EuCliD® – A Medical Registry

Efficacy of vaccination against the SARS-CoV-2 virus in patients with chronic kidney disease on hemodialysis

SARS-CoV-2 has had a great impact on world health, patients on hemodialysis have a higher rate of infection and death due to COVID-19. Vaccination is important to control infection and improve the prognosis of infected patients. To describe the efficacy of vaccination against SARS-CoV-2 in Chilean patients on hemodialysis during the year 2021. Retrospective observational study. A total of 9,712 clinical records were reviewed. Data were presented as summary measures. Fisher's exact test, Mann-Whitney U test, and multivariate logistic regression were used for the analysis. Risk and survival analysis were calculated, considering a statistical significance of less than 0.05. The average age of the patients attended was 61.5 ± 14.6 years. Average time on dialysis 67.6 months and 35.0% diabetic. 93.2% of patients were vaccinated against SARS-CoV-2, 70.7% of them received booster doses. The risk of infection was higher for those who received one or no dose, compared to those who received booster doses against SARS-CoV-2: OR = 252.46 [165.13; 401.57]. Of the infected patients, 15.7% died from COVID-19. The risk of death was higher in unvaccinated or single-dose patients compared to those vaccinated with two doses: OR = 2.64 [2.23; 3.12]. Patients with two doses and a booster had a longer survival compared to those who received one or no dose of vaccination against SARS-CoV-2 (p < .05). The vaccination in Chile, which started in February 2021, has demonstrated that booster doses against SARS-CoV-2 significantly reduced the risk of infection, hospitalization, and death due to COVID-19 in patients on hemodialysis.

Patient Survival With Extended Home Hemodialysis Compared to In-Center Conventional Hemodialysis

Introduction

More frequent and/or longer hemodialysis (HD) has been associated with improvements in numerous clinical outcomes in patients on dialysis. Home HD (HHD), which allows more frequent and/or longer dialysis with lower cost and flexibility in treatment planning, is not widely used worldwide. Although, retrospective studies have indicated better survival with HHD, this issue remains controversial. In this multicenter study, we compared thrice-weekly extended HHD with in-center conventional HD (ICHD) in a large patient population with a long-term follow-up.

Methods

We matched 349 patients starting HHD between 2010 and 2014 with 1047 concurrent patients on ICHD by using propensity scores. Patients were followed-up with from their respective baseline until September 30, 2018. The primary outcome was overall survival. Secondary outcomes were technique survival; hospitalization; and changes in clinical, laboratory, and medication parameters.

Results

The mean duration of dialysis session was 418 ± 54 minutes in HHD and 242 ± 10 minutes in patients on ICHD. All-cause mortality rate was 3.76 and 6.27 per 100 patient-years in the HHD and the ICHD groups, respectively. In the intention-to-treat analysis, HHD was associated with a 40% lower risk for all-cause mortality than ICHD (hazard ratio [HR] = 0.60; 95% confidence interval [CI] 0.45 to 0.80; P < 0.001). In HHD, the 5-year technical survival was 86.5%. HHD treatment provided better phosphate and blood pressure (BP) control, improvements in nutrition and inflammation, and reduction in hospitalization days and medication requirement.

Conclusion

These results indicate that extended HHD is associated with higher survival and better outcomes compared to ICHD.

From electronic health records to clinical management systems: how the digital transformation can support healthcare services

Healthcare systems worldwide are currently undergoing significant transformations in response to increasing costs, a shortage of healthcare professionals and the growing complexity of medical needs among the population. Value-based healthcare reimbursement systems are emerging as an attempt to incentivize patient-centricity and cost containment. From a technological perspective, the transition to digitalized services is intended to support these transformations. A Health Information System (HIS) is a technological solution designed to govern the data flow generated and consumed by healthcare professionals and administrative staff during the delivery of healthcare services. However, the exponential growth of digital capabilities and applied advanced analytics has expanded their traditional functionalities and brought the promise of automating administrative procedures and simple repetitive tasks, while enhancing the efficiency and outcomes of healthcare services by incorporating decision support tools for clinical management. The future of HIS is headed towards modular architectures that can facilitate implementation and adaptation to different environments and systems, as well as the integration of various tools, such as artificial intelligence (AI) models, in a seamless way. As an example, we present the experience and future developments of the European Clinical Database (EuCliD®). EuCliD is a multilingual HIS used by 20 000 nurses and physicians on a daily basis to manage 105 000 patients treated in 1100 clinics in 43 different countries. EuCliD encompasses patients' follow-up, automatic reporting and mobile applications while enabling efficient management of clinical processes. It is also designed to incorporate multiagent systems to automate repetitive tasks, AI modules and advanced dynamic dashboards.

Development and validation of AI-based triage support algorithms for prevention of intradialytic hypotension

BACKGROUND

Intradialytic hypotension remains one of the most recurrent complications of dialysis sessions. Inadequate management can lead to adverse outcomes, highlighting the need to develop personalized approaches for the prevention of intradialytic hypotension. Here, we sought to develop and validate two AI-based risk models predicting the occurrence of symptomatic intradialytic hypotension at different time points.

METHODS

The models were built using the XGBoost algorithm and they predict the occurrence of intradialytic hypotension in the next dialysis session and in the next month. The initial dataset, obtained from routinely collected data in the EuCliD® Database, was split to perform model derivation, training and validation. Model performance was evaluated by concordance statistic and calibration charts; the importance of features was assessed with the Shapley Additive Explanation (SHAP) methodology.

RESULTS

The final dataset included 1,249,813 dialysis sessions, and the incidence rate of intradialytic hypotension was 10.07% (95% CI 10.02-10.13). Our models retained good discrimination (AUC around 0.8) and a suitable calibration yielding to the selection of three classification thresholds identifying four distinct risk groups. Variables providing the most significant impact on risk estimates were blood pressure dynamics and other metrics mirroring hemodynamic instability over time.

CONCLUSIONS

Recurrent symptomatic intradialytic hypotension could be reliably and accurately predicted using routinely collected data during dialysis treatment and standard clinical care. Clinical application of these prediction models would allow for personalized risk-based interventions for preventing and managing intradialytic hypotension.

Effectiveness of COVID-19 vaccines in a large European hemodialysis cohort

Background

Hemodialysis patients have high-risk of severe SARS-CoV-2 infection but were unrepresented in randomized controlled trials evaluating the safety and efficacy of COVID-19 vaccines. We estimated the real-world effectiveness of COVID-19 vaccines in a large international cohort of hemodialysis patients.

Methods

In this historical, 1:1 matched cohort study, we included adult hemodialysis patients receiving treatment from December 1, 2020, to May 31, 2021. For each vaccinated patient, an unvaccinated control was selected among patients registered in the same country and attending a dialysis session around the first vaccination date. Matching was based on demographics, clinical characteristics, past COVID-19 infections and a risk score representing the local background risk of infection at vaccination dates. We estimated the effectiveness of mRNA and viral-carrier COVID-19 vaccines in preventing infection and mortality rates from a time-dependent Cox regression stratified by country.

