Examine the optimal multidisciplinary care teams for patients with chronic kidney disease from a nationwide cohort study

Background

Multidisciplinary team-based integrated care (MDC) has been recommended for patients with chronic kidney disease (CKD). However, team-based specific structured care systems are not yet established. Therefore, we investigated the efficacy of MDC system and the optimal number of professionals that make up the team for maintaining kidney function and improving prognosis.

Methods

This nationwide, multicenter, observational study included 2,957 Japanese patients with CKD who received MDC from 2015 to 2019. The patients were divided into four groups according to the number of professionals in the MDC team. Groups A, B, C, and D included nephrologists and one, two, three, and four or more other professionals, respectively. Changes in the annual decline in estimated glomerular filtration rate before and after MDC were evaluated. Cox regression was utilized to estimate the correlation between each group and all-cause mortality and the start of renal replacement therapy (RRT) for 7 years.

Results

The change in eGFR significantly improved between before and at 6, 12, and 24 months after MDC in all groups (all p < 0.0001). Comparing group D to group A (reference), the hazard ratio (HR) for all-cause mortality and the start of the RRT was 0.60 (95% confidence interval, 0.48-0.73; p < 0.0001) after adjustment for multiple confounders. Lower HR in group D was confirmed in both diabetes and nondiabetes subgroups.

Conclusion

An MDC team comprised of five or more professionals might be associated with improvements in mortality and kidney prognosis. Furthermore, MDC might be effective for treating CKD other than diabetes.

Inpatient multidisciplinary care can prevent deterioration of renal function in patients with chronic kidney disease: a nationwide cohort study

Background

Multidisciplinary care is necessary to prevent worsening renal function and all-cause mortality in patients with chronic kidney disease (CKD) but has mostly been investigated in the outpatient setting. In this study, we evaluated the outcome of multidisciplinary care for CKD according to whether it was provided in an outpatient or inpatient setting.

Methods

This nationwide, multicenter, retrospective, observational study included 2954 Japanese patients with CKD stage 3-5 who received multidisciplinary care in 2015-2019. Patients were divided into two groups: an inpatient group and an outpatient group, according to the delivery of multidisciplinary care. The primary composite endpoint was the initiation of renal replacement therapy (RRT) and all-cause mortality, and the secondary endpoints were the annual decline in the estimated glomerular filtration rate (ΔeGFR) and the changes in proteinuria between the two groups.

Results

Multidisciplinary care was provided on an inpatient basis in 59.7% and on an outpatient basis in 40.3%. The mean number of health care professionals involved in multidisciplinary care was 4.5 in the inpatient group and 2.6 in the outpatient group (P < 0.0001). After adjustment for confounders, the hazard ratio of the primary composite endpoint was significantly lower in the inpatient group than in the outpatient group (0.71, 95% confidence interval 0.60-0.85, P = 0.0001). In both groups, the mean annual ΔeGFR was significantly improved, and proteinuria significantly decreased 24 months after the initiation of multidisciplinary care.

Conclusion

Multidisciplinary care may significantly slow deterioration of eGFR and reduce proteinuria in patients with CKD and be more effective in terms of reducing initiation of RRT and all-cause mortality when provided on an inpatient basis.

Effectiveness and current status of multidisciplinary care for patients with chronic kidney disease in Japan: a nationwide multicenter cohort study

Background

Multidisciplinary care is well established in clinical practice, but its effectiveness in patients with chronic kidney disease (CKD) remains unclear. The aim of this study was to determine whether multidisciplinary care could help to avoid worsening kidney function in patients with CKD.

Methods

This nationwide study had a multicenter retrospective observational design and included 3015 Japanese patients with CKD stage 3–5 who received multidisciplinary care. We assessed the annual decrease in estimated glomerular filtration rate (ΔeGFR) and urinary protein in the 12 months before and 24 months after the start of multidisciplinary care. All-cause mortality and initiation of renal replacement therapy were investigated according to baseline characteristics.

