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Kingsmore D, Edgar B, Stevenson K, Greenlaw N, Aitken E, Jackson A, Thomson P. A practical review of barriers and challenges to a definitive randomised trial of grafts versus fistula. J Vasc Access 2024:11297298241234610. [PMID: 38436199 DOI: 10.1177/11297298241234610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
A definitive randomised controlled trial of arteriovenous fistula (AVF) versus arteriovenous grafts (AVG) has been advocated for more than a decade, but as yet, none has been completed. The aim of this article is to summarise the theoretical barriers, review the difficulties in trial design and practicalities that have thus far prevented this from occurring.
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Affiliation(s)
- David Kingsmore
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ben Edgar
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Karen Stevenson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nicola Greenlaw
- Glasgow Clinical Trials Unit, Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Emma Aitken
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Andrew Jackson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter Thomson
- Department of Renal Medicine, Queen Elizabeth University Hospital, Glasgow, UK
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Jia X, Tang X, Li Y, Xu D, Moreira P. Update of dialysis initiation timing in end stage kidney disease patients: is it a resolved question? A systematic literature review. BMC Nephrol 2023; 24:162. [PMID: 37286965 DOI: 10.1186/s12882-023-03184-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/27/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND The exact optimal timing of dialysis for ESKD patients remains unknown. This study systematically reviewed the available evidence with regard to the optimal initiation of maintenance dialysis in ESKD patients. METHODS An electronic search was performed in Embase, PubMed and the Cochrane Library in order to find studies investigating associations between variables reference to "start of dialysis" and outcomes. Quality assessment and bias assessment were performed by the Newcastle-Ottawa scale and the ROBINSI tool. Due to the heterogeneity of studies, a meta-analysis could not be performed. RESULTS Thirteen studies were included; four studies included only haemodialysis patients, three peritoneal dialysis, six both; study outcomes included mortality, cardiovascular events, technique failure, quality of life and others. Nine studies mainly focused on the optimal GFR of maintenance dialysis initiation; five studies showed none association between GFR and mortality or other adverse outcomes, two studies showed dialysis initiation at higher GFR levels were with poor prognosis, and 2 studies showed higher GFR levels with better prognosis. Three studies paid attention to comprehensive assessment of uremic signs and/or symptoms for optimal dialysis initiation; uremic burden based on 7 uremic indicators (hemoglobin, serum albumin, blood urea nitrogen, serum creatinine, potassium, phosphorus, and bicarbonate) were not associated with mortality; another equation (combination of sex, age, serum creatinine, blood urea nitrogen, serum albumin, haemoglobin, serum phosphorus, diabetes mellitus, and heart failure) based on fuzzy mathematics to assess the timing of haemodialysis initiation was accuracy to prognose 3-year survival; the third study found that volume overload or hypertension was associated with the highest risk for subsequent mortality. Two studies compared urgent or optimal start in dialysis, a study reported increased survival in optimal start patients, another reported no differences between Urgent-Start-PD and Early-Start-PD regarding 6-month outcomes. LIMITATIONS Heterogeneity among the studies was quite high, with differences in sample size, variable and group characteristics; no RCT studies were included, which weakened the strength of evidences. CONCLUSIONS The criteria for dialysis initiation were varied. Most studies proved that GFR at dialysis initiation was not associated with mortality, timing of dialysis initiation should not be based on GFR, assessments of volume load and patient's tolerance to volume overload are prospective approaches.
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Affiliation(s)
- Xiaoyan Jia
- Department of Nephrology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China
- Shandong Institute of Nephrology, No.16766 Jingshi Road, Jinan, 250014, China
| | - Xueqing Tang
- Department of Nephrology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China
- Shandong Institute of Nephrology, No.16766 Jingshi Road, Jinan, 250014, China
| | - Yunfeng Li
- Department of Nursing, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China
| | - Dongmei Xu
- Department of Nephrology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China.
- Shandong Institute of Nephrology, No.16766 Jingshi Road, Jinan, 250014, China.
| | - Paulo Moreira
- International Healthcare Management Research & Development Centre, Shandong Provincial Qianfoshan Hospital AND Atlantica Instituto Universitario, Gestao em Saude, Oeiras, Portugal, Jinan, 250014, China.