Results

In the effectiveness analysis concerning mRNA vaccines, we observed 850 SARS-CoV-2 infections and 201 COVID-19 related deaths among the 28110 patients during a mean follow up of 44 ± 40 days. In the effectiveness analysis concerning viral-carrier vaccines, we observed 297 SARS-CoV-2 infections and 64 COVID-19 related deaths among 12888 patients during a mean follow up of 48 ± 32 days. We observed 18.5/100-patient-year and 8.5/100-patient-year fewer infections and 5.4/100-patient-year and 5.2/100-patient-year fewer COVID-19 related deaths among patients vaccinated with mRNA and viral-carrier vaccines respectively, compared to matched unvaccinated controls. Estimated vaccine effectiveness at days 15, 30, 60 and 90 after the first dose of a mRNA vaccine was: for infection, 41.3%, 54.5%, 72.6% and 83.5% and, for death, 33.1%, 55.4%, 80.1% and 91.2%. Estimated vaccine effectiveness after the first dose of a viral-carrier vaccine was: for infection, 38.3% without increasing over time and, for death, 56.6%, 75.3%, 92.0% and 97.4%.

Conclusion

In this large, real-world cohort of hemodialyzed patients, mRNA and viral-carrier COVID-19 vaccines were associated with reduced COVID-19 related mortality. Additionally, we observed a strong reduction of SARS-CoV-2 infection in hemodialysis patients receiving mRNA vaccines.

Modifiable Risk Factors Are Important Predictors of COVID-19-Related Mortality in Patients on Hemodialysis

Introduction

Patients with end-stage kidney disease face a higher risk of severe outcomes from SARS-CoV-2 infection. Moreover, it is not well known to what extent potentially modifiable risk factors contribute to mortality risk. In this historical cohort study, we investigated the incidence and risk factors for 30-day mortality among hemodialysis patients with SARS-CoV-2 infection treated in the European Fresenius Medical Care NephroCare network using conventional and machine learning techniques.

Methods

We included adult hemodialysis patients with the first documented SARS-CoV-2 infection between February 1, 2020, and March 31, 2021, registered in the clinical database. The index date for the analysis was the first SARS-CoV-2 suspicion date. Patients were followed for up to 30 days until April 30, 2021. Demographics, comorbidities, and various modifiable risk factors, expressed as continuous parameters and as key performance indicators (KPIs), were considered to tap multiple dimensions including hemodynamic control, nutritional state, and mineral metabolism in the 6 months before the index date. We used logistic regression (LR) and XGBoost models to assess risk factors for 30-day mortality.

Results

We included 9,211 patients (age 65.4 ± 13.7 years, dialysis vintage 4.2 ± 3.7 years) eligible for the study. The 30-day mortality rate was 20.8%. In LR models, several potentially modifiable factors were associated with higher mortality: body mass index (BMI) 30-40 kg/m2 (OR: 1.28, CI: 1.10-1.50), single-pool Kt/V (OR off-target vs on-target: 1.19, CI: 1.02-1.38), overhydration (OR: 1.15, CI: 1.01-1.32), and both low (<2.5 mg/dl) and high (≥5.5 mg/dl) serum phosphate levels (OR: 1.52, CI: 1.07-2.16 and OR: 1.17, CI: 1.01-1.35). On-line hemodiafiltration was protective in the model using KPIs (OR: 0.86, CI: 0.76-0.97). SHapley Additive exPlanations analysis in XGBoost models shows a high influence on prediction for several modifiable factors as well, including inflammatory parameters, high BMI, and fluid overload. In both LR and XGBoost models, age, gender, and comorbidities were strongly associated with mortality.

Conclusion

Both conventional and machine learning techniques showed that KPIs and modifiable risk factors in different dimensions ascertained 6 months before the COVID-19 suspicion date were associated with 30-day COVID-19-related mortality. Our results suggest that adequate dialysis and achieving KPI targets remain of major importance during the COVID-19 pandemic as well.

The Cardiovascular Literature-Based Risk Algorithm (CALIBRA): Predicting Cardiovascular Events in Patients With Non-Dialysis Dependent Chronic Kidney Disease

Background and Objectives

Cardiovascular (CV) disease is the main cause of morbidity and mortality in patients suffering from chronic kidney disease (CKD). Although it is widely recognized that CV risk assessment represents an essential prerequisite for clinical management, existing prognostic models appear not to be entirely adequate for CKD patients. We derived a literature-based, naïve-bayes model predicting the yearly risk of CV hospitalizations among patients suffering from CKD, referred as the CArdiovascular, LIterature-Based, Risk Algorithm (CALIBRA).

Methods

CALIBRA incorporates 31 variables including traditional and CKD-specific risk factors. It was validated in two independent CKD populations: the FMC NephroCare cohort (European Clinical Database, EuCliD®) and the German Chronic Kidney Disease (GCKD) study prospective cohort. CALIBRA performance was evaluated by c-statistics and calibration charts. In addition, CALIBRA discrimination was compared with that of three validated tools currently used for CV prediction in CKD, namely the Framingham Heart Study (FHS) risk score, the atherosclerotic cardiovascular disease risk score (ASCVD), and the Individual Data Analysis of Antihypertensive Intervention Trials (INDANA) calculator. Superiority was defined as a ΔAUC>0.05.

Results

CALIBRA showed good discrimination in both the EuCliD® medical registry (AUC 0.79, 95%CI 0.76-0.81) and the GCKD cohort (AUC 0.73, 95%CI 0.70-0.76). CALIBRA demonstrated improved accuracy compared to the benchmark models in EuCliD® (FHS: ΔAUC=-0.22, p<0.001; ASCVD: ΔAUC=-0.17, p<0.001; INDANA: ΔAUC=-0.14, p<0.001) and GCKD (FHS: ΔAUC=-0.16, p<0.001; ASCVD: ΔAUC=-0.12, p<0.001; INDANA: ΔAUC=-0.04, p<0.001) populations. Accuracy of the CALIBRA score was stable also for patients showing missing variables.

Conclusion

CALIBRA provides accurate and robust stratification of CKD patients according to CV risk and allows score calculations with improved accuracy compared to established CV risk scores also in real-world clinical cohorts with considerable missingness rates. Our results support the generalizability of CALIBRA across different CKD populations and clinical settings.

