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Curtis KA, Waikar SS, Mc Causland FR. Higher NT-proBNP levels and the risk of intradialytic hypotension at hemodialysis initiation. Hemodial Int 2024; 28:77-84. [PMID: 37875429 DOI: 10.1111/hdi.13125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Elevated N-terminal pro B-type natriuretic peptide (NT-proBNP) is a potent predictor of adverse outcomes in hemodialysis initiation. These patients often experience intradialytic hypotension, which may partially reflect cardiac dysfunction, but the association of NT-proBNP with intradialytic hypotension is not clear. METHODS We performed a post hoc analysis of a randomized trial that tested mannitol versus placebo in 52 patients initiating hemodialysis (NCT01520207). NT-proBNP was measured prior to the first and third sessions (n = 87). Mixed-effects models (adjusting for randomized treatment, sex, race, age, diabetes, heart failure, catheter use, pre-dialysis systolic blood pressure, pre-dialysis weight, ultrafiltration volume, serum sodium, bicarbonate, urea nitrogen, phosphate, albumin, hemoglobin, and session length) were fit to examine the association of NT-proBNP with systolic blood pressure decline (pre-dialysis minus nadir systolic blood pressure). Additionally, mixed-effects Poisson models were fit to examine the association with intradialytic hypotension (≥20 mmHg decline in systolic blood pressure). FINDINGS Mean age was 55 ± 16 years; 33% had baseline heart failure. The median NT-proBNP was 5498 [25th-75th percentile 2011, 14,790] pg/mL; 26 sessions (30%) were complicated by intradialytic hypotension. In adjusted models, each unit higher log-NT-proBNP was associated with 6.0 mmHg less decline in systolic blood pressure (95%CI -9.2 to -2.8). Higher pre-dialysis NT-proBNP, per log-unit, was associated with a 52% lower risk of intradialytic hypotension (IRR 0.48, 95%CI 0.23-0.97), without evidence for effect modification by randomized treatment (P-interaction = 0.17). DISCUSSION In patients initiating hemodialysis, higher NT-proBNP is associated with less decline in intradialytic systolic blood pressure and lower risk of intradialytic hypotension. Future studies should investigate if higher pre-dialysis NT-proBNP levels may identify patients who might tolerate more aggressive ultrafiltration.
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Affiliation(s)
- Katherine A Curtis
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Milken Institute School of Public Health, The George Washington University, Washington DC, USA
| | - Sushrut S Waikar
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Finnian R Mc Causland
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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2
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Hazara AM, Bhandari S. Age, Gender and Diabetes as Risk Factors for Early Mortality in Dialysis Patients: A Systematic Review. Clin Med Res 2021; 19:54-63. [PMID: 33582647 PMCID: PMC8231690 DOI: 10.3121/cmr.2020.1541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 10/11/2020] [Accepted: 12/11/2020] [Indexed: 02/07/2023]
Abstract
Objective: To study the impact of age, gender, and presence of diabetes (any type) on the risk of early deaths (180-day mortality) in patients starting long-term hemodialysis (HD) therapy.Design: Systematic review of the literature.Setting: Out-patient (non-hospitalized), community-based HD therapy world-wide.Participants: Patients with advanced chronic kidney disease (CKD) starting long-term HD treatment for end-stage renal disease (ESRD).Methods: Medline and EMBASE were searched for studies published between 1/1/1985 and 12/31/2017. Observational studies involving adult subjects commencing HD were included. Data extracted included population characteristics and settings. In addition, patient or treatment related factors studied with reference to their relationship with the risk of early mortality were documented. The Quality in Prognosis Studies tool was used to assess risk of bias in individual studies. Findings were summarized, and a narrative account was drawn.Results: Included were 26 studies (combined population 1,098,769; representing 287,085 person-years of observation for early mortality). There were 17 cohort and 9 case-control studies. Risk of bias was low in 13 and high in a further 13 studies. Patients who died in the early period were older than those who survived. Mortality rates increased with advancing age. Female gender was associated with slightly increased early mortality rates in larger and higher quality studies. The available data showed conflicting results in relation to the association of diabetes and risk of early mortality.Conclusions: This systematic review evaluated the impact of key demographic and co-morbid factors on risk of early mortality in patients starting maintenance HD. The information could help in delivering more tailored prognostic information and planning of future interventions.
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Affiliation(s)
- Adil M Hazara
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
- Hull York Medical School, Hull, United Kingdom
| | - Sunil Bhandari
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
- Hull York Medical School, Hull, United Kingdom
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3
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Guo JCL, Pan HC, Yeh BY, Lu YC, Chen JL, Yang CW, Chen YC, Lin YH, Chen HY. Associations Between Using Chinese Herbal Medicine and Long-Term Outcome Among Pre-dialysis Diabetic Nephropathy Patients: A Retrospective Population-Based Cohort Study. Front Pharmacol 2021; 12:616522. [PMID: 33679399 PMCID: PMC7930622 DOI: 10.3389/fphar.2021.616522] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/21/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Chronic kidney disease (CKD) has become a worldwide burden due to the high co-morbidity and mortality. Diabetic nephropathy (DN) is one of the leading causes of CKD, and pre-dialysis is one of the most critical stages before the end-stage renal disease (ESRD). Although Chinese herbal medicine (CHM) use is not uncommon, the feasibility of using CHM among pre-dialysis DN patients remains unclear. Materials and methods: We analyzed a population-based cohort, retrieved from Taiwan’s National Health Insurance Research Database, to study the long-term outcome of using CHM among incident pre-dialysis DN patients from January 1, 2004, to December 31, 2007. All patients were followed up to 5 years or the occurrence of mortality. The risks of all-cause mortality and ESRD were carried out using Kaplan-Meier and competing risk estimation, respectively. Further, we demonstrated the CHM prescriptions and core CHMs using the Chinese herbal medicine network (CMN) analysis. Results: A total of 6,648 incident pre-dialysis DN patients were analyzed, including 877 CHM users and 5,771 CHM nonusers. With overlap weighing for balancing all accessible covariates between CHM users and nonusers, we found the use of CHM was associated with lower all-cause mortality (0.22 versus 0.56; log-rank test: p-value <0.001), and the risk of mortality was 0.42 (95% CI: 0.36–0.49; p-value <0.001) by adjusting all accessible covariates. Further, the use of CHM was associated with a lower risk of ESRD (cause-specific hazard ratio: 0.59, 95%CI: 0.55–0.63; p-value <0.001). Also, from the 5,901 CHM prescriptions, we found Ji-Sheng-Shen-Qi-Wan, Astragalus mongholicus Bunge or (Astragalus membranaceus (Fisch.) Bge.), Plantago asiatica L. (or Plantago depressa Willd.), Salvia miltiorrhiza Bunge, and Rheum palmatum L. (or Rheum tanguticum (Maxim. ex Regel) Balf., Rheum officinale Baill.) were used as core CHMs for different CHM indications. Use of core CHMs was associated with a lower risk of mortality than CHM users without using core CHMs. Conclusions: The use of CHM seemed feasible among pre-dialysis DN patients; however, the beneficial effects still need to be validated by well-designed clinical trials.
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Affiliation(s)
- Jenny Chun-Ling Guo
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Heng-Chih Pan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Bo-Yan Yeh
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yen Chu Lu
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jiun-Liang Chen
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Wei Yang
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chun Chen
- School of Medicine, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsuan Lin
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsing-Yu Chen
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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4
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Varughese S, Agarwal SK, Raju TR, Khanna T. Options of Renal Replacement Therapy in CKDu. Indian J Nephrol 2020; 30:261-263. [PMID: 33273791 PMCID: PMC7699668 DOI: 10.4103/ijn.ijn_396_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/08/2020] [Accepted: 07/03/2020] [Indexed: 11/17/2022] Open
Abstract
Patients with advanced Chronic Kidney Disease of Unknown origin (CKDu) need to plan for renal replacement therapy. The patients usually affected are probably best served with living-related renal transplantation. Potential donors from the same area are possibly at risk for developing CKDu and need close monitoring post kidney donation. Peritoneal dialysis (PD) is probably a better option as hemodialysis (HD) centers are located in urban areas only and patients have the convenience of receiving therapy at home. The “PD first” pilot project of Sri Lanka is a unique initiative that trains community physicians to offer PD to patients with advanced CKDu. In Telengana and Andhra Pradesh, the Aarogyasri insurance scheme provides for poor patients to avail of free HD and transplantation in government and private hospitals. Much more needs to be done to care for all those who are affected. A public–private partnership model for providing comprehensive care to patients with advanced CKDu can be undertaken in all areas affected by CKDu that makes renal replacement therapy (RRT) available and accessible, irrespective of financial and social limitations.
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Affiliation(s)
- Santosh Varughese
- Professor and Head of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjay K Agarwal
- Professor and Head of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - T Ravi Raju
- Dr. N.T.R. University of Health Sciences, Vijayawada, Andhra Pradesh, India
| | - Tripti Khanna
- Division of NCD, Indian Council of Medical Research (ICMR), New Delhi, India
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5
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Li PKT, Law MC, Chow KM, Leung CB, Kwan BCH, Chung KY, Szeto CC. Good Patient and Technique Survival in Elderly Patients on Continuous Ambulatory Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080702702s34] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The aging population has significant implications for the community. The increasing number of elderly end-stage renal disease (ESRD) patients presses the renal team to find an appropriate management plan. We used a retrospective analysis to study the effectiveness of continuous ambulatory peritoneal dialysis (CAPD) in elderly ESRD patients. Of the 328 CAPD patients recruited for the study, 121 were in the elderly group (≥ 65 years of age), and 207 were in the control group (under 65 years of age). Median age in the elderly group was 71 years, and in the control group, 51 years. The elderly group had a higher prevalence (54.5%) of diabetes mellitus. The 2-year and 5-year rates of patient survival were 89.3% and 54.8% respectively in the elderly group and 92.2% and 62.9% in the control group ( p = 0.19). The 2-year and 5-year rates of technique survival were 84.0% and 45.7% respectively in the elderly group and 80.9% and 49.1% in the control group ( p = 0.75). The probability of a 12-month peritonitis-free period was 76.6% in the elderly group and 76.5% in the control group ( p = 0.75). One hundred elderly patients (82.6% of the group) performed their CAPD exchanges by themselves. We observed no significant difference in clinical outcome—including patient survival, technique survival, and peritonitis-free period—between the elderly self-care CAPD and the elderly assisted CAPD groups. In elderly ESRD patients, CAPD is an effective dialysis modality. A slightly longer training time is to be expected for elderly patients. Self-care CAPD for elderly patients who are capable of performing their own exchanges provides them with an independent home life.
