Andreas Pierratos Tribute: Personal Reflections

Since the passing of Andreas Pierratos on November 15, 2022, we have had many occasions to reflect on what our relationship with a friend and colleague has meant. We have done this in solitude, with colleagues while at work and more recently, in a tribute organized at Humber River Hospital on March 26, 2023. We also had the opportunity to expand, in the February 2023 issue of the Nephrology News & Issues, on his many contributions to nephrology and to the betterment of patients' lives. For this collaboration, we thought we would share our personal reflections of this unique individual, with the hope that this effort would provide a deeper appreciation of his unique humanity.

Nephrologists' Attitudes Regarding Psychosocial Care in Hemodialysis Units

Background:

There is a high prevalence of psychosocial issues affecting patients with kidney failure.

Objective:

We sought to examine Canadian nephrologists’ attitudes and opinions regarding the importance of renal patient psychosocial care, nephrologists’ roles, and experience with psychosocial care in addition to what barriers, if any, prevent these physicians from providing psychosocial care to their patients.

Design:

A self-administered, survey questionnaire.

Setting:

Online.

Sample:

Canadian Society of Nephrology members who predominantly work in clinical care with adult, in-center hemodialysis patients.

Measurements:

Measurements of the survey include demographics, training, and nephrologists’ opinions regarding their role in administering psychosocial care, potential administrative and patient time constraints, accessibility of other health care workers for this activity, and factors that influence or impede physicians’ ability to address their patients’ psychosocial needs.

Methods:

A self-administered survey was sent to almost 500 members of the Canadian Society of Nephrology between November 2018 and December 2018. The survey questionnaire was designed to gather opinions and attitudes on psychosocial care delivery as well as potential influencing factors on nephrologists’ ability to provide this care. A univariate statistical analysis was used to analyze survey responses.

Results:

A total of 30 nephrologists responded to the survey, generating a 6% response rate. Respondents varied across provinces, with the majority being staff nephrologists (80%). While over 94% of respondents either agreed or strongly agreed that focus on psychosocial care improves patient outcomes, only 43% felt that staff nephrologists were suited to provide this care to patients; 97% of respondents believed social workers to be the most suited to provide this. Lack of additional supporting health care members, the need for additional training, too many administrative duties, and empathy fatigue were some of the predominant barriers respondents felt prevented them from addressing the psychosocial care of their patients.

Limitations:

A low response rate for the survey was obtained, roughly 6%, limiting our ability to draw definitive conclusions. Survey answers by respondents may be different from those by nonrespondents. Answers may be subject to social desirability and/or selection bias.

Conclusion:

Nephrologists believe that the current psychosocial care of patients in hemodialysis units is inadequate. However, further research is necessary to elucidate the barriers nephrologists face in providing psychosocial care and the changes required to most effectively implement optimal psychosocial care for patients with kidney failure in hemodialysis units.

Health state utilities associated with major clinical events in the context of secondary hyperparathyroidism and chronic kidney disease requiring dialysis

BACKGROUND

Patients with chronic kidney disease (CKD) and secondary hyperparathyroidism (SHPT) who require dialysis are at increased risk for cardiovascular events and bone fractures. To assist in economic evaluations, this study aimed to estimate the disutility of these events beyond the impact of CKD and SHPT.

METHODS

A basic one-year health state was developed describing CKD and SHPT requiring dialysis. Further health states added acute events (cardiovascular events, fractures, and surgical procedures) or chronic post-event effects. Acute health states described a year including an event, and chronic health states described a year subsequent to an event. General population participants in Canada completed time trade-off interviews from which utilities were derived. Pairwise comparisons were made between the basic state and event, and between comparable health states.

RESULTS

A total of 199 participants (54.8% female; mean age = 46.3 years) completed interviews. Each health state had ≥130 valuations. The mean (SD) utility of the basic health state was 0.60 (0.34). For acute events, mean utility differences versus the basic state were: myocardial infarction, -0.06; unstable angina, -0.05; peripheral vascular disease (PVD) with amputation, -0.33; PVD without amputation, -0.11; heart failure, -0.14; stroke, -0.30; hip fracture, -0.14; arm fracture, -0.04; parathyroidectomy, +0.02; kidney transplant, +0.06. Disutilities for chronic health states were: stable angina, -0.09; stroke, -0.27; PVD with amputation, -0.30; PVD without amputation, -0.12; heart failure, -0.14.

CONCLUSIONS

Cardiovascular events and fractures were associated with lower utility scores, suggesting a perceived decrease in quality of life beyond the impact of CKD and SHPT.