Validation of a Novel Predictive Algorithm for Kidney Failure in Patients Suffering from Chronic Kidney Disease: The Prognostic Reasoning System for Chronic Kidney Disease (PROGRES-CKD)

Current equation-based risk stratification algorithms for kidney failure (KF) may have limited applicability in real world settings, where missing information may impede their computation for a large share of patients, hampering one from taking full advantage of the wealth of information collected in electronic health records. To overcome such limitations, we trained and validated the Prognostic Reasoning System for Chronic Kidney Disease (PROGRES-CKD), a novel algorithm predicting end-stage kidney disease (ESKD). PROGRES-CKD is a naïve Bayes classifier predicting ESKD onset within 6 and 24 months in adult, stage 3-to-5 CKD patients. PROGRES-CKD trained on 17,775 CKD patients treated in the Fresenius Medical Care (FMC) NephroCare network. The algorithm was validated in a second independent FMC cohort (n = 6760) and in the German Chronic Kidney Disease (GCKD) study cohort (n = 4058). We contrasted PROGRES-CKD accuracy against the performance of the Kidney Failure Risk Equation (KFRE). Discrimination accuracy in the validation cohorts was excellent for both short-term (stage 4-5 CKD, FMC: AUC = 0.90, 95%CI 0.88-0.91; GCKD: AUC = 0.91, 95% CI 0.86-0.97) and long-term (stage 3-5 CKD, FMC: AUC = 0.85, 95%CI 0.83-0.88; GCKD: AUC = 0.85, 95%CI 0.83-0.88) forecasting horizons. The performance of PROGRES-CKD was non-inferior to KFRE for the 24-month horizon and proved more accurate for the 6-month horizon forecast in both validation cohorts. In the real world setting captured in the FMC validation cohort, PROGRES-CKD was computable for all patients, whereas KFRE could be computed for complete cases only (i.e., 30% and 16% of the cohort in 6- and 24-month horizons). PROGRES-CKD accurately predicts KF onset among CKD patients. Contrary to equation-based scores, PROGRES-CKD extends to patients with incomplete data and allows explicit assessment of prediction robustness in case of missing values. PROGRES-CKD may efficiently assist physicians' prognostic reasoning in real-life applications.

Time-dependent lipid profile inversely associates with mortality in hemodialysis patients - independent of inflammation/malnutrition

BACKGROUND

Patients with end-stage kidney disease have an extremely high cardiovascular mortality rate, but there is a paradoxical relationship between lipid profile and survival in haemodialysis patients. To investigate whether inflammation/malnutrition confounds the associations between lipids and mortality, we studied a full lipid profile comprising of five clinically well-established lipid parameters and its associations with mortality in a large, multinational European cohort with a median follow-up >3 years.

METHODS

The association between quartiles of total, high-density lipoprotein (HDL), non-HDL, low-density lipoprotein (LDL) cholesterol, as well as triglyceride, levels and the end-points of all-cause, cardiovascular and non-cardiovascular mortality was assessed in a cohort of 5,382 incident, adult haemodialysis patients from >250 Fresenius Medical Care dialysis centres out of 14 participating countries using baseline and time-dependent Cox models. Analyses were fully adjusted and stratified for inflammation/malnutrition status and other patient-level variables.

RESULTS

Time-dependent quartiles of total, HDL, non-HDL and LDL cholesterol were inversely associated with the hazard for all-cause, cardiovascular and non-cardiovascular mortality. Compared with the lowest quartile of the respective lipid parameter, hazard ratios of other quartiles were <0.86. Similar, albeit weaker, associations were found with baseline lipid profile and mortality. Neither time-dependent nor baseline associations between lipid profile and mortality were affected by inflammation/malnutrition, statin use or geography.

CONCLUSIONS

Baseline and time-dependent lipid profile are inversely associated with mortality in a large, multicentre cohort of incident haemodialysis patients. Inflammation/malnutrition is not a confounder nor effect modificator of the associations between lipid profile and mortality in European haemodialysis patients.

Enhanced Sentinel Surveillance System for COVID-19 Outbreak Prediction in a Large European Dialysis Clinics Network

Accurate predictions of COVID-19 epidemic dynamics may enable timely organizational interventions in high-risk regions. We exploited the interconnection of the Fresenius Medical Care (FMC) European dialysis clinic network to develop a sentinel surveillance system for outbreak prediction. We developed an artificial intelligence-based model considering the information related to all clinics belonging to the European Nephrocare Network. The prediction tool provides risk scores of the occurrence of a COVID-19 outbreak in each dialysis center within a 2-week forecasting horizon. The model input variables include information related to the epidemic status and trends in clinical practice patterns of the target clinic, regional epidemic metrics, and the distance-weighted risk estimates of adjacent dialysis units. On the validation dates, there were 30 (5.09%), 39 (6.52%), and 218 (36.03%) clinics with two or more patients with COVID-19 infection during the 2-week prediction window. The performance of the model was suitable in all testing windows: AUC = 0.77, 0.80, and 0.81, respectively. The occurrence of new cases in a clinic propagates distance-weighted risk estimates to proximal dialysis units. Our machine learning sentinel surveillance system may allow for a prompt risk assessment and timely response to COVID-19 surges throughout networked European clinics.

Leveraging digital transformation to empower clinical governance: enhancement in intermediate clinical endpoints and patients' survival after implementation of a continuous quality improvement program in a large dialysis network

BACKGROUND

Treatment of end-stage kidney disease patients is extremely challenging given the inter-connected functional derangements and comorbidities characterizing the disease. Continuous Quality Improvement (CQI) in healthcare is a structured clinical governance process helping physicians adhere to best clinical practices. The digitization of patient medical records and data warehousing technologies has standardized and enhanced the efficiency of the CQ&Iacute;s evidence generation process. There is limited evidence that ameliorating intermediate outcomes would translate into better patient-centered outcomes. We sought to evaluate the relationship between Fresenius Medical Care (FME) medical patient review CQI (MPR-CQI) implementation and patients' survival in a large historical cohort study.

METHODS

We included all incident adult patients with 6 months survival on chronic dialysis registered in the EMEA region between 2011-2018. We compared medical Key Performance Indicator (KPI) target achievements and 2-year mortality for patients enrolled prior and after to MPR-CQI policy onset (Cohort A and Cohort B). We adopted a structural equation model where MPR-CQI policy was the exogenous explanatory variable, KPI target achievements the mediator variable, and survival was the outcome of interest.

RESULTS

4.270 patients (Cohort A: 2.397; Cohort B: 1.873) met the inclusion criteria. We observed an increase in KPI target achievements after MPR-CQI policy implementation. Mediation analysis demonstrated a significant reduction in mortality due to indirect effect of MPR-CQI implementation through improvement in KPI target achievement occurring in the post-implementation era (OR: 0.70; 95%CI: 0.65-0.76; p < 0.0001).

CONCLUSIONS

Our study suggests that MPR-CQI achieved by standardized clinical practice and periodical, structured, medical patient review may improve patients' survival through improvement in medical KPIs.

Haemodialysis therapy and sustainable growth: a corporate experience in France

Introduction

Sustainable growth and environmental issues are currently a topic for all human activities, and dialysis represents a real challenge in this field because of high water and power consumption and the production of large amounts of care-related waste. In this article we describe data collection implemented in the NephroCare centres in France and the changes observed during a 13-year period regarding environmental parameters.

Methods

Monthly data collection (eco-reporting) was implemented in NephroCare centres in France in 2005. It covers three topics designed as key performance indicators (KPIs): electricity and water consumption and care-related waste production expressed, respectively, as kilowatt-hour (kWh), litres (L) and kilograms per session. We report on the three action plans (2005–10, 2011–14 and 2015–18) and changes observed during this 13-year period.

Results

During the period, power and water consumption declined by 29.6% (from 23.1 to 16.26 kWh/session) and 52% (from 801 to 382 L/session), respectively. At the same time, the yearly number of dialysis sessions has increased from 169 335 to 399 336. The sources of savings came both from improvements in the dialysis technology (dialysis machines and water treatment systems) and from updating and remodelling of the dialysis unit equipment and buildings. The care-related waste decreased from 1.8 to 1.1 kg because of regular staff training and the retrofiltration system, allowing the voiding of the remaining saline solution after dialysis. These savings have been estimated as equivalent to 102 440 tons of carbon dioxide.