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Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Man Ching Law
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Kai Ming Chow
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Chi-Bon Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Bonnie Ching-Ha Kwan
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Kwok Yi Chung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China
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6
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Chung SH, Lindholm B, Lee HB. Influence of Initial Nutritional Status on Continuous Ambulatory Peritoneal Dialysis Patient Survival. Perit Dial Int 2020. [DOI: 10.1177/089686080002000105] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives To evaluate the influence of initial nutritional status on continuous ambulatory peritoneal dialysis (CAPD) patient survival and to identify factors determining initial nutritional status and patient mortality. Design Prospective single-center study. Setting Kidney Center, Soon Chun Hyang University Hospital. Patients A total of 91 consecutive CAPD patients, who underwent initial nutritional assessment at Soon Chun Hyang University Hospital, Seoul, Korea, between September 1994 and January 1999, was included in this study. All patients were assessed at a mean of 7 days after beginning CAPD (range 3 – 24 days). Forty-eight patients were male, 50 were diabetics, and their mean age was 53.9 years (range 22 – 76 years). Methods Nutritional status was assessed by subjective global assessment (SGA), biochemical and anthropometric measurements, fat-free edema-free (FFEF) body mass by creatinine kinetics, urea kinetic studies, and calculation of the normalized protein equivalent of total nitrogen appearance (nPNA). Results By SGA, 55% were classified as having normal nutrition while 45% had signs of malnutrition; 61% of female and 31% of male patients, and 54% of diabetics and 34% of nondiabetics were classified as malnourished. Initial FFEF body mass, blood urea nitrogen (BUN), serum albumin (sAlb), residual renal function (RRF), and weekly total creatinine clearance were significantly lower in the malnourished patients than in the patients with normal nutrition. On multiple regression analysis, only FFEF body mass was an independent determinant of SGA score. On 31 January 1999, 41 patients were still on CAPD, 15 patients had died, and 27 patients had been transferred to hemodialysis. Those who died during observation were older and had lower initial FFEF body mass, % lean body mass, BUN, sAlb, RRF, and SGA score. The 2-year patient survival rate was significantly lower in the malnourished than in normal patients (67.1% vs 91.7%, p = 0.02). On Cox proportional hazards analysis, initial age, malnutrition assessed by SGA, and FFEF body mass were identified as factors determining death. Conclusion Malnutrition was present in 45% of patients commencing CAPD when assessed by SGA. Initial FFEF body mass was a determinant of SGA score and predicted death. Malnutrition as assessed by SGA was also an independent predictor of death. Initial nutritional status, therefore, appears to exert a powerful influence on CAPD patient survival.
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Affiliation(s)
- Sung Hee Chung
- Hyonam Kidney Laboratory, Soon Chun Hyang University Hospital, Seoul, Korea
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Hi Bahl Lee
- Hyonam Kidney Laboratory, Soon Chun Hyang University Hospital, Seoul, Korea
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7
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Agrawal A, Saran R, Nolph KD. Continuum and Integration of Pre-Dialysis Care and Dialysis Modalities. Perit Dial Int 2020. [DOI: 10.1177/089686089901902s46] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alok Agrawal
- Division of Nephrology, Department of Internal Medicine, University of Missouri Health Sciences Center, and Dalton Cardiovascular Research Center, Columbia, Missouri, U.S.A
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Missouri Health Sciences Center, and Dalton Cardiovascular Research Center, Columbia, Missouri, U.S.A
| | - Karl D. Nolph
- Division of Nephrology, Department of Internal Medicine, University of Missouri Health Sciences Center, and Dalton Cardiovascular Research Center, Columbia, Missouri, U.S.A
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8
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Lameire N, Van Biesen W, Dombros N, Dratwa M, Faller B, Gahl GM, Gokal R, Krediet RT, La Greca G, Maiorca R, Matthys E, Ryckelynck JP, Selgas R, Walls J. The Referral Pattern of Patients with Esrd is a Determinant in the Choice of Dialysis Modality. Perit Dial Int 2020. [DOI: 10.1177/089686089701702s32] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Nicholas Dombros
- Renal Division, AHEPA Aristotelian University Hospital, Thessaloniki, Greece
| | - Max Dratwa
- Renal Division, Brugmann Hospital, Brussels, Belgium
| | | | - Gerhard M. Gahl
- Department of Nephrology and Medical Intensive Care, Rudolf Virchow University Hospital, Berlin, Germany
| | - Ram Gokal
- Renal Division, Manchester Royal Infirmary, Manchester, England
| | - Raymond T. Krediet
- Renal Unit, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Rosario Maiorca
- Division of Nephrology, University of Brescia, Brescia, Italy
| | - Erve Matthys
- Renal Division, St. Jan Hospital, Bruges, Belgium
| | | | - Rafael Selgas
- Renal Division, University Hospital, La Paz, Madrid, Spain
| | - John Walls
- Renal Division, Leicester General Hospital, Leicester, England
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9
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Harris SA, Lamping DL, Brown EA, Constantinovici N. Clinical outcomes and Quality of Life in Elderly Patients on Peritoneal Dialysis versus Hemodialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080202200404] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
♦ Objective To compare clinical outcomes and quality of life (QOL) in elderly patients on peritoneal dialysis (PD) and hemodialysis (HD) in the North Thames Dialysis Study. ♦ Design A 12-month prospective cohort study. ♦ Setting Four hospital-based renal units in London, UK. ♦ Patients 174 patients that were 70 years or older at the start of dialysis, separated into two cohorts: 78 new patients (36 PD, 42 HD) that were recruited after 90 days of chronic dialysis; and 96 stock patients (42 PD, 54 HD) that were already on dialysis during the recruitment period. ♦ Main Outcome Measures 12-month survival and hospitalization rate, and QOL assessed at baseline and at 6 and 12 months by the SF-36 and the Symptoms/Problems scale of the Kidney Disease Quality of Life Questionnaire (KDQOL). ♦ Results Peritoneal dialysis and HD patients were similar for sociodemographic and clinical characteristics. Annual mortality and hospitalization rates in PD versus HD patients were 26.1 versus 26.4 deaths/100 person–years and 1.9 versus 2.0 admissions/person–year, respectively. Adjusted relative risks showed no effect of modality on clinical outcomes. Multiple linear regression analyses of QOL at baseline showed similar SF-36 scores between PD and HD patients, but higher KDQOL scores in PD patients (3.5 points higher, 95% confidence interval 0.3 – 6.6). There was, however, no effect of dialysis modality on QOL at 6 or 12 months. ♦ Conclusions Clinical outcomes and QOL are similar in elderly people on PD and HD. Peritoneal dialysis is a viable option for more than a carefully selected minority of elderly people requiring dialysis.
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Affiliation(s)
| | - Susan A.C. Harris
- Department of Renal Medicine, Charing Cross Hospital, Royal Free and University College Medical School, London, United Kingdom
| | - Donna L. Lamping
- Health Services Research Unit, London School of Hygiene & Tropical Medicine, Royal Free and University College Medical School, London, United Kingdom
| | - Edwina A. Brown
- Department of Renal Medicine, Charing Cross Hospital, Royal Free and University College Medical School, London, United Kingdom
| | - Niculae Constantinovici
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, United Kingdom
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10
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Mircescu G, Garneata L, Florea L, Cepoi V, Capsa D, Covic M, Gherman–Caprioara M, Gluhovschi G, Golea OS, Barbulescu C, Rus E, Santimbrean C, Mardare N, Covic A. The Success Story of Peritoneal Dialysis in Romania: Analysis of Differences in Mortality by Dialysis Modality and Influence of Risk Factors in a National Cohort. Perit Dial Int 2020. [DOI: 10.1177/089686080602600224] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background This report describes the status of renal replacement therapy (RRT), particularly continuous ambulatory peritoneal dialysis (CAPD), in Romania (a country with previously limited facilities), outlines the fast development rate of CAPD, and presents national changes in a European context. Methods Trends in the development of RRT were analyzed in 2003 on a national basis using annual center questionnaires from 1995 to 2003. Survival data and prognostic risk factors were calculated retrospectively from a representative sample of 2284 patients starting RRT between 1 January 1995 and 31 December 2001 (44% of the total RRT population investigated). Results The annual rate of increase in the number of RRT patients (11%) was supported mainly by an exponential development of the CAPD population (+600%); the hemodialysis (HD) growth rate was stable (+33%) and renal transplantation had a marginal contribution. The characteristics of both HD and PD incident patients changed according to current European epidemiology (increasing age and prevalence of diabetes and nephroangiosclerosis). There were significant differences between PD and HD incident populations, PD patients being significantly older and having a higher prevalence of diabetic nephropathy and baseline comorbidities, probably reflecting different inclusion policies. The estimated overall survival of RRT patients in Romania was 90.6% at 1 year [confidence interval (CI) 89.4 – 91.8] and 62.2% at 5 years (CI 59.4 – 65.0). The initial treatment modality did not significantly influence patients’ survival. There was no difference in unadjusted technique survival during the first 2 years; afterwards, there was a clear advantage for HD, with more patients being transferred from PD to HD. Several factors seemed to significantly and negatively influence PD patients’ survival (Cox regression analysis): male gender, lack of predialysis erythropoietin treatment, and initial comorbidities. Stratified analysis to discover the influence of these factors on patients’ survival revealed that HD was associated with an increased risk of death in the younger nondiabetic end-stage renal disease population, regardless of other coexisting comorbid conditions. However, in older patients (>65 years) and in diabetics, regardless of the presence or absence of associated comorbid conditions, there was no significant difference in death rates between HD and PD patients. Conclusions We report an impressive quantitative and qualitative development of CAPD in one of the rapidly growing Central and Eastern Europe countries. CAPD should be the method of choice for young nondiabetic end-stage renal disease patients. Improvement in predialysis nephrologic care and in transplantation rates is required to further ensure the ultimate success of the Romanian PD program.
