recommend boosters of SARS-CoV-2 mRNA-based vaccines. The long-term humoral response of hemodialysis patients infected with SARS-CoV-2 after receiving a booster of SARS-CoV-2 mRNA-based vaccines has been incompletely characterized. Here, we determined the long-term humoral response of hemodialysis patients to two and three doses of the Pfizer BioNTech (BNT162b2) mRNA SARS-CoV-2 vaccine and investigated the effect of postbooster SARS-CoV-2 infection on antibody levels over time.

Methods

Samples were collected on a monthly basis and tested for anti-SARS-CoV-2 antibodies against anti-spike S1 domain. Thirty-five hemodialysis patients were enrolled in the original study and 27 of these received a booster. Patients were followed up to 6 months after the first two doses and an additional 7 months after the third BNT162b2 dose. Results are presented as the internationally harmonized binding antibody units (BAU/mL).

Results

Antibody level significantly increased from prebooster to 2 weeks postbooster, with a median [25th, 75th percentile] rise from 52.72 [28.55, 184.7] to 6216 [3806, 11,730] BAU/mL in the total population. Of patients with a negative or borderline detectable antibody level 6 months after vaccination who received a third dose, 89% developed positive antibody levels 2 weeks postbooster. Postbooster antibody levels declined an average rate of 29% per month in infection-naïve patients. Antibody levels spiked in patients infected with SARS-CoV-2 after receiving a booster but declined rapidly. No patients infected postbooster required hospitalization.

Conclusions

A third dose of BNT162b2 restores antibody levels to high levels in dialysis patients but levels decline over time. A third dose did not necessarily prevent infection, but no patients suffered severe infection or required hospitalization. SARS-CoV-2 recovered patients appear to have a blunted rise in antibody levels after a third dose. Although patients infected with SARS-CoV-2 postbooster had an immediate spike in antibody levels, these declined over time.

Long-term outcome of kidney function in patients with ANCA-associated vasculitis

BACKGROUND

Kidney involvement is common in ANCA associated vasculitis (AAV) and prognosis determined by the severity of kidney damage. This study focused on long-term kidney outcomes, defining possible risk factors and comparing the performance of three different histological classifications to predict outcomes for patients with AAV.

METHODS

The dataset included 848 patients with newly diagnosed AAV who participated in 7 RCTs (1995-2012). Follow up information obtained from questionnaires sent to the principal investigators of the original RCTs.

RESULTS

The cumulative incidence of end-stage kidney disease (ESKD) at 5 and 10 years was 17% and 22%, respectively. Patients who developed ESKD had reduced patient survival compared to those with preserved kidney function (HR: 2.8, P-value < 0.001). Comparing patients with AAV and kidney involvement to a matched general population, patients with AAV had poor survival outcomes, even in early stages of CKD. The main cause of death was infection followed by cardiovascular disease in patients developing ESKD and malignancy in those who did not. 34% of patients with initial need for dialysis recovered kidney function after treatment. 35 out of 175 in need of kidney replacement therapy (KRT) during follow up received a kidney transplant with good outcome; 86% patient survival at 10 years.In the subcohort of 214 patients with available kidney biopsies, three scoring systems were tested: the Berden classification, the Renal Risk Score (RRS), and the Mayo Clinic Score (MCCS). The scores highlighted the importance of normal glomeruli and severe glomerulosclerosis on kidney survival (P < 0.001 and P = 0.001, respectively). The RRS demonstrated a moderate prediction of kidney survival (AUC: 0.79; SE: 0.03, 95% CI: 0.71-0.83).

CONCLUSIONS

Early diagnosis is extremely important. Even milder forms of kidney involvement have an impact on the prognosis. Patients in need of KRT had the lowest survival rates, but kidney transplantation has shown favorable outcomes for eligible AAV patients. The three histologic scoring systems were all identified as independent prognostic factors for kidney outcome.

Prevalence of Cognitive Impairment and Relationships with Other Factors in Patients with End Stage Kidney Disease Receiving Hemodialysis

Despite recommendations, cognitive screening in patients with end stage kidney disease (ESKD) rarely happens, leading to underestimates of cognitive impairment (CI) prevalence and missed opportunities for intervention. We aimed to describe CI prevalence and associated factors in 100 patients receiving in-center hemodialysis aged 50 years and older. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA). Descriptive analysis techniques characterized the sample and estimated mean scores. Non-parametric and parametric tests explored relationships among MoCA scores and other patient factors. Of the 100 patients, 32% had normal cognitive function, 56% mild CI, and 12% moderate CI. Age, income, and education level significantly corelated with cognitive function in our sample. Identifying clinical factors and appropriate follow up for abnormal screening are crucial next steps in managing cognitive impairment in patients with ESKD receiving in-center hemodialysis.

Long-term safety and efficacy of left atrial appendage occlusion in dialysis patients with atrial fibrillation: a multi-center, prospective, open label, observational study

Background

The prevalence of atrial fibrillation (AF) in end stage kidney disease (ESKD) patients undergoing dialysis is high, however, the high risk of bleeding often hampers with a correct anticoagulation in ESKD patients with AF, despite high thromboembolic risk. Left atrial appendage (LAA) occlusion is a anticoagulation (OAT) for thromboembolism prevention in AF populations with high hemorrhagic risk.

Methods and Results

The purpose of the study was to evaluate the efficacy and safety of LAA occlusion in a cohort of dialysis patients undergoing the procedure (LAA occlusion cohort, n = 106), in comparison with two other ESKD cohorts, one taking warfarin (Warfarin cohort, n = 114) and the other without anticoagulation therapy (No-OAT cohort, n = 148). After a median follow-up of 4 years, a Cox regression model, adjusted for possible confounding factors, showed that the hazard ratios (HRs) of thromboembolic events in the LAA occlusion cohort were 0.19 (95%CI 0.04-0.96; p = 0.045) and 0.16 (95%CI 0.04-0.66; p = 0.011) as compared with Warfarin and No-OAT cohorts, respectively. The HR of bleeding in the LAA occlusion cohort was 0.37 (95%CI 0.16-0.83; p = 0.017) compared to Warfarin cohort, while there were no significant differences between the LAA occlusion and the No-OAT cohort (HR 0.51; 95%CI 0.23-1.12; p = 0.094). Adjusted Cox regression models showed lower mortality in patients undergoing LAA occlusion as compared with both the Warfarin cohort (HR 0.60; 95%CI 0.38-0.94; p = 0.027) and no-OAT cohort (HR 0.52; 95%CI 0.34-0.78; p = 0.002). Thromboembolic events in the LAA occlusion cohort were lower than expected according to the CHA2DS2VASc score (1.7 [95%CI 0.3-3.0] vs 6.7 events per 100 person/years, p < 0.001).

Conclusion

In ESKD patients with AF, LAA occlusion is safe and effective and is associated with reduced mortality compared with OAT or no therapy.

Platelet-albumin-bilirubin score and neutrophil-to-lymphocyte ratio predict intensive care unit admission in patients with end-stage kidney disease infected with the Omicron variant of COVID-19: a single-center prospective cohort study

OBJECTIVES

The objective of this study was to develop clinical scores to predict the risk of intensive care unit (ICU) admission in patients with COVID-19 and end stage kidney disease (ESKD).

METHODS

This was a prospective study in which 100 patients with ESKD were enrolled and divided into two groups: the ICU group and the non-ICU group. We utilized univariate logistic regression and nonparametric statistics to analyze the clinical characteristics and liver function changes of both groups. By plotting receiver operating characteristic curves, we identified clinical scores that could predict the risk of ICU admission.