Discussion

Implementation of KPIs and their regular monitoring by trained staff to evaluate water and power consumption and the reduction of care-related water production are essential to implement actions to reduce the impact of dialysis on the environment. These data show the importance of water treatment and dialysis technology to decrease water and power consumption and the production of care-related waste as well as upgrading or remodelling of buildings housing dialysis units. Other measures are discussed, including the reuse of rejected water by reverse osmosis, as well as behavioural changes that are needed to reach sustainable development of dialysis.

Conclusion

The first step to reach ‘green’ dialysis is to collect precise information from defined KPIs. This is the only way to design action plans to reduce the impact of dialysis therapy on the environment. Beyond this, the nephrology community must be sensitized to this challenge to be proactive and to anticipate future regulations.

Survival on four compared with three times per week haemodialysis in high ultrafiltration patients: an observational study

Background

The harm caused by the long interdialytic interval in three-times-per-week haemodialysis regimens (3×WHD) may relate to fluid accumulation and associated high ultrafiltration rate (UFR). Four-times-per-week haemodialysis (4×WHD) may offer a solution, but its impact on mortality, hospitalization and vascular access complications is unknown.

Methods

From the AROii cohort of incident in-centre haemodialysis patients, 3×WHD patients with a UFR >10 mL/kg/h were identified. The hazard for the outcomes of mortality, hospitalization and vascular access complications in those who switched to 4×WHD compared with staying on 3×WHD was estimated using a marginal structural Cox proportional hazards model. Adjustment included baseline patient and treatment characteristics with inverse probability weighting used to adjust for time-varying UFR and cardiovascular comorbidities.

Results

From 10 637 European 3×WHD patients, 3842 (36%) exceeded a UFR >10 mL/kg/h. Of these, 288 (7.5%) started 4×WHD and at baseline were more comorbid. Event rates while receiving 4×WHD compared with 3×WHD were 12.6 compared with 10.8 per 100 patient years for mortality, 0.96 compared with 0.65 per year for hospitalization and 14.7 compared with 8.0 per 100 patient years for vascular access complications. Compared with 3×WHD, the unadjusted hazard ratio (HR) for mortality on 4×WHD was 1.05 [95% confidence interval (CI) 0.78–1.42]. Following adjustment for baseline demographics, time-varying treatment probability and censoring risks, this HR was 0.73 (95% CI 0.50–1.05; P = 0.095). Despite these adjustments on 4×WHD, the HR for hospitalization remained elevated and vascular access complications were similar to 3×WHD.

Conclusions

This observational study was not able to demonstrate a mortality benefit in patients switched to 4×WHD. To demonstrate the true benefits of 4×WHD requires a large, well-designed clinical trial. Our data may help in the design of such a study.

Association of changes in bone mineral parameters with mortality in haemodialysis patients: insights from the ARO cohort

BACKGROUND

There is little information in haemodialysis (HD) patients on whether temporal changes in serum calcium, phosphate or intact parathyroid hormone (iPTH) are associated with mortality.

METHODS

We analysed associations of phosphate, total calcium and iPTH with all-cause and cardiovascular mortality in 8817 incident HD patients from the European second Analyzing Data, Recognizing Excellence and Optimizing Outcomes (AROii) cohort enrolled in 2007-09, which were prospectively followed for a median of 3 years, using time-dependent Cox proportional hazards models. We evaluated changes in risk over time depending on changes in phosphate, calcium or iPTH.

RESULTS

The association of phosphate and iPTH with all-cause mortality was U-shaped, with the lowest risk ranges between 1.20 and 1.89 mmol/L for phosphate and between 239 and 710 ng/L for iPTH. For total calcium, the associations were J-shaped, with an increased risk for all-cause mortality at levels >2.36 mmol/L. Lowest risk ranges for cardiovascular mortality did not change markedly for all three parameters. If iPTH was below the lowest risk range at baseline (iPTH <239 ng/L), a subsequent increase in levels was associated with improved survival. For phosphate, an increase or decrease out of the lowest risk range was associated with increased mortality risk. For calcium, this was only the case when the values increased above the lowest risk range.

CONCLUSION

In the AROii cohort, the ranges of bone mineral biomarkers associated with the lowest mortality ranges were largely consistent with the current Kidney Disease: Improving Global Outcomes chronic kidney disease-mineral and bone disorder guideline recommendations. Allowing a suppressed iPTH to increase was associated with a lower mortality, whereas shifts of phosphate or calcium outside the lowest risk range increased mortality.

Hospitalization and mortality following non-attendance for hemodialysis according to dialysis day of the week: a European cohort study

BACKGROUND

The extension of the interdialytic interval due to due to dialysis session non-attendance varies according to which session of the week the patient misses. The impact of this on subsequent hospitalization and mortality is unknown.

METHODS

The ARO cohort study prospectively collected data from hemodialysis patients across 15 European countries on demography, comorbidity, laboratory, hospitalisation, mortality and individual hemodialysis sessions from 2007 to 2014. Event rates for death and hospitalisation according to dialysis day of the week were calculated for patients who attended the three previous scheduled hemodialysis sessions, who then on the next scheduled dialysis day either attended or did not attend. The hazard ratio for these events following non-attendance for the first compared to the second dialysis session of the week was estimated using Cox proportional hazards model adjusted for patient demographics.

RESULTS

3.8 million hemodialysis sessions in 9397 patients were analysed. The non-attendance rates for Monday/Wednesday/Friday sessions were 0.8, 0.9% & 1.4% respectively, and for Tuesday/Thursday/Saturday sessions were 0.6, 1.0% & 1.2% respectively. Compared to those who attended, for the 48-72 h between non-attendance and the next scheduled haemodialysis session, mortality significantly increased from 4.86 to 51.9/100 pt-yrs and hospitalisation increased from 0.58 to 2.1/yr. As time from the two-day break increased, the risk associated with non-attendance lessened: compared to missing the second hemodialysis session, missing the first session had a hazard ratio for mortality of 2.04 (95% CI 1.27-3.29), and for hospitalisation 1.78 (95% CI 1.29-2.47). In patients who attended their scheduled dialysis session and the three preceding, after the two-day break there were absolute increases in mortality (8.3 vs. 4.9/100 pt-yrs) and hospitalisation (1.0 vs. 0.6/yr for the rest of the week) comparable to previous studies.

CONCLUSIONS

In addition to hospitalisation and mortality increases seen after the two-day break, additional harm may be manifested in the greater increases in mortality and hospitalisation observed after non-attendance for the first hemodialysis session after the two-day break compared to missing other sessions.

Is high-volume post-dilution haemodiafiltration associated with risk of fluid volume imbalance? A national multicentre cross-sectional cohort study

Background

Fluid overload is frequent among hemodialysis (HD) patients. Dialysis therapy itself may favor sodium imbalance from sodium dialysate prescription. As on-line hemodiafiltration (OL-HDF) requires large amounts of dialysate infusion, this technique can expose to fluid accumulation in case of a positive sodium gradient between dialysate and plasma. To evaluate this risk, we have analyzed and compared the fluid status of patients treated with HD or OL-HDF in French NephroCare centers.