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Affiliation(s)
- Gabriel Mircescu
- “Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest
- Romanian Renal Registry, Romania
| | | | - Laura Florea
- Dialysis and Transplantation Center, “C.I. Parhon” University Hospital, Iasi
| | - Vasile Cepoi
- Dialysis and Transplantation Center, “C.I. Parhon” University Hospital, Iasi
| | | | - Maria Covic
- Dialysis and Transplantation Center, “C.I. Parhon” University Hospital, Iasi
- Romanian Renal Registry, Romania
| | | | | | | | | | - Elvira Rus
- “Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest
| | | | - Nicoleta Mardare
- Dialysis and Transplantation Center, “C.I. Parhon” University Hospital, Iasi
| | - Adrian Covic
- Dialysis and Transplantation Center, “C.I. Parhon” University Hospital, Iasi
- Romanian Renal Registry, Romania
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11
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Herrera-Añazco P, Ortiz PJ, Peinado JE, Tello T, Valero F, Hernandez AV, Miranda JJ. In-hospital mortality among incident hemodialysis older patients in Peru. Int Health 2020; 12:142-147. [PMID: 31294777 PMCID: PMC7057138 DOI: 10.1093/inthealth/ihz037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/08/2018] [Accepted: 04/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Understanding the pattern of mortality linked to end stage renal disease (ESRD) is important given the increasing ageing population in low- and middle-income countries. METHODS We analyzed older patients with ESRD with incident hemodialysis, from January 2012 to August 2017 in one large general hospital in Peru. Individual and health system-related variables were analyzed using Generalized Linear Models (GLM) to estimate their association with in-hospital all-cause mortality. Relative risk (RR) with their 95% confidence intervals (95% CI) were calculated. RESULTS We evaluated 312 patients; mean age 69 years, 93.6% started hemodialysis with a transient central venous catheter, 1.7% had previous hemodialysis indication and 24.7% died during hospital stay. The mean length of stay was 16.1 days (SD 13.5). In the adjusted multivariate models, we found higher in-hospital mortality among those with encephalopathy (aRR 1.85, 95% CI 1.21-2.82 vs. without encephalopathy) and a lower in-hospital mortality among those with eGFR ≤7 mL/min (aRR 0.45, 95% CI 0.31-0.67 vs. eGFR>7 mL/min). CONCLUSIONS There is a high in-hospital mortality among older hemodialysis patients in Peru. The presence of uremic encephalopathy was associated with higher mortality and a lower estimated glomerular filtration rate with lower mortality.
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Affiliation(s)
- Percy Herrera-Añazco
- Universidad San Ignacio de Loyola, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru.,Departamento de Nefrologia, Hospital Nacional 2 de Mayo, Lima, Peru
| | - Pedro J Ortiz
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jesus E Peinado
- Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Tania Tello
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Fabiola Valero
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Adrian V Hernandez
- University of Connecticut/Hartford Hospital Evidence-based Practice Center, Hartford, CT, USA.,Universidad San Ignacio de Loyola, Unidad de Revisiones Sistemáticas y Meta anáñisis, Guias de Práctica Clínica y Evaluaciones Tecnológicas Sanitarias, Lima, Peru
| | - J Jaime Miranda
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru.,CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
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12
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Hazara AM, Bhandari S. Early Mortality Rates After Commencement of Maintenance Hemodialysis: A Systematic Review and Meta-Analysis. Ther Apher Dial 2019; 24:275-284. [PMID: 31574577 DOI: 10.1111/1744-9987.13437] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/10/2019] [Accepted: 09/17/2019] [Indexed: 12/13/2022]
Abstract
Mortality rates are reported to be high soon after the commencement of maintenance HD for ESRD. Our aim was to estimate early mortality rates (deaths within 180 days of starting therapy), through a systematic review of literature, in this patient population. Medline and EMBASE were searched for publications between 1 January 1985 and 31 December 2017. Observational studies reporting deaths involving adults commencing HD were included. The Quality in Prognosis Studies tool was used to assess risk of bias in studies. Crude mortality rates (expressed in 100 person-years) and age-standardized mortality ratios (SMR) were calculated. Meta-analyses of these rates were conducted for studies with lowest risk of bias (i.e. highest quality). In total, 32 studies were included (combined population: 1 083 264) representing 283 277 person-years of observation; median follow-up: 90 days. Mortality rates ranged between 12.8 and 55.6 per 100 person-years. Cardiovascular causes accounted for the majority of early deaths. Meta-analysis of high-quality studies showed an overall crude mortality rate of 32.6 per 100 person-years (95% CI 32.4-32.8). This equates to 16.3% mortality in first 180 days of starting HD. Six high-quality studies contained sufficient data for calculation of SMR. Meta-analysis of SMRs showed that patients starting HD therapy sustain 8.8 times higher mortality rates compared to the general population. We have combined the results of high-quality studies to produce new estimates of early mortality rates after commencement of HD therapy. This information can help relay more reliable prognostic information to this patient population.
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Affiliation(s)
- Adil M Hazara
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK.,Hull York Medical School, Hull, UK
| | - Sunil Bhandari
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK.,Hull York Medical School, Hull, UK
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13
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Wojtaszek E, Grzejszczak A, Grygiel K, Małyszko J, Matuszkiewicz-Rowińska J. Urgent-Start Peritoneal Dialysis as a Bridge to Definitive Chronic Renal Replacement Therapy: Short- and Long-Term Outcomes. Front Physiol 2019; 9:1830. [PMID: 30662408 PMCID: PMC6328466 DOI: 10.3389/fphys.2018.01830] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/06/2018] [Indexed: 01/28/2023] Open
Abstract
Background: The peritoneal dialysis (PD) urgent-start pathway, without typical 2-week break-in period, was meant for late-referral patients able and prone to join PD-first program, with its main advantages such as: keeping the vascular system intact, preserving their residual renal function and retaining life-style flexibility. We compared the short- and long-term outcomes of consecutive 35 patients after urgent- and 94 patients after the planned start of PD as the first choice. Methods: The study included all incident end-stage renal disease patients starting PD program between January 2005 and December 2015, classified into two groups: those with urgent (unplanned) and those with elective (planned) start. Urgent PD was initiated as an overnight automatic procedure (APD) with dwell volume gradually increased, and after 2–3 weeks, target PD method was established. Results: The mean time between catheter implantation and PD start was 3.5 ± 2.3 in urgent and 16.2 ± 1.7 days in planned-start groups (p < 0.00001). 51% of the patients in the urgent-start group required PD during first 48 h after catheter insertion. Mean follow-up of 17.6 ± 11.09 months (median: 19.0) was in the urgent-start group and 28.6 ± 26.6 months (median: 19.5) in the planned-start group. The early mechanical complications were observed more often in the urgent-start group (29 vs. 4%, p = 0.00005). The only significant predictors of early mechanical complications were serum albumin (p = 0.02) and time between the catheter insertion and PD start. The first year patient survival and technique survival censored for death and kidney transplantation were not significantly different between groups. In Cox proportional analysis the independent risk factors for patient survival as well as for method and patient survival appeared Charlson Comorbidity Index CCI (HR 1.4; p = 0.01 and 1.24; p = 0.02) and time from catheter implantation to PD start with HR 5.11; p = 0.03 and 4.29; p = 0.04 for <2 days, while time >14 days lost its predictive value (p = 0.07). Conclusion: Peritoneal dialysis may be a feasible and safe alternative to HD in patients who need to start dialysis urgently without established dialysis access, with an acceptable complications rates, as well as patient and technique survival.
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Affiliation(s)
- Ewa Wojtaszek
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Agnieszka Grzejszczak
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Katarzyna Grygiel
- Department of General, Vascular and Transplant Surgery, Warsaw Medical University, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
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14
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Early mortality in patients with chronic kidney disease who started emergency haemodialysis in a Peruvian population: Incidence and risk factors. Nefrologia 2018; 38:425-432. [PMID: 30032858 DOI: 10.1016/j.nefro.2017.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 09/04/2017] [Accepted: 11/09/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To estimate early mortality in patients with chronic kidney disease who started emergency haemodialysis between 2012 and 2014 in a national referral hospital in Lima, Peru, and to identify risk factors. DESIGN, CHARACTERISTICS, PARTICIPANTS AND MEASUREMENTS A retrospective cohort study was conducted by reviewing the medical records of all patients admitted to the hospital's Haemodialysis Unit from 2012 to 2014. Early mortality, defined as death within the first 90 days of starting haemodialysis, as well as age, gender, chronic kidney disease aetiology, comorbidities, cause of death, estimated glomerular filtration rate, vascular access and other variables were evaluated in patients who initiated emergency haemodialysis. Early mortality was estimated using frequencies and risk factors were determined by Poisson regression with robust variance. RESULTS 43.4% of patients were female, 51.5% were aged≥65 years and the early mortality rate was 9.3%. The main risk factors were estimated glomerular filtration rate>10 ml/min/1.73m2 (RR: 2.72 [95% CI: 1.60-4.61]); age≥65 years (RR: 2.51 [95% CI: 1.41-4.48]); central venous catheter infection, RR: 2.25 (95% CI: 1.08-4.67); female gender, RR: 2.15 (95% CI: 1.29-3.58); and albumin<3.5g/dl (RR: 1.97 [95% CI: 1.01-3.82]). CONCLUSIONS Early mortality was 9.3%. The main risk factor was starting haemodialysis with an estimated glomerular filtration rate>10ml/min/1.73m2.
