Hemodialysis in Asia

The burden of chronic kidney disease in Asia region: a review of the evidence, current challenges, and future directions

The disease burden of chronic kidney disease (CKD) and its impact on healthcare systems has been poorly studied in Asia, a socioeconomically diverse region with wide variations in availability, access, and quality of CKD care. The high CKD burden in this region is predominantly driven by an increased prevalence of risk factors including diabetes mellitus, hypertension, obesity, and use of traditional medicines and is further aggravated by challenges associated with effective implementation of population-based screening and surveillance systems in early detection and intervention of CKD. The Asian continent mostly comprised of low- and middle-income countries with resource restraints lacks robust population-based CKD registries resulting in a paucity of data on CKD incidence and prevalence, various treatment modalities, uptake of current guidelines, and the overall impact of implementation of developmental programs. There is an urgent need for a collaborative action plan between the healthcare community and governments in this region to detect CKD in its early stages and prevent its complications including kidney failure, cardiovascular disease, and death. Research- based evidence on the impact of early detection, sustainable treatment options, quality of life, delay or avoidance of dialysis, and related cost analysis is the need of the hour. We highlight successful implementation of strategic and policy-sharing programs adopted in a few countries; also, consolidate available region-specific data, quantify estimates of CKD burden and propose strategies with a multidisciplinary approach involving patients, the healthcare community and governmental bodies to combat CKD and its complications.

Comparison of the quality of life and biochemical characteristics of patients undergoing hemodialysis and peritoneal dialysis: a systematic review and meta-analysis

BACKGROUND

End-stage kidney failure (ESKF) requires kidney replacement therapy (KRT), which has a significant effect on the quality of life (QoL) of patients. Globally, well-established treatment options for ESKF include HD, PD, and kidney transplantation. Each has a unique effect on a patient's QoL in terms of their physical, mental, and social health. The objective of this study was to evaluate and compare the QoL of patients undergoing PD and HD by utilizing the 36-item Short Form Health Survey (SF-36), EuroQoL-5-dimension (EQ-5D), and WHOQOL-BREF questionnaires.

METHODS

We performed a comprehensive review and meta-analysis by identifying relevant research through the use of ScienceDirect, CINAHL, MEDLINE, and Google Scholar. These studies examined patients with ESKF who were undergoing either HD or PD and reported changes in QoL and biochemical characteristics. If heterogeneity was present, we calculated and pooled the standardized mean differences (SMDs) in QoL among modalities via a random effects model.

RESULTS

This analysis included twenty-five (25) studies that examined the QoL and biochemical characteristics of a total of 5,440 participants. Among these participants, 3465 (63.75%) were receiving HD, and 1975 (36.25%) were receiving PD. The QoL instruments assess a variety of effects. However, these studies demonstrate that PD consistently performs better than HD in multiple assessment components, including for burdens of kidney disease, general health, mental health, and emotional. Nevertheless, there was no significant difference in the QoL scores regarding cognitive ability, energy levels, physical health, patient satisfaction, psychology, social interaction, emotional well-being, sexual functioning, or sleeping patterns between these modalities.

CONCLUSION

The study's findings show that patients with PD have a higher QoL in comparison to those with HD. Despite reports of enhanced QoL among PD patients, their global prevalence remains relatively low. Therefore, healthcare professionals should prioritize the development and implementation of strategies for ESKF patients, considering PD as the primary treatment. The results suggest a trend favoring PD over HD in various aspects of QOL. However, the significant heterogeneity and the lower number of PD patients require careful interpretation of these findings.

Lived experiences of people with chronic kidney disease on maintenance dialysis: a systematic review and thematic synthesis of qualitative studies

AIM

Chronic Kidney Disease (CKD) has emerged as a global public health concern. People with the most advanced stage of CKD require renal replacement therapies, either dialysis (the focus of this study) or a kidney transplant. Research on CKD has primarily focused on its clinical, epidemiological, and public health aspects. However, studies exploring the lived experiences of individuals on dialysis and the key factors influencing these experiences are limited, particularly in low- and middle-income settings. Therefore, this study aims to synthesize the existing literature on the illness experience of people living with CKD who are on maintenance dialysis across different country contexts.

METHODS

Adhering to PRISMA and PiCO guidelines for systematic review, we identified original studies published between 2000 and 2024, focusing on the lived experience of patients with CKD on dialysis, across PubMed, Web of Science, and Scopus databases. A thematic analysis was conducted based on two frameworks: Michael Bury's biographical disruption model of chronic illness, and the framework on internal and external factors affecting self-care.

RESULTS

A total of 59 studies were included, and the following key themes were identified: 1) disrupted biographies among people on dialysis, which included: (a) diagnosis and initiation of dialysis, (b) disabling physical symptoms and functional limitations, (c) impaired socio-occupational functioning, (d) uncertainty and psychological distress, and (e) changes in self-image and identity; and 2) biographical repair, which included: (a) coping with CKD and dialysis, (b) coping styles, and (c) coping strategies. The key internal factors influencing the lived experiences were personal beliefs and misconceptions about CKD, feelings of shame and guilt, financial constraints, and spirituality. The external factors included family and social support, information and treatment received from the clinical team, social stigma, availability and quality of dialysis services, and access to health insurance.

CONCLUSIONS

This review deepens our understanding of the lived experiences of individuals undergoing maintenance dialysis across diverse settings and illuminates the internal and external factors that shape these experiences. Our findings emphasize the necessity of a holistic and person-centred approach to dialysis care and highlight the need to make dialysis services more accessible and affordable in low- and lower-middle-income countries.

Demographic and Clinical Profile of Haemodialysis Patients with End-Stage Renal Disease in a Northern Nigerian Hospital: A Retrospective Analysis of Patterns and Outcomes

Background

Chronic kidney disease (CKD) is a global health challenge with increasing prevalence and substantial impacts on healthcare systems, particularly in low- and middle-income countries. Limited access to resources for managing CKD and end-stage renal disease (ESRD) in these regions exacerbates mortality and morbidity, highlighting the need for effective and accessible healthcare strategies. This study examines CKD prevalence, management practices, and outcomes across various populations, with a focus on the challenges faced in sub-Saharan Africa.

Methodology

This study utilized a retrospective, observational design to examine patient records from the haemodialysis unit at Yusuf Dantsoho Memorial General Hospital, Kaduna State, Nigeria. The research focused on the sociodemographic, clinical, and dialysis-related characteristics of patients who underwent haemodialysis between January 2019 and October 2024.

Results

CKD prevalence has significantly increased worldwide, with ESRD incidence notably in our centre. Access to dialysis varied greatly, with low-resource settings struggling to meet demand, contributing to poorer outcomes. In Africa, studies show that less than 10% of patients who needed dialysis accessed it. Additionally, CKD patients in lower-income regions often present with advanced diseases due to inadequate screening and preventive care. High mortality rates were linked to limited access to early treatment and a lack of government support for subsidizing renal care.

Conclusion

There was a pressing need to improve CKD prevention, early diagnosis, and treatment in resource-limited settings to reduce the burden of ESRD. Increased government investment, enhanced screening programs, and sustainable funding models for dialysis were essential to mitigate the impact of CKD.

Risk factors associated with mortality among patients on maintenance hemodialysis: The Thailand Renal Replacement Therapy registry

INTRODUCTION

End-stage kidney disease (ESKD) has been increasing in prevalence across the world, including Thailand, and patients with ESKD on hemodialysis have a high mortality risk.

METHODS

A retrospective cohort study was performed across 855 hemodialysis centers in the Thailand Renal Replacement Therapy registry. The database and mortality data were analyzed.