Method

This is a cross-sectional and retrospective analysis of prevalent dialysis patients. Data were extracted from the EUCLID5 data base. Patients were split in 2 groups (HD and OL-HDF) and compared as whole group or matched patients for fluid status criteria including predialysis relative fluid overload (RelFO%) status from the BCM^®.

Results

2242 patients (age 71 years; female: 39%; vintage: 38 months; Charlson index: 6) were studied. 58% of the cohort were prescribed post-dilution OL-HDF. Comparing the HD and OL-HDF groups, there was no difference between HD and OL-HDF patients regarding the predialysis systolic BP, the interdialytic weight gain, the dialysate-plasma sodium gradient, and the predialysis RelFO%. The stepwise logistic regression did not find dialysis modality (HD or OL-HDF) associated with fluid overload or high predialysis systolic blood pressure. In OL-HDF patients, monthly average convective or weekly infusion volumes per session were not related with the presence of fluid overload.

Conclusions

In this cross-sectional study we did not find association between the use of post-dilution OL-HDF and markers of fluid volume excess. Aligned dialysis fluid sodium concentrations to patient predialysis plasma sodium and regular monitoring of fluid volume status by bioimpedance spectroscopy may have been helpful to manage adequately the fluid status in both OL-HDF and HD patients.

Detecting high-risk chronic kidney disease-mineral bone disorder phenotypes among patients on dialysis: a historical cohort study

BACKGROUND

The clinical management of chronic kidney disease-mineral bone disorder (CKD-MBD) remains extremely challenging, partially due to difficulties in defining high-risk phenotypes based on serum biomarkers. We evaluated the prevalence and outcomes of 27 mutually exclusive CKD-MBD phenotypes in a large, multi-national cohort of chronic dialysis patients over a 5-year follow-up study.

METHODS

In this historical cohort study, we enrolled all haemodialysis patients registered in EuCliD® on 1 July 2011 across 28 Europe, the Middle East and Africa (EMEA) and South American countries. We created 27 mutually exclusive phenotypes based on combinations of serum parathyroid hormone (PTH), phosphorus (P) and calcium (Ca) 6-month averages (L, low; T, target; H, high). We tested the association between CKD-MBD phenotypes and 5-year mortality and hospitalization risk by outcome risk score-adjusted proportional hazard regression.

RESULTS

We enrolled 35 721 eligible patients. Eastern European and South American countries generally achieved poorer CKD-MBD control when compared with Western European countries (prevalence ratio: 0.79; P < 0.001). There were 15 795 deaths [126.7 deaths/1000 person-years; 95% confidence interval (CI) 124.7-128.7]; 18 014 had at least one hospitalization (203.9 hospitalizations/1000 person-years; 95% CI 201.0-206.9); the incidence of the composite endpoint was 280.0 events/1000 person-years (95% CI 276.6-283.5). In the fully adjusted model, relative mortality risk ranged from hazard ratio (HR) = 1.07 (PTH/Ca/P: TLT) to HR = 1.59 (PTH/Ca/P: LTL), whereas the relative composite endpoint risk ranged from HR = 1.07 (PTH/Ca/P: TTH) to HR = 1.36 (PTH/Ca/P: LTL).

CONCLUSION

We identified several CKD-MBD phenotypes associated with reduced hospitalization-free survival and increased mortality. Ranking of relative risk estimates or excess events concurs in informing healthcare priority setting.

Impact of body mass index on short-term and long-term survival in prevalent hemodialysis patients

INTRODUCTION

Numerous studies showed that higher body mass index (BMI) is associated with better survival in hemodialysis (HD) patients. Most of them evaluated short-term mortality. It has been suggested that presence of inflammation may be a key modifier of relationship between BMI and mortality in incident HD patients. We examined whether presence of inflammation modifies the association between BMI and mortality in both short-term and long-term follow-up in a large group of prevalent HD patients.

METHODS

A total of 3.252 HD patients from 41 HD centers were enrolled; the patients were divided into quartiles based on time-averaged BMI (Q1 < 21.5, Q2 21.5 to <24.3, Q3 24.3 to <27.4, Q4 ≥ 27.4 kg/m² ). Inflammation status was defined as present (inflamed) (C-reactive protein (CRP) ≥1.0 mg/dL and/or serum albumin ≤3.5 g/dL) or absent (noninflamed).

FINDINGS

During 7 years of follow-up 1386 patients (42.6%) died. Compared to noninflamed patients, inflamed patients in the lowest BMI quartile showed 5-fold increased risk for mortality in the short-term (95% confidence interval [CI] 2.82-9.22, P < 0.001) and 3-fold in the long-term (95%CI 2.42-4.27, P < 0.001) compared to the highest BMI quartile. Whereas, inflamed patients in the highest BMI quartile experienced 2-fold increased risk in short-term (95%CI 1.17-3.74, P = 0.01) and 1.68-fold increased risk in long-term (95%CI 1.30-2.18, P < 0.001) than in noninflamed patients. The protective effect of BMI for overall mortality was present in all age groups, in both genders, in patient with and without diabetes. BMI was not a mortality predictor in patients with HD duration more than 76 months at baseline. The protective effect of BMI was observed in all albumin tertiles. In patients in the lowest CRP tertile, BMI was not associated with mortality.

DISCUSSION

Higher BMI is associated with lower short-term and long-term mortality risk, especially in patients with inflammation in a prevalent HD population.

Proton Pump Inhibitor Usage and the Risk of Mortality in Hemodialysis Patients

Introduction

Long-term inappropriate proton pump inhibitors use (PPIs) is a matter of concern because of the risks associated with their long-term use in older patients with chronic conditions. The risk of PPI treatment in hemodialysis patients remains unexplored.

Methods

We assessed the relationship between the use of PPIs and the risk of death in hemodialysis patients throughout a retrospective multicenter propensity score–matched study. Information about demographic, hemodialysis treatment, laboratory data, and concomitant medication was obtained from the EuCliD database (Fresenius Medical Care). We studied 1776 hemodialysis patients on PPI therapy compared to 466 patients not receiving PPIs. The resulting population comprising 2 groups of 410 matched patients was studied.

Results

PPI use was associated with hypomagnesemia (Mg <1.8 mg/dl (0.75 mmol/l); odds ratio [OR] = 2.70, 95% confidence interval [CI] = 1.38−5.27, P < 0.01). The exposure to PPIs in the full patient cohort was identified as an independent predictor for all-cause mortality in both univariate (HR = 3.16, 95% CI = 1.69–5.90, P < 0.01) and multivariate (HR = 2.70, 95% CI = 1.38–5.27, P < 0.01) Cox regression models. Moreover PPI use was identified as a predictor of CV mortality (HR = 1.51, 95% CI = 1.05−2.20, P = 0.03) Of the 820 patients matched throughout the propensity score analysis, the hazard ratios for all-cause mortality (HR = 1.412, 95% CI = 1.04–1.93, P = 0.03) and CV mortality (HR = 1.67, 95% CI = 1.03−2.71, P = 0.04) were higher among patients on PPIs versus those not on PPIs.