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15
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Lee BJ, Hsu CY, Parikh RV, Leong TK, Tan TC, Walia S, Liu KD, Hsu RK, Go AS. Non-recovery from dialysis-requiring acute kidney injury and short-term mortality and cardiovascular risk: a cohort study. BMC Nephrol 2018; 19:134. [PMID: 29890946 PMCID: PMC5996504 DOI: 10.1186/s12882-018-0924-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023] Open
Abstract
Background The high mortality and cardiovascular disease (CVD) burden in patients with end-stage renal disease (ESRD) is well-documented. Recent literature suggests that acute kidney injury is also associated with CVD. It is unknown whether patients with incident ESRD due to dialysis-requiring acute kidney injury (AKI-D) are at higher short-term risk for death and CVD events, compared with incident ESRD patients without preceding AKI-D. Few studies have examined the impact of recovery from AKI-D on subsequent CVD risk. Methods In this retrospective cohort study, we evaluated adult members of Kaiser Permanente Northern California who initiated dialysis from January 2009 to September 2015. Preceding AKI-D and subsequent outcomes of death and CVD events (acute coronary syndrome, heart failure, ischemic stroke or transient ischemic attack) were identified from electronic health records. We performed multivariable Cox regression models adjusting for demographics, comorbidities, medication use, and laboratory results. Results Compared to incident ESRD patients who experienced AKI-D (n = 1865), patients with ESRD not due to AKI-D (n = 3772) had significantly lower adjusted rates of death (adjusted hazard ratio [aHR] 0.56, 95% CI: 0.47–0.67) and heart failure hospitalization (aHR 0.45, 0.30–0.70). Compared to AKI-D patients who did not recover and progressed to ESRD, AKI-D patients who recovered (n = 1347) had a 30% lower adjusted relative rate of death (aHR 0.70, 0.55–0.88). Conclusions Patients who transition to ESRD via AKI-D are a high-risk subgroup that may benefit from aggressive monitoring and medical management, particularly for heart failure. Recovery from AKI-D is independently associated with lower short-term mortality.
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Affiliation(s)
- Benjamin J Lee
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Rishi V Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, 94612, USA
| | - Thomas K Leong
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, 94612, USA
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, 94612, USA
| | - Sophia Walia
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, 94612, USA
| | - Kathleen D Liu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA.,Division of Critical Care, Department of Anesthesia, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Raymond K Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, 94612, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94158, USA
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16
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A propensity-matched comparison of hard outcomes in children on chronic dialysis. Eur J Pediatr 2018; 177:117-124. [PMID: 29143935 DOI: 10.1007/s00431-017-3040-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 10/24/2017] [Accepted: 10/30/2017] [Indexed: 11/27/2022]
Abstract
UNLABELLED Data concerning outcomes of children on hemodialysis (HD) and peritoneal dialysis (PD) are scarce and frequently derived from single-center experiences. We sought to compare survival and transplantation rates in a large cohort of PD and HD patients. We extracted all patients initiating dialysis under 16 years of age between 2004 and 2013 from the Italian Registry of Pediatric Chronic Dialysis. Patients on PD were propensity-matched to those on HD based on gender, age, primary cause of ESRD, and the number of co-morbidities. Stratified Cox proportional hazard models were used to compare outcomes by dialysis modality. Three hundred ten patients were matched from 452 incident patients. In the unmatched cohort, PD patients were younger, more likely to be diagnosed with CAKUT, and had a higher urine output than HD patients. In the propensity-matched cohort, covariates were balanced between the two groups. At 2 years, the cumulative hazard ratio for death was similar (CHR 0.95, 95% CI 0.17-5.20) for HD relative to PD patients; and at 5 years, the CHR was lower for HD patients (0.22 95% CI 0.16-0.29). The cumulative incidence of transplantation at 3 years after dialysis initiation was 60.9% in HD patients and 59.7% in PD patients, with a CHR of 1.03 (95% CI 0.73-1.45). CONCLUSIONS Pediatric PD and HD patients have distinct characteristics. After controlling for treatment-selection biases, children selected to start on PD or HD exhibit a similar mortality risk during the first 2 years on treatment, after which this risk increases in PD children. What is Known: • Few studies have compared hard outcomes in children on maintenance dialysis. • Children started on different dialysis modalities have distinct characteristics that impact on survival. What is New: • After controlling for treatment-selection biases, children selected to start dialysis on PD or HD exhibit a similar mortality risk during the first 2 years on treatment, after which this risk appears to be increased in PD children. • An "integrative care" approach should be used in children on PD, switching them to HD when PD-related morbidity tends to increase.
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17
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Abraham G, Gupta A. Safe and Cost-Effective Peritoneal Dialysis Access by Skilled Nephrologists in Developing Countries. Perit Dial Int 2017; 36:587-588. [PMID: 27903849 DOI: 10.3747/pdi.2016.00088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Georgi Abraham
- Nephrology, Madras Medical Mission, 4-A, Dr. J. Jayalalitha Nagar, Mogappair, Chennai, Tamil Nadu, India
| | - Amit Gupta
- Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India
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18
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Panocchia N, Tazza L, Di Stasio E, Liberatori M, Vulpio C, Giungi S, Lucani G, Antocicco M, Bossola M. Mortality in hospitalized chronic kidney disease patients starting unplanned urgent haemodialysis. Nephrology (Carlton) 2016; 21:62-7. [PMID: 26173588 DOI: 10.1111/nep.12561] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 11/26/2022]
Abstract
AIM Data on the outcome of chronic kidney disease (CKD) patients who are hospitalized and start unplanned urgent haemodialysis (HD) are lacking. This prospective, longitudinal, observational study aimed to define the hospital mortality rate and associated factors in CKD patients who start unplanned urgent HD. METHODS Between January 2003 and December 2009, all patients with CKD who were hospitalized, diagnosed with ESRD and started unplanned urgent haemodialysis at Haemodialysis Service of the Catholic University of Rome, Italy were recruited. Exclusion criteria were: acute renal failure, prior history of dialysis, multiple organ failure, coma, and dementia. Hospital mortality rate was the primary outcome. RESULTS Three and hundred sixteen patients were studied: 99 died after 19.5 ± 27.3 days and 217 survived until discharge. Of these, 154 were prescribed chronic HD and 63 restored renal function. Patients who died were significantly older and had a higher Charlson Comorbidity Index score. The mortality rates were 51.1% in patients with 81-90 years, 37.8% with 71-80 years, 34.1% with 61-70 years and 13.9% with age ≤60 years. Logistic regression analysis showed that age only was an independent risk factor for all-cause mortality. CONCLUSIONS In CKD patients who need hospitalization and start unplanned urgent haemodialysis the mortality is very high and significantly related to age.
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Affiliation(s)
- Nicola Panocchia
- Haemodialysis Service, Department of Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Luigi Tazza
- Haemodialysis Service, Department of Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Enrico Di Stasio
- Department of Biochemistry, Catholic University of the Sacred Heart, Rome, Italy
| | - Massimo Liberatori
- Haemodialysis Service, Department of Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Carlo Vulpio
- Haemodialysis Service, Department of Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Stefania Giungi
- Haemodialysis Service, Department of Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanna Lucani
- Haemodialysis Service, Department of Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Manuela Antocicco
- Department of Geriatrics, Catholic University of the Sacred Heart, Rome, Italy
| | - Maurizio Bossola
- Haemodialysis Service, Department of Surgery, Catholic University of the Sacred Heart, Rome, Italy
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19
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Yang H, Chen YH, Hsieh TF, Chuang SY, Wu MJ. Prediction of Mortality in Incident Hemodialysis Patients: A Validation and Comparison of CHADS2, CHA2DS2, and CCI Scores. PLoS One 2016; 11:e0154627. [PMID: 27148867 PMCID: PMC4858249 DOI: 10.1371/journal.pone.0154627] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/16/2016] [Indexed: 11/24/2022] Open
Abstract
Background The CHADS2 and CHA2DS2 scores are usually applied for stroke prediction in atrial fibrillation patients, and the Charlson comorbidity index (CCI) is a commonly used scale for assessing morbidity. The role in assessing mortality with score system in hemodialysis is not clear and comparisons are lacking. We aimed at evaluating CHADS2, CHA2DS2, and CCI scores to predict mortality in incident hemodialysis patients. Methods Using data from the Nation Health Insurance system of Taiwan (NHIRD) from 1 January 2005 to 31 December 2009, individuals ≧20 y/o who began hemodialysis identified by procedure code and receiving dialysis for > 3 months were included for our study. Renal transplantation patients after dialysis or PD patients were excluded. We calculated the CHADS2, CHA2DS2, and CCI score according to the ICD-9 code and categorized the patients into three groups in each system: 0–1, 2–3, over 4. A total of 3046 incident hemodialysis patients enrolled from NHIRD were examined for an association between the separate scoring systems (CHADS2, CHA2DS2, and CCI score) and mortality. Results CHADS2 and CHA2DS2 scores revealed good predictive value for total mortality (CHADS2 AUC = 0.805; CHA2DS2 AUC = 0.790). However, the CCI score did not reveal a similarly satisfying result (AUC = 0.576). Conclusions Our results show that CHADS2 and CHA2DS2 scores can be applied for mortality prediction in incident hemodialysis patients.