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Chen J, Wang J, Liu Y, Zhao G, Gao F, Hu M, Wang W, Lin HL. Mortality and associated risk factors between young and elderly maintenance haemodialysis patients: a multicentre retrospective cohort study in China. BMJ Open 2023; 13:e066675. [PMID: 36746548 PMCID: PMC9906252 DOI: 10.1136/bmjopen-2022-066675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES Mortality and associated risk factors in young and elderly haemodialysis patients with end-stage kidney disease (ESKD) have not been well examined in China. Therefore, we aimed to assess the all-cause mortality and risk factors associated with all-cause mortality between young and elderly haemodialysis patients in China. DESIGN A population-based multicentre retrospective cohort study. SETTING Using the Dialysis Initiation based on Fuzzy mathematics Equation study data, patients with ESKD undergoing maintenance haemodialysis from 24 centres in China from 1 January 2008 to 30 September 2015. PARTICIPANTS 1601 enrolled patients with ESKD were categorised into young group (18-44 years old) and elderly (≥60 years old) group. OUTCOME MEASURES The primary outcome was all-cause mortality. We estimated overall survival using a log-rank test. Cox proportional hazard regression analysis was implemented to identify risk factors and HR associated all-cause mortality. RESULTS During a mean follow-up of 48.17±25.59 months, of the 1601 subjects, 319 (19.92%) patients death, including 64 (9.97%) in young group and 255 (26.59%) in elderly group, respectively. The cumulative survival in elderly group was lower than young group (Log Rank tests=63.31, p<0.001). Multivariate Cox proportional hazards analysis showed the cardiovascular disease (HR, 2.393; 95% CI 1.532 to 3.735; p<0.001), cerebrovascular disease (HR, 2.542; 95% CI 1.364 to 4.739; p=0.003) and serum albumin<3.5 g/dL (HR, 1.725; 95% CI 1.091 to 2.726; p=0.020) at the haemodialysis initiation were associated with increased risk of all-cause mortality in elderly groups; however, the cardiovascular disease only was associated with increased risk of all-cause mortality in young groups. CONCLUSIONS The all-cause mortality of elderly haemodialysis patients were higher than young haemodialysis patients in China. Identified risk factors associated all-cause mortality may inform development of age-appropriate treatment, intervention strategies and improve survival prognosis of this unique population.
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Affiliation(s)
- Jilin Chen
- Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jinling Wang
- Nephrology, Dalian Renal Care Hospital, Dalian, Liaoning, China
| | - Ying Liu
- Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Guangben Zhao
- Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Fengdi Gao
- Business cooperation Center third department, China Medical Tribune, Beijing, China
| | - Menghong Hu
- Internal medicine, Graduate School, Dalian Medical University, Dalian, Liaoning, China
| | - Weidong Wang
- Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Hong-Li Lin
- Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- The Center for the Transformation Medicine of Kidney Disease of Liaoning Province, Dalian, Liaoning, China
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Chen J, Liu Y, Chen X, Sun X, Li W, Yang W, Li P, Sun X, Wang D, Jiang H, Shi W, Liu W, Fu P, Ding X, Chang M, Liu S, Yang X, Cao N, Chen M, Ni Z, Chen J, Sun S, Liang X, Wang H, He Y, Gao B, Wang J, Hao L, Liu J, Li S, He Q, Liu H, Yi N, Shao F, Jiao J, Ma Y, Yao L, Sun Y, Li D, Szczech L, Fang M, Odeh Z, Lin H. Assessment of dialysis initiation by a fuzzy mathematics equation (ADIFE): a study protocol for a randomised controlled trial. BMJ Open 2019; 9:e023162. [PMID: 31501092 PMCID: PMC6738726 DOI: 10.1136/bmjopen-2018-023162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Starting dialysis early or late both result in a low quality of life and a poor prognosis in patients undergoing haemodialysis. However, there remains no consensus on the optimal timing of dialysis initiation, mainly because of a lack of suitable methods to assess variations in dialysis initiation time. We have established a novel equation named DIFE (Dialysis Initiation based on Fuzzy-mathematics Equation) through a retrospective, multicentre clinical cohort study in China to determine the most suitable timing of dialysis initiation. The predictors of the DIFE include nine biochemical markers and clinical variables that together influence dialysis initiation. To externally validate the clinical accuracy of DIFE, we designed the assessment of DIFE (ADIFE) study as a prospective, open-label, multicentre, randomised controlled trial to assess the clinical outcomes among patients who initiate dialysis in an optimal start dialysis group and a late-start dialysis group, based on DIFE. METHODS AND ANALYSIS A total of 388 enrolled patients with end-stage renal disease will be randomised 1:1 to the optimal start dialysis group, with a DIFE value between 30 and 35, or the late-start dialysis group, with a DIFE value less than 30, using the Randomization and Trial Supply Management system. Participants will be assessed for changes in signs and symptoms, dialysis mode and parameters, biochemical and inflammatory markers, Subjective Global Assessment, Kidney Disease Quality of Life Short Form, Cognitive Assessment, medical costs, adverse events and concomitant medication at baseline, predialysis visiting stage and postdialysis visiting stage, every 12-24 weeks. The following data will be recorded on standardised online electronic case report forms. The primary endpoint is 3-year all-cause mortality. The secondary endpoints include non-fatal cerebrocardiovascular events, annual hospitalisation rate, quality of life, medical costs and haemodialysis related complications. ETHICS AND DISSEMINATION Ethical approval was obtained from the Ethics Committee of the First Affiliated Hospital of Dalian Medical University China (registration no: YJ-KY-2017-119) and the ethics committees of all participating centres. The final results of the ADIFE trial will be presented to the study sponsor, clinical researchers and the patient and public involvement reference group. Findings will be disseminated through peer-reviewed journals, Clinical Practice Guidelines and at scientific meetings. TRIAL REGISTRATION NUMBER ClinicalTrial.gov. Registry (NCT03385902); pre-results.