Conclusion

The study data suggest that the PPI treatment should be regularly monitored and prescribed only when indicated.

Anti-parathyroid treatment effectiveness and persistence in incident haemodialysis patients with secondary hyperparathyroidism

BACKGROUND

Anti-parathyroid treatment initiation and discontinuation are important decisions in chronic haemodialysis (HD) patients, where pill burden is often excessive. The present study aimed to describe secondary hyperparathyroidism (sHPT) drug therapy changes in HD patients.

METHODS

Retrospective observational cohort study of incident European HD patients with sHPT who were prescribed calcitriol or alfacalcidol (alpha calcitriol), paricalcitol or cinacalcet.

RESULTS

Treatment-naïve patients prescribed alpha calcitriol (N=2259), paricalcitol (N=1689) and cinacalcet (N=1245) were considered for analysis. Serum intact parathyroid hormone (iPTH) levels decreased post-initiation with all treatment modalities; serum calcium and phosphate levels increased in response to activated vitamin D derivatives but decreased with cinacalcet. Approximately one-third of alpha calcitriol and paricalcitol patients but less than one-quarter of cinacalcet patients discontinued treatment. Although the three groups had comparable serum iPTH control at the time of treatment discontinuation, they differed in terms of calcium and phosphate levels. Following discontinuation, the evolution of laboratory parameters differed by treatment modality: whilst iPTH increased for all three treatment groups, calcium and phosphate decreased in patients who were being treated with alpha calcitriol and paricalcitol at the time of discontinuation, and increased in those who had been treated with cinacalcet.

CONCLUSIONS

In conditions of daily clinical practice, attaining and maintaining recommended biochemical control of sHPT appears to be more frequently achievable with cinacalcet than with activated vitamin D compounds.

Hyponatraemia, mortality and haemodialysis: An unexplained association

BACKGROUND

As in the general population, in patients on haemodialysis (HD) hyponatraemia is associated with higher mortality risk. The objective of this article was to study the relationship between predialysis serum sodium (sNa) and mortality in an HD population. We also intended to define hyponatraemia and determine the characteristics of hyponatraemic patients in terms of anthropometric data, analytical features, dialysis measurements and hydration (bioimpedance).

METHODS

Observational, descriptive study of a cohort of HD incident patients. The independent variable was the mean of each patient's sNa analysed during their first 6 months on HD.

RESULTS

A total of 4,153 patients were included in the study. Mean age was 64.7 years; 65.2% of the patients were male and 35% were diabetics. Mean follow-up time was 21.48 (SD) (1.31) months. sNa had a normal distribution, with a mean (SD)=138.46 (2.7) mEq/l. Body weight, diabetes mellitus, systolic blood pressure, interdialytic weight gain, total ultrafiltration, serum glucose, albumin and creatinine, vascular access and haemodialysis type, acquire significant differences between sodium quartiles. Lean tissue index (LTI) in patients with low serum sodium, Q1 (135 mEq/l), was significantly lower than the LTI of patients from the other serum sodium quartiles. Patients with sNa<136 mEq/l had a higher independent mortality risk (OR=1.62) (Cox regression analysis).

CONCLUSIONS

HD patients with hyponatraemia patients have a poor prognosis and present malnutrition or fluid overload.

Inflammation Modifies the Paradoxical Association between Body Mass Index and Mortality in Hemodialysis Patients

High body mass index (BMI) is paradoxically associated with better outcome in hemodialysis (HD) patients. Persistent inflammation commonly features in clinical conditions where the obesity paradox is described. We examined the relationship between BMI and mortality in HD patients, accounting for inflammation, in a historic cohort study of 5904 incident HD patients enrolled in 2007-2009 (312 facilities; 15 European countries) with ≥3 months of follow-up. Patients were classified by presence (n=3231) or absence (n=2673) of inflammation (C-reactive protein ≥10 mg/l and/or albumin ≤35 g/l). Patients were divided into quintiles by BMI (Q1-Q5: <21.5, 21.5-24.0, >24.0-26.4, >26.4-29.8, and >29.8 kg/m(2), respectively). Noninflamed patients in BMI Q5 formed the reference group. During a median follow-up period of 36.7 months, 1929 deaths occurred (822 cardiovascular), with 655 patients censored for renal transplantation and 1183 for loss to follow-up. Greater mortality was observed in inflamed patients (P<0.001). In fully adjusted time-dependent analyses, the all-cause mortality risk in noninflamed patients was higher only in the lowest BMI quintile (hazard ratio [HR, 1.80; 95% confidence interval [95% CI], 1.26 to 2.56). No protective effect was associated with higher BMI quintiles in noninflamed patients. Conversely, higher BMI associated with lower all-cause mortality risk in inflamed patients (HR [95% CI] for Q1: 5.63 [4.25 to 7.46]; Q2: 3.88 [2.91 to 5.17]; Q3: 2.89 [2.16 to 3.89]; Q4: 2.14 [1.59 to 2.90]; and Q5: 1.77 [1.30 to 2.40]). Thus, whereas a protective effect of high BMI was observed in inflamed patients, this effect was mitigated in noninflamed patients.

Propensity score matching and persistence correction to reduce bias in comparative effectiveness: the effect of cinacalcet use on all-cause mortality

Purpose

The generalisability of randomised controlled trials (RCTs) may be limited by restrictive entry criteria or by their experimental nature. Observational research can provide complementary findings but is prone to bias. Employing propensity score matching, to reduce such bias, we compared the real‐life effect of cinacalcet use on all‐cause mortality (ACM) with findings from the Evaluation of Cinacalcet Therapy to Lower Cardiovascular Events (EVOLVE) RCT in chronic haemodialysis patients.

Methods

Incident adult haemodialysis patients receiving cinacalcet, recruited in a prospective observational cohort from 2007–2009 (AROii; n = 10,488), were matched to non‐exposed patients regardless of future exposure status. The effect of treatment crossover was investigated with inverse probability of censoring weighted and lag‐censored analyses. EVOLVE ACM data were analysed largely as described for the primary composite endpoint.

Results

AROii patients receiving cinacalcet (n = 532) were matched to 1790 non‐exposed patients. The treatment effect of cinacalcet on ACM in the main AROii analysis (hazard ratio 1.03 [95% confidence interval (CI) 0.78–1.35]) was closer to the null than for the Intention to Treat (ITT) analysis of EVOLVE (0.94 [95%CI 0.85–1.04]). Adjusting for non‐persistence by 0‐ and 6‐month lag‐censoring and by inverse probability of censoring weight, the hazard ratios in AROii (0.76 [95%CI 0.51–1.15], 0.84 [95%CI 0.60–1.18] and 0.79 [95%CI 0.56–1.11], respectively) were comparable with those of EVOLVE (0.82 [95%CI 0.67–1.01], 0.83 [95%CI 0.73–0.96] and 0.87 [95%CI 0.71–1.06], respectively).

Conclusions

Correcting for treatment crossover, we observed results in the ‘real‐life’ setting of the AROii observational cohort that closely mirrored the results of the EVOLVE RCT. Persistence‐corrected analyses revealed a trend towards reduced ACM in haemodialysis patients receiving cinacalcet therapy. © 2015 The Authors. Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons Ltd.