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Affiliation(s)
- Hsun Yang
- Department of Nephrology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Yi-Hsin Chen
- Department of Nephrology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
- * E-mail:
| | - Teng-Fu Hsieh
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Medical Research, Taichung Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Shiun-Yang Chuang
- Department of Medical Research, Taichung Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
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20
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Dias DB, Banin V, Mendes ML, Barretti P, Ponce D. Peritoneal dialysis can be an option for unplanned chronic dialysis: initial results from a developing country. Int Urol Nephrol 2016; 48:901-6. [PMID: 26897038 DOI: 10.1007/s11255-016-1243-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/05/2016] [Indexed: 01/31/2023]
Affiliation(s)
| | - Vanessa Banin
- Botucatu School of Medicine, Distrito de Rubião Junior, São Paulo, 18600090, Brazil
| | - Marcela Lara Mendes
- Botucatu School of Medicine, Distrito de Rubião Junior, São Paulo, 18600090, Brazil
| | - Pasqual Barretti
- Botucatu School of Medicine, Distrito de Rubião Junior, São Paulo, 18600090, Brazil
| | - Daniela Ponce
- Botucatu School of Medicine, Distrito de Rubião Junior, São Paulo, 18600090, Brazil.
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21
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Besarab A, Chernyavskaya E, Motylev I, Shutov E, Kumbar LM, Gurevich K, Chan DTM, Leong R, Poole L, Zhong M, Saikali KG, Franco M, Hemmerich S, Yu KHP, Neff TB. Roxadustat (FG-4592): Correction of Anemia in Incident Dialysis Patients. J Am Soc Nephrol 2015; 27:1225-33. [PMID: 26494833 DOI: 10.1681/asn.2015030241] [Citation(s) in RCA: 188] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 06/29/2015] [Indexed: 12/19/2022] Open
Abstract
Safety concerns with erythropoietin analogues and intravenous (IV) iron for treatment of anemia in CKD necessitate development of safer therapies. Roxadustat (FG-4592) is an orally bioavailable hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitor that promotes coordinated erythropoiesis through HIF-mediated transcription. We performed an open-label, randomized hemoglobin (Hb) correction study in anemic (Hb≤10.0 g/dl) patients incident to hemodialysis (HD) or peritoneal dialysis (PD). Sixty patients received no iron, oral iron, or IV iron while treated with roxadustat for 12 weeks. Mean±SD baseline Hb was 8.3±1.0 g/dl in enrolled patients. Roxadustat at titrated doses increased mean Hb by ≥2.0 g/dl within 7 weeks regardless of baseline iron repletion status, C-reactive protein level, iron regimen, or dialysis modality. Mean±SEM maximal change in Hb from baseline (ΔHb(max)), the primary endpoint, was 3.1±0.2 g/dl over 12 weeks in efficacy-evaluable patients (n=55). In groups receiving oral or IV iron, ΔHb(max) was similar and larger than in the no-iron group. Hb response (increase in Hb of ≥1.0 g/dl from baseline) was achieved in 96% of efficacy-evaluable patients. Mean serum hepcidin decreased significantly 4 weeks into study: by 80% in HD patients receiving no iron (n=22), 52% in HD and PD patients receiving oral iron (n=21), and 41% in HD patients receiving IV iron (n=9). In summary, roxadustat was well tolerated and corrected anemia in incident HD and PD patients, regardless of baseline iron repletion status or C-reactive protein level and with oral or IV iron supplementation; it also reduced serum hepcidin levels.
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Affiliation(s)
| | - Elena Chernyavskaya
- Budgetary Healthcare Institution of Omsk Region, City Clinical Hospital #1, Omsk, Russia
| | | | - Evgeny Shutov
- State Budgetary Healthcare Institution of Moscow, City Clinical Hospital, Moscow, Russia
| | | | | | - Daniel Tak Mao Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | | | - Lona Poole
- FibroGen, Inc., San Francisco, California
| | - Ming Zhong
- FibroGen, Inc., San Francisco, California
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22
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Bae EH, Kim HY, Kang YU, Kim CS, Ma SK, Kim SW. Risk factors for in-hospital mortality in patients starting hemodialysis. Kidney Res Clin Pract 2015; 34:154-9. [PMID: 26484040 PMCID: PMC4608878 DOI: 10.1016/j.krcp.2015.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/21/2015] [Accepted: 07/22/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Incident hemodialysis patients have the highest mortality in the first several months after starting dialysis. This study evaluated the in-hospital mortality rate after hemodialysis initiation, as well as related risk factors. METHODS We examined in-hospital mortality and related factors in 2,692 patients starting incident hemodialysis. The study population included patients with acute kidney injury, acute exacerbation of chronic kidney disease, and chronic kidney disease. To determine the parameters associated with in-hospital mortality, patients who died in hospital (nonsurvivors) were compared with those who survived (survivors). Risk factors for in-hospital mortality were determined using logistic regression analysis. RESULTS Among all patients, 451 (16.8%) died during hospitalization. The highest risk factor for in-hospital mortality was cardiopulmonary resuscitation, followed by pneumonia, arrhythmia, hematologic malignancy, and acute kidney injury after bleeding. Albumin was not a risk factor for in-hospital mortality, whereas C-reactive protein was a risk factor. The use of vancomycin, inotropes, and a ventilator was associated with mortality, whereas elective hemodialysis with chronic kidney disease and statin use were associated with survival. The use of continuous renal replacement therapy was not associated with in-hospital mortality. CONCLUSION Incident hemodialysis patients had high in-hospital mortality. Cardiopulmonary resuscitation, infections such as pneumonia, and the use of inotropes and a ventilator was strong risk factors for in-hospital mortality. However, elective hemodialysis for chronic kidney disease was associated with survival.
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Affiliation(s)
- Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ha Yeon Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Yong Un Kang
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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23
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Glickman MH, Burgess J, Cull D, Roy-Chaudhury P, Schanzer H. Prospective multicenter study with a 1-year analysis of a new vascular graft used for early cannulation in patients undergoing hemodialysis. J Vasc Surg 2015; 62:434-41. [DOI: 10.1016/j.jvs.2015.03.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/02/2015] [Indexed: 11/25/2022]
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24
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Ibrahim S, Darwish H, Fayed A. Late initiation of dialysis in diabetic Egyptian patients. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2015. [DOI: 10.4103/1110-7782.159450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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25
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Abraham G, Varughese S, Mathew M, Vijayan M. A review of acute and chronic peritoneal dialysis in developing countries. Clin Kidney J 2015; 8:310-7. [PMID: 26034593 PMCID: PMC4440475 DOI: 10.1093/ckj/sfv029] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 04/13/2015] [Indexed: 12/19/2022] Open
Abstract
Various modalities of renal replacement therapy (RRT) are available for the management of acute kidney injury (AKI) and end-stage renal disease (ESRD). While developed countries mainly use hemodialysis as a form of RRT, peritoneal dialysis (PD) has been increasingly utilized in developing countries. Chronic PD offers various benefits including lower cost, home-based therapy, single access, less requirement of highly trained personnel and major infrastructure, higher number of patients under a single nephrologist with probably improved quality of life and freedom of activities. PD has been found to be lifesaving in the management of AKI in patients in developing countries where facilities for other forms of RRT are not readily available. The International Society of Peritoneal Dialysis has published guidelines regarding the use of PD in AKI, which has helped in ensuring uniformity. PD has also been successfully used in certain special situations of AKI due to snake bite, malaria, febrile illness, following cardiac surgery and in poisoning. Hemodialysis is the most common form of RRT used in ESRD worldwide, but some countries have begun to adopt a 'PD first' policy to reduce healthcare costs of RRT and ensure that it reaches the underserved population.
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Affiliation(s)
- Georgi Abraham
- Madras Medical Mission Hospital , Chennai, Tamil Nadu , India ; Pondicherry Institute of Medical Sciences , Pondicherry, Tamil Nadu , India
| | | | - Milly Mathew
- Madras Medical Mission Hospital , Chennai, Tamil Nadu , India
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Eckardt KU, Gillespie IA, Kronenberg F, Richards S, Stenvinkel P, Anker SD, Wheeler DC, de Francisco AL, Marcelli D, Froissart M, Floege J. High cardiovascular event rates occur within the first weeks of starting hemodialysis. Kidney Int 2015; 88:1117-25. [PMID: 25923984 PMCID: PMC4653589 DOI: 10.1038/ki.2015.117] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 02/12/2015] [Accepted: 02/26/2015] [Indexed: 12/25/2022]
Abstract
Early mortality is high in hemodialysis (HD) patients, but little is known about early cardiovascular event (CVE) rates after HD initiation. To study this we analyzed data in the AROii cohort of incident HD patients from over 300 European Fresenius Medical Care dialysis centers. Weekly rates of a composite of CVEs during the first year and monthly rates of the composite and its constituents (coronary artery, cerebrovascular, peripheral arterial, congestive heart failure, and sudden cardiac death) during the first 2 years after HD initiation were assessed. Of 6308 patients that started dialysis within 7 days, 1449 patients experienced 2405 CVEs over the next 2 years. The first-year CVE rate (30.2/100 person-years; 95% CI, 28.7-31.7) greatly exceeded the second-year rate (19.4/100; 95% CI, 18.1-20.8). Composite CVEs were highest during the first week with increased risk compared with the second year, persisting until the fifth month. Except for sudden cardiac death, temporal patterns of rates for all CVE categories were very similar, with highest rates during the first month and a high-risk period extending to 4 months. Higher or lower cumulative weekly dialysis dose, lower blood flow, and lower net ultrafiltration during dialysis were associated with CVE during the high-risk period, but not during the post high-risk period. Thus, the incidence of CVE in the first weeks after HD initiation is much higher than during subsequent periods which raises concerns that HD initiation may trigger CVEs.