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Affiliation(s)
- Jilin Chen
- Graduate School of Dalian Medical University, Dalian, Liaoning, China
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University. Kidney Research Institute of Dalian Medical University, Dalian, Liaoning, China
| | - Ying Liu
- Graduate School of Dalian Medical University, Dalian, Liaoning, China
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University. Kidney Research Institute of Dalian Medical University, Dalian, Liaoning, China
| | - Xiangmei Chen
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Xuefeng Sun
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Wei Li
- Medical Research & Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wang Yang
- Medical Research & Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ping Li
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Ximing Sun
- School of Control Science and Engineering, Dalian University of Technology, Dalian, China
| | - Degang Wang
- School of Control Science and Engineering, Dalian University of Technology, Dalian, China
| | - Hongli Jiang
- Blood Purification Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wei Shi
- Division of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wenhu Liu
- Department of Nephrology, Beijing Friendship Hospital Attached Capital Medical University, Beijing, China
| | - Ping Fu
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming Chang
- Department of Nephrology, Dalian Municipal Central Hospital, Dalian, China
| | - Shuxin Liu
- Department of Nephrology, Dalian Municipal Central Hospital, Dalian, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ning Cao
- Department of Nephrology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Menghua Chen
- Department of Nephrology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Zhaohui Ni
- Department of Nephrology, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Chen
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shiren Sun
- Department of Nephrology, Xijing hospital of The Fourth Military Medical University, Xi'an, China
| | - Xinling Liang
- Department of Nephrology, Guangdong General Hospital, Guangzhou, Guangdong, China
| | - Huimin Wang
- Department of Nephrology, General Hospital of Benxi Iron and Steel Co., Ltd, Benxi, China
| | - Yani He
- Department of Nephrology, Daping Hospital Affiliated to Army Military Medical University, Chongqing, China
| | - Bihu Gao
- Department of Nephrology, Affiliated Zhong Shan Hospital of Dalian University, Dalian, China
| | - Jianqin Wang
- Department of Nephrology, Lanzhou University Second Hospital, Lanzhou, China
| | - Lirong Hao
- Department of Nephrology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jian Liu
- Department of Nephrology, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Suhua Li
- Department of Nephrology, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Qiang He
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China
| | - Hongmei Liu
- Department of Nephrology, An Steel Group Hospital, Anshan, China
| | - Na Yi
- Department of Nephrology, An Steel Group Hospital, Anshan, China
| | - Fengmin Shao
- Department of Nephrology, The People's Hospital of Zhengzhou University and Henan Provincial People's Hospital, Zhengzhou, China
| | - Jundong Jiao
- Department of Nephrology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yuhuan Ma
- Department of Nephrology, General Hospital of Mining Industry Group FuXin, FuXin, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Yi Sun
- Department of Nephrology, General Hospital Affiliated To Shenyang Medical College, Shenyang, China
| | - Detian Li
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, China
| | | | - Ming Fang
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University. Kidney Research Institute of Dalian Medical University, Dalian, Liaoning, China
| | - Zach Odeh
- Graduate School of Dalian Medical University, Dalian, Liaoning, China
| | - Hongli Lin
- Graduate School of Dalian Medical University, Dalian, Liaoning, China
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University. Kidney Research Institute of Dalian Medical University, Dalian, Liaoning, China
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