RESULTS

A total of 58 952 patients were included. The survival rates at 1, 3, and 5 years were 93.5%, 69.7%, and 41.2%, respectively. On multivariate analysis, factors such as aging, permanent catheter or arteriovenous graft, twice-weekly hemodialysis, low levels of urea reduction ratio, normalized protein catabolic rate, hemoglobin, transferrin saturation, serum albumin, LDL-cholesterol, intact-parathyroid hormone, uric acid, sodium, phosphate, and bicarbonate were significantly related to death.

CONCLUSION

Mortality is high in ESKD patients on hemodialysis. Age, type of vascular access, twice-weekly hemodialysis, inadequate dialysis, low protein intake, anemia, abnormal electrolytes, and bone mineral disorders are associated with all-cause mortality.

Association between Asian race and perioperative outcomes after carotid revascularization varies with Asian procedure density

OBJECTIVE

Postoperative outcomes following carotid revascularization are understudied in Asian patients. We aimed to assess whether disease severity and postoperative outcomes following carotid revascularization differ between Asian and White patients, and whether this varies with Asian procedure density.

METHODS

We analyzed the Vascular Quality Initiative Carotid Endarterectomy and Carotid Artery Stenting datasets from 2003 to 2021. Regions were divided into tertiles based on Asian procedure density. Propensity scores were used to match Asian and White patients based on patient factors and procedure type. The primary outcome variable was a collapsed composite of in-hospital ipsilateral stroke/death/myocardial infarction. χ2 tests were used to assess association between Asian race and disease severity, center and surgeon volume, and 1-year outcomes. Logistic and Cox regressions were performed between the matched cohorts.

RESULTS

A total of 1766 Asian and 159,608 White patients underwent carotid revascularization, and we identified 2704 patients (1352 Asian and 1352 White) in the matched cohorts. Among propensity matched patients, all-comer Asian patients more commonly had >80% ipsilateral stenosis (63% vs 52%; P < .001) and a moderate/severe preoperative Rankin score (7.6% vs 5.1%; P = .007). The rate of in-hospital stroke/death/myocardial infarction was higher in Asian patients (2.6% vs 1.3%; P = .012), and this disparity was more pronounced in the lowest tertile of Asian procedure density (4.3% vs 0.5%; P < .001). Logistic regression in the propensity-matched cohort demonstrated Asian race was associated with lower odds of intervention at highest volume centers (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2-0.3; P < .001) and by highest volume surgeons (OR, 0.3; 95% CI, 0.3-0.4; P < .001). Asian race was associated with higher odds of in-hospital stroke/death/myocardial infarction (OR, 2.0; 95% CI, 1.1-3.8; P = .031), and there was a significant interaction between Asian procedure density and the relationship between Asian race and this outcome (interaction P = .001). After accounting for center and surgeon volume, the association of Asian race and the composite outcome was mitigated (OR, 1.5; 95% CI, 0.7-3.3; P = .300). Cox regression between the matched cohorts demonstrated that Asian race was associated with lower 1-year mortality (hazard ratio, 0.5; 95% CI, 0.3-0.7; P = .001) and higher risk of 1-year reintervention (hazard ratio, 16; 95% CI, 1.8-142; P = .013).

CONCLUSIONS

Asian patients are more likely to present with a higher degree of carotid stenosis, higher preoperative risk, and experience worse perioperative outcomes. The association of Asian race with perioperative stroke/death/myocardial infarction varies with Asian procedure density and is also confounded by center and surgeon volume. These results highlight the importance of understanding referral patterns and cultural effects on outcomes disparities in Asian patients.

Investigation of treatment volume versus circulating blood volume during Rheocarna treatment

INTRODUCTION

Rheocarna's therapeutic effect is associated with fibrinogen (Fib) and low-density lipoprotein cholesterol (LDL-C) adsorptive removal. This study aimed to retrospectively investigate the association between treatment volume (TV) and circulating blood volume (CBV) and the Fib removal rate (Fib-RR) and LDL-C-RR.

METHODS

CBV and TV/CBV, cut-off value (CO value), and area under the receiver operating characteristic (ROC) curve (AUC) were calculated. The Fib-RR and LDL-C-RR at the midterm and end of treatment were compared. The groups were further categorized into three groups with TV/CBV lower than or higher than the CO value at the midterm and end (midterm/end; Group L: lower than/lower than CO; Group L/H: lower than/higher than CO; Group H: higher than/higher than CO), and the Fib-RR and LDL-RR of each group at the midterm and end were compared.

RESULTS

ROC analysis revealed a TV of 1.480 times the BV as CO value, which showed a maximum Youden index predicting a Fib-RR of 20% (AUC: 0.828). Among the three groups, Group L and Group L/H demonstrated significantly higher Fib-RR and LDL-C-RR at the end of the study than in the midterm, while Group H exhibited no difference.

CONCLUSION

The results reveal that a treatment volume of 1.5 times the circulating blood volume is a sufficient solute removal capacity in the Rheocarna-enabled cases.

Comparison between intermittent claudication versus chronic limb-threatening ischemia in peripheral arterial disease: a retrospective multicenter cohort study

Purpose

The anatomical distribution, characteristics of lesions, and treatment modalities for peripheral artery disease (PAD) are diverse. Endovascular intervention is popular for symptomatic PAD, for both intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI). We aimed to investigate the endovascular devices used by comparing patients with PAD referred for endovascular revascularization with IC and CLTI.

Methods

We identified 736 patients with PAD enrolled in the multicenter PAD registry in South Korea from 2019 to 2022. Of these patients, 636 received endovascular treatment at the time of this study. After excluding missing data, we analyzed 506 patients with IC or CLTI. Patients' characteristics, target lesions, and endovascular device data such as type, length, balloon diameter, and stent, were examined. Procedure outcomes of the aortoiliac, femoropopliteal, and below-the-knee lesions were analyzed.

Results

Patients with CLTI were more likely to have diabetes mellitus, below-the-knee interventions, and multilevel PAD than the IC group. Patients with IC had more aortoiliac artery lesions and underwent atherectomies than the CLTI group (63.3% and 61.1% vs. 39.7% and 40.6%, respectively; P < 0.001). In patients with femoropopliteal lesions, those with CLTI were more revascularized with stents than the patients with IC, without significant differences (35.3% vs. 29.1%, P = 0.161). Compared to the IC group, the CLTI patients showed significantly worse rates of primary patency, amputation, and mortality (P = 0.029, P < 0.001, and P < 0.001, respectively).

Conclusion

Among Korean patients with PAD, there is a significant difference in baseline and lesion characteristics, endovascular strategies, and short-term follow-up outcomes among those with IC and CLTI.

Bone aluminum accumulation in the current era

In the last few years, evidence from the Brazilian Registry of Bone Biopsy (REBRABO) has pointed out a high incidence of aluminum (Al) accumulation in the bones of patients with CKD under dialysis. This surprising finding does not appear to be merely a passive metal accumulation, as prospective data from REBRABO suggest that the presence of Al in bone may be independently associated with major adverse cardiovascular events. This information contrasts with the perception of epidemiologic control of this condition around the world. In this opinion paper, we discussed why the diagnosis of Al accumulation in bone is not reported in other parts of the world. We also discuss a range of possibilities to understand why bone Al accumulation still occurs, not as a classical syndrome with systemic signs of intoxication, as occurred it has in the past.