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Affiliation(s)
- Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | | | - Florian Kronenberg
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Peter Stenvinkel
- Department of Renal Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre, Göttingen, Germany
| | | | - Angel L de Francisco
- Servicio de Nefrología, Hospital Universitario Valdecilla, Universidad de Cantabria, Santander, Spain
| | | | | | - Jürgen Floege
- Division of Nephrology and Immunology, Department of Medicine, RWTH University of Aachen, Aachen, Germany
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Abstract
In their study based on data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) census database, including 86,886 hemodialysis patients from 11 countries, Robinson and colleagues show that in all countries studied, mortality is higher in the first 120 days after the start of dialysis than after this period. We discuss factors that may affect international differences in early mortality, including current dialysis initiation practices and withdrawal from dialysis.
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Hill CJ, Maxwell AP, Cardwell CR, Freedman BI, Tonelli M, Emoto M, Inaba M, Hayashino Y, Fukuhara S, Okada T, Drechsler C, Wanner C, Casula A, Adler AI, Lamina C, Kronenberg F, Streja E, Kalantar-Zadeh K, Fogarty DG. Glycated Hemoglobin and Risk of Death in Diabetic Patients Treated With Hemodialysis: A Meta-analysis. Am J Kidney Dis 2014; 63:84-94. [DOI: 10.1053/j.ajkd.2013.06.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 06/27/2013] [Indexed: 12/31/2022]
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Ivarsen P, Povlsen JV. Can peritoneal dialysis be applied for unplanned initiation of chronic dialysis? Nephrol Dial Transplant 2013; 29:2201-6. [PMID: 24353321 DOI: 10.1093/ndt/gft487] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Late referral of patients with chronic kidney disease (CKD) and unforeseeable deterioration of residual renal function in known CKD patients remain a major problem leading to the need of unplanned start on chronic dialysis without a mature access for dialysis. In most centres worldwide, these patients are started on haemodialysis (HD) using a temporary tunnelled central venous catheter (CVC) for access. However, during the last decade, increasing clinical experience with unplanned start on peritoneal dialysis (PD) right after PD catheter implantation has been published. Key studies are reviewed in the present paper, and the results seem to indicate that compared with patients starting PD in a planned setting with peritoneal resting after PD catheter implantation, patients starting unplanned PD have an increased risk of mechanical complications but apparently no increased risk of infectious complications. In contrast, patients starting unplanned HD using a temporary CVC have an increased risk of both mechanical and infectious complications when compared with patients starting planned HD using an arterio-venous fistula or a permanent CVC. Regarding clinical outcome in terms of survival, unplanned PD seems to be at least as safe as unplanned HD. Combining the unplanned PD programme with a nurse-assisted PD programme is crucial in order to offer the patient a real opportunity to choose a home-based dialysis option. In conclusion, unplanned start on PD seems to be a feasible, safe and efficient alternative to unplanned start on HD for the late referred patient with end-stage renal disease and urgent need for dialysis.
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Affiliation(s)
- Per Ivarsen
- Department of Renal Medicine, Aarhus University Hospital and Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Johan V Povlsen
- Department of Renal Medicine, Aarhus University Hospital and Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Robinson BM, Zhang J, Morgenstern H, Bradbury BD, Ng LJ, McCullough KP, Gillespie BW, Hakim R, Rayner H, Fort J, Akizawa T, Tentori F, Pisoni RL. Worldwide, mortality risk is high soon after initiation of hemodialysis. Kidney Int 2013; 85:158-65. [PMID: 23802192 PMCID: PMC3877739 DOI: 10.1038/ki.2013.252] [Citation(s) in RCA: 220] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 05/03/2013] [Accepted: 05/09/2013] [Indexed: 02/07/2023]
Abstract
Mortality rates for maintenance hemodialysis patients are much higher than the general population and are even greater soon after starting dialysis. Here we analyzed mortality patterns in 86,886 patients in 11 countries focusing on the early dialysis period using data from the Dialysis Outcomes and Practice Patterns Study, a prospective cohort study of in-center hemodialysis. The primary outcome was all-cause mortality, using time-dependent Cox regression, stratified by study phase adjusted for age, sex, race, and diabetes. The main predictor was time since dialysis start as divided into early (up to 120 days), intermediate (121-365 days), and late (over 365 days) periods. Mortality rates (deaths/100 patient-years) were 26.7 (95% confidence intervals 25.6-27.9), 16.9 (16.2-17.6), and 13.7 (13.5-14.0) in the early, intermediate, and late periods, respectively. In each country, mortality was higher in the early compared to the intermediate period, with a range of adjusted mortality ratios from 3.10 (2.22-4.32) in Japan to 1.15 (0.87-1.53) in the United Kingdom. Adjusted mortality rates were similar for intermediate and late periods. The ratio of elevated mortality rates in the early to the intermediate period increased with age. Within each period, mortality was higher in the United States than in most other countries. Thus, internationally, the early hemodialysis period is a high-risk time for all countries studied, with substantial differences in mortality between countries. Efforts to improve outcomes should focus on the transition period and the first few months of dialysis.
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Affiliation(s)
- Bruce M Robinson
- 1] Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA [2] Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jinyao Zhang
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Hal Morgenstern
- 1] Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA [2] Departments of Epidemiology and Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Brian D Bradbury
- 1] Center for Observational Research, Amgen, Thousand Oaks, California, USA [2] Department of Epidemiology, University of California, Los Angeles School of Public Health, Los Angeles, California, USA
| | - Leslie J Ng
- Center for Observational Research, Amgen, Thousand Oaks, California, USA
| | | | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Raymond Hakim
- Department of Internal Medicine, Vanderbilt University, Division of Nephrology, Nashville, Tennessee, USA
| | - Hugh Rayner
- Birmingham Heartlands Hospital, Birmingham, UK
| | - Joan Fort
- University Hospital Vall d'Hebron, Barcelona, Spain
| | - Tadao Akizawa
- Showa University School of Medicine, Shinagawa, Tokyo, Japan
| | - Francesca Tentori
- 1] Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA [2] Department of Internal Medicine, Vanderbilt University, Division of Nephrology, Nashville, Tennessee, USA
| | - Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
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31
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[Smoking cessation in case of chronic kidney disease]. Nephrol Ther 2012. [PMID: 23199888 DOI: 10.1016/j.nephro.2012.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Smoking is one of the main causes of morbidity and mortality around the world. In France, despite increase of cost of cigarettes and exclusion of smoking in public places, daily smoking consummation remains high, particularly in women and young. Now, smoking is considered as a compartmental and/or psychologic and/or physic addiction. There are many categories of smokers and smoking cessation strategies must be tailored to individual level. Whatever the etiology of chronic kidney disease, in dialysis patient as transplanted, hypertension and vascular diseases are strong determinants of prognosis. In this way, there is a need for stronger involvement of nephrologists in the process of smoking cessation of their patients. Therapeutics and strategies are reviewed.
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32
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Silva LK, Bregman R, Lessi D, Leimann B, Alves MB. [Study on blindness: mortality of patients with chronic kidney disease during non-elective hemodialysis]. CIENCIA & SAUDE COLETIVA 2012; 17:2971-80. [PMID: 23175304 DOI: 10.1590/s1413-81232012001100014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/30/2012] [Indexed: 11/22/2022] Open
Abstract
Chronic kidney disease (CKD) leads to renal failure and the need for renal replacement therapy (RRT). Secondary prevention may postpone CKD for many years. This retrospective study sought to analyze prognostic factors and estimate the mortality of patients with CKD secondary to diabetes mellitus and to hypertension that initiate RRT through non-elective hemodialysis at an emergency hospital unit in Rio de Janeiro, from hospital admission until transfer to referral units. The mortality rate was 35.1%. The study detected a significant difference between the survival curves according to disease etiology (log-rank and Peto, p=0.02) and the presence of functional arteriovenous fistulae (log-rank, p=0.0099; Peto, p=0.0090). Multivariate analysis (Cox model) revealed a 7% increase in the risk of death (p=0.002) by one-year increment in age; the presence of a functional fistule was associated to an 81% reduction in the risk of death (p=0.03). About one third of patients with CKD followed by hypertension or diabetes that initiate renal replacement therapy through non-elective hemodialysis die before being transferred to a referral unit, indicating low access to secondary prevention in CKD, including surgery for arteriovenous fistula creation.
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Affiliation(s)
- Letícia Krauss Silva
- Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rua Leopoldo Bulhões 1480/714, Manguinhos, 21041210 Rio de Janeiro RJ, Brazil.
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Nordio M, Limido A, Maggiore U, Nichelatti M, Postorino M, Quintaliani G. Survival in Patients Treated by Long-term Dialysis Compared With the General Population. Am J Kidney Dis 2012; 59:819-28. [DOI: 10.1053/j.ajkd.2011.12.023] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Accepted: 12/12/2011] [Indexed: 11/11/2022]
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34
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Luxton G. The CARI guidelines. Timing of referral of chronic kidney disease patients to nephrology services (adult). Nephrology (Carlton) 2012; 15 Suppl 1:S2-11. [PMID: 20591032 DOI: 10.1111/j.1440-1797.2010.01224.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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35
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Chan KE, Maddux FW, Tolkoff-Rubin N, Karumanchi SA, Thadhani R, Hakim RM. Early outcomes among those initiating chronic dialysis in the United States. Clin J Am Soc Nephrol 2011; 6:2642-9. [PMID: 21959599 DOI: 10.2215/cjn.03680411] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Approximately one million Americans initiated chronic dialysis over the past decade; the first-year mortality rate reported by the U.S. Renal Data System was 19.6% in 2007. This estimate has historically excluded the first 90 days of chronic dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS To characterize the mortality and hospitalization risks for patients starting chronic renal replacement therapy, we followed all patients initiating dialysis in 1733 facilities throughout the United States (n = 303,289). Mortality and hospitalizations within the first 90 days were compared with outcomes after this period, and the results were analyzed. Standard time-series analyses were used to depict the weekly risk estimates for each outcome. RESULTS Between 1997 and 2009, >300,000 patients initiated chronic dialysis and were followed for >35 million dialysis treatments; the highest risk for morbidity and mortality occurred in the first 2 weeks of treatment. The initial 2-week risk of death for a typical dialysis patient was 2.72-fold higher, and the risk of hospitalization was 1.95-fold higher when compared to a patient who survived the first year of chronic dialysis (week 53 after initiation). Similarly, over the first 90 days, the risk of mortality and hospitalization remained elevated. Thereafter, between days 91 and 365, these risks decreased considerably by more than half. Surviving these first weeks of dialysis was most associated with the type of vascular access. Initiating dialysis with a fistula was associated with a decreased early death risk by 61%, whereas peritoneal dialysis decreased the risk by 87%. CONCLUSIONS The first 2 weeks of chronic dialysis are associated with heightened mortality and hospitalization risks, which remain elevated over the ensuing 90 days.