Temporal risk profile for infectious and noninfectious complications of hemodialysis access

Vascular access complications are a major cause of morbidity in patients undergoing hemodialysis, and determining how the risks of different complications vary over the life of an access may benefit the design of prevention strategies. We used data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) to assess the temporal profiles of risks for infectious and noninfectious complications of fistulas, grafts, and tunneled catheters in incident hemodialysis patients. We used longitudinal data to model time from access placement or successful treatment of a previous complication to subsequent complication and considered multiple accesses per patient and repeated access complications using baseline and time-varying covariates to obtain adjusted estimates. Of the 7769 incident patients identified, 7140 received at least one permanent access. During a median follow-up of 14 months (interquartile range, 7-22 months), 10,452 noninfectious and 1131 infectious events (including 551 hospitalizations for sepsis) occurred in 112,085 patient-months. The hazards for both complication types declined over time in all access types: They were 5-10 times greater in the first 3-6 months than in later periods after access placement or a remedial access-related procedure. The hazards declined more quickly with fistulas than with grafts and catheters (P<0.001; Weibull regression). These data indicate that risks for noninfectious and infectious complications of the hemodialysis access decline over time with all access types and suggest that prevention strategies should target the first 6 months after access placement or a remedial access-related procedure.

A modeled economic evaluation of sevelamer for treatment of hyperphosphatemia associated with chronic kidney disease among patients on dialysis in the United Kingdom

OBJECTIVE

There is limited information regarding the cost-effectiveness of sevelamer for the treatment of hyperphosphatemia in chronic kidney disease (CKD) patients on dialysis in the UK. Using a UK National Health Service (NHS) perspective and final results of the Dialysis Clinical Outcomes Revisited (DCOR) study, an evaluation was performed to determine the cost-effectiveness of sevelamer compared to calcium-based phosphate binders for the first-line treatment of hyperphosphatemia in CKD patients on dialysis.

METHODS

A Markov model was developed to estimate life years, quality-adjusted life years (QALYs), costs, incremental cost per life year (LY) gained, and QALY gained. Treatment-specific overall survival up to 44 months, hospitalizations, and resource utilization were derived from the DCOR study. Survival was extrapolated to a lifetime horizon using Weibull regression analysis. Unit costs and utility estimates specific to the UK were obtained from the published literature. Sub-group analyses were conducted based on data reported from the DCOR study for increasing age cut-points. Outcomes and costs were modeled for a lifetime horizon.

RESULTS

In the base case analysis, the use of sevelamer resulted in a gain of ∼0.73 LYs and 0.44 QALYs per patient (discounted at 3.5% per year). Total per-patient costs were higher for sevelamer, resulting in an incremental cost of £22,157 per QALY gained and £13,427 per LY gained (in £2009). Increasingly favorable cost per QALY ratios were observed with increasing age cut-points, ranging from £15,864 for patients ≥45 to £13,296 for patients ≥65 years of age. Results were most sensitive to assumptions regarding overall survival and the inclusion of dialysis costs. Key limitations of the analysis included the use of non-UK trial data for survival and hospitalizations, and the exclusion of quality-of-life impacts associated with hospitalization.

CONCLUSIONS

In CKD patients receiving dialysis, treatment of hyperphosphatemia with sevelamer offers good value for money compared with calcium-based binders.

Modifiable practices associated with sudden death among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study

BACKGROUND AND OBJECTIVES

Sudden death is common in hemodialysis patients, but whether modifiable practices affect the risk of sudden death remains unclear.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study analyzed 37,765 participants in 12 countries in the Dialysis Outcomes and Practice Patterns Study to explore the association of the following practices with sudden death (due to cardiac arrhythmia, cardiac arrest, and/or hyperkalemia): treatment time [TT] <210 minutes, Kt/V <1.2, ultrafiltration volume >5.7% of postdialysis weight, low dialysate potassium [K(D) <3]), and prescription of Q wave/T wave interval-prolonging drugs. Cox regression was used to estimate effects on mortality, adjusting for potential confounders. An instrumental variable approach was used to further control for unmeasured patient-level confounding.

RESULTS

There were 9046 deaths, 26% of which were sudden (crude mortality rate, 15.3/100 patient-years; median follow-up, 1.59 years). Associations with sudden death included hazard ratios of 1.13 for short TT, 1.15 for large ultrafiltration volume, and 1.10 for low Kt/V. Compared with K(D) ≥3 mEq/L, the sudden death rate was higher for K(D) ≤1.5 and K(D)=2-2.5 mEq/L. The instrumental variable approach yielded generally consistent findings. The sudden death rate was elevated for patients taking amiodarone, but not other Q wave/T wave interval-prolonging drugs.