RESULTS

Out of the 100 patients with Omicron infection, 12 patients were transferred to the ICU due to disease aggravation, with an average of 9.08 days from hospitalization to ICU transfer. Patients transferred to the ICU more commonly experienced shortness of breath, orthopnea, and gastrointestinal bleeding. The peak liver function and changes from baseline in the ICU group were significantly higher, with p values <.05. We found that the baseline platelet-albumin-bilirubin score (PALBI) and neutrophil-to-lymphocyte ratio (NLR) were good predictors of ICU admission risk, with area under curve values of 0.713 and 0.770, respectively. These scores were comparable to the classic Acute Physiology and Chronic Health Evaluation II (APACHE-II) score (p > .05).

CONCLUSION

Patients with ESKD and Omicron infection who are transferred to the ICU are more likely to have abnormal liver function. The baseline PALBI and NLR scores can better predict the risk of clinical deterioration and early transfer to the ICU for treatment.

Tunneled Dialysis Catheters: Perspective from a Single Interventional Radiology Center

Tunneled dialysis catheters (TDCs) serve as vascular access for hemodialysis (HD) or plasmapheresis. This study examines the frequency and indications for TDC placement and removal by an interventional radiology service over a 5-year period. Indications for catheter placement (n = 289) included HD for patients with end stage kidney disease (65%) or acute kidney injury (AKI, 24%), and plasmapheresis (11%). Indications for catheter removal included infection (20%), dysfunction (33%), no longer needed (40%), and patient issues (7%). TDCs provide access for HD when a functioning arteriovenous access does not exist. Using a TDC in patients with AKI reduces catheter complications, such as mechanical dysfunction and infection, and provides better dialysis delivery. TDC placement in patients with AKI, despite its time and resource intensity, provides medical and financial benefits.

Sleep Disturbances in Older Adults Receiving Dialysis

Sleep disturbances are serious issues in individuals with end stage kidney disease because they are associated with worsening kidney function and other negative health outcomes, especially in older adults. Our analysis aimed to provide clinicians with the conceptual clarity required for managing sleep disturbances in older patients who are receiving dialysis. A literature review revealed three attributes that define this population's sleep disturbances: sleep initiation and maintenance difficulties, restless sleep and short sleep, and abnormal breathing during sleep. Con sidering the serious consequences and correlates of sleep disturbances in older patients who are receiving dialysis, tailored interventions are needed to improve their sleep. Our literature review, concept analysis, and case studies provide key information for designing future mechanistic, clinical-translational, and interventional research.

Reprocessing and reuse of dialyzers: A technological solution for balancing cost and quality in lower and middle-income countries

Hemodialysis is the commonest kidney replacement therapy (KRT) globally and rapidly growing in developing countries, while in developed countries it is reaching a plateau. The penetration of hemodialysis (HD) varies widely among countries and is largely influenced by socioeconomics, healthcare financing, particularly by government, local infrastructure, healthcare workforce, health system characteristics, and affordability of the population. Biomedical equipment, consumables, disposables, and labor are major cost drivers of KRT. Implementing strategies to balance cost and quality of care is an arduous task for health care planning, delivery, and patient care in low- and middle-income countries. In this context, the cost of dialyzers which form a significant component of the recurring cost of HD can be reduced by reuse after appropriate reprocessing. But this practice is largely abandoned in developed countries because of concerns of safety. However, the evidence against the reuse of modern dialyzers is not robust and certainly not based on well-designed randomized trials. The industrialization of dialysis delivery, the interests of equipment manufacturers and the nature of dialysis delivery have propelled single use of dialyzers. In this context, developing countries needing to expand HD services access at low cost are caught at crossroads. Process improvements are needed to standardize reprocessing that prioritizes safety while maintaining effectiveness. Recent advances in mobile and internet technologies could make this an achievable reality. We propose such an approach that would ensure treatment effectiveness, patient and healthcare provider safety, efficient resource utilization, and cost control.

Comparing the Fried frailty phenotype versus the Veterans Affairs frailty index among dialysis dependent patients

INTRODUCTION

Frailty in dialysis patients is a modifiable disease state which can increase mortality if left untreated but remains underdiagnosed as frailty evaluations can be arduous or time consuming. We evaluate the agreement between a clinical frailty construct (Fried frailty phenotype, FFP) against and an electronic health record-based Veterans Affairs Frailty Index (VAFI) and their association with mortality.

METHODS

A retrospective cohort analysis of 764 participants from the ACTIVE/ADIPOSE study was performed. Frailty as measured by VAFI and FFP was obtained and Kappa statistic estimating concordance between the two scores were calculated. Differences in mortality risk were analyzed according to presence or absence of frailty.

FINDINGS

When assessing agreement between the VAFI and FFP, the kappa statistic was 0.09 (95% confidence interval [CI] 0.02-0.16) suggesting a low level of agreement. Frailty was independently associated with higher mortality risk (hazards ratio [HR] 1.40-1.42 in fully adjusted models depending upon frailty construct). Discordantly frail patients by construct had a higher risk of mortality though this was not statistically significant after adjustment. However, concordantly frail patients had much higher mortality risk compared to concordantly nonfrail (adjusted HR 2.08, 95% CI 1.44-3.01).

DISCUSSION

Poor agreement between constructs is likely reflective of the multifactorial definition of frailty. While further longitudinal studies are needed to determine if the VAFI would be beneficial in the reassessment of frailty, it may be beneficial as a cue for further frailty testing (e.g., with FFP) with the combination of multiple frail constructs providing improved prognostic information.

Intra-Cranial Arterial Calcifications in Hemodialysis Patients

Background and objectives: Vascular calcification is an integral part of atherosclerosis and has been reported to be an independent risk factor for cardiovascular diSsease. Intra Cranial Arterial Calcifications (ICAC) in maintenance hemodialysis (MHD) is highly prevalent. Materials and Methods: The aim of this retrospective study was to assess the predictors and outcomes of ICAC in MHD patients compared to a control group without kidney disease. A blinded neuroradiologist graded ICAC in brain imaging (computerized tomography) of MHD patients. Age- and sex-matched patients with normal kidney function served as the control group. Results: A total of 280 patients were included in the cohort; 140 of them were MHD patients with a mean ICAC score of 2.3 ± 0.2 versus a mean ICAC score of 1.4 ± 0.2 in the control group (p < 0.01). More than 90% of hemodialysis patients in our study had some degree of ICAC. Lower albumin and higher phosphorus and CRP levels were associated with increased ICACs. The multivariate analysis model for predictors of 1-year mortality demonstrated an increased odds ratio for mortality as the ICAC score increased. Conclusions: ICAC is very prevalent among MHD patients and results not simply from passive deposition of calcium and phosphate but rather from complex and active processes involving inflammation and structural changes in blood vessels. ICAC independently predicted all-cause mortality and may help with risk stratification of this high-risk population.

Burden of Paediatric Kidney Diseases in a Tertiary Care Hospital in Harare, Zimbabwe

Background

The pattern of paediatric kidney diseases across different regions is influenced by genetic, racial, and environmental differences.

Objectives

The aim of this study was to review the current spectrum and outcome of childhood kidney diseases at Parirenyatwa Group of Hospitals and highlight the challenges of care.

Design

Retrospective observational study.

Methods

Data on all children below 16 years of age hospitalised for any kidney disease over an 8-month period (1 January-31 August 2022) were retrieved and retrospectively analysed. Kidney diseases were categorised as per standard definitions.