Results

Most of the patients had CKD stage 3b or higher and a median eGFR of 23.5 mL/min/1.73 m2. The multidisciplinary care teams consisted of health care professionals from an average of four disciplines. ΔeGFR was significantly smaller at 6, 12, and 24 months after initiation of multidisciplinary care (all P < 0.0001), regardless of the primary cause of CKD and its stage when multidisciplinary intervention was started. Urinary protein level also decreased after initiation of multidisciplinary care. After a median follow-up of 2.9 years, 149 patients had died and 727 had started renal replacement therapy.

Conclusion

Multidisciplinary care may significantly slow the decline in eGFR in patients with CKD and might be effective regardless of the primary disease, including in its earlier stages. Multidisciplinary care is recommended for patients with CKD stage 3–5.

Trial registration

UMIN00004999.

Effects of Calcium Polystyrene Sulfonate Formulation Change from Dry Syrup to Oral Solution in Patients with Chronic Kidney Disease

Calcium polystyrene sulfonate, a cation exchange resin preparation, is used to treat hyperkalaemia. The effects of switching from dry syrup to oral solution forms have been rarely evaluated. We investigated changes in serum potassium levels, incidence of adverse events, and patients' perception and satisfaction associated with the change in calcium polystyrene sulfonate dosage forms from dry syrup to oral solution in chronic kidney disease patients. The study population was comprised of 24 patients. The chronic kidney disease cause, glomerular filtration rate category, and albuminuria category was G4 in 10 cases (41.7%) and G5 in 8 cases (33.3%). No significant difference was observed between groups before and after the change in dosage form. Contrastingly, the ease of intake (P=0.0047), taste (P=0.0056), and satisfaction (P<0.001) indicated positive significant improvements. Changing the calcium polystyrene sulfonate dosage form from dry syrup to oral solution in patients with chronic kidney disease improved patient satisfaction while maintaining efficacy and safety. For patients in whom weight gain is not a problem, we recommend changing the dosage form from dry syrup to oral solution for calcium polystyrene sulfonate.

Effect of multidisciplinary care of dialysis initiation for outpatients with chronic kidney disease

BACKGROUND

The aim of comprehensive multidisciplinary care (MDC) by the chronic kidney disease (CKD) team is not only to prevent worsening renal function, but also provide education on the selection of renal replacement therapy (RRT) by shared decision making (SDM). The purpose of this study was to examine the effects of MDC for predialysis outpatients on dialysis therapy, especially with regard to peritoneal dialysis (PD).

METHODS

This study evaluated 112 CKD patients who underwent dialysis at our hospital starting from 2012, with 53 outpatients receiving MDC from the CKD team and 59 outpatients not receiving MDC. Annual decreases in the estimated glomerular filtration rates (ΔeGFR), the duration from the time of intervention to dialysis initiation, the urgent dialysis rate using a temporary catheter, and the PD selection rate were compared and examined between the two groups. The ΔeGFR, the duration from intervention to PD initiation, and the PD retention rate were compared between 18 PD patients in the MDC group and 10 PD patients in the non-MDC group.

RESULTS

The MDC group had a significantly lower ΔeGFR, significantly longer duration, and a significantly lower urgent dialysis initiation rate versus the non-MDC group. Moreover, there was a significantly higher PD selection rate, significantly prolonged duration, and significantly higher PD retention rate.

CONCLUSIONS

Multidisciplinary CKD team care for outpatients is effective in delaying the progression of CKD and avoiding the initiation of urgent dialysis; contributing to improved PD selectivity and continuity by SDM.

Comparison of mediastinal lymph node metastases from adenocarcinoma of the esophagogastric junction versus lower esophageal squamous cell carcinoma with involvement of the esophagogastric junction