Transcatheter aortic valve replacement in patients with severe aortic stenosis reduced the frequency of intradialytic hypotension

Intradialytic hypotension (IDH) is a common complication during hemodialysis that increases cardiovascular morbidity and mortality. Aortic stenosis (AS) is a cause of IDH. Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients with severe AS. However, whether TAVR reduce the frequency of IDH has not been investigated. This study aims to verify the efficacy of TAVR for reduction of the frequency of IDH. Consecutive hemodialysis patients who underwent TAVR at Sendai Kosei Hospital from February 2021 to November 2021 with available records 1 month before and 3 months after TAVR were included in the study. IDH was defined as a decrease in systolic blood pressure by 20 mmHg or a decrease in the mean blood pressure by 10 mmHg associated with hypotensive symptoms or requiring intervention. Patients with ≥ 3 episodes of IDH in ten hemodialysis sessions comprised the IDH group. Overall, 18/41 (43.9%) patients were classified into the IDH group. In ten hemodialysis sessions, IDH events were observed 2.1, 4.3, and 0.4 times in the overall cohort, IDH group, and non-IDH group, respectively. After TAVR, the incidence of IDH decreased from 43.2 to 10.3% (p < 0.0001) and IDH improved significantly in 15 patients in the IDH group. The result suggested that severe AS was the major cause of IDH in this cohort, and TAVR may be an effective treatment option for reduction of the frequency of IDH in patients with severe AS.

DeepVAQ : an adaptive deep learning for prediction of vascular access quality in hemodialysis patients

BACKGROUND

Chronic kidney disease is a prevalent global health issue, particularly in advanced stages requiring dialysis. Vascular access (VA) quality is crucial for the well-being of hemodialysis (HD) patients, ensuring optimal blood transfer through a dialyzer machine. The ultrasound dilution technique (UDT) is used as the gold standard for assessing VA quality; however, its limited availability due to high costs impedes its widespread adoption. We aimed to develop a novel deep learning model specifically designed to predict VA quality from Photoplethysmography (PPG) sensors.

METHODS

Clinical data were retrospectively gathered from 398 HD patients, spanning from February 2021 to February 2022. The DeepVAQ model leverages a convolutional neural network (CNN) to process PPG sensor data, pinpointing specific frequencies and patterns that are indicative of VA quality. Meticulous training and fine-tuning were applied to ensure the model's accuracy and reliability. Validation of the DeepVAQ model was carried out against established diagnostic standards using key performance metrics, including accuracy, specificity, precision, F-score, and area under the receiver operating characteristic curve (AUC).

RESULT

DeepVAQ demonstrated superior performance, achieving an accuracy of 0.9213 and a specificity of 0.9614. Its precision and F-score stood at 0.8762 and 0.8364, respectively, with an AUC of 0.8605. In contrast, traditional models like Decision Tree, Naive Bayes, and kNN demonstrated significantly lower performance across these metrics. This comparison underscores DeepVAQ's enhanced capability in accurately predicting VA quality compared to existing methodologies.

CONCLUSION

Exemplifying the potential of artificial intelligence in healthcare, particularly in the realm of deep learning, DeepVAQ represents a significant advancement in non-invasive diagnostics. Its precise multi-class classification ability for VA quality in hemodialysis patients holds substantial promise for improving patient outcomes, potentially leading to a reduction in mortality rates.

Prevalence, Microbial Etiology and Risk Factors Associated With Healthcare Associated Infections Among End Stage Renal Disease Patients on Renal Replacement Therapy

End stage renal disease (ESRD) patients on renal replacement therapy (RRT) have an increased risk of morbidity and mortality due to healthcare associated infections (HCAIs). The aim of this study is to determine the prevalence, microbial etiology, and risk factors associated with HCAIs among ESRD patients on RRT. A multicenter, retrospective study was conducted from June to December 2019. ESRD patients with minimum of 6 months on RRT were included, while pregnant patients and patients <18 years were excluded. To reduce the risk of selection bias, all patients were randomly selected using a simple random sampling technique. The prevalence showing the proportion of patients that acquired HCAI since the initiation of dialysis until 2019 was calculated using the European patients' academy (EUPATI) formula. Risk factors were assessed using univariate and multivariate regression analysis. The prevalence of HCAI among ESRD patients was 174/400 (43.5%). Catheter related bloodstream infection (CRBSI) was the most common infection [64(36.8%)], followed by peritonitis [45(25.8%)] and pneumonia [37(21.2%)]. Out of 382 total pathogens identified, 204 (53.4%) were Gram positive and 162 (42.4%) were Gram negative. Both methicillin sensitive staphylococcus aureus (MSSA) and methicillin resistant staphylococcus aureus (MRSA) showed statistically significant associations (p<0.05) with CRBSI. Use of multiple accesses, increased blood sugar levels, low serum sodium levels and higher CRP concentration increased the occurrence of HCAIs. The burden of HCAIs among the patients undergoing RRT is high. Preventive strategies and optimum empirical therapy of antibiotics should be used to reduce the risk of these infections among ESRD patients.

Multicentre, observational, retrospective cohort of hyperkalaemia burden at haemodialysis facility-level in China: the Visualize-HD study protocol

OBJECTIVES

Hyperkalaemia is a potentially life-threatening disorder in patients undergoing haemodialysis (HD). Excess mortality and hospitalisation have been associated with hyperkalaemia (HK) after the long (2-day) interdialytic interval (LIDI) in patients on thrice a week HD compared with the short (1-day) interdialytic interval. Moreover, not much research has been conducted in China on the descriptive epidemiology and management of HK among different HD centres. The aim of this study is to address this evidence gap by investigating the risk factors associated with HK clinical burden at the HD facility level, current HD centres management patterns, serum potassium management patterns, as well as the risk factors associated with crude mortality in China.

DESIGN

Multicentre, observational, retrospective cohort study.

SETTING

This study plans to enrol 300 HD centres across China. Haemodialysis centres having ≥100 patients on maintenance HD within 3 years before study initiation, with participation willingness, routine blood collection post-LIDI and death records will be included.

PARTICIPANTS

Patients aged ≥18 years and on chronic HD for ≥3 months will be considered eligible. Summary data about serum potassium, characteristics of patients, facility practice patterns will be collected at HD facility level and death records will be at the patient level.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome will be to examine the association between suspected risk factors and HK prevalence at HD facility level. Suspected risk factors include dialysis prescriptions and serum potassium testing frequency, characteristics of patients and related medication usage. The secondary outcome will be to determine the HK prevalence, serum potassium management pattern and risk factors associated with crude mortality. The primary and secondary outcomes will be analysed using regression models. Exploratory outcomes will further investigate the risk factors associated with serum potassium ≥6.0 and ≥6.5 mmol/L.

CONCLUSION

The study is expected to provide insights to improve dialysis practice patterns and understand the clinical burden of HK.

ETHICS AND DISSEMINATION

This study protocol was reviewed and approved by the Institutional Review Boards and Ethics Committee of Peking University People's Hospital (Approval number: 2020PHB324-01). The results will be disseminated through national and international presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT05020717.

Risk Factors for Lower Extremity Amputation in Patients with End-Stage Kidney Disease: A Nationwide Cohort Study

Individuals with end-stage kidney disease (ESKD) on dialysis are at a high risk of developing foot ulcerations and undergoing subsequent lower extremity amputation (LEA), which can exert significant impacts on their quality of life and contribute to rising healthcare costs. We aimed to identify risk factors associated with LEA in patients with ESKD to predict LEA progression and eventually prevent it. We used 18 years (2002-2019) of data from the Korean National Health Insurance Service (KNHIS). Data were collected from patients with ESKD who underwent renal replacement therapy (RRT) and had no history of amputation caused by trauma or toxins. The risk factors were compared between patients with or without LEA. We collected data from 220,838 patients newly diagnosed with ESKD, including 6348 in the LEA group and 214,490 in the non-LEA group. The total incidence of LEA was 2.9%. Older age, male gender, lower income, non-metropolitan residence, diabetes mellitus, dialysis treatment (compared to kidney transplantation), microvascular disease, peripheral vascular disease, endovascular procedure, and endovascular operation were associated with an increased risk of LEA. Thus, individuals with ESKD who are at a higher risk for LEA should be closely monitored, and kidney transplantation should be considered as a preventative measure.