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Affiliation(s)
- Kevin E Chan
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
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36
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Ng LJ, Chen F, Pisoni RL, Krishnan M, Mapes D, Keen M, Bradbury BD. Hospitalization risks related to vascular access type among incident US hemodialysis patients. Nephrol Dial Transplant 2011; 26:3659-66. [PMID: 21372255 DOI: 10.1093/ndt/gfr063] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The excess morbidity and mortality related to catheter utilization at and immediately following dialysis initiation may simply be a proxy for poor prognosis. We examined hospitalization burden related to vascular access (VA) type among incident patients who received some predialysis care. METHODS We identified a random sample of incident US Dialysis Outcomes and Practice Patterns Study hemodialysis patients (1996-2004) who reported predialysis nephrologist care. VA utilization was assessed at baseline and throughout the first 6 months on dialysis. Poisson regression was used to estimate the risk of all-cause and cause-specific hospitalizations during the first 6 months. RESULTS Among 2635 incident patients, 60% were dialyzing with a catheter, 22% with a graft and 18% with a fistula at baseline. Compared to fistulae, baseline catheter use was associated with an increased risk of all-cause hospitalization [adjusted relative risk (RR) = 1.30, 95% confidence interval (CI): 1.09-1.54] and graft use was not (RR = 1.07, 95% CI: 0.89-1.28). Allowing for VA changes over time, the risk of catheter versus fistula use was more pronounced (RR = 1.72, 95% CI: 1.42-2.08) and increased slightly for graft use (RR = 1.15, 95% CI: 0.94-1.41). Baseline catheter use was most strongly related to infection-related (RR = 1.47, 95% CI: 0.92-2.36) and VA-related hospitalizations (RR = 1.49, 95% CI: 1.06-2.11). These effects were further strengthened when VA use was allowed to vary over time (RR = 2.31, 95% CI: 1.48-3.61 and RR = 3.10, 95% CI: 1.95-4.91, respectively). A similar pattern was noted for VA-related hospitalizations with graft use. Discussion. Among potentially healthier incident patients, hospitalization risk, particularly infection and VA-related, was highest for patients dialyzing with a catheter at initiation and throughout follow-up, providing further support to clinical practice recommendations to minimize catheter placement.
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Affiliation(s)
- Leslie J Ng
- Department of Biostatistics and Epidemiology, Amgen Inc, Thousand Oaks, CA, USA
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37
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Mendelssohn DC, Curtis B, Yeates K, Langlois S, MacRae JM, Semeniuk LM, Camacho F, McFarlane P. Suboptimal initiation of dialysis with and without early referral to a nephrologist. Nephrol Dial Transplant 2011; 26:2959-65. [PMID: 21282303 DOI: 10.1093/ndt/gfq843] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Our objective was to examine patients who initiate renal replacement therapy (RRT) at 10 representative Canadian centers, characterize their initiation as inpatient or outpatient and describe their initial type of dialysis access, duration of pre-dialysis care and clinical status at the time of dialysis initiation. We also examined the impact of an optimal dialysis start (i.e. initiated as an outpatient with an arteriovenous fistula, arteriovenous graft or peritoneal dialysis catheter) on subsequent health outcomes. METHODS Charts of consecutive incident RRT patients were identified from 1 July to 31 December 2006. Information was collected until 6 months after the initiation or until death, transplant or transfer. RESULTS Three hundred and thirty-nine incident RRT patients were studied: 39.6% initiated as an inpatient; 54% started hemodialysis (HD) with a central venous catheter; 15.3% had <1 month predialysis care, while 64.6% had >1 year. Optimal starts occurred in 39.5% of patients. For HD patients, optimal starts occurred in 19.8%. Suboptimal starts were noted in patients referred <12 months prior to end-stage renal disease (44%) and in patients referred earlier (56%). The composite end point of death, transfusion or subsequent hospitalization was significantly reduced with an optimal start [hazard ratio 0.47 (95% confidence interval 0.32-0.68), P = 0.0001]. CONCLUSIONS Suboptimal initiation of dialysis is common in patients referred early or late. The benefits of early referral are lost if dialysis is initiated suboptimally. There is a need to identify factors that lead to suboptimal initiation despite early referral.
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Affiliation(s)
- David C Mendelssohn
- Department of Nephrology, Humber River Regional Hospital and University of Toronto, Toronto, Canada.
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38
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Pedagogos E. Coronary artery, cerebrovascular and peripheral vascular disease. Nephrology (Carlton) 2010; 15 Suppl 1:S19-23. [DOI: 10.1111/j.1440-1797.2010.01227.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wingard RL, Chan KE, Lazarus JM, Hakim RM. The "right" of passage: surviving the first year of dialysis. Clin J Am Soc Nephrol 2010; 4 Suppl 1:S114-20. [PMID: 19995993 DOI: 10.2215/cjn.04360709] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Mortality risk for dialysis patients is highest in the first year. We previously showed a 41% mortality benefit associated with a pilot case management program for incident hemodialysis patients (n = 918). The RightStart Program (RSP) provided prompt medical management and self-management education and was recently expanded to more facilities. We conducted a matched cohort analysis to validate the expanded program's continued effectiveness. Death risk was reduced for RS patients (n = 4308) versus matched controls (C; n = 4308) by 34% (hazard ratio = 0.66, P < 0.0001) at 120 d and 22% at 1 yr (hazard ratio = 0.78, P < 0.0001). RS patients had lower hospitalization during the first year (RS = 15.5 days per patient year versus C = 16.9, P < 0.01). At 120 d, more RS patients achieved hemoglobin 11 to 12 g/dl (RS = 22.4% versus C = 19.7%, P < 0.01), eKt/V > or = 1.2 (RS = 66% versus C = 53.5%, P < 0.01), albumin > or = 4.0 g/dl (RS = 26% versus C = 22%, P < 0.01), and phosphorus 3.5 to 5.5 mg/dl (RS = 52.4% versus C = 45.4%). At 120 d, RS patients had a greater reduction in catheter use (RS = 32% versus C = 25%, P < 0.01) and more vitamin D orders (RS = 60% versus C = 55%, P < 0.01). Expansion of RS to a larger incident patient population results in significant reduction of morbidity and mortality associated with improvement of intermediate outcomes.
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Affiliation(s)
- Rebecca L Wingard
- Medical Department, Fresenius Medical Care North America, 750 Old Hickory Blvd, Suite 230, Brentwood, TN 37027, USA.
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40
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EGHAN BA, AMOAKO-ATTA K, KANKAM CA, NSIAH-ASARE A. Survival pattern of hemodialysis patients in Kumasi, Ghana: A summary of forty patients initiated on hemodialysis at a new hemodialysis unit. Hemodial Int 2009; 13:467-71. [DOI: 10.1111/j.1542-4758.2009.00379.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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41
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Jain P, Cockwell P, Little J, Ferring M, Nicholas J, Richards N, Higgins R, Smith S. Survival and transplantation in end-stage renal disease: a prospective study of a multiethnic population. Nephrol Dial Transplant 2009; 24:3840-6. [DOI: 10.1093/ndt/gfp455] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Cass A, Snelling P, Cunningham J, Wang Z, Hoy W. Timing of nephrology referral: a study of its effects on the likelihood of transplantation and impact on mortality. Nephrology (Carlton) 2008. [DOI: 10.1046/j.1440-1797.7.s.15.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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43
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Tazza L, Di Napoli A, Bossola M, Valle S, Pezzotti P, Luciani G, Di Lallo D. Ageing of patients on chronic dialysis: Effects on mortality--A 12-year study. Nephrol Dial Transplant 2008; 24:940-7. [DOI: 10.1093/ndt/gfn575] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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44
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Abstract
Chronic kidney disease (CKD) is a complex disease affecting more than 20 million individuals in the United States. Progression of CKD is associated with a number of serious complications, including increased incidence of cardiovascular disease, hyperlipidemia, anemia, and metabolic bone disease. CKD patients should be assessed for the presence of these complications and receive optimal treatment to reduce their morbidity and mortality. A multidisciplinary approach is required to accomplish this goal.