CONCLUSIONS

This study identified modifiable dialysis practices associated with higher risk of sudden death, including short TT, large ultrafiltration volume, and low K(D). Because K(D) <3 mEq/L is common and easy to change, K(D) tailoring may prevent some sudden deaths. This hypothesis merits testing in clinical trials.

Abstract P187: Assessing Gender Bias in the Treatment of Cardiovascular Disease in Canada

The objective of this study was to determine the presence of gender bias in the treatment of CVD in Canada. Gender bias has been explored extensively in the treatment of CVD, particularly AMI. Previous research is inconsistent in suggesting that women who suffer an AMI are treated less optimally than men. To date, gender bias has not been well addressed in other CVD's, specifically CVA, CABG, or RRT. In an attempt to get a clearer grasp of the problem, CAP was also studied and served as a control. Retrospective chart reviews for all AMI's, CVA's, CABG's, and CAP's in 1995/6, 1998/9, and 2000/1 in two locations of Newfoundland (St. John's and central) were reviewed. Outcomes were analyzed for differences between men and women. Adjusting for baseline differences, regression models were used to assess the following: AMI - time to thrombolytics, admission to CCU, death, discharge beta blockers, ACE/ARB, anti-lipids, ASA; CVA - LOS, transfer to and time to rehabilitation center, death; CABG - time to CABG; CAP - appropriateness of antibiotics (AB), death. RRT was analyzed from the results of the STARRT (Study To Assess Renal Replacement Therapy) study, a Canadian multicentre retrospective chart review of incident dialysis patients followed for six months. Outcomes were explored for differences in care between men and women. Optimal care was based on 1) length of pre-dialysis care; 2) modality choice; 3) access; 4) laboratory parameters at dialysis start; 5) clinical outcomes. Women who had suffered an AMI had a significantly longer time to thrombolytics and were less likely to be admitted to the CCU but did not differ significantly from men in other modes of treatment. Women who were RRT patients began dialysis at a lower eGFR level after receiving less pre-dialysis care than men. Women who received treatment for CAP were less likely than men to receive the appropriate AB's according to the 1993 guidelines for AB treatment of CAP. There were no significant treatment differences between men and women who had suffered a CVA or who had had a CABG. There were no gender differences in death for any of the diseases. There is little evidence of a significant gender bias in cardiovascular disease in Canada. A potential gender bias in the treatment of CVD patients needs to be explored further.

Naturally occurring higher hemoglobin concentration does not increase mortality among hemodialysis patients

A small percentage of hemodialysis patients maintain higher hemoglobin concentrations without transfusion or erythropoietic therapy. Because uncertainty exists regarding the effects of higher hemoglobin concentration on mortality and quality of life among hemodialysis patients, studying this group of patients with sufficient endogenous erythropoietin may provide additional insights. The prospective, observational Dialysis Outcomes and Practice Patterns Study provides an opportunity to investigate this group. Among 29,796 patients in 12 nations, 545 (1.8%) maintained hemoglobin concentrations >12 g/dl for 4 months without erythropoietic support. This subset tended to be male, to have a longer duration of end-stage renal disease, and to not dialyze via a catheter. Cystic disease as the underlying cause of renal failure was over-represented in this group but was present in only 25%. Lung disease, smoking, and cardiovascular disease were associated with increased likelihood of naturally higher hemoglobin concentration. Quality-of-life scores were not higher among this subset compared with the other patients. Unadjusted mortality risk for patients with hemoglobin >12 g/dl and no erythropoietic therapy was lower than for the other patients, but after thorough adjustment for case mix, there was no difference between groups (relative risk, 0.98; 95% CI 0.80 to 1.19). These data show that naturally occurring hemoglobin concentration >12 g/dl does not associate with increased mortality among hemodialysis patients.

Perceived barriers to guidelines in peritoneal dialysis

BACKGROUND

Little is known regarding barriers to guideline adherence in the nephrology community. We set out to identify perceived barriers to evidence-based medicine (EBM) and measurement of continuous quality indicators (CQI) in an international cohort of peritoneal dialysis (PD) practitioners.

METHODS

Subscribers to an online nephrology education site (Nephrology Now) were invited to participate in an online survey. Nephrology Now is a non-profit, monthly mailing list that highlights clinically relevant articles in nephrology. Four hundred and seventy-five physicians supplying PD care participated in an online survey assessing their use of EBM and CQI in their PD practice. Ordinal logistic regression was utilized to determine relationships between baseline characteristics and EBM and CQI practices.