Effects of different palliative care models on decedents with kidney failure receiving maintenance dialysis: a nationwide population-based retrospective observational study in Taiwan

OBJECTIVES

Patients with kidney failure receiving maintenance dialysis are a particularly important population and carry a heavy disease burden. However, evidence related to palliative care for patients with kidney failure receiving maintenance dialysis remains scarce, especially in regard to palliative care consultation services and palliative home care. This study aimed to evaluate the effects of different palliative care models on aggressive treatment among patients with kidney failure receiving maintenance dialysis during the end of life.

DESIGN

A population-based retrospective observational study.

SETTING

This study used a population database maintained by Taiwan's Ministry of Health and Welfare in combination with Taiwan's National Health Research Insurance Database.

PARTICIPANTS

We enrolled all decedents who were patients with kidney failure receiving maintenance dialysis from the period 1 January 2017 to 31 December 2017 in Taiwan.

MAIN EXPOSURE MEASURE

Hospice care during the 1-year period before death.

MAIN OUTCOME MEASURES

Eight aggressive treatments within 30 days before death, more than one emergency department visit, more than one admission, a longer than 14-day admission, admission to an intensive care unit, death in hospital, endotracheal tube use, ventilator use and need for cardiopulmonary resuscitation.

RESULTS

A total of 10 083 patients were enrolled, including 1786 (17.7%) patients with kidney failure who received palliative care 1 year before death. Compared with patients without palliative care, patients with palliative care had significantly less aggressive treatments within 30 days before death (Estimates: -0.09, CI: -0.10 to -0.08). Patients with inpatient palliative care, palliative home care or a mixed model experienced significantly lower treatment aggressiveness within 30 days before death.

CONCLUSIONS

Palliative care, particularly use of a mixed care model, inpatient palliative care and palliative home care in patients with kidney failure receiving dialysis, could all significantly reduce the aggressiveness of treatment within 30 days before death.

Asian race is associated with peripheral arterial disease severity and postoperative outcomes

OBJECTIVE

The nature of peripheral arterial disease and postoperative outcomes are understudied in Asian patients. We aimed to determine if there are disparities in disease severity at the time of presentation and postoperative outcomes with regard to Asian race.

METHODS

We analyzed the Society for Vascular Surgery Vascular Quality Initiative Peripheral Vascular Intervention dataset from 2017 to 2021, which includes endovascular lower extremity interventions. Propensity scores were used to match White and Asian patients based on age, sex, comorbidities, ambulatory/functional status, and intervention level. Differences were examined with regard to Asian race across all patients in the United States, Canada, and Singapore, and separately in the United States and Canada only. The primary outcome was emergent intervention. We also examined differences in severity of disease and postoperative outcomes.

RESULTS

A total of 80,312 White and 1689 Asian patients underwent peripheral vascular intervention. After propensity score matching, we identified 1669 matched pairs of patients across all centers including Singapore and 1072 matched pairs in the United States and Canada only. Among the matched cohort consisting of all centers, Asian patients had a higher rate of emergent intervention to prevent limb loss (5.6% vs 1.7%, P < .001). The majority of Asian patients presented with chronic limb threatening ischemia at a higher rate than White patients within the cohort including Singapore (71% vs 66%, P = .005). Within both propensity-matched cohorts, the rate of in-hospital death was higher in Asian patients (all centers: 3.1% vs 1.2%, P < .001; United States and Canada only: 2.1% vs 0.8%, P = .010). Logistic regression demonstrated greater odds of emergent intervention in Asian patients from all centers including Singapore (odds ratio [OR], 3.3; 95% confidence interval [CI], 2.2-5.1, P < .001) but not in the United States and Canada only (OR, 1.4; 95% CI, 0.8-2.8, P = .261). In addition, Asian patients had greater odds of in-hospital death in both matched cohorts (all centers: OR, 2.6; 95% CI, 1.5-4.4, P < .001; United States and Canada: OR, 2.5; 95% CI, 1.1-5.8, P = .026). Asian race was associated with a greater risk of loss of primary patency at 18 months (all centers: hazard ratio, 1.5; CI, 1.2-1.8, P = .001; United States and Canada only: hazard ratio, 1.5; CI, 1.2-1.9, P = .002).

CONCLUSIONS

Asian patients are more likely to present with advanced peripheral arterial disease and undergo emergent intervention to prevent limb loss, in addition to having worse postoperative outcomes and long-term patency. These results highlight the need for improved screening and postoperative follow-up in this understudied population.

Risk Factors of Arteriovenous Fistula Stenosis of Patients with Maintenance Hemodialysis

Objective

To investigate the risk factors of arteriovenous fistula stenosis in maintenance hemodialysis patients.

Methods

A total of 80 patients with maintenance hemodialysis in our hospital from January 2017 to January 2022 were included. According to the stenosis degree of the arteriovenous fistula, patients were divided into a stenosis group (n = 35) and an unobstructed group (n = 45). Laboratory examination data, such as the demographic characteristics of patients, past medical history, the use of traditional Chinese medicine (TCM), the TCM for improving blood circulation to promote blood circulation and remove blood stasis, and cellular immune function, were collected. Multivariate Logistic regression analysis was used to analyze the influencing factors.

Results

There was no significant difference in the age, sexuality, body mass index, proportion of patients with coronary heart disease, cephalic vein diameter, radial artery diameter, albumin, fibrinogen, and blood calcium levels between the two groups (P > 0.05). Compared with the unobstructed group, the stenosis group had higher rates of diabetes and hypertension as well as significantly higher levels of platelets, parathyroid hormone, and D-dimer (P < 0.05). The proportion of TCM application in the stenosis group was 28.6% (10/35), which was significantly lower than that in the unobstructed group 57.8% (26/45). The difference was statistically significant (χ ² = 6.785, P=0.009). The levels of CD3+ (37.5 ± 5.1% vs. 42.0 ± 4.8%), CD4+ (35.7 ± 3.2% vs. 39.6 ± 3.1%) and CD4+/CD8+ (1.4 ± 0.3 vs. 2.4 ± 1.0) in the stenosis group were significantly lower, while CD8+ level was significantly higher (26.8 ± 5.1% vs. 18.5 ± 6.2%) than that in the unobstructed group (P < 0.001). Logistic regression analysis indicated that the usage of TCM was an independent risk factor for arteriovenous fistula stenosis after adjustment for other factors (odds ratio [OR] 0.302; 95% confidence interval [95% CI] 0.100-0.896; P=0.039).

Conclusions

Less use of traditional Chinese medicine for activating blood circulation and removing blood stasis and poor cellular immune function are important factors affecting the function of the arteriovenous fistula in patients with maintenance hemodialysis, which is worthy of clinical attention.

The Effect of Spiritual Care on Anxiety and Depression Level in Patients Receiving Hemodialysis Treatment: a Randomized Controlled Trial

The present study was conducted to determine the effect of spiritual care on the anxiety and depression levels of patients receiving hemodialysis treatment. The research was carried out between January and May 2019 in a training and research hospital hemodialysis unit in the Eastern Anatolian Region of Turkey. The research was completed with a total of 71 patients (33 experiments, 38 controls) who received hemodialysis treatment. Regarding in-group comparison, the difference between the mean scores of pre-test and post-test of the patients concerning the anxiety and depression in the experimental group was found to be statistically significant (p ˂ 0.05). It was determined that training for strengthening spirituality was effective in reducing the anxiety and depression levels of patients receiving hemodialysis treatment. It can be suggested that spiritual care should be used as a complementary method in health care practices to increase the effectiveness of the treatment.