Dialysis patients and cardiovascular problems: can technology solve the complex equation?

Patients with end-stage kidney disease undergoing chronic hemodialysis present higher mortality rates compared with the general population. Once patients are on hemodialysis, the risk of cardiovascular death is approximately 30-times higher than the general population, and still remains 10- to 20-times higher after stratification for age, gender and presence of diabetes. Approximately half of patient deaths on dialysis are attributed to cardiovascular causes, including coronary heart disease, cerebrovascular disease, peripheral vascular disease and heart failure. The cardiovascular burden of the hemodialysis patient arises from three different sources: risks inherent to the patient and the uremic syndrome, traditional risk factors and risk factors related to the dialysis therapy. Based on these considerations and the fact that several aspects of the dialysis procedure can cause either a cardiovascular burden or modify the burden already present, new technologies should be directed towards the approach of a possible 'cardioprotective dialysis therapy'. This approach may significantly contribute new techniques and new dialysis machines. Born to make dialysis easy and safe, the new machines feature several options that make monitoring and online hemodiafiltration a simple routine. These and other features could make dialysis better tolerated and more efficient in protecting from fatal cardiovascular events.

Computational intelligence for the Balanced Scorecard: studying performance trends of hemodialysis clinics

OBJECTIVES

The Balanced Scorecard (BSC) is a general, widely employed instrument for enterprise performance monitoring based on the periodic assessment of strategic Key Performance Indicators that are scored against preset targets. The BSC is currently employed as an effective management support tool within Fresenius Medical Care (FME) and is routinely analyzed via standard statistical methods. More recently, the application of computational intelligence techniques (namely, self-organizing maps) to BSC data has been proposed as a way to enhance the quantity and quality of information that can be extracted from it. In this work, additional methods are presented to analyze the evolution of clinic performance over time.

METHODS

Performance evolution is studied at the single-clinic level by computing two complementary indexes that measure the proportion of time spent within performance clusters and improving/worsening trends. Self-organizing maps are used in conjunction with these indexes to identify the specific drivers of the observed performance. The performance evolution for groups of clinics is modeled under a probabilistic framework by resorting to Markov chain properties. These allow a study of the probability of transitioning between performance clusters as time progresses for the identification of the performance level that is expected to become dominant over time.

RESULTS

We show the potential of the proposed methods through illustrative results derived from the analysis of BSC data of 109 FME clinics in three countries. We were able to identify the performance drivers for specific groups of clinics and to distinguish between countries whose performances are likely to improve from those where a decline in performance might be expected. According to the stationary distribution of the Markov chain, the expected trend is best in Turkey (where the highest performance cluster has the highest probability, P=0.46), followed by Portugal (where the second best performance cluster dominates, with P=0.50), and finally Italy (where the second best performance cluster has P=0.34).

CONCLUSION

These results highlight the ability of the proposed methods to extract insights about performance trends that cannot be easily extrapolated using standard analyses and that are valuable in directing management strategies within a continuous quality improvement policy.

Clinical audit improves hypertension control in hemodialysis patients

BACKGROUND

In patients on hemodialysis (HD), hypertension is a risk factor for cardiovascular disease. In this study we tested the effectiveness of a clinical audit in improving blood pressure (BP) control in HD patients. 


METHODS

177 adult, prevalent patients undergoing dialysis in NephroCare centers in Italy were audited. At the conclusion of the audit, individual strategies were developed in order to improve BP control. Patient data was collected and examined at months -1 (Pre), 0 (the date of the audit- Audit), and +1 and +6 after the audit (Post-1 and Post-6, respectively).
We recorded BP, information on factors affecting BP, and anti-hypertensive drug regimen. The primary outcome of the study was to decrease prevalence of hypertension (BP ≥ 140/90 mmHg). Secondary outcomes were a reduction in average BP in hypertensive patients and/or a decrease in drug delivery associated with lower or unchanged BP.


RESULTS

104 patients out of 177 (58.7%) were hypertensive at Audit. BP levels were directly related to comorbidity and male sex, and inversely related to dialysate sodium concentration. The announcement of the audit alone was associated with a decreased prevalence of hypertension (Pre 64.4% to Audit 58.7%); a further decrease followed the audit (Post-1 51.1%, Post-6 47.6%, p<0.05 vs. Audit). Systolic BP in hypertensive patients also decreased (mean decrease was -8.5 and -14.1; p = 0.007 and p<0.001 at Post-1 and Post-6). Number of drugs assumed was significantly lower at Post-1 and Post-6 vs. Audit (p = 0.005 and p<0.001, respectively).


CONCLUSIONS

A clinical audit is an effective tool to improve BP control in HD patients.

Impact of mineral and bone disorder on healthcare resource use and associated costs in the European Fresenius medical care dialysis population: a retrospective cohort study

Background

Secondary hyperparathyroidism (SHPT) is associated with mortality in patients with chronic kidney disease (CKD), but the economic consequences of SHPT have not been adequately studied in the European population. We assessed the relationship between SHPT parameters (intact parathyroid hormone [iPTH], calcium, and phosphate) and hospitalisations, medication use, and associated costs among CKD patients in Europe.

Methods

The analysis of this retrospective cohort study used records of randomly selected patients who underwent haemodialysis between January 1, 2005 and December 31, 2006 at participating European Fresenius Medical Care facilities in 10 countries. Patients had ≥ 1 iPTH value recorded, and ≥ 1 month of follow-up after a 3-month baseline period during which SHPT parameters were assessed. Time at risk was post-baseline until death, successful renal transplantation, loss to follow-up, or the end of follow-up. Outcomes included cost per patient-month, rates of hospitalisations (cardiovascular disease [CVD], fractures, and parathyroidectomy [PTX]), and use of SHPT-, diabetes-, and CVD-related medications. National costs were applied to hospitalisations and medication use. Generalised linear models compared costs across strata of iPTH, total calcium, and phosphate, adjusting for baseline covariates.

Results

There were 6369 patients included in the analysis. Mean ± SD person-time at risk was 13.1 ± 6.4 months. Patients with iPTH > 600 pg/mL had a higher hospitalisation rate than those with lower iPTH. Hospitalisation rates varied little across calcium and phosphate levels. SHPT-related medication use varied with iPTH, calcium, and phosphate. After adjusting for demographic and clinical variables, patients with baseline iPTH > 600 pg/mL had 41% (95% CI: 25%, 59%) higher monthly total healthcare costs compared with those with iPTH in the K/DOQI target range (150–300 pg/mL). Patients with baseline phosphate and total calcium levels above target ranges (1.13–1.78 mmol/L and 2.10–2.37 mmol/L, respectively) had 38% (95% CI: 27%, 50%) and 8% (95% CI: 0%, 17%) higher adjusted monthly costs, respectively. Adjusted costs were 25% (95% CI: 18%, 32%) lower among patients with baseline phosphate levels below the target range. Results were consistent in sensitivity analyses.

Conclusions

These data suggest that elevated SHPT parameters increase the economic burden of CKD in Europe.