The distribution of mediastinal lymph node metastasis in patients with adenocarcinoma of the esophagogastric junction (AEG) remains unclear. Additionally, the distribution of nodal mediastinal metastasis from squamous cell carcinoma (SCC) of the lower esophagus with involvement of the esophagogastric junction remains unclear, given the very limited number of these patients. In this retrospective review, we compared the outcomes of radical lymphadenectomy of the mediastinum, including upper mediastinal lymphadenectomy, between patients with AEG and those with SCC. From 2005 to 2017, 69 consecutive patients underwent esophagectomy via right thoracotomy or minimally invasive esophagectomy for a Siewert type I or II tumor with esophageal invasion ≥3 cm. We analyzed the incidences of mediastinal lymph node metastasis in this group relative to those of 73 patients with SCC with involvement of the esophagogastric junction who consecutively underwent esophagectomy during the same period. Mediastinal lymph node metastasis was seen in 26 of 69 patients with AEG (38%), with upper, middle, lower mediastinal nodal metastasis instances of 20%, 17%, and 23%, respectively. Mediastinal lymph node metastasis was seen in 23 of 73 patients with SCC (32%), with upper, middle, lower mediastinal nodal metastasis instances of 12%, 16%, and 19%, respectively. This mediastinal lymph nodal metastasis distribution did not statistically differ between patients with AEG and those with SCC. The relapse-free survival outcomes were poor for patients with clinical (P < 0.01) or pathological (P < 0.01) nodal metastasis of the mediastinum with AEG. In contrast, patients with clinical or pathological mediastinal nodal metastases of SCC did not have extremely poor survival outcomes, compared to patients with AEG. Despite the limited dataset available for analysis, patients with AEG and those with SCC might exhibit similar incidences and distribution of mediastinal lymph node metastasis. However, the clinical or pathological metastasis of AEG to the mediastinum was associated with poor survival outcomes, even if radical mediastinal lymphadenectomy including the upper mediastinal lymphadenectomy was performed.

Resistance to Erythropoiesis-Stimulating Agents in Pre-Dialysis and Post-Dialysis Mortality in Japanese Incident Hemodialysis Patients

BACKGROUND/AIMS

There is lack of definitive evidence about the association between erythropoiesis-stimulating agent (ESA) responsiveness in the pre-dialysis phase and mortality. Therefore, we conducted a hospital-based, retrospective, cohort study to assess the predictive value of ESA response for prognosis in incident hemodialysis patients.

METHODS

A total of 108 patients without preexisting cardiovascular disease who had been started on maintenance hemodialysis were studied. ESA responsiveness just before starting dialysis was estimated using an erythropoietin resistance index (ERI). The endpoint was defined as all-cause death.

RESULTS

During a mean follow-up period of 3.1 ± 1.6 years, 18 (17%) patients died. Overall, the multivariate Cox regression analysis revealed that the log-transformed ERI remained an independent predictor of all-cause death after adjustment using a propensity score (hazard ratio 2.25, 95% CI 1.25-4.06).

CONCLUSIONS

Among incident hemodialysis patients, hyporesponsiveness to ESA may be associated with mortality.

Resistance to Erythropoiesis-Stimulating Agents in Pre-Dialysis and Post-Dialysis Mortality in Japanese Incident Hemodialysis Patients

BACKGROUND/AIMS

There is lack of definitive evidence about the association between erythropoiesis-stimulating agent (ESA) responsiveness in the pre-dialysis phase and mortality. Therefore, we conducted a hospital-based, retrospective, cohort study to assess the predictive value of ESA response for prognosis in incident hemodialysis patients.

METHODS

A total of 108 patients without preexisting cardiovascular disease who had been started on maintenance hemodialysis were studied. ESA responsiveness just before starting dialysis was estimated using an erythropoietin resistance index (ERI). The endpoint was defined as all-cause death.

RESULTS

During a mean follow-up period of 3.1 ± 1.6 years, 18 (17%) patients died. Overall, the multivariate Cox regression analysis revealed that the log-transformed ERI remained an independent predictor of all-cause death after adjustment using a propensity score (hazard ratio 2.25, 95% CI 1.25-4.06).

CONCLUSIONS

Among incident hemodialysis patients, hyporesponsiveness to ESA may be associated with mortality.