Organelle Stress and Metabolic Derangement in Kidney Disease

Advanced multiomics analysis has revealed novel pathophysiological mechanisms in kidney disease. In particular, proteomic and metabolomic analysis shed light on mitochondrial dysfunction (mitochondrial stress) by glycation in diabetic or age-related kidney disease. Further, metabolic damage often results from organelle stress, such as mitochondrial stress and endoplasmic reticulum (ER) stress, as well as interorganelle communication, or "organelle crosstalk", in various kidney cells. These contribute to progression of the disease phenotype. Aberrant tubular mitochondrial lipid metabolism leads to tubular inflammation and fibrosis. This review article summarizes updated evidence regarding organelle stress, organelle crosstalk, and metabolic derangement in kidney disease.

“Machine-Dependent”: The Lived Experiences of Patients Receiving Hemodialysis in Pakistan

This study aimed to explore the lived experiences of patients receiving maintenance hemodialysis in Pakistan. Purposive sampling was used to recruit 24 patients and six healthcare professionals, each participated in a semi-structured interview. Interpretive Phenomenological Analysis was used to analyze interviews’ data. Two superordinate themes, “The experience of hemodialysis” and “The conceptualizations of hemodialysis” as well as six sub-themes were identified. The experience of hemodialysis was related to, the implications of HD procedure on everyday life, social, cognitive, emotional, financial, and occupational influences. While all participants recognized the importance of hemodialysis for their survival, their conceptualizations of the treatment varied. Despite facing multiple challenges, optimism and independence were observed among participants. Stigma related to hemodialysis, and role adaptation, which appear unique to the Pakistani context, highlight a need for tailored interventions designed to enhance and maintain the mental health of patients receiving hemodialysis in Pakistan.

Assessing the financial burden of hemodialysis treatment in Malaysia

Background

Patients with chronic kidney disease (CKD) spend substantial money on hemodialysis (HD) treatment. The growing intersection between socioeconomic status and financial burden represents an emerging challenge to the CKD community.

Objective

This study assessed the financial burden of HD treatment on patients at a Malaysian tertiary teaching hospital.

Methods

A cross-sectional study was carried out in the HD unit at a Malaysian tertiary teaching hospital from January to February 2021. Patients undergoing HD were purposively selected. A self-administered questionnaire was used to collect data on socio-demographic, finances, the patient's health history, treatment costs, and healthcare utilization. In addition, Pearson Chi-Square tests were used to analyze the data.

Results

A total of 100 patients receiving HD treatment were included in the study. The mean age was 62.06 years (SD = 27.50), with 52% reporting moderate financial burdens. The financial burden was associated with employment status, salary, and income class among HD patients (p <0.05).

Conclusion

Evidence showed a large proportion of Malaysian patients receiving HD treatment came from the B40 income bracket. The findings indicate that financial burdens can impact HD patients and are related to employment status, salary, and income class. Therefore, the ability to identify HD patients' financial needs is critical in nursing practice.

A Review of Commercial Developments and Recent Laboratory Research of Dialyzers and Membranes for Hemodialysis Application

Dialyzers have been commercially used for hemodialysis application since the 1950s, but progress in improving their efficiencies has never stopped over the decades. This article aims to provide an up-to-date review on the commercial developments and recent laboratory research of dialyzers for hemodialysis application and to discuss the technical aspects of dialyzer development, including hollow fiber membrane materials, dialyzer design, sterilization processes and flow simulation. The technical challenges of dialyzers are also highlighted in this review, which discusses the research areas that need to be prioritized to further improve the properties of dialyzers, such as flux, biocompatibility, flow distribution and urea clearance rate. We hope this review article can provide insights to researchers in developing/designing an ideal dialyzer that can bring the best hemodialysis treatment outcomes to kidney disease patients.

Tuberculosis treatment delay and nosocomial exposure remain important risks for patients undergoing regular hemodialysis

BACKGROUND AND OBJECTIVE

Studies have reported an increased tuberculosis (TB) incidence among patients with end-stage renal disease (ESRD). This nationwide nested Case-control study investigated the risk of active TB due to nosocomial exposure and its correlation with the delay in TB treatment in hemodialysis patients.

METHODS

Adult (aged ≥20 years) patients with incident ESRD over 2000-2010 were identified from Taiwan National Health Insurance Research Database; 2331 patients with incident active TB (Case) were matched with 11,655 patients without TB (control) by age, sex, year of ESRD onset, Charlson comorbidity index, chronic obstructive pulmonary disease, and diabetes mellitus, at a 1:5 case-to-control ratio.

RESULTS

Compared with the control group, the Case group had greater nosocomial exposure to index patients with pulmonary TB (2.36 vs. 0.11 month of exposure, p < 0.001). Nosocomial exposure increased active TB risk (adjusted odds ratio [OR; 95% confidence interval, CI]: 1.60 [1.55-1.66] per month of exposure), particularly when the exposure time was either within 6 months before the index case was diagnosed or 6-15 months before the ESRD patient became an incident active TB case. For patients with active TB, cough-related medication prescriptions (proxy for cough symptoms) exponentially increased over 6 months before TB treatment.

CONCLUSION

Nosocomial exposure attributed to delay in the diagnosis of index pulmonary TB is important in TB transmission among patients undergoing regular hemodialysis. Additional studies investigating how TB can be diagnosed and treated early are warranted.

SUMMARY AT A GLANCE

Our study revealed that nosocomial exposure, attributed to delay in pulmonary TB diagnosis, is important in TB transmission among patients undergoing regular hemodialysis. Strategies to diagnose and treat TB early are crucial to infection control, and they warrant further investigations.

The Association Between Uric Acid and Symmetric Dimethylarginine Levels in the Patients Undergoing Twice-weekly Hemodialysis

Background: Uric acid (UA) levels are associated with increased risk of cardiovascular events and mortality in hemodialysis patients. However, there are still conflicting data on the mechanism of increased risks related to uric acid levels. Objectives: This study assessed the association between uric acid levels and symmetric dimethylarginine (SDMA), as a marker of cardiovascular disease, in the subjects undergoing hemodialysis twice weekly. Methods: This was a cross-sectional study conducted in a tertiary hospital in Jakarta, Indonesia. We included all the adults who underwent hemodialysis twice weekly for at least three months in our hospital. Subjects already on uric acid lowering therapy, pregnant or lactating women and those with a history of malignancy were excluded. Uric acid and SDMA levels were measured at the same time in pre-dialysis venous blood samples. Bivariate analysis was performed using the Mann-Whitney U test or one-way ANOVA. Results: A total of 126 subjects were included. The median level of UA was 8.4 mg/dL (IQR: 2.6, min: 4.1, max: 13.6), and 72 subjects (57.14%) had UA levels of 8 mg/dL or higher. The median SDMA level was 535.5 (312.7) mmol/dL (min: 119.7, max: 1895.5). Subjects with UA levels > 8 mg/dL had significantly higher SDMA levels compared to subjects with UA levels < 8 mg/dL (550.1 (IQR: 357.25) vs 491.35 (IQR: 181.1), P: 0.0475). Conclusions: In twice-weekly hemodialysis patients, UA levels above 8 mg/dL were associated with increased SDMA levels.