RESULTS

The majority of physicians were nephrologists (89.7%), and 50.4% worked in an academic centre. Respondents were from the following geographic regions: 13.5% Canadian, 24% American, 23.8% European, 4.4% Australian, 5.3% South American, 10.7% African and 12.2% Asian. Adherence to PD clinical practice guidelines were generally strong; however, lower adherence was associated with countries with lower healthcare expenditure, not using personal digital assistant (PDA), the longer the physician had been practising and smaller (< 20 patients per centre) PD practice.

CONCLUSIONS

International variation in guideline adherence may be influenced by a country's healthcare expenditure, physician's PDA use and experience, and size of PD practice which may impact future guideline development and implementation.

International trends in erythropoietin use and hemoglobin levels in hemodialysis patients

Hemoglobin levels and the dose of erythropoiesis-stimulating agents (ESAs) have risen over time in hemodialysis patients within the United States. There are concerns that these trends may be driven by reimbursement policies that provide potential incentives to increase this use. To determine this we studied trends in the use of ESA and hemoglobin levels in hemodialysis patients and the relationship of these trends to the mode of reimbursement. Using the Dialysis Outcomes and Practice Patterns Study (DOPPS) database of hemodialysis we analyzed facility practices in over 300 randomly selected dialysis units in 12 countries. At each of three phases (years 1996-2001, 2002-2004, and 2005-present), we randomly selected over 7500 prevalent hemodialysis, hemofiltration, or hemodiafiltration patients. ESA usage rose significantly in every country studied except Belgium. All but Sweden demonstrated a substantial increase in hemoglobin levels. In 2005 more than 40% of patients had hemoglobin levels above the KDOQI upper target limit of 120 g/l in all but Japan. These trends appeared to be independent of the manner of reimbursement even though the United States is the only country with significant financial incentives promoting increased use of these agents. Thus, our study found that prescribing higher doses of ESAs and achieving higher hemoglobin levels by physicians reflects a broad trend across DOPPS countries regardless of the reimbursement policies.

Health-related quality of life in CKD Patients: correlates and evolution over time

BACKGROUND AND OBJECTIVES

Very few large-scale studies have investigated the determinants of health-related quality of life (HRQOL) in chronic kidney disease (CKD) patients not on dialysis or the evolution of HRQOL over time.

DESIGN AND SETTING

A prospective evaluation was undertaken of HRQOL in a cohort of 1186 CKD patients cared for in nephrology clinics in North America. Baseline and follow-up HRQOL were evaluated using the validated Kidney Disease Quality Of Life instrument.

RESULTS

Baseline measures of HRQOL were reduced in CKD patients in proportion to the severity grade of CKD. Physical functioning score declined progressively with more advanced stages of CKD and so did the score for role-physical. Female gender and the presence of diabetes and a history of cardiovascular co-morbidities were also associated with reduced HRQOL (physical composite score: male: 41.0 +/- 10.2; female: 37.7 +/- 10.8; P < 0.0001; diabetic: 37.3 +/- 10.6; nondiabetic: 41.6 +/- 10.2; P < 0.0001; history of congestive heart failure, yes: 35.4 +/- 9.7; no: 40.3 +/- 10.6; P < 0.0001; history of myocardial infarction, yes: 36.1 +/- 10.0; no: 40.2 +/- 10.6; P < 0.0001). Anemia and beta blocker usage were also associated with lower HRQOL scores. HRQOL measures declined over time in this population. The main correlates of change over time were age, albumin level and co-existent co-morbidities.

CONCLUSIONS

These observations highlight the profound impact CKD has on HRQOL and suggest potential areas that can be targeted for therapeutic intervention.

Health-related quality of life and hemoglobin levels in chronic kidney disease patients

BACKGROUND

The relationship between quality of life (QofL) and anemia has been the subject of recent debates; it has been suggested that the QofL changes associated with the treatment of anemia of chronic kidney disease (CKD) or ESRD patients should not be used in making decisions to treat anemia in CKD patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study examines the relationship between Kidney Disease Quality of Life (KDQofL) questionnaire domains and hemoglobin (Hgb) levels in 1200 patients with stage 3, 4, and 5 CKD followed in seven centers. QofL measures were compared in a stepwise fashion for hemoglobin levels of <11, 11 to <12, 12 to <13, and > or =13. ANOVA was used to examine the relationship between QofL scores and Hgb level, age, CKD stage, and albumin level; a history of diabetes, congestive heart failure, or myocardial infarction; use of erythropoetic-stimulating agents (ESA); and the interaction of hemoglobin level and ESA.