Clinical utility of exhaled carbon monoxide in assessing preoperative smoking status and risks of postoperative morbidity after esophagectomy

Whereas smoking constitutes a significant risk factor for postesophagectomy morbidity, there is no reliable method to assess the smoking status of patients prior to the procedure. Since exhaled carbon monoxide (CO) is an indicator of recent smoking, this paper hypothesizes that this is a useful parameter in assessing current smoking status and may help predict morbidity following esophagectomy. Sixty-nine patients, who had undergone elective three-incision esophagectomy with two- or three-field lymphadenectomy for esophageal cancer, were prospectively studied between February 2015 and September 2017. At surgical admission, they were asked about their smoking history, their exhaled CO levels were evaluated, and they were grouped into three based on their CO levels. These were 0 parts per million (ppm), >0 and <7 ppm, and ≥7 ppm. Their postoperative morbidity was also assessed. Approximately 13.5% of the patients showed high levels of exhaled CO ≥ 7 ppm, despite preoperatively reporting smoking cessation for over a month. Morbidities of the Clavien-Dindo classification (CDc) ≥ II increased as exhaled CO levels increased and severe morbidity of CDc ≥ IIIb frequently was observed in patients with exhaled CO levels ≥7 ppm. The logistic regression analysis showed that exhaled CO level ≥7 ppm was an independent risk factor for severe postesophagectomy morbidity. Overall, the results of this study suggest that exhaled CO levels may be useful in estimating current smoking status and that it may also help give an estimation of the risk of postesophagectomy morbidity.

Oesophagectomy with or without supraclavicular lymphadenectomy after neoadjuvant treatment for squamous cell carcinoma of the oesophagus

Background

Treatment of supraclavicular nodes remains controversial among patients with oesophageal squamous cell carcinoma. This study assessed the outcomes of patients who underwent oesophagectomy with or without supraclavicular lymphadenectomy after neoadjuvant treatment.

Methods

This was a single-centre retrospective cohort study. Patients with oesophageal squamous cell carcinoma and clinically negative supraclavicular nodes who underwent oesophagectomy after neoadjuvant treatment between January 2005 and December 2015 were included. Overall and relapse-free survival were compared between patients who did or did not undergo supraclavicular nodal dissection. Propensity score matching was used to correct for differences in prognostic factors between the groups.

Results

Some 223 patients underwent supraclavicular lymphadenectomy. The prevalence of pathologically confirmed supraclavicular metastasis was 10·3 per cent, and these patients had poor 5-year relapse-free (7 per cent) and overall (14 per cent) survival. Only two of 55 patients who did not undergo supraclavicular lymphadenectomy had recurrent disease in the supraclavicular region without distant metastasis. There was no statistically significant difference between the groups in relapse-free survival (hazard ratio (HR) 0·95, 95 per cent c.i. 0·61 to 1·47; P = 0·821) or overall survival (HR 0·86, 0·52 to 1·40; P = 0·544). Similarly, no significant difference in relapse-free or overall survival was observed between the propensity score-matched groups.

Conclusion

For patients with clinically negative supraclavicular lymph nodes, prophylactic supraclavicular lymphadenectomy may be omitted when neoadjuvant treatment is administered.

Stable DHLA–PEG capped PbS quantum dots: from synthesis to near-infrared biomedical imaging

Stability, biocompatibility and near-infrared photoluminescence of PbS nanocrystals capped with PEG-based ligands open up realistic prospects for non-invasive bioimaging applications.

Associations of aniseikonia with metamorphopsia and retinal displacements after epiretinal membrane surgery

PurposeTo determine the correlation of the degree of aniseikonia with the retinal displacements and metamorphopsia in patients that have undergone successful epiretinal membrane (ERM) surgery.MethodsSubjects were 28 eyes with an ERM in 28 patients. The New Aniseikonia Test (NAT) and M-CHARTS were used to quantify the degree of preoperative and postoperative aniseikonia and metamorphopsia. We also evaluated the distance between the intersections of 2 sets of retinal vessels situated vertically or horizontally by using spectral-domain optical coherence tomography (SD-OCT) images in 28 patients.ResultsThe vertical score of M-CHARTS (MV) was not significantly improved, but the horizontal score of M-CHARTS (MH) was significantly improved at 1 week, 1 month, and 3 months postoperatively. The preoperative NAT score was significantly correlated with the preoperative MH. The NAT score at 3 months was significantly correlated with the MH at 3 months and the MV at 3 months. The preoperative NAT score was significantly correlated with the ratio of the vertical retinal displacement at 1 month and at 3 months after surgery. However, the NAT scores did not improve significantly at any postoperative times.ConclusionsThe degree of aniseikonia was significantly correlated with the degree of metamorphopsia and the tangential displacement of the retina after ERM surgery. Aniseikonia is difficult to improve and metamorphopsia may be a more sensitive parameter to detect the functional recovery after successful ERM surgery.