Procalcitonin (PCT)-guided antibiotic stewardship in Asia-Pacific countries: adaptation based on an expert consensus meeting

Introduction Recently, an expert consensus on optimal use of procalcitonin (PCT)-guided antibiotic stewardship was published focusing mainly on Europe and the United States. However, for Asia-Pacific countries, recommendations may need adaptation due to differences in types of infections, available resources and standard of clinical care. Methods Practical experience with PCT-guided antibiotic stewardship was discussed among experts from different countries, reflecting on the applicability of the proposed Berlin consensus algorithms for Asia-Pacific. Using a Delphi process, the group reached consensus on two PCT algorithms for the critically ill and the non-critically ill patient populations. Results The group agreed that the existing evidence for PCT-guided antibiotic stewardship in patients with acute respiratory infections and sepsis is generally valid also for Asia-Pacific countries, in regard to proposed PCT cut-offs, emphasis on diagnosis, prognosis and antibiotic stewardship, overruling criteria and inevitable adaptations to clinical settings. However, the group noted an insufficient database on patients with tropical diseases currently limiting the clinical utility in these patients. Also, due to lower resource availabilities, biomarker levels may be measured less frequently and only when changes in treatment are highly likely. Conclusions Use of PCT to guide antibiotic stewardship in conjunction with continuous education and regular feedback to all stakeholders has high potential to improve the utilization of antibiotic treatment also in Asia-Pacific countries. However, there is need for adaptations of existing algorithms due to differences in types of infections and routine clinical care. Further research is needed to understand the optimal use of PCT in patients with tropical diseases.

Prevalence and Associated Factors of Frailty and Mortality in Patients with End-Stage Renal Disease Undergoing Hemodialysis: A Systematic Review and Meta-Analysis

Hemodialysis is the most common type of treatment for end-stage renal disease (ESRD). Frailty is associated with poor outcomes such as higher mortality. ESRD patients have a higher prevalence of frailty. This systematic review and meta-analysis aimed to identify the prevalence and associated factors of frailty and examine whether it is a predictor of mortality among ESRD patients undergoing hemodialysis. Five electronic databases including PubMed, Embase, CINAHL, Web of Science, and Cochrane Library were searched for relevant studies up to 30 November 2020. A total of 752 articles were found, and seven studies with 2604 participants in total were included in the final analysis. The pooled prevalence of frailty in patients with ESRD undergoing hemodialysis was 46% (95% Confidence interval (CI) 34.2−58.3%). Advanced age, female sex, and the presence of diabetes mellitus increased the risk of frailty in ESRD patients undergoing hemodialysis. Our main finding showed that patients with frailty had a greater risk of all-cause mortality compared with those without (hazard ratio (HR): 2.02, 95% CI: 1.65−2.48). To improve ESRD patient outcomes, healthcare professionals need to assess the frailty of older ESRD patients, particularly by considering gender and comorbidities. Comprehensive frailty screening tools for ESRD patients on hemodialysis need to be developed.

Bilateral Optic Atrophy in a Young Patient With Chronic Anaemia Secondary to End-Stage Renal Disease

End-stage renal disease (ESRD) is associated with a number of serious complications, including increased cardiovascular disease, anaemia and metabolic bone disease. Optic atrophy secondary to chronic anaemia in ESRD is rare. We report a case of bilateral optic atrophy in a young patient with chronic anaemia secondary to ESRD. A 23-year-old lady with ESRD, presented with progressive blurring of vision in her left eye for a period of six months. Visual acuity in the left eye was counting finger and the right eye was 6/6. Left optic nerve functions were significantly reduced. Bilateral anterior segments and intraocular pressure were normal. Funduscopy showed bilateral pale disc with arteriolar attenuation. The infective, autoimmune and demyelinating screening were negative. Serial full blood count indicated low haemoglobin and haematocrit value. The full blood picture revealed normocytic normochromic anaemia. Neuroimaging was normal. The patient was diagnosed as having bilateral optic atrophy secondary to chronic anaemia due to ESRD. Chronic anaemia is a potential cause of optic atrophy in a young patient with chronic disease. Management of anaemia in such cases is crucial to prevent irreversible complications including optic atrophy and blindness.

Implementation of PDOPPS in a middle-income country: Early lessons from Thailand

BACKGROUND

Despite the implementation of a 'Peritoneal Dialysis (PD) First' policy in Thailand since 2008, nationwide PD practices and patients' outcomes have rarely been reported.

METHODS

As part of the multinational PD Outcomes and Practice Patterns Study (PDOPPS), PD patients from 22 PD centres from different geographic regions, sizes and affiliations, representing Thailand PD facilities, have been enrolled starting in May 2016. Demographic, clinical and laboratory data and patients' outcomes were prospectively collected and analysed.

RESULTS

The pilot and implementation phases demonstrated excellent concordance between study data and validation data collected at enrolment. In the implementation phase, 848 PD patients (including 262 (31%) incident PD patients) were randomly sampled from 5090 patients in participating centres. Almost all participants (95%) performed continuous ambulatory PD (CAPD), and a high proportion had hypoalbuminemia (67%, serum albumin < 3.5 g/dL), anaemia (42%, haemoglobin <10 g/dL) and hypokalaemia (37%, serum potassium < 3.5 mmol/L). The peritonitis rate was 0.40 episodes/year, but the culture-negative rate was high (0.13 episodes/year, 28% of total episodes). The patients from PD clinics located in Bangkok metropolitan region had higher socio-economic status, more optimal nutritional markers, blood chemistries, haemoglobin level and lower peritonitis rates compared to the provincial regions, emphasizing the centre effect on key success factors in PD.

CONCLUSIONS

Participation in the PDOPPS helps unveil the critical barriers to improving outcomes of PD patients in Thailand, including a high prevalence of hypokalaemia, anaemia, poor nutritional status and culture-negative peritonitis. These factors should be acted upon to formulate solutions and implement quality improvement on a national level.

Quality of Life of End Stage Renal Disease Patients Undergoing Dialysis in Southern Part of Kerala, India: Financial Stability and Inter-dialysis Weight Gain as Key Determinants

Background: Quality of Life (QoL) reflects the quality and outcome of healthcare along with key indicators of performance such as mortality and morbidity.

Objective: The aim of the study was to measure the QoL among patients with End Stage Renal Disease (ESRD) on maintenance hemodialysis and to understand various correlates of QoL.

Methods: A total of 95 ESRD patients from three dialysis centres in Southern districts of Kerala were interviewed. QoL was measured using vernacular version of World Health Organization Quality Of Life – Brief Version (WHOQOL-BREF) questionnaire.

Results: The mean age of the patients was 56.2 ± 13 years and 73.7% were males. Mean converted scores for overall QoL was 42.37 ± 21.3 and Health-related QoL (HRQoL) was 43.3 ± 18.3, indicating poor QoL. Males had significantly higher physical domain scores (p < 0.03). Occupation, income and Socio-economic Status (SES) influenced overall HRQoL while better income and higher SES predicted better scores in psychological and environmental domains.

Conclusion: Patients with better control over inter-dialysis weight gain (≤1600 g) had significantly higher scores. This study highlights the importance of using QoL tools in assessing the QoL of patients and the factors contributing to it.

Factors related to spiritual health in Chinese haemodialysis patients: A multicentre cross-sectional study

Aim

This study aimed to investigate the current situation of the spiritual health of maintenance haemodialysis (MHD) patients in China and analyse the influencing factors.

Methods

A total of 418 patients who underwent maintenance haemodialysis in three grade A tertiary hospitals were selected. The influencing factors were evaluated with demographic questionnaire, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp-12), Family APGAR Index, Herth Hope Index (HHI) and Acceptance of Illness Scale (AIS).

Results

Spiritual health was positively correlated with the HHI, Family APGAR and AIS scores. Nationality, HHI score, Family APGAR score and AIS score were independent influencing factors of spiritual health. MHD patients had a moderate level of spiritual health. Nationality, hope, family function and acceptance of illness were significant predictors of spiritual health. Patients who have higher hope levels, better family functioning and better illness acceptance may maintain better spiritual health.