Results

Kidney disease accounted for 2.2% (n = 50) of all 2264 admissions in the paediatric unit, with males constituting 60% (n = 30). Age ranged from 2 weeks to 13 years (mean 5.5 ± 3.5 years) with 58.0% being under 5 years. The commonest diagnoses in the unit were acute kidney injury (AKI) (n = 16, 32%) nephrotic syndrome (n = 16, 32%), hypertension (n = 12, 24%) and end stage kidney disease (ESKD) (n = 11, 22%) with some children presenting with more than 1 diagnosis. Only 3 out of 11 children with ESKD and 3 out of 8 children with AKI who required dialysis could be offered dialysis due to limited resources. Overall mortality rate was 32% (16/50): 5 children with AKI, 2 with nephrotic syndrome and normal kidney function, 8 with ESKD and 1 with Fanconi syndrome.

Conclusion

Childhood kidney disease contributes significantly to hospitalisations at our institution with highest mortality among children with ESKD. The study highlighted the need for provision of essential drugs and kidney replacement therapy for children with kidney disease at our institution.

Dialysis Patient Experiences During the COVID-19 Pandemic: A Survey Study

Rationale & Objective

The coronavirus disease 2019 (COVID-19) pandemic imposed several changes in the care of patients with kidney failure receiving dialysis. We explored patient care experiences during the pandemic.

Study Design

The study team verbally administered surveys including Likert scale multiple-choice questions and open-ended questions and recorded responses.

Setting & Participants

Surveys were administered to adults receiving dialysis through an academic nephrology practice after the first wave of the COVID-19 pandemic.

Exposure

Outpatient dialysis treatment during the COVID-19 pandemic.

Outcomes

Perceptions of care and changes in health.

Analytical Approach

Multiple-choice responses were quantified using descriptive statistics. Thematic analysis was used to code open-ended responses and derive themes surrounding patient experiences.

Results

A total of 172 patients receiving dialysis were surveyed. Most patients reported feeling "very connected" to the care teams. Seventeen percent of participants reported transportation issues, 6% reported difficulty obtaining medications, and 9% reported difficulty getting groceries. Four themes emerged as influencing patient experiences during the pandemic: 1) the COVID-19 pandemic did not significantly affect participants' experience of dialysis care; 2) the COVID-19 pandemic significantly impacted other aspects of participants' lives, which in turn were felt to affect mental and physical health; 3) regarding dialysis care experience more generally, participants valued consistency, dependability, and personal connection to staff; and 4) the COVID-19 pandemic highlighted the importance of external social support.

Limitations

Surveys were administered early in the COVID-19 pandemic, and patient perspectives have not been reassessed. Further qualitative analysis using semi-structured interviews was not performed. Survey distribution in additional practice settings, using validated questionnaires, would increase generalizability of the study. The study was not powered for statistical analysis.

Conclusions

Early in the COVID-19 pandemic, perceptions of dialysis care were unchanged for most patients. Other aspects of participants' lives were impacted, which affected their health. Subpopulations of patients receiving dialysis may be more vulnerable during the pandemic: those with histories of mental health conditions, non-White patients, and patients treated by in-center hemodialysis.

Plain-language summary

Patients with kidney failure continue to receive life-sustaining dialysis treatments during the coronavirus disease 2019 (COVID-19) pandemic. We sought to understand perceived changes in care and mental health during this challenging time. We administered surveys to patients receiving dialysis after the initial wave of COVID-19, asking questions on topics including access to care, ability to reach care teams, and depression. Most participants did not feel that their dialysis care experiences had changed, but some reported difficulties in other aspects of living such as nutrition and social interactions. Participants highlighted the importance of consistent dialysis care teams and the availability of external support. We found that patients who are treated with in-center hemodialysis, are non-White, or have mental health conditions may have been more vulnerable during the pandemic.

The 50th Anniversary of the Implementation of PL 92-603: A Major Change in the Care of Patients with End Stage Kidney Disease

Fifty years ago, in July 1973, providing care to patients with end stage kidney disease changed dramatically with the implementation of legislation (PL 92-603) that deemed chronic renal disease to be a disability and provided coverage under Medicare for the treatment of the disease. In this article, we discuss the impact of the implementation of PL 92-603.

Sustained in vivo perfusion of a re-endothelialized tissue engineered kidney graft in a human-scale animal model

Introduction: Despite progress in whole-organ decellularization and recellularization, maintaining long-term perfusion in vivo remains a hurdle to realizing clinical translation of bioengineered kidney grafts. The objectives for the present study were to define a threshold glucose consumption rate (GCR) that could be used to predict in vivo graft hemocompatibility and utilize this threshold to assess the in vivo performance of clinically relevant decellularized porcine kidney grafts recellularized with human umbilical vein endothelial cells (HUVECs). Materials and methods: Twenty-two porcine kidneys were decellularized and 19 were re-endothelialized using HUVECs. Functional revascularization of control decellularized (n = 3) and re-endothelialized porcine kidneys (n = 16) was tested using an ex vivo porcine blood flow model to define an appropriate metabolic glucose consumption rate (GCR) threshold above which would sustain patent blood flow. Re-endothelialized grafts (n = 9) were then transplanted into immunosuppressed pigs with perfusion measured using angiography post-implant and on days 3 and 7 with 3 native kidneys used as controls. Patent recellularized kidney grafts underwent histological analysis following explant. Results: The glucose consumption rate of recellularized kidney grafts reached a peak of 39.9 ± 9.7 mg/h at 21 ± 5 days, at which point the grafts were determined to have sufficient histological vascular coverage with endothelial cells. Based on these results, a minimum glucose consumption rate threshold of 20 mg/h was set. The revascularized kidneys had a mean perfusion percentage of 87.7% ± 10.3%, 80.9% ± 33.1%, and 68.5% ± 38.6% post-reperfusion on Days 0, 3 and 7, respectively. The 3 native kidneys had a mean post-perfusion percentage of 98.4% ± 1.6%. These results were not statistically significant. Conclusion: This study is the first to demonstrate that human-scale bioengineered porcine kidney grafts developed via perfusion decellularization and subsequent re-endothelialization using HUVEC can maintain patency with consistent blood flow for up to 7 days in vivo. These results lay the foundation for future research to produce human-scale recellularized kidney grafts for transplantation.

Association between vascular access type and depression in hemodialysis patients

INTRODUCTION

Hemodialysis is the most common treatment used for end-stage kidney disease (ESKD) patients and an arteriovenous fistula (AV) fistula is the preferred vascular access. The goal of our study was to investigate potential associations between vascular access type and depression.

METHODS

This was a cross-sectional survey of 180 patients receiving maintenance hemodialysis. The Beck Depression Inventory was used to assess degree of depression. Demographic factors, treatment details, and laboratory values were obtained from the hospital medical record.

FINDINGS

Fifty-two percent (n = 93) of the patients were being dialyzed using an AV fistula and 48% (n = 87) via a tunneled cuffed catheter. No significant differences were found between access type use in terms of gender (p = 0.266), presence of diabetes, hypertension, or peripheral artery disease (p = 0.409, p = 0.323, p = 0.317; respectively). The prevalence of Beck Depression Inventory scores greater than 14 (marking presence of depression) was significantly higher in the patients being dialyzed with a tunneled cuffed catheters (61%) compared to patients dialyzed with an AV fistula (36%) (p = 0.001).

DISCUSSION

We found statistically higher depression scores among patients receiving hemodialysis with a tunneled cuffed catheter.

