Japanese society for dialysis therapy clinical guideline for "hemodialysis initiation for maintenance hemodialysis"

Association between periodontal condition and kidney dysfunction in Japanese adults: A cross-sectional study

Recent studies have demonstrated that chronic kidney disease (CKD) may be associated with the progression of periodontal disease. Diabetes mellitus (DM) is a major risk factor for CKD. The objective of this study was to clarify the relationship between periodontal condition and kidney dysfunction in patients who had kidney failure with or without DM. One hundred sixty-four patients with kidney dysfunction were enrolled (male: N = 105; female: N = 59), and the relationship between periodontal condition and kidney dysfunction was analyzed in a cross-sectional study. The subjects were divided into three groups: (a) patients with DM, (b) dialysis patients with nephropathy due to various kidney diseases, and (c) dialysis patient with nephropathy due to DM (diabetic nephropathy). Then, the effect of DM on the periodontal condition was analyzed. The patients were also stratified by CKD stage (into G1-G5) using the estimated glomerular filtration rate (eGFR), and the G5 group was divided in patients with or without DM. Correlations between eGFR and parameters of periodontal condition were calculated in patients from G1 to G4. The number of missing teeth was significantly higher in dialysis patients with diabetic nephropathy than in patients with DM, whereas alveolar bone loss did not show a significant difference among the three groups. In addition, the G5 patients with DM had a significantly higher number of missing teeth than the other CKD groups, whereas alveolar bone loss did not show a significant difference. In G5 patients with DM, Community Periodontal Index and Oral Hygiene Index scores were significantly higher than in G1-4 patients with DM. There was a significant negative correlation between eGFR and the number of missing teeth. Patients with diabetic nephropathy have a higher rate of periodontal problems such as missing teeth in Japanese adults.

A societal cost-of-illness study of hemodialysis in Lebanon

AIM

Renal failure is a growing public health problem, and is mainly treated by hemodialysis. This study aims to estimate the societal costs of hemodialysis in Lebanon.

METHODS

This was a quantitative, cross-sectional cost-of-illness study conducted alongside the Nutrition Education for Management of Osteodystrophy trial. Costs were assessed with a prevalence-based, bottom-up approach, for the period of June-December 2011. The data of 114 patients recruited from six hospital-based units were collected through a questionnaire measuring healthcare costs, costs to patients and family, and costs in other sectors. Recall data were used for the base-case analysis. Sensitivity analyses employing various sources of resources use and costs were performed. Costs were uprated to 2015US$. Multiple linear regression was conducted to explore the predictors of societal costs.

RESULTS

The mean 6-month societal costs were estimated at $9,258.39. The larger part was attributable to healthcare costs (91.7%), while costs to patient and family and costs in other sectors poorly contributed to the total costs (4.2% and 4.1%, respectively). In general, results were robust to sensitivity analyses. Using the maximum value for hospitalization resulted in the biggest difference (+15.5% of the base-case result). Female gender, being widowed/divorced, having hypertension comorbidity, and higher weekly time on dialysis were significantly associated with greater societal costs.

LIMITATIONS

Information regarding resource consumption and cost were not readily available. Rather, they were obtained from a variety of sources, with each having its own strengths and limitations.

CONCLUSION

Hemodialysis represents a high societal burden in Lebanon. Using extrapolation, its total annual cost for the Lebanese society is estimated at $61,105,374 and the mean total annual cost ($18,516.7) is 43.70% higher than the gross domestic product per capita forecast for 2015. Measures to reduce the economic burden of hemodialysis should be taken, by promoting chronic kidney disease's prevention and encouraging transplantation.

The Glomerular Filtration Rate (GFR) at Dialysis Initiation and Mortality in Chronic Kidney Disease (CKD) in East Asian Populations: A Meta-analysis

Objective The impact of dialysis initiation on survival is still somewhat controversial. Given that race or ethnicity has been observed to be a predictor of mortality and the rate of progression of chronic kidney disease, we conducted a meta-analysis to investigate the effect of early vs. late dialysis initiation on mortality in East Asian populations. Methods All eligible cohort studies of target were selected from the MEDLINE (PubMed), EMBASE, The Cochrane Library and the Clinical Trials Registry databases from inception to October 2014. The data were extracted with all-cause mortality rates as the primary outcome, and pooled adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. Results Ten studies examined the association between early vs. late dialysis initiation and mortality. Compared to late dialysis initiation, patients who received early dialysis initiation had a higher overall mortality risk (adjusted HR, 1.36; 95% CI, 1.0-1.85; p<0.05) in East Asian populations. In a subgroup analysis, baseline characteristic differences (adjusted HR, 2.0; 95%CI, 1.56-2.57; p<0.001), initial dialysis modalities (adjusted HR, 2.12; 95% CI, 1.72-2.62; p<0.001) and follow up duration (adjusted HR, 1.59; 95% CI, 1.19-2.12; p=0.002), demonstrated that the association between early dialysis initiation and mortality were significant. Conclusion A higher glomerular filtration rate (early) at the initiation of dialysis is associated with a higher all-cause mortality risk in East Asian populations.

Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices

More than 2 million people worldwide are being treated for end-stage kidney disease (ESKD). This Series paper provides an overview of incidence, modality use (in-centre haemodialysis, home dialysis, or transplantation), and mortality for patients with ESKD based on national registry data. We also present data from an international cohort study to highlight differences in haemodialysis practices that affect survival and the experience of patients who rely on this therapy, which is both life-sustaining and profoundly disruptive to their quality of life. Data illustrate disparities in access to renal replacement therapy of any kind and in the use of transplantation or home dialysis, both of which are widely considered preferable to in-centre haemodialysis for many patients with ESKD in settings where infrastructure permits. For most patients with ESKD worldwide who are treated with in-centre haemodialysis, overall survival is poor, but longer in some Asian countries than elsewhere in the world, and longer in Europe than in the USA, although this gap has reduced. Commendable haemodialysis practice includes exceptionally high use of surgical vascular access in Japan and in some European countries, and the use of longer or more frequent dialysis sessions in some countries, allowing for more effective volume management. Mortality is especially high soon after ESKD onset, and improved preparation for ESKD is needed including alignment of decision making with the wishes of patients and families.

Physical function at the time of dialysis initiation is associated with subsequent mortality

BACKGROUND

In dialysis patients, physical function is associated with mortality. However, the association between physical function at the time of dialysis initiation and subsequent mortality remains unknown.

METHODS

A total of 1496 patients with chronic kidney disease who initiated dialysis at 17 centers participating in the Aichi Cohort Study of the Prognosis in Patients Newly Initiated into Dialysis, a multicenter prospective cohort study, were included. The patients were divided into the high (H)-, middle (M)-, and low (L)-score groups according to Barthel index (BI) at the time of dialysis initiation, and the all-cause, cardiovascular disease (CVD)-related, and infection-related mortality rates were compared. Moreover, factors affecting all-cause mortality were investigated. The effects of BI on mortality were assessed in the patients stratified by age, sex, and history of CVD or cerebral infarction.

RESULTS

A log-rank test for the Kaplan-Meier survival curve showed significant differences between the three groups in all-cause, CVD-related, and infection-related mortality rates (p < 0.001). Cox proportional hazard regression analysis with the step-wise method showed a significantly higher risk of all-cause mortality in the M and L groups than in the H group (M group: HR 1.612, 95 % CI 1.075-2.417; L group: HR 1.994, 95 % CI 1.468-2.709). Regardless of the age categories and the history of CVD, the risk of all-cause mortality was significantly higher in the L group than in the H group.

CONCLUSION

Physical function assessed by BI at the time of dialysis initiation was found to be associated with subsequent mortality.

Relationship between mortality and speed of eGFR decline in the 3 months prior to dialysis initiation

BACKGROUND

The timing for initiating dialysis in chronic kidney disease is often determined by the clinical symptoms and estimated glomerular filtration rate (eGFR). However, very few studies have examined how the speed of kidney function decline before initiating dialysis relates to mortality after dialysis initiation. Here, we report our examination of the relationship between the speed of eGFR decline in the 3 months prior to dialysis initiation and mortality.

METHODS

The study included 1292 new dialysis patients who were registered in the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis. The subjects were placed in 4 groups based on the speed of eGFR decline in the 3 months before initiating dialysis (eGFR at 3 months before initiation-eGFR at initiation) <2: ≥2, <4: ≥4, <6: ≥6 mL/min/1.73 m². All-cause, cardiovascular, and infection-related mortality rates were compared using Kaplan-Meier curves. A multivariate analysis using the Cox proportional hazard model was used to extract the factors that contributed to all-cause mortality.

RESULTS

The group with faster eGFR decline exhibited significantly more heart failure symptoms when dialysis was initiated. Rapid eGFR decline correlated with prognosis (log-rank test: all-cause mortality p < 0.001, cardiovascular mortality p < 0.001). The speed of eGFR decline was related to elevated all-cause mortality rates [eGFR decline 10 mL/min/1.73 m², HR (95 % CI) = 1.53 (1.12-2.08)].

CONCLUSIONS

This study showed that patients with rapid eGFR decline in the 3 months before initiating dialysis more often presented with heart failure symptoms when dialysis was initiated and had poorer survival prognoses.

Significance of the decreased risk of dialysis-related amyloidosis now proven by results from Japanese nationwide surveys in 1998 and 2010

BACKGROUND

Although dialysis technology greatly improved in recent years, it remained unclear whether those improvements helped decrease the incidence of dialysis-related amyloidosis (DRA). Accordingly, we retrospectively compared the incidence of first-time carpal tunnel surgery (CTS)-as proxy for DRA onset-in two cohorts of chronic hemodialysis patients, with the second cohort studied after dialysis methods (especially dialyzate quality control) had greatly improved.

METHODS

We used the 1998 and 2010 Japan Renal Data Registries to compare crude risk of first-time CTS the following year. After adjusting for patient background and laboratory data, odds ratios (ORs) for CTS in the whole cohorts and the populations matched by propensity score (PS) for hemodialysis and hemodiafiltration were calculated at a 95% confidence interval.

RESULTS

Of note, 2 02 726 patients were analyzed. In the 1998 cohort, 1.77% experienced first-time CTS compared with 1.30% of the 2010 cohort (P < 0.001); with 2010 as referent, the adjusted 1998 OR was 2.22 (1.68-2.95). Both crude risks and adjusted ORs were analyzed by dialysis vintage, age, pre-dialysis β2-microglobulin (β2m) and β2m clearance, risk of CTS trending 1.5-2.0 higher in 1998 than 2010. The reduction was most prominent in patients with longer dialysis vintage, patients who were younger, and those with lower pre-dialysis β2m levels. Similar results were obtained by PS-matched analysis. We also found that β2m clearance >80% may reduce risk of CTS.

CONCLUSIONS

The incidence of first-time CTS as proxy for DRA decreased significantly from 1998 to 2010. Several factors may have contributed to this decrease, including improved dialysis methods.