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45
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Gutiérrez OM, Tamez H, Bhan I, Zazra J, Tonelli M, Wolf M, Januzzi JL, Chang Y, Thadhani R. N-terminal Pro-B–Type Natriuretic Peptide (NT-proBNP) Concentrations in Hemodialysis Patients: Prognostic Value of Baseline and Follow-up Measurements. Clin Chem 2008; 54:1339-48. [DOI: 10.1373/clinchem.2007.101691] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
AbstractBackground: Increased N-terminal pro-B–type natriuretic peptide (NT-proBNP) concentrations are associated with increased cardiovascular mortality in chronic hemodialysis patients. Previous studies focused on prevalent dialysis patients and examined single measurements of NT-proBNP in time.Methods: We measured NT-proBNP concentrations in 2990 incident hemodialysis patients to examine the risk of 90-day and 1-year mortality associated with baseline NT-proBNP concentrations. In addition, we calculated the change in concentrations after 3 months in a subset of 585 patients to examine the association between longitudinal changes in NT-proBNP and subsequent mortality.Results: Increasing quartiles of NT-proBNP were associated with a monotonic increase in 90-day [quartile 1, referent; from quartile 2 to quartile 4, hazard ratio (HR) 1.7–6.3, P < 0.001] and 1-year (quartile 1, referent; from quartile 2 to quartile 4, HR 1.7–4.9, P < 0.001) all-cause mortality. After multivariable adjustment, these associations remained robust. When examined using a multivariable fractional polynomial, increased NT-proBNP concentrations were associated with increased 90-day (HR per unit increase in log NT-proBNP 1.5, 95% CI 1.3–1.7) and 1-year (HR per unit increase in log NT-proBNP 1.4, 95% CI 1.3–1.5) all-cause mortality. In addition, patients with the greatest increase in NT-proBNP after 3 months of dialysis had a 2.4-fold higher risk of mortality than those with the greatest decrease in NT-proBNP.Conclusions: NT-proBNP concentrations are independently associated with mortality in incident hemodialysis patients. Furthermore, the observation that longitudinal changes in NT-proBNP concentrations were associated with subsequent mortality suggests that monitoring serial NT-proBNP concentrations may represent a novel tool for assessing adequacy and guiding therapy in patients initiating hemodialysis.
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Affiliation(s)
- Orlando M Gutiérrez
- Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hector Tamez
- Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ishir Bhan
- Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Marcello Tonelli
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Myles Wolf
- Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James L Januzzi
- Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Yuchiao Chang
- General Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ravi Thadhani
- Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Improvement in eGFR in patients with chronic kidney disease attending a nephrology clinic. Int Urol Nephrol 2008; 40:841-8. [PMID: 18386153 DOI: 10.1007/s11255-008-9360-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 02/18/2008] [Indexed: 12/21/2022]
Abstract
BACKGROUND The adverse effects arising from late referral to a nephrologist of patients with chronic kidney disease (CKD) are well known. Retrospectively we examined the initial characteristics of patients referred in various stages of CKD to our nephrology division and tried to identify potential baseline factors associated with subsequent changes in estimated glomerular filtration rate (eGFR). PATIENTS AND METHODS Between September 1997 and June 2006 1,443 patients (909 male, 534 female) with CKD, with eGFRs ranging from 15 to 89 ml/min, were referred to our nephrology division and categorized using the National Kidney Foundation classification for CKD based on eGFR. The slope of eGFR change (ml/min-1/1.73/m2-1/year-1) was determined by linear regression analysis and the patients were divided into five groups: (1) significantly progressive slope (deterioration) (more negative than -5 ml/min/year); (2) mildly progressive slope (>-5 to <or=-1); (3) stable slope (>-1 to <or=+1); (4) mildly improved slope (>+1 to <or=+5), and (5) significantly improved slope (>or=+5). RESULTS At the first nephrology referral, 5.8% of the patients were on CKD stage 2 (eGFR: 90-60 ml/m), 46.7% on CKD stage 3 (eGFR: 59-30 ml/m), and 47.5% on CKD stage 4 (eGFR: 29-15 ml/m) CKD. Significantly improved slope was detected in 48.2% of CKD stage 2 patients, 29.3% of CKD stage 3 patients, and only 14.7% of CKD stage 4 patients (P<0.05). Being in stage 4 or stage 3 versus being in stage 2 significantly reduced the likelihood of an improved slope in logistic regression analysis whereas age, gender, presence of hypertension, and diabetes mellitus did not reach the level of significance. CONCLUSION Referral to a nephrology clinic can lead not only to arrest of progression of CKD but also to regression/improvement. Early referral is a positive predictive factor for improvement in eGFR, which emphasizes the importance of such referral. The previously held idea that, once established, CKD progresses invariably is not valid anymore.
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Fujimaki H, Kasuya Y, Kawaguchi S, Hara S, Koga S, Takahashi T, Mizuno S. [Relevant factors concerning phenomena related to the process of initiating dialysis in elderly patients with chronic renal failure: predicting the outcomes of subsequent phenomena at the stage of the initial phenomenon]. Nihon Ronen Igakkai Zasshi 2008; 45:81-89. [PMID: 18332577 DOI: 10.3143/geriatrics.45.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
AIM We previously investigated the relevant factors concerning each individual phenomenon related to the process of initiating dialysis in elderly patients with chronic renal failure. Background factors that were identified as relevant factors were significant in terms of enabling us to predict the outcome of each phenomenon in new patients. However, the significance of these factors in predicting the outcomes of subsequent phenomena at the stage of the initial phenomenon was unclear. This was attributed to the fact that the subjects with phenomena decreased in number and because of changes in characteristics (hereafter, changes in subjects) with the progression of the process of initiating dialysis. In the present study, we aimed to identify relevant factors for predicting the outcomes of subsequent phenomena at the stage of the initial phenomenon. For this purpose, we assumed that "progression of the process of initiating dialysis does not result in significant reductions in the number of cases and causes only minor changes in characteristics". METHODS We studied a total of 152 patients with advanced chronic renal failure aged >or=60 years. Background factors were investigated in all patients. The following phenomena were analyzed: acceptance of dialysis, urgency of initiating dialysis, alleviation of disease, and returning home. In order to identify new relevant factors, we focused on the order and condition of the process by which each background factor was narrowed down during logistic regression analysis for each phenomenon. We determined which background factor to focus on for each phenomenon based on changes in background factors. RESULTS Age and cognitive function were related to the urgency of initiating dialysis and alleviation of disease. Age, walking ability, and cognitive function were related to returning home. Age was eliminated at the final stage of logistic regression analysis for alleviation of disease and at the penultimate stage of logistic regression analysis for returning home. CONCLUSION We simulated the restoration of cases lost during the process of initiating dialysis in order to determine the relationship of age to alleviation of disease as well as returning home. Although age significantly affected alleviation of disease, its relationship to returning home was unclear. Age was thus identified as a new relevant factor for alleviation of disease. In addition, all relevant factors identified from investigation of each phenomenon enabled prediction of outcomes of subsequent phenomena at the stage of the initial phenomenon.
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Affiliation(s)
- Hiroshi Fujimaki
- Bureau of Social Welfare and Public Health, Tokyo Metropolitan Government
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Nydegger A, Strauss BJG, Heine RG, Asmaningsih N, Jones CL, Bines JE. Body composition of children with chronic and end-stage renal failure. J Paediatr Child Health 2007; 43:740-5. [PMID: 17640285 DOI: 10.1111/j.1440-1754.2007.01167.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Protein energy malnutrition is common in children with chronic renal failure (CRF) and may negatively impact on clinical outcome. Although the aetiology of malnutrition is multifactorial, descriptive information on body composition may guide nutritional interventions aimed at optimising nutritional status. METHODS This prospective cohort study in children with CRF was conducted from April 1999 to November 2000. Patients were categorised according to their glomerular filtration rate (GFR) into CRF and end-stage renal failure (ESRF). Body composition was assessed based on anthropometry, total body potassium (TBK), total body protein (TBP) and dual X-ray absorptiometry (DEXA). RESULTS Fifteen patients (10 male, 5 female; mean age: 13.4 +/- 4.3 years) were studied, including eight patients with CRF (mean GFR: 17.0 +/- 7.2 mL/min/1.73 m(2)) and seven patients with ESRF (mean GFR: 6.4 +/- 1.7 mL/min/1.73 m(2)). Patients in both groups (n = 15) had deficits in height and TBP (mean z-score height-for-age: -1.19 +/- 1.05, P < 0.01; mean z-score TBP: -0.71 +/- 0.71, P < 0.05). There were no significant differences in weight, height, fat-free mass, TBK and TBP between patients with CRF and ESRF. CONCLUSIONS Linear growth impairment and decreased TBP are common in children with chronic and ESRF. TBK and DEXA may underestimate the degree of malnutrition in these patients.
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Affiliation(s)
- Andreas Nydegger
- Department of Gastroenterology, Royal Children's Hospital, Parkville, Victoria, Australia
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Wingard RL, Pupim LB, Krishnan M, Shintani A, Ikizler TA, Hakim RM. Early intervention improves mortality and hospitalization rates in incident hemodialysis patients: RightStart program. Clin J Am Soc Nephrol 2007; 2:1170-5. [PMID: 17942761 DOI: 10.2215/cjn.04261206] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Annualized mortality rates of chronic hemodialysis (CHD) patients in their first 90 d of treatment range from 24 to 50%. Limited studies also show high hospitalization rates. It was hypothesized that a structured quality improvement program (RightStart), focused on medical needs and patient education and support, would improve outcomes for incident CHD patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 918 CHD incident patients were prospectively enrolled in a multicenter RightStart Program, and compared with a time-concurrent group of 1020 control patients from non-RightStart clinics. RightStart patients received 3 mo of intervention in management of anemia, dosage of dialysis, nutrition, and dialysis access and a comprehensive educational program. Outcomes were tracked for up to 12 mo. RESULTS At 3 mo, RightStart patients had higher albumin and hematocrit values. Dose of dialysis and permanent access placement were not statistically significantly different from control subjects. Compared with baseline, Mental Composite Score for RightStart patients improved significantly. Mean hospitalization days per patient year were reduced with RightStart versus control subjects. Mortality rates at 3, 6, and 12 mo were 20, 18, and 17 for RightStart patients versus 39, 33, and 30 deaths per 100 patient-years for control subjects, respectively. CONCLUSIONS A structured program of prompt medical and educational strategies in incident CHD patients results in improved morbidity and mortality that last up to 1 yr.
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Affiliation(s)
- Rebecca L Wingard
- Fresenius Medical Care-North America, Inc., Nashville, Tennessee, USA
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