RESULTS

The results demonstrate that with increasing Hgb levels there is a statistically significant increase in all four physical domains, the energy/vitality domain, and the physical composite score of the SF-36, and the general health score on the kidney disease component of the questionnaire. The most dramatic improvements in these various domains occurred between the <11 and the 11 to 12 group.

CONCLUSIONS

Higher Hgb levels are associated with improved QofL domains of the KDQofL questionnaire. These findings have implications for the care of CKD patients in terms of the initiation of and the Hgb target of ESA therapy.

Perceived knowledge among patients cared for by nephrologists about chronic kidney disease and end-stage renal disease therapies

The need to educate patients in order to enable them to participate in making appropriate choices for all therapeutic options in end stage renal disease would seem obvious yet there are many barriers to providing such information. We measured 'perceived knowledge' of the therapeutic options for end stage renal disease in a cohort of patients with chronic kidney disease in established treatment programs. A self administered questionnaire was given to 676 patients with stage 3-5 chronic kidney disease as part of the CRIOS study designed to identify trends in practice patterns and outcomes over a 4 year period. The median patient age was 66, about three-fourths were Caucasian and almost half were diabetic. When patients were asked to rate their level of knowledge, about one-third reported limited or no understanding of their chronic kidney disease and no awareness regarding their treatment options. A significant and substantial number of patients indicated they had no familiarity with transplant, hemodialysis, and continuous ambulatory or automated peritoneal dialysis. Perceived knowledge improved with the progression of kidney disease and frequency of nephrology visits; however, only about half of patients with 4 or more nephrology appointments in the prior year reported knowing of hemodialysis, continuous ambulatory peritoneal dialysis or transplant. Age, gender and disease had no impact on levels of patient knowledge, but African-Americans reported having significantly less understanding than Asians or Caucasians. These findings suggest that the lack of perception concerning the treatment options chronic kidney and end stage renal disease reflects, in part, problems with the education of patients by nephrologists and not a lack of referral of these patients to nephrologists for care. The discrepancy of perceived knowledge between African-Americans and other races needs special attention.

Diagnosis and management of insomnia in dialysis patients

Sleep-related complaints affect 50-80% of patients on dialysis. Sleep disorders impair quality of life significantly. Increasing evidence suggests that sleep disruption has a profound impact both on an individual and on a societal level. The etiology of sleep disorders is often multifactorial: biologic, social, and psychological factors play a role. This is especially true for insomnia, which is the most common sleep disorder in different populations, including patients on dialysis. Biochemical and metabolic changes, lifestyle factors, depression, anxiety, and other underlying sleep disorders can all have an effect on the development and persistence of sleep disruption, leading to chronic insomnia. Insomnia is defined as difficulty initiating or maintaining sleep, or having nonrestorative sleep. It is also associated with daytime consequences, such as sleepiness and fatigue, and impaired daytime functioning. In most cases, the diagnosis of insomnia is based on the patient's history, but in some patients objective assessment of sleep pattern may be necessary. Optimally the treatment of insomnia involves the combination of both pharmacologic and nonpharmacologic approaches. In some cases acute insomnia resolves spontaneously, but if left untreated, it may lead to chronic sleep problems. The treatment of chronic insomnia is often challenging. There are only a few studies specifically addressing the management of this sleep disorder in patients with chronic renal disease. Considering the polypharmacy and altered metabolism in this patient population, treatment trials are clearly needed. This article reviews the diagnosis of sleep disorders with a focus on insomnia in patients on dialysis.

Reviews: Diagnosis and Management of Sleep Apnea Syndrome and Restless Legs Syndrome in Dialysis Patients

Sleep complaints are very common in patients with end-stage renal disease (ESRD) and contribute to their impaired quality of life. Both obstructive and central sleep apnea syndromes are reported more often in patients on dialysis than in the general population. Impaired daytime functioning, sleepiness, and fatigue, as well as cognitive problems, are well known in patients with sleep apnea. Increasing evidence supports the pathophysiological role of sleep apnea in cardiovascular disorders, which are the leading cause of death in ESRD patients. Uremic factors may be involved in the pathogenesis of sleep apnea in this patient population and optimal dialysis may reduce disease severity. Furthermore, treatment with continuous positive airway pressure may improve quality of life and may help to manage hypertension in these patients. Secondary restless legs syndrome is highly prevalent in patients on maintenance dialysis. The pathophysiology of the disorder may also involve uremia-related factors, iron deficiency, and anemia, but genetic and lifestyle factors might also play a role. The treatment of restless legs syndrome involves various pharmacologic approaches and might be challenging in severe cases. In this article we review the diagnosis and treatment of sleep apnea and restless legs syndrome, with a focus on dialysis patients. We also briefly review current data regarding sleep problems after transplantation, since these studies may indirectly shed light on the possible pathophysiological role of uremia or dialysis in the etiology of sleep disorders. Considering the importance of sleep disorders, more awareness among professionals involved in the care of patients on dialysis is necessary. Appropriate management of sleep disorders could improve the quality of life and possibly even impact upon survival of renal patients.