Failure of neoadjuvant chemotherapy for resectable esophageal squamous cell carcinoma

Neoadjuvant treatment has become standard care for patients with resectable esophageal cancer. However, some patients cannot undergo surgery or curative resection because of disease progression during neoadjuvant treatment. The aim of this study is to identify the pretreatment characteristics of patients in whom neoadjuvant treatment failed. The study enrolled 231 patients who underwent chemotherapy with cisplatin and 5-fluorouracil (CF) as neoadjuvant therapy for T1N1-3 or T2-3 any-N esophageal squamous cell carcinoma (ESCC). Of these patients, 201 (87.0%) underwent curative resection (R0) and 30 (13.0%) could not undergo curative resection; 19 patients (8.2%) underwent incomplete resection (R1 or R2), and 11 patients (4.8%) could not undergo surgery because of disease progression. We compared clinical characteristics and survival between patients who underwent curative resection (curative group) and those who could not undergo curative resection (noncurative group) to determine the factors predicting noncurative treatment. The noncurative group had significantly worse disease-specific survival than the curative group (P < 0.001). All patients in the noncurative group had cT3 tumors. In 141 patients with cT3 tumors, those in the noncurative group were more likely to have higher serum SCC antigen concentration (P = 0.021), location of the main tumor in the upper to the middle third of the esophagus (P = 0.071), intramural metastases (P < 0.001), advanced N category (P = 0.016), and bulky lymph node metastases (P = 0.060). Multivariate logistic regression analysis identified location of the main tumor in the upper to the middle third of the esophagus (P = 0.047), intramural metastases (P = 0.002), and nodal metastases (N1, P = 0.014; N2, P = 0.015, respectively) as independent predictors of treatment failure in patients with cT3 tumors. Neoadjuvant CF therapy alone may not be effective for patients with cT3 tumors accompanied by these risk factors, and the efficacy of alternative strategies, such as triplet chemotherapy or chemoradiotherapy, should be evaluated.

Transplant Procurement Management Model Training: Marked Improvement in the Mindset of In-Hospital Procurement Coordinators at Hyogo Prefecture, Japan

BACKGROUND

The organ donation rate in Japan is much lower than that in other developed countries for several reasons. An advanced educational program for in-hospital procurement coordinators is a possible solution for this. We introduced a Transplant Procurement Management (TPM) educational program at Hyogo Prefecture, Japan.

METHODS

Ten healthcare professionals at Hyogo Prefecture participated in the Advanced International TPM course to educate themselves on TPM and held 2 TPM Model Organ Procurement Training Workshops at Hyogo Prefecture for in-hospital procurement coordinators. Furthermore, we held 2 workshops outside Hyogo Prefecture and at the same time undertook a pre-workshop questionnaire survey to evaluate the ability and motivation with respect to organ donation. To evaluate the effectiveness of the workshops, we conducted post-workshop and 3-months-after workshop questionnaire surveys.

RESULTS

The results of the pre-workshop survey revealed that in-hospital procurement coordinators lacked the knowledge regarding the entire organ donation process, the current status of organ donation in Japan, and the definition of brain death. Moreover, they did not completely understand the meaning of "organ donation." The results of the post-workshop questionnaire survey showed that the educational program was effective to improve the knowledge and skills of organ donation and motivated behavioral changes among the participants.

CONCLUSIONS

The survey results showed that our TPM model educational program offered sufficient knowledge and skills to increase organ donation at Hyogo Prefecture. We will continue this program and make an effort to further contribute to the Japanese organ donation activities.