Norvancomycin plasma concentration monitoring in hemodialysis patients with end stage kidney disease: A retrospective cohort study

Blood concentration monitoring plays an important role in the rational use of norvancomycin. However, the reference interval for the norvancomycin plasma concentration in the treatment of infections in hemodialysis patients with end stage kidney disease is undefined. To determine the safe and effective interval for the norvancomycin plasma trough concentration, 39 patients treated with hemodialysis and norvancomycin were analyzed retrospectively. The norvancomycin plasma concentration before hemodialysis was tested as the trough concentration. The associations of the norvancomycin trough concentration with efficacy and adverse reactions were evaluated. No norvancomycin concentration above 20 μg/mL was detected. The trough concentration, but not the dose, had a significant effect on the anti-infectious efficacy. Compared with the low norvancomycin trough concentration group (<9.30 μg/mL), the high concentration group (9.30-20.0 μg/mL) had improved efficacy (OR = 15.45, p < 0.01) with similar side effects (OR = 0.5417, p = 0.4069). It is beneficial to maintain the norvancomycin trough concentration at 9.30-20.0 μg/mL to achieve a good anti-infectious effect in hemodialysis patients with end stage kidney disease. Plasma concentration monitoring provides a data basis for the individual treatment of infections with norvancomycin in hemodialysis patients.

Effects of Exercise on Physiologic and Psychologic Outcomes in Patients with End Stage Kidney Disease on Hemodialysis: A Quasi-Experimental Study

End stage kidney disease (ESKD), a public health concern, has overwhelming effects on individuals' holistic wellbeing. Hemodialysis, albeit a life-saving treatment for patients with ESKD, can lead to muscle atrophy, weakness, and decreased quality of life mostly due to an inactive lifestyle. This quasi-experimental, pre-post design was used to study the effects of exercise on physiologic and psychologic outcomes of patients with ESKD at a hemodialysis unit in Lebanon. Patients acted as their own controls and were assessed before and after introducing the exercise program. Data were collected on quality of life of patients as well as their dialysis adequacy. Results showed that while there was a significant improvement in the dialysis adequacy post-exercise intervention, quality of life was not affected.

In-hospital mortality of heparin-induced thrombocytopenia in end-stage kidney disease. A retrospective national population-based cohort study

AIM

Heparin induced thrombocytopenia (HIT) and end stage kidney disease (ESKD) are independent conditions associated with increased mortality and morbidity, however, whether ESKD is an independent risk factor for increased mortality in HIT admissions is not well studied. Therefore, we aimed to compare in-hospital mortality in HIT admissions based on their ESKD status.

METHODS

This is a retrospective cohort study of HIT hospitalizations aged 18 and older using the 2016-2019 national inpatient sample (NIS) database.

RESULTS

From 2016 to 2019 we had 12 161 admissions for HIT among 28 484 087 total hospitalizations. The annual incidence rate for HIT admissions per 100 000 admissions were: 47, 46, 41.1, and 36.6, respectively (p < .001) in 2016, 2017, 2018, and 2019 respectively. Among HIT admissions, the mean age was 64.3 years, 46.8% were females, 68% were Whites and 16% were Blacks. Black patients have a significantly higher likelihood of in-hospital mortality than White patients (aOR 1.25; 95% CI: 1.06, 1.48; p = .007). Patients who did not have any insurance or self-pay had higher mortality compared to Medicare (aOR 1.64; 95% CI: 1.13, 2.38; p = .009). ESKD status was not associated with higher or lower in-hospital mortality among HIT admissions (aOR 1.002; 95% CI: 0.84, 1.19; p = .981) after adjusting for age, sex, race, and insurance status.

CONCLUSION

There are no higher or lower odds of in-hospital mortality in the ESKD subgroup in HIT admissions in adults. Decreasing incidence of HIT hospitalizations was seen over the years from 2016 to 2019.

Plasma exchange as an adjunctive therapy in anti-neutrophil cytoplasm antibody-associated vasculitis

INTRODUCTION

We summarize evidence for the role of therapeutic plasma exchange (TPE) in the treatment of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). TPE rapidly removes ANCA IgG, complement and coagulation factors important in the pathogenesis of AAV. TPE has been used in patients with rapidly deteriorating renal function to achieve early disease control, allowing time for immunosuppressive agents to prevent resynthesis of ANCA. The PEXIVAS trial challenged the utility of TPE in AAV, as it did not show benefit of adjunctive TPE on a combined end point of end stage kidney disease (ESKD) and death.

AREAS COVERED

We analyze data from PEXIVAS and other trials of TPE in AAV, an up-to-date meta-analysis, and recently published large cohort studies.

EXPERT OPINION

There remains a role for the use of TPE in AAV in certain groups of patients, in particular those with severe renal involvement (Cr >500 μmol/L or dialysis-dependent). It should be considered in patients with Cr >300 μmol/L and rapidly deteriorating function, or with life-threatening pulmonary hemorrhage. A separate indication is patients double positive for anti-GBM antibodies and ANCA. TPE may have the greatest benefit as part of steroid-sparing immunosuppressive treatment strategies.

Mortality Risk of Patients Treated in Dialysis Facilities with Payment Reductions under ESRD Quality Incentive Program

BACKGROUND

The Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program (ESRD QIP) measures quality of care delivered by dialysis facilities and imposes Medicare payment reductions for quality lapses. We assessed the association between payment reductions and patient mortality, a quality indicator not included in the ESRD QIP measure set.

METHODS

Association between mortality and ESRD QIP facility payment reduction based on the year of performance was expressed as the unadjusted rate and patient case-mix-adjusted hazard ratio. We also measured association between mortality and 1-year changes in payment reductions. Retrospective patient cohorts were defined by their treating dialysis facility on the first day of each year (2010-2018).

RESULTS

Facility performance resulted in payment reductions for 5%-42% of dialysis facilities over the 9 study years. Patients experienced progressively higher mortality at each payment reduction level. Across all years, unadjusted mortality was 17.3, 18.1, 18.9, 20.3, and 23.9 deaths per 100 patient-years for patients in facilities that received 0%, 0.5%, 1%, 1.5%, and 2% payment reductions, respectively. The adjusted hazard ratio showed a similar stepwise pattern by the level of payment reduction: 1.0 (reference), 1.08 (95% confidence interval [CI], 1.07 to 1.09), 1.15 (95% CI, 1.13 to 1.16), 1.19 (95% CI, 1.16 to 1.21), and 1.34 (95% CI, 1.29 to 1.39). Strength of the association increased from 2010 to 2016. Patients treated in facilities that improved over 1 year generally experienced lower mortality; patients in facilities that performed worse on ESRD QIP measures generally experienced higher mortality.

CONCLUSIONS

Patient mortality was associated with ESRD QIP facility payment reductions in dose-response and temporal patterns.

Empagliflozin in Adults with Chronic Kidney Disease (CKD): Current Evidence and Place in Therapy

Chronic kidney disease guidelines and disease modifying therapy have seen a dramatic shift in the last 5 years. The SGLT2 inhibitor class of medications has been catapulted from hyperglycemia management medications, to cardiovascular and kidney disease improvement therapies. Multiple trials looking at dedicated cardiovascular and kidney endpoints have resulted in favorable results. This review will target empagliflozin and the exciting journey that it has taken along this path. Empagliflozin has been studied for hyperglycemia, cardiovascular, and kidney hard outcome endpoints. Both patients with diabetes and without have been rigorously studied and shown surprising results. The major implications for patients on empagliflozin will be shown. Future studies and directions are highly anticipated to add to the growing knowledge of the SGLT2 inhibitor class, as well as discover possibilities for new disease states to benefit from empagliflozin.

Post-transplant ejection fraction and renal failure in cardiac transplant recipients: An analysis of the OPTN database

BACKGROUND

Despite improved life expectancy from a heart transplant, transplant recipients remain at high risk for renal dysfunction and failure, including end-stage kidney disease (ESKD). The onset of ESKD is a poor prognostic marker and is associated with increased mortality in this setting, as in others. There is a need to identify risk factors for ESKD among heart transplant recipients in contemporary settings.