A cross-sectional immunosurveillance study of anti-EPO antibody levels in CRF patients receiving epoetin alfa in 5 Ontario Renal Centers

BACKGROUND

Epoetin alfa (Eprex*; Johnson & Johnson, Manati, PR) has been used successfully to correct the anemia of chronic renal failure for more than 12 years. Anti-erythropoietin (anti-EPO) antibodies have been reported in a small number of patients, resulting in a blood disorder, pure red cell aplasia (PRCA). To evaluate the utility of a large-scale anti-EPO antibody screening program in patients with chronic kidney disease (CKD) administered epoetin alfa, a study involving 5 large renal centers in southern Ontario, Canada, was conducted.

METHODS

More than 1,500 hemodialysis, peritoneal dialysis, and predialysis patients were screened for the prevalence of anti-EPO antibodies by means of a radioimmunoprecipitation (RIP) assay. Serum samples were drawn and shipped to PPD Development (Richmond, VA) for the immunoprecipitation assay. Serum EPO levels also were measured. All samples that tested positive or borderline for antibodies were sent to MDS Pharma Services (Montreal, Canada) for the neutralization assay.

RESULTS

Of 1,531 samples tested, 1 patient tested low-positive and 3 borderline results were detected by means of RIP. PRCA previously was diagnosed in the patient with the low-positive antibody level; the patient was treated with cyclosporine and currently is being administered epoetin alfa with good response. The 3 patients with borderline antibody results manifested no clinical signs of PRCA. Neutralization assays performed on all 4 serum samples were negative for anti-EPO antibodies.

CONCLUSION

Results from this surveillance study show that the prevalence of antibody to EPO in patients with CKD administered epoetin alfa in 5 Canadian renal centers is low, and the value of a large-scale antibody screening program for PRCA cannot be justified.

Medical decision-making and information needs in end-stage renal disease patients

Health information and decision-making are increasingly important to patients with diverse illnesses. The aim of this study was to examine health information needs and decision-making in individuals with end-stage renal disease (ESRD) and to examine the influence of age and gender. A self-report survey was administered to 197 consecutive ESRD patients receiving renal replacement therapy. Their mean age was 52.8 years; 58.2% were male, 64.3% were on hemodialysis, and 35.7% on peritoneal dialysis. Actual participation levels in decision-making were not necessarily in agreement with the preferred degree of participation. Eighty percent of patients wanted the health care team (HCT) to make their treatment decisions for them, but only 40% of those who preferred autonomous and 30% of those who preferred shared decision making with their HCT reported that this was their actual experience. Consequently, many more patients perceived that their decision-making was made by their HCT than preferred this. No significant gender differences were observed; however, older participants preferred and experienced their HCT make their treatment decisions (P<.05). All patients wanted high levels of information with some differences by gender and age. HCT should strive to ascertain and meet the information needs and treatment decision-making roles preferred by individual patients.

Canadian survey of clinical status at dialysis initiation 1998-1999: a multicenter prospective survey

AIMS

The current growth in end-stage kidney disease populations has led to increased efforts to understand the impact of status at dialysis initiation on long-term outcomes. Our main objective was to improve the understanding of current Canadian nephrology practice between October 1998 and December 1999.

METHODS

Fifteen nephrology centers in 7 provinces participated in a prospective data collection survey. The main outcome of interest was the clinical status at dialysis initiation determined by: residual kidney function, preparedness for chronic dialysis as measured by presence or absence of permanent peritoneal or hemodialysis access, hemoglobin and serum albumin. Uremic symptoms at dialysis initiation were also recorded, however, in some cases these symptom data were obtained retrospectively.

RESULTS

Data on 251 patients during 1-month periods were collected. Patients commenced dialysis at mean calculated creatinine clearance levels of approximately 10 ml/min, with an average of 3 symptoms. 35% of patients starting dialysis had been known to nephrologists for less than 3 months. These patients are more likely to commence without permanent access and with lower hemoglobin and albumin levels. Even of those known to nephrologists, only 66% had permanent access in place.