The Adverse Effect of COVID Pandemic on the Care of Patients With Kidney Diseases in India

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has affected the care of patients with noncommunicable diseases, including those suffering from kidney-related ailments. Many parts of the world, including India, adopted lockdown to curb community transmission of disease. The lockdown affected transportation, access to health care facilities, and availability of medicines and consumables as well as outpatient and inpatient services. We aimed to analyze the effect of lockdown imposed due to the COVID-19 pandemic on the care of patients with kidney diseases in India.

METHODS

We surveyed 19 major hospitals (8 in the public and 11 in the private sector) to determine the effect of lockdown on the care of patients with kidney disease, including those on dialysis after the first 3 weeks of lockdown.

RESULTS

The total number of dialysis patients in these centers came down from 2517 to 2404. Approximately 710 (28.2%) patients missed 1 or more dialysis sessions, 69 (2.74%) required emergency dialysis sessions, 104 (4.13%) stopped reporting for dialysis, and 9 (0.36%) were confirmed to have died. Outpatient attendance in the surveyed hospital came down by 92.3%, and inpatient service reduced by 61%. Tele-consultation was started but was accessed by only a small number of patients.

CONCLUSION

Lack of preparedness before lockdown resulted in an interruption in health care services and posed an immediate adverse effect on the outcome of dialysis patients and patients with kidney disease in India. The long-term impact on the health of patients with less severe forms of kidney disease remains unknown.

Increasing access to integrated ESKD care as part of universal health coverage

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle-income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.

2018 Kidney Disease: Improving Global Outcomes (KDIGO) Hepatitis C in Chronic Kidney Disease Guideline Implementation: Asia Summit Conference Report

In 2018, Kidney Disease: Improving Global Outcomes (KDIGO) published a clinical practice guideline on the prevention, diagnosis, evaluation, and treatment of hepatitis C virus (HCV) infection in chronic kidney disease (CKD). The guideline synthesized recent advances, especially in HCV therapeutics and diagnostics, and provided clinical recommendations and suggestions to aid healthcare providers and improve care for CKD patients with HCV. To gain insight into the extent that the 2018 guideline has been adopted in Asia, KDIGO convened an HCV Implementation Summit in Hong Kong. Participants included nephrologists, hepatologists, and nurse consultants from 8 Southeast Asian countries or regions with comparable high-to-middle economic ranking by the World Bank: mainland China, Hong Kong, Japan, Malaysia, Singapore, South Korea, Taiwan, and Thailand. Through presentations and discussions, meeting participants described regional practice patterns related to the KDIGO HCV in CKD guideline, identified barriers to implementing the guideline, and developed strategies for overcoming the barriers in Asia and around the world.

Dialysis Decision Making and Preferences for End-of-Life Care: Perspectives of Pakistani Patients Receiving Maintenance Dialysis

CONTEXT

Previous studies from the U.S. and Canada report deficiencies in informed decision making and a need to improve end-of-life (EoL) care in patients undergoing dialysis. However, there is a paucity of literature on these issues in Pakistani dialysis patients, who differ from Western patients in culture, religion, and available health care services.

OBJECTIVES

To study informed dialysis decision-making and EoL attitudes and beliefs in Pakistani patients receiving dialysis.

METHODS

We used convenience sampling to collect 522 surveys (90% response rate) from patients in seven different dialysis units in Pakistan. We used an existing dialysis survey tool, translated into Urdu, and backtranslated to English. A facilitator distributed the survey, explained questions, and orally administered it to patients unable to read.

RESULTS

Less than one-fourth of the respondents (23%) felt informed about their medical condition, and 45% were hopeful that their condition would improve in the future. More than half (54%) wished to know their prognosis, and 80% reported having no prognostic discussion. Almost 63% deemed EoL planning important, but only 5% recalled discussing EoL decisions with a doctor during the last 12 months. Nearly 62% of the patients regretted their decision to start dialysis. Patients' self-reported knowledge of hospice (5%) and palliative care (7.9%) services was very limited, yet 46% preferred a treatment plan focused on comfort and symptom management rather than life extension.

CONCLUSION

Pakistani patients reported a need for better informed dialysis decision making and EoL care and better access to palliative care services. These findings underscore the need for palliative care training of Pakistani physicians and in other developing countries to help address communication and EoL needs of their dialysis patients.

The relation between epicardial fat tissue thickness and atrial fibrillation ın hemodialysis patients

The prevalence of arrhythmia has increased in hemodialysis (HD) patients and the most frequent is atrial fibrillation (AF). It was reported that the amount of epicardial fat tissue (EFT) in the population without renal disease is closely related to AF. In the present study of ours, the relation between EFT thickness and AF was examined in HD patients. A total of 79 patients who underwent HD for periods longer than 3 months were included in the study. The mean age of the patients was 53.6 ± 15.2 years and 50.6% were male. The mean EFT thicknesses were measured as 7.2 ± 2.3 mm (3-12). A positive correlation was found between the EFT thickness and age, C-reactive protein, and left ventricle rear wall thickness. AF was found in 18 (22.8%) patients in the Holter ECG examination. When the group with AF was compared with the non-AF group; although the mean HD duration of the group with AF was longer, there were no significant differences in terms of epicardial adipose tissue thickness and other parameters. In the present study, no relations were found between EFT thickness and AF frequency in HD patients. Further studies with a larger number of the patient population are needed in this regard.

A Combination of Hemodialysis with Hemoperfusion Helped to Reduce the Cardiovascular-Related Mortality Rate after a 3-Year Follow-Up: A Pilot Study in Vietnam

AIMS

Moderate to severe hyperparathyroidism (parathyroid hormone [PTH] concentrations ≥600 pg/mL) may increase the risk of cardiovascular problems and bone disease. We assume that a combination of hemodialysis with hemoperfusion may reduce the cardiovascular-related mortality rate in maintenance hemodialysis.

SUBJECTS AND METHODS

From 625 maintenance hemodialysis patients, 93 people met with our inclusion criteria. Based on the level of serum PTH, the patients were divided into 2 groups: 46 patients who underwent a combination of hemodialysis and hemoperfusion (HD + HP group) for consecutive 3 years and 47 patients who used hemodialysis only (HD group).

RESULTS

During 3 years of follow-up, the ratio of mortality was 4.3% in the HD + HP group which was significantly lower than in the HD group (17%), p = 0.049. Based on Kaplan-Meier analysis of cardiovascular-related mortality, patients in the HD group (red line) exhibited a significantly higher death rate compared to the HD + HP group (violet line) (log-rank test, p = 0.049).

CONCLUSION

We demonstrated that a combination of hemodialysis and hemoperfusion for 3 years helped to reduce the cardiovascular-related mortality rate.

Hemodialysis at Doorstep - "Hub-and-Spoke" Model of Dialysis in a Developing Country

End-stage kidney disease has become a huge burden in our country. There has been an increase in dialysis centers across the country. State-funded dialysis has been initiated in many states of India. However, most of the centers are concentrated in the cities. Patients living in the peripheral districts have to travel long distance to reach the dialysis centers. In addition, there is a dearth of nephrology services in the peripheral areas. To address this problem, the hub-and- spoke model of dialysis has been initiated in Telangana state in South India, which has brought dialysis at the doorstep for people residing in remote districts. This study highlights the important features of this model.

Contemporary cardiovascular outcomes in Taiwanese patients undergoing endovascular therapy for symptomatic lower extremity peripheral arterial disease

BACKGROUND/PURPOSE

To investigate contemporary cardiovascular (CV) outcomes in Taiwanese patients with symptomatic low extremity peripheral artery disease treated with endovascular therapy.