METHODS

We conducted an analysis of adult heart transplant recipients transplanted between 2008 and 2021 in the Organ Procurement and Transplantation Network database. 22 737 adult recipients of heart transplants alone were included in this analysis. We examined LVEF measured 1 year after transplant, and LVEF updated annually for association with ESKD using multivariate Cox regression models.

RESULTS

LVEF at 1-year after transplant was associated with ESKD in multivariate models (Hazard Ratio 1.33 per 10-unit decrease, 95% CI 1.23-1.43, p < .001). In multivariate models using categorized LVEF, mildly reduced ejection fraction (EF 40%-50%) was associated with ESKD (HR 1.76, 95% CI 1.45-2.14, p < .001), as was reduced ejection fraction (EF < 40%, HR 2.86, 95% CI 2.01-4.07, p < .001), relative to individuals with preserved ejection fraction (EF > 50%). These associations were consistent when using annually updated ejection fraction.

CONCLUSIONS

Post-transplant left ventricular ejection fraction has value in predicting end stage kidney disease among adults who receive heart transplants alone. LVEF is routinely measured as part of contemporary post heart transplant care, and a diminished LVEF should signal to clinicians that a recipient is at increased risk of renal failure.

Focal Crescentic Glomerulonephritis Following COVID-19 Viral Vector Vaccination

Vaccination is a vital tool aimed at curbing the COVID-19 pandemic, and the FDA has authorized several vaccines for emergency use to combat COVID-19. Our patient presented with acute kidney injury two weeks after receiving the first dose of the COVID-19 Janssen (Johnson & Johnson) vaccine. Renal biopsy confirmed focal crescentic glomerulonephritis. The patient has been unable to achieve remission after diagnosis and is now a candidate for a kidney transplant. In conclusion, this case report provides insight into the possible relationship between glomerular disease following COVID-19 Janssen (Johnson & Johnson) vaccination. Based on this presented case, new-onset or relapse of glomerular diseases presenting post-COVID-19 vaccination should be observed as a possible adverse event to large-scale COVID-19 vaccination.

Genetic Susceptibility to Chronic Kidney Disease: Links, Risks and Management

Chronic kidney disease (CKD) is associated with significant morbidity and mortality worldwide. In recent years, our understanding of genetic causes of CKD has expanded significantly with several renal conditions having been identified. This review discusses the current landscape of genetic kidney disease and their potential treatment options. This review will focus on cystic kidney disease, glomerular disease with genetic associations, congenital anomalies of kidneys and urinary tract (CAKUT), autosomal dominant-tubulointerstitial kidney disease (ADTKD), inherited nephrolithiasis and nephrocalcinosis.

Level of Depression and Anxiety on Quality of Life Among Patients Undergoing Hemodialysis

Background

Despite the growing concern worldwide regarding the quality of life (QoL) and mental well-being among chronic kidney disease (CKD), a few research has been done to address this issue. The study aims to measure depression, anxiety, and QoL prevalence among Jordanian patients with End Stage Renal Disease (ESRD) on hemodialysis and how all of these variables are correlated.

Methods

This is a cross-sectional, interview-based study on patients at the Jordan University Hospital (JUH) dialysis unit. Sociodemographic factors were collected, and the prevalence of depression, anxiety disorder, and QOL was assessed using the Patient Health Questionnaire 9 (PHQ9), the Generalized Anxiety Disorder 7-item (GAD7), and the WHOQOL-BREF, respectively.

Results

In a study of 66 patients, 92.4% had depression, and 83.3% had generalised anxiety disorder. Females had significantly higher depression scores than males (mean = 6.2 ± 3.77 vs 2.9 ± 2.8, p < 0.001), and single patients had significantly higher anxiety scores than married patients (mean = 6.1 ± 6 vs 2.9 ± 3.5, p = 0.03). Age was positively correlated with depression scores (rs= 0.269, p = 0.03), and QOL domains showed an indirect correlation with GAD7 and PHQ9 scores. Males had higher physical functioning scores than females (mean = 64.82 vs 58.87, p = 0.016), and patients who studied in universities had higher physical functioning scores than those with only school education (mean of College/University = 78.81 vs mean of School Education = 66.46, p = 0.046). Patients taking <5 medications had higher scores in the environmental domain (p = 0.025).

Conclusion

The high prevalence of depression, GAD, and low QOL in ESRD patients on dialysis highlights the need for caregivers to provide psychological support and counselling for these patients and their families. This can promote psychological health and prevent the onset of psychological disorders.

Conservative Kidney Management: When, Why, and For Whom?

Deciding between dialysis and conservative kidney management (CKM) in an elderly or seriously ill person with kidney failure is complex and requires shared decision making. Patients and families look to their nephrologist to provide an individualized recommendation that aligns with patient-centered goals. For a balanced and considered decision to be made, dialysis should not be the default and nephrologists need to be familiar with relevant prognostic information including survival, symptom burden, functional trajectory, and quality of life with dialysis and with CKM. CKM is a holistic, proactive, and multidisciplinary treatment for kidney failure. For some elderly comorbid patients, CKM improves symptom burden and aligns with quality-of-life goals, with modest or no loss of longevity. CKM can be provided by a nephrologist alone but ideally is managed through partnership with a dedicated supportive or palliative care service embedded within the nephrology practice. Treatment decisions are best discussed early in the disease trajectory and occur over many consultations, and nephrologists should be upskilled in communication to better support patients and families in these important conversations. Nephrologists should remain actively involved in their patients' care through to end-of-life care.

Effects of Mediterranean Diet, DASH Diet, and Plant-Based Diet on Outcomes among End Stage Kidney Disease Patients: A Systematic Review and Meta-Analysis

BACKGROUND

The Mediterranean, Dietary Approach to Stop Hypertension (DASH), and plant-based diets may provide cardiovascular benefit to the general population. However, data on their effect on end stage kidney disease (ESKD) patients are limited. This systematic review aims to assess the impact of Mediterranean, DASH, and plant-based diets on outcomes among ESKD patients.

METHODS

A literature review was conducted in EMBASE, MEDLINE, and Cochrane databases from inception through September 2022 to identify studies that assess the clinical outcomes of Mediterranean, DASH, or plant-based diets on ESKD patients on hemodialysis (HD) or peritoneal dialysis (PD). Effect estimates from the individual studies were derived utilizing the random-effect, generic inverse variance approach of DerSimonian and Laird.

RESULTS

Seven studies with 9400 ESKD patients (8395 HD and 1005 PD) met the eligibility criteria and were included in the data analysis. Pooled odds ratios (ORs) of mortality for ESKD patients who adhered to the Mediterranean versus plant-based diet were 0.49 (95% CI: 0.07-3.54; two studies, I² = 67%) and 0.87 (95% CI: 0.75-1.01; two studies, I² = 0%), respectively. Data on mortality for ESKD patients on a DASH diet were limited to one study with an OR of 1.00 (95% CI: 0.89-1.12). The pooled OR of cardiovascular mortality among ESKD patients who adhered to a plant-based diet was 0.86 (95% CI: 0.68-1.08; two studies, I² = 0%), compared to those who did not. Data on cardiovascular mortality among those with Mediterranean and DASH diet were limited to one study with ORs of 1.14 (95% CI: 0.90-1.43) and 1.19 (95% CI: 0.99-1.43), respectively. Mediterranean diet adherence was found to be associated with reduced risk of left ventricular hypertrophy (LVH) with an OR of 0.82 (95% CI: 0.68-0.99) in a study including 127 ESKD patients. The risk of hyperkalemia was not significant among those with a plant-based diet with an OR of 1.00 (95% CI: 0.94-1.07) in a study including 150 ESKD patients.