CONCLUSIONS

Patients commencing dialysis in Canada appear to be doing so in relative concordance with published guidelines with respect to timing of initiation. Despite an increased awareness of kidney disease, a substantial number of patients continues to commence dialysis without previous care by a nephrologist. Of those who are seen by nephrologists, clinical and laboratory parameters are suboptimal according to current guidelines. This survey serves as an important baseline for future comparisons after the implementation of educational strategies for referring physicians and nephrologists.

Cardiovascular disease in patients with chronic kidney disease: getting to the heart of the matter

The high prevalence of cardiovascular disease (CVD) in patients with kidney disease is well described. This Canadian, multicenter, observational cohort study reports the prevalence and risk factors of CVD associated with kidney disease, in a cohort of patients with established chronic kidney disease (CKD), who are followed-up by nephrologists. This analysis sought to answer 2 questions: (1) in patients with established CKD, are the prevalence and progression of CVD accounted for by conventional or uremia-related risk factors, and (2) to what extent can progression to renal replacement therapy (RRT) be explained by CVD versus traditional risk factors for kidney disease? This study population consists of 313 patients (predominantly men) who had a mean age of 56 years and a mean creatinine clearance of 36 mL/min. Thirty percent were diabetic. The overall prevalence of CVD was 46%, and was independent of severity of kidney dysfunction (P = 0.700). The median follow-up time was 23 months, for a total of 462 patient years. We note the overall incidence of CVD events (new CVD or worsening of CVD) was 47/244 (20%). The best predictors of new CVD events among those without preexisting CVD were diabetes (odds ratio [OR] = 5.35, P = 0.018) and age (OR = 1.26, P = 0.08). In those with preexisting CVD, low diastolic pressure (DP) (OR =.72, P = 0.004) and high triglycerides (OR = 1.48, P = 0.019) at baseline were independent predictors of progression of CVD. We could not determine an independent impact of kidney function on CVD in the overall cohort. Furthermore, we determined that the presence of CVD itself confers an increased risk for progression to RRT (relative risk [RR] = 1.58, P = 0.047), adjusted for kidney function. This is the first in-depth analysis of CVD in a cohort of patients with established chronic kidney disease who are not on dialysis. The question regarding the impact of the altered biology of uremia in contributing to CVD progression remains unanswered, and clearly needs further study. However, the findings do raise the issue of whether aggressive treatment of CVD and risk factors might, in fact, reduce progression to RRT. Further large-scale, observational studies as well as interventional studies are needed to more clearly understand the complex biology of cardiovascular and kidney disease progression.

Nonreferral and nonacceptance to dialysis by primary care physicians and nephrologists in Canada and the United States

Research from Canada and the United States suggests that not offering dialysis to patients who might benefit still occurs. This study was conducted to investigate nonreferral and nonacceptance to dialysis by primary care physicians (PCPs) and nephrologists in these countries. We surveyed a random sample of Canadian and US PCPs and nephrologists concerning their attitudes toward and experience with withholding dialysis in patients with advanced chronic renal failure. In response to a question about whether the physician believes there should be an age beyond which dialysis should not be offered, 12% of Canadian PCPs, 20% of US PCPs, 4% of Canadian nephrologists, and 9% of US nephrologists answered yes. When asked about their recommendations concerning dialysis initiation in 10 vignettes of patients with impending end-stage renal disease (ESRD), the responses of Canadian and US physicians were similar. PCPs compared with nephrologists were less likely to recommend dialysis in cases with physical illnesses and more likely to recommend it in cases with neuropsychiatric impairments. Over a 3-year period, 13% of Canadian PCPs and 19% of US PCPs reported nonreferral to dialysis at least once. Withholding rates were 25% for Canadian PCPs, 16% for US PCPs, 13% for Canadian nephrologists, and 17% for US nephrologists. We conclude that although nonreferral of patients who might benefit from dialysis still occurs, it does not seem to be common, and the attitudes of Canadian and US physicians toward this issue are similar and could not entirely account for the much greater incidence of treated ESRD in the United States. PCPs and nephrologists should continue to be educated about the modern criteria for patient selection for dialysis.

Effect of hemoglobin levels in hemodialysis patients with asymptomatic cardiomyopathy

BACKGROUND

Hemoglobin levels below 10 g/dL lead to left ventricular (LV) hypertrophy, LV dilation, a lower quality of life, higher cardiac morbidity, and a higher mortality rate in end-stage renal disease. The benefits and risks of normalizing hemoglobin levels in hemodialysis patients without symptomatic cardiac disease are unknown.

METHODS

One hundred forty-six hemodialysis patients with either concentric LV hypertrophy or LV dilation were randomly assigned to receive doses of epoetin alpha designed to achieve hemoglobin levels of 10 or 13.5 g/dL. The study duration was 48 weeks. The primary outcomes were the change in LV mass index in those with concentric LV hypertrophy and the change in cavity volume index in those with LV dilation.