Prognostic and clinical impact of sarcopenia in esophageal squamous cell carcinoma

Recently, depletion of skeletal muscle mass (sarcopenia) has been linked to poor prognosis in several types of cancers, but has not been investigated in esophageal squamous cell carcinoma (ESCC). This retrospective study investigates the relationship between sarcopenia and clinical outcome in ESCC patients treated by surgical resection or definitive chemoradiation therapy (dCRT). The study was retrospectively conducted in a single academic hospital in Kumamoto, Japan, and involved 325 ESCC patients (256 surgical cases and 69 dCRT cases) treated between April 2005 and April 2011. Skeletal muscle mass was quantified by radiologic measures using standard computed tomography scans. The skeletal muscle tissue in the 325 ESCC patients was distributed as follows: mean: 47.10; median: 46.88; standard deviation (SD): 7.39; range: 31.48-71.11; interquartile range, 46.29-47.90. Skeletal muscle tissue was greater in male patients than in female patients (P < 0.0001), but was independent of other clinical and tumor features. Sarcopenia was not significantly associated with overall survival (log rank P = 0.54). Lymph node involvement significantly altered the relationship between sarcopenia and survival rate (P for interaction = 0.026). Sarcopenia significantly reduced the overall survival of patients without lymph node involvement (log rank P = 0.035), but was uncorrelated with overall survival in patients with lymph involvement (log rank, P = 0.31). The anastomosis leakage rate was significantly higher in the sarcopenia group than in the non-sarcopenia group (P = 0.032), but other surgical complications did not significantly differ between the two groups. Sarcopenia in ESCC patients without lymph node involvement is associated with poor prognosis, indicating sarcopenia as a potential biomarker for identifying patients likely to experience an inferior outcome. Moreover, sarcopenia was associated with anastomosis leakage but no other short-term surgical outcome.

Spatial and Temporal Brain Responses to Noxious Heat Thermal Stimuli in Burning Mouth Syndrome

Burning mouth syndrome (BMS) is an idiopathic orofacial pain condition. Although the pathophysiology of BMS is not clearly understood, central and peripheral neuropathic mechanisms are thought to be involved. The authors compared brain response to noxious heat stimuli in 16 right-handed women with primary BMS and 15 sex- and age-matched right-handed healthy female controls. A thermal stimulus sequence of 32 °C to 40 °C to 32 °C to 49 °C was repeated 4 times in a cycle. Warm and noxious heat stimuli were delivered with a Peltier thermode placed on the right palm or right lower lip for 32 s each in a session. Functional magnetic resonance imaging data were obtained by recording echoplanar images with a block design. Statistical Parametric Mapping 8 software was used to analyze the data. Patients and controls both reported feeling more pain during palm stimulation than during lip stimulation. Repetition of noxious heat stimulus on the lower lip but not on the palm induced habituation in brain activity in the cingulate cortex without reduction in pain perception. Multiple regression analysis revealed a correlation between perceived pain intensity and suppression of brain activity in the anterior cingulate cortex when the repeated thermal sequence was applied at the lower lip. Furthermore, the response of the parahippocampal area differed in BMS patients and controls when the same repeated thermal sequence was applied at the palm. The authors’ findings indicate that BMS patients show specific brain responses due to impaired function of the central and peripheral nervous systems (clinical trial registration: UMIN000015002).

The FRAX ® as a predictor of mortality in Japanese incident hemodialysis patients: an observational, follow-up study

The World Health Organization Fracture Risk Assessment Tool (FRAX(®)) was recently developed to estimate the 10-year absolute risk of osteoporotic fracture among the general population. However, the evidence for its use in chronic kidney disease patients has been lacking, and the association between the FRAX(®) and mortality is unknown. Therefore, a hospital-based, prospective, cohort study was conducted to evaluate the predictive ability of the FRAX(®) for mortality in hemodialysis patients. A total of 252 patients who had been started on maintenance hemodialysis, 171 men and 81 women, with a mean age of 67 ± 14 years, was studied. The endpoint was defined as all-cause death. The Cox proportional hazards model was used to calculate hazard ratios and 95 % confidence intervals. During the mean follow-up period of 3.4 ± 2.7 years, 61 deaths occurred. The median (interquartile range) of the FRAX(®) for major osteoporotic fracture was 6.9 (4.6-12.0) % in men and 19.0 (7.6-33.0) % in women. Cumulative survival rates at 5 years after starting dialysis, with the FRAX(®) levels above and below the median, were 51.9 and 87.9 %, respectively, in men and 67.4 and 83.7 %, respectively, in women. Overall, in men, the multivariate Cox regression analyses revealed that the log-transformed FRAX(®) remained an independent predictor of death after adjusting by confounding variables. However, in women, the significant association between the FRAX(®) value and the outcome was eliminated if age was put into these models. Among Japanese hemodialysis patients, the FRAX(®) seems to be useful for predicting death, especially in men.