CONCLUSIONS

While our systematic review demonstrated no significant associations of Mediterranean, DASH, and plant-based diets with reduced all-cause mortality or cardiovascular mortality, there was also no evidence that suggested harmful effects of these diets to ESKD patients.

Frequency of Intradialytic Hypertension Using Kidney Disease: Improving Global Outcomes (KDIGO) Suggested Definition in a Single Hemodialysis Centre in Pakistan

OBJECTIVES

 To estimate the frequency of intradialytic hypertension (IDH) in our centre as per the definition suggested by Kidney Disease: Improving Global Outcomes (KDIGO).

METHODS

 A cross-sectional study was conducted at the dialysis department of The Kidney Centre Post Graduate Training Institute (PGTI) Karachi, Pakistan from August 2021 to October 2021 among 263 end-stage kidney disease (ESKD) patients on maintenance hemodialysis (MHD) aged ≥ 18 years of both genders. The study outcome was the frequency of IDH as per the latest KDIGO suggested definition i.e., systolic blood pressure (SBP) rise of > 10 mm Hg from pre- to post-dialysis within the hypertensive range in at least four out of six consecutive dialysis treatments. Frequencies (%) and mean (±SD) were calculated for categorical and continuous variables respectively, using SPSS version 21 (IBM Corp., Armonk, NY, USA).

RESULTS

 Among 263 patients, the mean age was 51.02 (±14.1) years and 56.3% were males. Around 30.8% of patients were dialysis-dependent for 1.1 to three years. The most common comorbidity was hypertension (88.6%). Standard dialysate calcium of 3mEq/l was received by 91.6% of study participants. About 78.7% of patients were using antihypertensive(s), out of which 85.5% were compliant and 37.6% were using a single antihypertensive. The most common antihypertensive in use was beta-blockers (78.3%). Around 16% of patients were found to have IDH. Age of the patients was significantly associated with IDH (p=0.038). The majority of the patients with IDH were those who were taking anti-hypertension medications as compared to the patients who were not taking them (p <0.004). Interdialytic weight gain was not a significant predictor for IDH.

CONCLUSION

 The frequency of IDH was 16% according to the latest suggested KDIGO definition. This is much lower than regional and global estimates according to earlier definitions. There is a dire need to establish a standardized definition of IDH in guidelines to diagnose, manage and compare data. Also, the association of IDH with fluid overload is not found in our study which emphasizes the need to evaluate other causative factors.

Development and Validation of a Lifetime Risk Model for Kidney Failure and Treatment Benefit in Type 2 Diabetes: 10-Year and Lifetime Risk Prediction Models

BACKGROUND AND OBJECTIVES

Individuals with type 2 diabetes are at a higher risk of developing kidney failure. The objective of this study was to develop and validate a decision support tool for estimating 10-year and lifetime risks of kidney failure in individuals with type 2 diabetes as well as estimating individual treatment effects of preventive medication.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The prediction algorithm was developed in 707,077 individuals with prevalent and incident type 2 diabetes from the Swedish National Diabetes Register for 2002-2019. Two Cox proportional regression functions for kidney failure (first occurrence of kidney transplantation, long-term dialysis, or persistent eGFR <15 ml/min per 1.73 m2) and all-cause mortality as respective end points were developed using routinely available predictors. These functions were combined into life tables to calculate the predicted survival without kidney failure while using all-cause mortality as the competing outcome. The model was externally validated in 256,265 individuals with incident type 2 diabetes from the Scottish Care Information Diabetes database between 2004 and 2019.

RESULTS

During a median follow-up of 6.8 years (interquartile range, 3.2-10.6), 8004 (1%) individuals with type 2 diabetes in the Swedish National Diabetes Register cohort developed kidney failure, and 202,078 (29%) died. The model performed well, with c statistics for kidney failure of 0.89 (95% confidence interval, 0.88 to 0.90) for internal validation and 0.74 (95% confidence interval, 0.73 to 0.76) for external validation. Calibration plots showed good agreement in observed versus predicted 10-year risk of kidney failure for both internal and external validation.

CONCLUSIONS

This study derived and externally validated a prediction tool for estimating 10-year and lifetime risks of kidney failure as well as life years free of kidney failure gained with preventive treatment in individuals with type 2 diabetes using easily available clinical predictors.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2022_11_04_CJN05020422.mp3.

Acute Kidney Injury From Biopsy-Proven Renal Oxalosis From Excessive Intake of Vitamin C Leading to End-Stage Kidney Disease

We are presenting a case of a 55-year-old Caucasian female who presented with acute kidney injury requiring hemodialysis. Her native kidney biopsy showed extensive crystals in both the cortex and medulla, morphologically consistent with calcium oxalate crystals. The etiology was attributed to vitamin C-induced kidney hyperoxaluria. She has remained hemodialysis dependent for more than three months since the initial presentation, establishing a diagnosis of end-stage kidney disease.

Symptom Burden before and after Dialysis Initiation in Older Patients

BACKGROUND AND OBJECTIVES

For older patients with kidney failure, lowering symptom burden may be more important than prolonging life. Dialysis initiation may affect individual kidney failure-related symptoms differently, but the change in symptoms before and after start of dialysis has not been studied. Therefore, we investigated the course of total and individual symptom number and burden before and after starting dialysis in older patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The European Quality (EQUAL) study is an ongoing, prospective, multicenter study in patients ≥65 years with an incident eGFR ≤20 ml/min per 1.73 m2. Using the dialysis symptom index (DSI), 30 symptoms were assessed every 3-6 months between 2012 and 2021. Scores for symptom number range from zero to 30 and, for burden, from zero to 150, with higher scores indicating more severity. Using mixed effects models, we studied symptoms during the year preceding and the year after dialysis initiation.

RESULTS

We included 456 incident patients on dialysis who filled out at least one DSI during the year before or after dialysis. At dialysis initiation, mean (SD) participant age was 76 (6) years, 75% were men, mean (SD) eGFR was 8 (3) ml/min per 1.73 m2, 44% had diabetes, and 46% had cardiovascular disease. In the year before dialysis initiation, symptom number increased +3.6 (95% confidence interval [95% CI], +2.5 to +4.6) and symptom burden increased +13.3 (95% CI, +9.5 to +17.0). In the year after, symptom number changed -0.9 (95% CI, -3.4 to +1.5) and burden decreased -5.9 (95% CI, -14.9 to -3.0). At dialysis initiation, "fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" had the highest prevalence of 81%, 69%, and 68%, respectively, with a burden of 2.7, 2.4, and 2.3, respectively. "Fatigue" somewhat improved after dialysis initiation, whereas the prevalence and burden of sexual symptoms further increased.

CONCLUSIONS

Symptom burden worsened considerably before and stabilized after dialysis initiation. "Fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" were considered most burdensome, of which only "fatigue" somewhat improved after dialysis initiation.