RESULTS

In patients with concentric LV hypertrophy, the changes in LV mass index were similar in the normal and low target hemoglobin groups. The changes in cavity volume index were similar in both targets in the LV dilation group. Treatment-received analysis of the concentric LV hypertrophy group showed no correlation between the change in mass index and a correlation between the change in LV volume index and mean hemoglobin level achieved (8 mL/m2 per 1 g/dL hemoglobin decrement, P = 0.009). Mean hemoglobin levels and the changes in LV mass and cavity volume index were not correlated in patients with LV dilation. Normalization of hemoglobin led to improvements in fatigue (P = 0.009), depression (P = 0.02), and relationships (P = 0.004).

CONCLUSIONS

Normalization of hemoglobin does not lead to regression of established concentric LV hypertrophy or LV dilation. It may, however, prevent the development of LV dilation, and it leads to improved quality of life.

Left ventricular mass index increase in early renal disease: impact of decline in hemoglobin

Cardiovascular disease occurs in patients with progressive renal disease both before and after the initiation of dialysis. Left ventricular hypertrophy (LVH) is an independent predictor of morbidity and mortality in dialysis populations and is common in the renal insufficiency population. LVH is associated with numerous modifiable risk factors, but little is known about LV growth (LVG) in mild-to-moderate renal insufficiency. This prospective multicenter Canadian cohort study identifies factors associated with LVG, measured using two-dimensional-targeted M-mode echocardiography. Eight centers enrolled 446 patients, 318 of whom had protocol-mandated clinical, laboratory, and echocardiographic measurements recorded. We report 246 patients with assessable echocardiograms at both baseline and 12 months with an overall prevalence of LVH of 36%. LV mass index (LVMI) increased significantly (>20% of baseline or >20 g/m2) from baseline to 12 months in 25% of the population. Other than baseline LVMI, no differences in baseline variables were noted between patients with and without LVG. However, there were significant differences in decline of Hgb level (-0.854 v -0.108 g/dL; P = 0.0001) and change in systolic blood pressure (+6.50 v -1.09 mm Hg; P = 0.03) between the groups with and without LVG. Multivariate analysis showed the independent contribution of decrease in Hgb level (odds ratio [OR], 1.32 for each 0.5-g/dL decrease; P = 0.004), increase in systolic blood pressure (OR, 1.11 for each 5-mm Hg increase; P = 0.01), and lower baseline LVMI (OR, 0.85 for each 10-g/m2; P = 0.011) in predicting LVG. Thus, after adjusting for baseline LVMI, Hgb level and systolic blood pressure remain independently important predictors of LVG. We defined the important modifiable risk factors. There remains a critical need to establish optimal therapeutic strategies and targets to improve clinical outcomes.

Percutaneously inserted silastic jugular hemodialysis catheters seldom cause jugular vein thrombosis

To find out whether internal jugular vein cannulation with a soft silastic hemodialysis access catheter causes jugular vein thrombosis, the authors carried out Doppler ultrasound examinations on 96 patients receiving hemodialysis who had undergone 144 separate catheter insertion episodes in 116 veins. Two internal jugular vein thromboses were found in 101 veins that had been the site of percutaneous insertions only. In addition, 5 internal jugular vein thromboses were identified in 15 veins that had been cannulated surgically with the Quinton PermCath. The authors conclude that percutaneous internal jugular vein cannulation for hemodialysis access causes an acceptably low incidence of jugular vein damage. This strengthens the case for preferential use of the internal jugular vein for vascular access in patients with end-stage renal failure, and suggests that percutaneous cannulation is less damaging than surgical insertion.

An enzymatic method for measuring serum mannitol and its use in hemodialysis patients

We evaluated two chemical methods for quantifying mannitol in serum, based on the oxidation of mannitol by periodate, and measurement of the formaldehyde formed with chromotropic acid (colorimetry) or acetylacetone (fluorometry). We found interference in these methods by serum glycerol. Additionally, a high-performance liquid chromatography (HPLC) method was evaluated and found to be specific but impractical for routine use. We therefore, developed an enzymatic fluorometric procedure, based on the oxidation of mannitol by beta-NAD to fructose and NADH, in the presence of the enzyme mannitol dehydrogenase (MD). MD is not commercially available and was partially purified from cultures of Leuconostoc mesenteroides. This new method is specific, sensitive, simple, and accurate and is proposed as the method of choice for measuring mannitol in the serum of patients who received this sugar alcohol during routine hemodialysis treatment.