Vascular Access Cannulation in Hemodialysis Patients – A Survey of Current Practice and its Relation to Dialysis dose

Purpose

The appropriate use of vascular access is of fundamental importance in the treatment of hemodialysis (HD) patients. This survey entailed collecting data on current practice of vascular access cannulation to assess its relation to dialysis dose.

Methods

This international, multicenter, observational, cross-sectional survey was performed in 171 dialysis centers of the European dialysis network of Fresenius Medical Care in Europe and South Africa during April 2009. Practice patterns of vascular access cannulations were documented by means of a 24-item questionnaire. Dialysis dose from the documented hemodialysis treatments was derived from the clinical database EuCliD®.

Results

In total, 10,807 cannulations in hemodialysis patients with either arteriovenous fistula (91%) or arteriovenous graft (9%) were documented. For the puncture, the area technique was applied most frequently using 15G and 16G needles. Blood flow rates were mostly between 300 and 400 mL/min and adjusted to the needle size used. In two-thirds of cases the arterial needle was placed first, mostly in an antegrade direction, with an average distance to the venous needle of 7.0±3.7 cm. More than two-thirds of the cannulations were performed by nurses with more than 5 years of experience in dialysis. A logistic regression model revealed a significantly higher odds ratio to attain Kt/V ≥ 1.2 for retrograde placement of the arterial needle, and for using needles with bigger diameter.

Conclusions

This survey covered a broad number of countries and centers and provides information on current practice of vascular access cannulation, their effect on dialysis dose, and serves as feedback to the dialysis centers for their quality management process.

Effects of telmisartan added to Angiotensin-converting enzyme inhibitors on mortality and morbidity in hemodialysis patients with chronic heart failure a double-blind, placebo-controlled trial

OBJECTIVES

the aim of this study was to determine whether telmisartan decreases all-cause and cardiovascular mortality and morbidity in hemodialysis patients with chronic heart failure (CHF) and impaired left ventricular ejection fraction (LVEF) when added to standard therapies with angiotensin-converting enzyme inhibitors.

BACKGROUND

in hemodialysis patients, CHF is responsible for a high mortality rate, but presently very few data are available with regard to this population.

METHODS

A 3-year randomized, double-blind, placebo-controlled, multicenter trial was performed involving 30 Italian clinics. Hemodialysis patients with CHF (New York Heart Association functional class II to III; LVEF ≤ 40%) were randomized to telmisartan or placebo in addition to angiotensin-converting enzyme inhibitor therapy. A total of 332 patients were enrolled (165 telmisartan, 167 placebo). Drug dosage was titrated to a target dose of telmisartan of 80 mg or placebo. Mean follow-up period was 35.5 ± 8.5 months (median: 36 months; range: 2 to 40 months). Primary outcomes were: 1) all-cause mortality; 2) cardiovascular mortality; and 3) CHF hospital stay.

RESULTS

at 3 years, telmisartan significantly reduced all-cause mortality (35.1% vs. 54.4%; p < 0.001), cardiovascular death (30.3% vs. 43.7%; p < 0.001), and hospital admission for CHF (33.9% vs. 55.1%; p < 0.0001). With Cox proportional hazards analysis, telmisartan was an independent determinant of all-cause mortality (hazard ratio [HR]: 0.51; 95% confidence interval [CI]: 0.32 to 0.82; p < 0.01), cardiovascular mortality (HR: 0.42; 95% CI: 0.38 to 0.61; p < 0.0001), and hospital stay for deterioration of heart failure (HR: 0.38; 95% CI: 0.19 to 0.51; p < 0.0001). Adverse effects, mainly hypotension, occurred in 16.3% of the telmisartan group versus 10.7% in the placebo group.

CONCLUSIONS

addition of telmisartan to standard therapies significantly reduces all-cause mortality, cardiovascular death, and heart failure hospital stays in hemodialysis patients with CHF and LVEF ≤ 40%. (Effects Of Telmisartan Added To Angiotensin Converting Enzyme Inhibitors On Mortality And Morbidity In Haemodialysed Patients With Chronic Heart Failure: A Double-Blind Placebo-Controlled Trial; NCT00490958).

Regional and national health care data repositories

Efforts are underway to define a national framework for secondary analysis of health-related data. In the meantime, regional health databases have been constructed using insurance claims data, clinical data from single large health care providers, clinical data from multiple collaborating health care providers, and public health data. Large-scale survey data also are available in government databases. Clinical laboratory results are an important component of all these databases because they can provide validation for manually assigned diagnostic and procedure codes and can support inference of key information not provided by coding, such as severity of disease and prevalence of risk factors.

Modeling in biomedical informatics—An exploratory analysis

OBJECTIVE

Modeling is a significant part of research, education and practice in biomedical and health informatics. Our objective was to explore which types of models of processes are used in current biomedical/health informatics research, as reflected in publications of scientific journals in this field. Also, the implications for medical informatics curricula were investigated.

METHODS

Retrospective, prolective observational study on recent publications of the two official journals of the International Medical Informatics Association (IMIA), the International Journal of Medical Informatics (IJMI) and Methods of Information in Medicine (MIM). All publications of the years 2004 and 2005 from these journals were indexed according to a given list of model types. Random samples out of these publications were analysed in more depth.

RESULTS

Three hundred and eighty-four publications have been analysed, 190 of IJMI and 194 of MIM. For publications in special issues (121 in IJMI) and special topics (132 in MIM) we found differences between theme-centered and conference-centered special issues/special topics (SIT) publications. In particular, we could observe a high variation between modeling in publications of theme-centered SITs. It became obvious that often sound formal knowledge as well as a strong engineering background is needed for carrying out this type of research. Usually, this knowledge and the related skills can be best provided in consecutive B.Sc. and M.Sc. programs in medical informatics (respectively, health informatics, biomedical informatics). If the focus should be primarily on health information systems and evaluation this can be offered in a M.Sc. program in medical informatics.

CONCLUSIONS

In analysing the 384 publications it became obvious that modeling continues to be a major task in research, education and practice in biomedical and health informatics. Knowledge and skills on a broad range of model types are needed in biomedical/health informatics.

Dialysis Patients and Cardiovascular Problems: Can Technology Help Solve the Complex Equation?

Patients with end-stage kidney disease undergoing chronic hemodialysis (HD) present higher mortality rates compared with the general population. Once patients are on HD, the risk of cardiovascular death is approximately 30 times higher than in the general population and remains 10-20 times higher after stratification for age, gender, and the presence of diabetes. About half the deaths of patients on dialysis are attributed to cardiovascular causes including coronary heart disease, cerebrovascular disease, peripheral vascular disease, and heart failure. The cardiovascular burden of the HD patient arises from three different sources: risks inherent to the patient and the uremic syndrome, traditional risk factors, and risk factors related to the dialysis therapy. Based on these considerations and the fact that several aspects of the dialysis procedure can either add to the cardiovascular burden or modify the existing burden, new technologies should be directed towards the approach of a potential 'cardioprotective dialysis therapy'; such an approach may be facilitated by the application of new techniques and advanced dialysis machines. Created to make dialysis easy and safe, new machines feature several options that make patient monitoring and online hemodiafiltration therapy routine procedures. These and other features will possibly make dialysis better tolerated and more efficient in protecting patients from undesirable or potentially fatal cardiovascular events.