Usefulness of an Upright T-Wave in Lead aVR for Predicting the Short-Term Prognosis of Incident Hemodialysis Patients: A Potential Tool for Screening High-Risk Hemodialysis Patients

BACKGROUND/AIMS

An upright T-wave in lead aVR (aVRT) has recently been reported to be associated with cardiovascular death and mortality among the general population and patients with prior cardiovascular disease (CVD). However, evidence for the predictive ability of aVRT in patients with chronic kidney disease is lacking. Therefore, a hospital-based, prospective, cohort study was conducted to evaluate the predictive ability of an upright aVRT for the short-term prognosis in incident hemodialysis patients.

METHODS

Among 208 patients who started maintenance hemodialysis, 79 with preexisting CVD (CVD cohort) and 129 with no history of CVD (non-CVD cohort), were studied. An upright and non-upright aVRT were defined as a wave with a positive deflection in amplitude of ≥0 mV and a negative deflection in amplitude of <0 mV, respectively. The endpoint was all-cause death.

RESULTS

Overall, the prevalence of an upright aVRT was 22.6% at baseline. During the mean follow-up period of 2.1 ± 1.0 years, 33 deaths occurred. Cumulative survival rates at 3 years after starting dialysis in patients with an upright and non-upright aVRT were 50.0 and 80.7%, respectively, in the CVD cohort and 92.0 and 91.3%, respectively, in the non-CVD cohort. In the CVD cohort, multivariate Cox regression analysis showed that an upright aVRT was an independent predictor of death after adjusting for confounding variables.

CONCLUSION

Among Japanese hemodialysis patients at high risk for CVD, an upright aVRT seems to be useful for predicting death.

Declining prevalence of coronary artery disease in incident dialysis patients over the past two decades

AIM

The medical management of patients with chronic kidney disease(CKD) has changed within the past 20 years. We speculate that this change has resulted in a decrease in the prevalence of atherosclerotic cardiovascular disease in patients with CKD. The aim of the present study was to analyze changes in the prevalence of coronary artery disease(CAD) in patients newly started on hemodialysis, as well as trends in clinical factors and medications over the past two decades.

METHODS

This single-center cross-sectional study examined data for 315 consecutive patients starting hemodialysis(age, 64±12 years; men, 73%; diabetic nephropathy, 57%) between January 1993 and December 2010. All patients were routinely screened for CAD within three months of starting hemodialysis, regardless of whether ischemic heart disease was suspected. The patients were categorized into six groups based on the date of the initial dialysis session in order to compare the historical prevalence of unidentified CAD(uCAD) in association with the clinical factors. In addition, we performed a subgroup analysis among 222 patients without known cardiac disease.

RESULTS

The prevalence of uCAD gradually declined from 69% to 25% over 18 years(p＜0.001 for trend). The mean high-density lipoprotein cholesterol(HDL-C) concentration increased(p＜0.001 for trend), while the median C-reactive protein(CRP) level decreased over time. In parallel with these trends, the proportion of statin users significantly increased over time(p＜0.001 for trend). The use of erythropoiesis-stimulating agents(ESAs) and renin angiotensin aldosterone system inhibitors(RAS-Is) also increased during the same period(both p＜0.001 for trend). A univariate logistic regression analysis identified a significant association between the prevalence of uCAD and the use of ESAs(OR: 0.565, p=0.016) or RAS-Is(OR: 0.501, p=0.004). In addition, a lower BMI, lower HDL-Clevel and higher CRP level were found to be closely associated with uCAD, independent of confounding variables. The findings for the new dialysis patients without cardiac disease were similar.

CONCLUSIONS

The prevalence of uCAD in patients with end-stage kidney disease has remarkably decreased over the past two decades. Major improvements in the medical management of CKD may modify the prevalence of coronary atherosclerosis.