The neutrophil-to-lymphocyte ratio may indicate when to start hemodialysis

We evaluated whether the neutrophil-to-lymphocyte ratio (NLR) could aid dialysis decision-making in combination with the clinical presentation and biochemical findings. We retrospectively evaluated the medical records of 279 patients who commenced chronic maintenance hemodialysis. We compared the laboratory findings at 6 months before dialysis to those at dialysis initiation. NLR cutoffs and risk factors for each of six uremic symptoms were determined. Mean age was 60.7 years and mean estimated glomerular filtration rate (eGFR) was 5.7 ± 2.5 mL/min/1.73 m² at the time of hemodialysis and 7.7 ± 3.8 mL/min/1.73 m² 6 months earlier (p < 0.001). The mean NLR increased significantly from 2.5 ± 1.0 to 4.9 ± 2.8 (p < 0.001). The NLR was positively correlated with the C-reactive protein level (r = 0.202, p = 0.009) and negatively correlated with those of albumin (r = −0.192, p = 0.001) and total CO₂ (r = −0.134, p = 0.023). The NLR cutoffs for neurological and gastrointestinal symptoms as determined using receiver operator curve analysis were 2.4 (area under the curve [AUC] 0.976; 95% confidence interval [CI] 0.960–0.993; sensitivity 92.2%; specificity 94.7%) and 3.6 (AUC 0.671; 95% CI 0.588–0.755; sensitivity 68.1%; specificity 63.5%), respectively. On multiple linear regression analysis of neurological symptoms, the NLR was a significant predictor (β = −0.218, p = 0.017), as was age (β = 0.314, p = 0.037). In conclusion, the NLR may serve as a supplementary marker predicting uremic symptoms and a need for hemodialysis in stage 5 CKD patients.

Menstrual Abnormalities and Reproductive Lifespan in Females with CKD: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Menstrual abnormalities and shortened reproductive lifespan are associated with shorter life expectancy and higher cardiovascular and osteoporosis risk in the general population, although the magnitude of these reproductive factor irregularities in females with CKD is unclear. This systematic review and meta-analysis aimed to summarize the current knowledge regarding menstrual abnormalities and reproductive lifespan among females with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A comprehensive bibliographic search (MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) was completed from database inception to February 2022 to identify all original articles reporting on females of reproductive age with nondialysis-dependent/nonkidney transplant CKD, dialysis-dependent CKD, or kidney transplantation and menstruation patterns, age of menarche, and/or menopause. Data extraction and study quality assessment were completed in duplicate. Random effects meta-analyses were used to derive pooled proportions estimates.

RESULTS

Forty-six studies were identified, and 35 were meta-analyzed, stratified by KRT modality and reported outcome. Menstrual abnormalities were present in 19%-47% of patients on hemodialysis and 75% of patients on peritoneal dialysis. Kidney transplantation was associated with a 7%-30% decrease in menstrual abnormalities. Reproductive lifespan was 32 years (95% confidence interval, 30 to 34 years). Although significant heterogeneity was present, study quality ranged from fair to good, and no evidence of publication bias was noted.

CONCLUSIONS

Menstrual abnormalities and shorter reproductive lifespan are common in females with CKD, although kidney transplantation may improve menstrual health.

Chinese Clinical Practice Guideline for the Management of "CKD-PeriDialysis"-the Periods Prior to and in the Early-Stage of Initial Dialysis

The National Experts Group on Nephrology have developed these guidelines to improve the management of pre-dialysis and initial dialysis patients with chronic kidney disease (CKD) (two periods contiguous with dialysis initiation termed here 'PeriDialysis CKD'). The pre-dialysis period is variable, whereas the initial dialysis period is more fixed at 3 months to 6 months after initiating dialysis. The new concept and characteristics of 'CKD-PeriDialysis' are proposed in the guideline. During the CKD-PeriDialysis period, the incidence rate of complications, mortality and treatment cost significantly increases and the glomerular filtration rate (GFR) rapidly decreases, which requires intensive management. The guideline systematically and comprehensively elaborates the recommendations for indicators to be used in for disease evaluation, timing and mode selection of renal replacement therapy, dialysis adequacy evaluation, and diagnosis and treatment of common PeriDialysis complications. Finally, future research directions of CKD-PeriDialysis are proposed. CKD-PeriDialysis management is a difficult clinical issue in kidney disease, and the development and implementation of these guidelines is important to improve the management of CKD-PeriDialysis patients in China, which could ultimately improve survival rates and quality of life, and reduce the medical burden.

A Neuroscientific Framework for Determining the Optimal Kidney Care Education and Training Solution

Educating and training patients with chronic kidney disease, their caregivers, and health care providers effectively is critical for ensuring high-quality care and achieving successful kidney care outcomes for patients. When this is lacking, it can lead to gaps in care and knowledge that negatively impact patient health and satisfaction, while increasing health care costs. In this article, we offer a three-step framework, grounded in learning science - the marriage of psychology and the neuroscience of learning - to determine the optimal education and training solution for any given learning task. First, one identifies the learning task to be solved. Second, the learning systems in the brain that need to be engaged to learn the specific task must be identified. Finally, the learning solution that optimally engages the relevant brain system is identified. We provide details of each step and examples in which the three-step framework can be applied. In addition, we discuss the use of these learning solutions to educate nephrology care providers about roles they may be considering for their careers, and the knowledge and skills required for those roles.

Pre-transplant cognitive screening is a poor predictor of post-transplant cognitive status

INTRODUCTION

Transplant centers hesitate to transplant patients with cognitive impairment. It is unclear if pre-kidney transplant (KT) cognitive screening can predict post-KT cognitive function.

METHODS

We evaluated pre- to post-KT cognitive function with the Montreal Cognitive Assessment (MoCA) in a cohort of 108 patients. We used an adjusted logistic regression model to assess pre- to post-KT changes in cognitive status (continuous variable) and a linear mixed model to assess changes in MoCA scores (categorical variable) pre- to post- KT.

RESULTS

The average pre- and post-KT MoCA scores were 25.3 ± 3.0 and 26.4 ± 2.8, respectively. Final pre-KT score did not predict post-KT cognitive status (OR = 1.08; 95% CI: .92-1.26; P = .35). 32% of the patients with a final pre-KT score ≥26 had at least one post-KT score < 26. Conversely, 61% of the patients with a final pre-KT score < 26 had at least one post KT score ≥26. In the linear mixed model analysis, the final pre-KT score was associated with a small, clinically insignificant (β = .34; 95% CI: .19-.49; P < .001) effect on the post-KT score.

CONCLUSION

A low pre-KT MoCA score is not a strong independent predictor of post-KT cognitive function and should not preclude patients from receiving a KT.

Improving Weight Measurement Compliance in the Intensive Care Unit

Fluid management is crucial in patients with end stage kidney disease, and weight measurement is an integral component of safe and effective care. Weight trends can indicate changes in volume status, especially in the acute care settings, but they are often missed. The purpose of this quality improvement project was to increase bodyweight measurement compliance rates in patients admitted to the intensive care unit by creating an automatic order generating a task list reminder on the nursing staff worklist. One month of data was collected pre-intervention and one month post intervention. Results indicate an increase in the percentage of weights taken post-intervention (p = 62.1%, SD = 11.2; p = 0.001) compared to pre-intervention (p = 28.9%, SD = 9.8).

Short-Term Mortality Associated with Outpatient Vascular Access Restoration Procedures

This study confirms the safety of endovascular interventions for thrombosis of hemodialysis access in outpatient and office-based settings.Risk of death in the week after vascular access procedure was not associated with hemodialysis access type (fistula versus graft).

Description and Outcomes of an Innovative Concurrent Hospice-Dialysis Program

BACKGROUND

Compared with the general Medicare population, patients with ESKD have worse quality metrics for end-of-life care, including a higher percentage experiencing hospitalizations and in-hospital deaths and a lower percentage referred to hospice. We developed a Concurrent Hospice and Dialysis Program in which patients may receive palliative dialysis alongside hospice services. The Program aims to improve access to quality end-of-life care and, ultimately, improve the experiences of patients, caregivers, and clinicians.

OBJECTIVES

We sought to describe (1) the Program and (2) enrollment and utilization characteristics of Program participants.

METHODS

We conducted a quantitative description of demographics, patient characteristics, and utilization of Program enrollees.

RESULTS

Of 43 total enrollees, 44% received at least one dialysis treatment, whereas 56% received no dialysis. The median (range) hospice length of stay was 9 (1-76) days for all participants and 13 (4-76) days for those who received at least one dialysis treatment. The average number of dialysis treatments was 3.5 (range 1-9) for hemodialysis and 19.2 (range 3-65) for peritoneal dialysis. Sixty-five percent of enrollees died at home, 23% in inpatient hospice, and 12% in a nursing facility; no patients died in the hospital.

CONCLUSIONS

Our 3-year experience with the Program demonstrated that enrollees had a longer median hospice stay than the previously reported 5-day median for patients with ESKD. Most patients received no further dialysis treatments despite the option to continue dialysis. Our experience provides evidence to support future work testing the effectiveness of such clinical programs to improve patient and utilization outcomes.

Prognostic Implications of a Morphometric Evaluation for Chronic Changes on All Diagnostic Native Kidney Biopsies

BACKGROUND

Semiquantitative visual inspection for glomerulosclerosis, interstitial fibrosis, and arteriosclerosis is often used to assess chronic changes in native kidney biopsies. Morphometric evaluation of these and other chronic changes may improve the prognostic assessment.

METHODS

We studied a historical cohort of patients who underwent a native kidney biopsy between 1993 and 2015 and were followed through 2021 for ESKD and for progressive CKD (defined as experiencing 50% eGFR decline, temporary dialysis, or ESKD). Pathologist scores for the percentages of globally sclerosed glomeruli (GSG), interstitial fibrosis and tubular atrophy (IFTA), and arteriosclerosis (luminal stenosis) were available. We scanned biopsy sections into high-resolution images to trace microstructures. Morphometry measures were percentage of GSG; percentage of glomerulosclerosis (percentage of GSG, ischemic-appearing glomeruli, or segmentally sclerosed glomeruli); percentage of IFTA; IFTA foci density; percentage of artery luminal stenosis; arteriolar hyalinosis counts; and measures of nephron size. Models assessed risk of ESKD or progressive CKD with biopsy measures adjusted for age, hypertension, diabetes, body mass index, eGFR, and proteinuria.

RESULTS

Of 353 patients (followed for a median 7.5 years), 75 developed ESKD and 139 experienced progressive CKD events. Visually estimated scores by pathologists versus morphometry measures for percentages of GSG, IFTA, and luminal stenosis did not substantively differ in predicting outcomes. However, adding percentage of glomerulosclerosis, IFTA foci density, and arteriolar hyalinosis improved outcome prediction. A 10-point score using percentage of glomerulosclerosis, percentage of IFTA, IFTA foci density, and any arteriolar hyalinosis outperformed a 10-point score based on percentages of GSG, IFTA, and luminal stenosis >50% in discriminating risk of ESKD or progressive CKD.

CONCLUSION

Morphometric characterization of glomerulosclerosis, IFTA, and arteriolar hyalinosis on kidney biopsy improves prediction of long-term kidney outcomes.

Kidney Function Trajectory within Six Months after Acute Kidney Injury Inpatient Care and Subsequent Adverse Kidney Outcomes: A Retrospective Cohort Study

Timing and extent of kidney function recovery after an acute kidney injury (AKI) episode are associated with chronic kidney disease onset and progression. This study aimed to categorize AKI recovery patterns within 6 months after index hospital discharge and associate them with kidney outcomes. This was a retrospective cohort study of 234,867 patients, hospitalized between 2010 and 2017, and classified as AKI or no AKI. Kidney function recovery from pre-hospitalization baseline within 1.5× serum creatinine (SCr) were evaluated at 3 and 6 months after hospital discharge and categorized as persistent non-recovery (PNR: SCr not recovered at 3 and 6 months), non-recovery (NR: SCr not recovered at 6 months), and recovery (SCr recovered at 6 months). A composite of incident chronic kidney disease, kidney replacement therapy, and estimated glomerular filtration rate reduction >30% from baseline and <15 mL/min/1.73 m2 was evaluated. Of 14,673 AKI surviving patients, 10.18% had PNR and 14.33% showed NR. Compared with no AKI, PNR and NR of AKI were associated with an increased risk of composite adverse outcomes (adjusted subdistribution hazard ratio (SHR) 4.55; 95% CI, 4.05−5.11; SHR, 3.54; 95% CI, 3.18−3.94, respectively). Patients with NR showed a greater risk of adverse outcomes than those with non-rapid recovery at 3 months after hospital discharge. The AKI recovery pattern within 6 months following inpatient care revealed an increasing continuum of risk of long-term adverse kidney outcomes. Risk stratification and a kidney function monitoring plan at discharge are needed to improve post-AKI care.

The Waxing, Waning, and Predictors of Humoral Responses to Vector-Based SARS-CoV-2 Vaccine in Hemodialysis Patients

Hemodialysis (HD) patients are vulnerable to coronavirus disease 2019 (COVID-19) and have a high mortality rate. We evaluated the anti-SARS-CoV-2 spike protein antibody (ACOV2S) levels in 385 HD patients before and 4 and 8 weeks after the second dose of vector-based ChAdOx1 nCoV-19 vaccine. For study control, week 4 ACOV2S levels after the second vaccination dose were measured in 66 healthcare workers (HCWs). The seroconversion rate of HD patients was 98.96% 4 weeks after the second vaccination. Despite low antibody levels before the second dose (week 0), week 4 ACOV2S levels after the second vaccine dose in HD patients increased prominently and were compatible with those in HCWs (p = 0.814 for HCWs vs. HD patients). The ACOV2S levels in HD patients waned significantly 8 weeks after the second vaccination dose (p < 0.001 at week 8 vs. 4). Older age and immunosuppressant use were negative predictors, while higher C-reactive protein (CRP) levels were positive predictors of ACOV2S waxing after the second vaccine dose in HD patients. Higher CRP levels and platelet counts were independently associated with decreased ACOV2S waning. The ChAdOx1 nCoV-19 vaccine is effective and safe for primary vaccination in HD patients and a booster dose is necessary.

Proinflammatory Diets and Risk of ESKD in US Adults with CKD

Background

Inflammation may affect long-term kidney function. Diet may play a role in chronic inflammation. We hypothesized that proinflammatory diets increase the risk of progression to kidney failure with replacement therapy (KFRT), and systemic inflammation is a mediator of the effect of diet on progression to KFRT.

Methods

In the 1988-1994 National Health and Nutrition Examination Survey linked to the national ESKD registry, in adults with CKD (eGFR 15-59 ml/min per 1.73 m²), aged ≥20 years, we calculated the Adapted Dietary Inflammatory Index (ADII) at baseline from a 24-hour dietary recall and an inflammation score (IS) using average of z scores of four inflammation biomarkers. We explored the association of the ADII and IS with risk of incident KFRT using Cox proportional model, adjusting for sociodemographics, physical activity, Framingham risk score, eGFR, and urinary ACR. We evaluated whether, and to what extent, IS mediated the effect of the ADII on KFRT incidence, using causal mediation analysis.

Results

Of 1084 adults with CKD, 109 (10%) developed KFRT. The ADII was associated with increased risk of KFRT (relative hazard [RH] per SD increase (2.56): 1.4 [1.04-1.78]). IS was also associated with KFRT (RH: 1.12; 95% CI, 1.02 to 1.25). Approximately 36% of the association between the ADII and KFRT was explained by IS.

Conclusions

Among adults with CKD, a proinflammatory diet was associated with risk of KFRT, and that association was partially explained by an increase in inflammatory markers. Dietary interventions that reduce inflammation may offer an approach for preventing KFRT.