METHODS

An observational cohort study with up to 155 months of follow-up was conducted using a single-center registry database between July 2005 and June 2017. Long-term outcomes and predictors of future CV events were analyzed in 936 patients with 1246 affected legs.

RESULTS

This study cohort comprised 21% claudicants and 79% critical limb ischemia (CLI) patients. Compared with claudicants, CLI patients had higher rates of medical comorbidities, tissue inflammation, and lesion complexities. During the study period, 349 patients died (130 CV deaths and 219 non-CV deaths), 306 had non-fatal CV events. The rates of 5-year freedom from all-cause mortality, major CV events (MACEs), and non-fatal CV events were 54.9%, 67.1%, and 56.6% respectively. For CLI patients, independent factors for all-cause mortality were age (odds ratio [OR] 1.03), atrial fibrillation (OR 1.79), albumin (OR 0.62), hematocrit (OR 0.96), body mass index (OR 0.94), C-reactive protein (OR 1.18), dialysis (OR 2.16), and non-ambulance (OR 2.05). Congestive heart failure, dialysis, and non-ambulance independently predicted the MACEs (OR 2.04, 1.93, and 1.67, respectively). For claudicants, coronary artery disease (CAD) was the essential factor for all-cause mortality (OR 2.24), MACE (OR 2.76) and non-fatal CV events (OR 1.82).

CONCLUSION

Long-term survival and MACE-free rates were significantly worse in CLI patients than in claudicants. Malnutrition and inflammation were associated with long-term survival. CAD, low hematocrit, dialysis, CHF, and ambulatory status predicted future CV events.

Changes in mortality hazard of the Korean long-term dialysis population: The dependencies of time and modality switch

BACKGROUND

Many studies have compared patient survival outcome between hemodialysis (HD) and peritoneal dialysis (PD); however, time-varying risks of dialysis modality have been rarely investigated. This study aimed to investigate dialysis modality switch and its association with the survival outcome in the Korean population.

METHODS

Data from the Korean Society of Nephrology were used. A total of 21,840 incident dialysis patients who started dialysis in or after 2000 were analyzed. For the survival analysis, both proportional and non-proportional hazard assumptions were applied. For the modality switch, time-varying covariate Cox regression was applied.

RESULTS

During the median follow-up of 8 years, PD group showed increased adjusted hazard ratio (HR) of 1.248 (95% CI 1.071-1.454, p = 0.004) for mortality. Interaction of PD status with female sex was significant with an HR of 1.080 (95% CI 1.000-1.165, p = 0.050). Dialysis modality switch was associated with increased HR of 1.094 (95% CI 1.015-1.180, p = 0.019), albeit switch from PD to HD did not show significant HR until 6 years. Interestingly, time-varying risk analysis showed a decreased HR of PD after 10 years in the non-switcher group, which was consistent in patients with high traditional risk factors (with diabetes, elderly).

CONCLUSIONS

PD was associated with increased HR of mortality in the first 8 years, then it was associated with decreased HR of mortality after 10 years. Dialysis modality switch was associated with increased mortality risk, but switch from PD to HD within 6 years did not show significant hazard of mortality.

Effects of online hemodiafiltration on anemia and nutritional status in chronic hemodialysis patients

Background

Online hemodiafiltration (OL-HDF) offers considerable advantages in clearance of molecules of various sizes. However, evidence of clinical effects of OL-HDF is scarce in Korea. In this study, we investigated changes in laboratory values over more than 12 months after switching to OL-HDF.

Methods

Adult patients with end-stage renal disease undergoing hemodialysis (HD) were prospectively enrolled in a K-cohort (CRIS no. KCT0003281) from 6 tertiary hospitals in South Korea. We recruited 435 patients, 339 of whom were on HD at enrollment. One hundred eighty-two patients were followed for more than 24 months. Among them, 44 were switched to OL-HDF for more than 12 months without conversion to HD. We used a paired t test to compare baseline and 24-month follow-up results.

Results

The mean age of the subjects was 61.2 ± 12.2 years, and 62.6% were male. The baseline hemoglobin level was not significantly different between HD and OL-HDF group (10.61 ± 1.15 vs. 10.46 ± 1.03 g/dL, P = 0.437). However, the baseline serum protein and albumin levels were significantly lower in the OL-HDF group (6.82 ± 0.49 vs. 6.59 ± 0.48 g/dL, P = 0.006; 3.93 ± 0.28 vs. 3.73 ± 0.29 g/dL, P < 0.001). In patients switched to OL-HDF, levels of hemoglobin and serum albumin significantly increased (10.46 ± 1.03 vs. 11.08 ± 0.82 g/dL, P = 0.001; 3.73 ± 0.29 vs. 3.87 ± 0.30 g/dL, P = 0.001). The normalized protein catabolic rate decreased after 24 months, but the change was not significant (1.07 ± 0.25 vs. 1.03 ± 0.21 g/kg/day, P = 0.433). Although the dose of erythropoiesis-stimulating agent was lower in patients who converted to HDF, it was not significantly different (-115.7 ± 189.7 vs. -170.5 ± 257.1 P = 0.206).

Conclusion

OL-HDF treatment over more than 12 months was associated with no harmful effects on anemia and nutritional status.

Development of a framework for minimum and optimal safety and quality standards for hemodialysis and peritoneal dialysis

Substantial heterogeneity in practice patterns around the world has resulted in wide variations in the quality and type of dialysis care delivered. This is particularly so in countries without universal standards of care and governmental (or other organizational) oversight. Most high-income countries have developed such oversight based on documentation of adherence to standardized, evidence-based guidelines. Many low- and lower-middle-income countries have no or only limited organized oversight systems to ensure that care is safe and effective. The implementation and oversight of basic standards of care requires sufficient infrastructure and appropriate workforce and financial resources to support the basic levels of care and safety practices. It is important to understand how these standards then can be reasonably adapted and applied in low- and lower-middle-income countries.

Prescribing peritoneal dialysis and achieving good quality dialysis in low and low-middle income countries

The provision of long-term renal replacement therapies for patients with end-stage kidney disease (ESKD) in low and low-middle income countries (LLMICs) has been a pervasive challenge, impeded mainly by monetary constraints, limited health-care resources, and geographical and logistic difficulties. Even for patients who could initiate dialysis, discontinuation of dialysis treatment due to the lack of financial sustainability is a valid concern. While the delivery of high-quality dialysis should not be compromised in these settings, perpetuity on dialysis is of paramount consideration for these patients, with sustaining life being just as important as achieving clinical well-being. As intensification of peritoneal dialysis (PD) prescription comes with immense cost in these settings, the strategy for stretching affordability of dialysis involves optimizing the number of PD exchanges required or delaying the transition to a high PD dose of four bags per day of continuous ambulatory PD (CAPD) prescription. This can be accomplished through the use of low-cost adjunctive treatment, by preserving residual kidney function and adopting incremental PD. The use of expensive, complex, or inaccessible monitoring tools for peritoneal membrane function and dialysis clearance could be replaced by clinical assessment and widely available biochemical indicators, which will significantly reduce the investigation costs, with consequent savings that could allow for lengthening the duration of PD therapy. Finally, it is important for each PD program in LLMICs to monitor these outcome indicators, to ensure the consistent delivery of acceptable quality of PD to their patients.

Standardising the measurement of physical activity in people receiving haemodialysis: considerations for research and practice

BACKGROUND

Physical activity (PA) is exceptionally low amongst the haemodialysis (HD) population, and physical inactivity is a powerful predictor of mortality, making it a prime focus for intervention. Objective measurement of PA using accelerometers is increasing, but standard reporting guidelines essential to effectively evaluate, compare and synthesise the effects of PA interventions are lacking. This study aims to (i) determine the measurement and processing guidance required to ensure representative PA data amongst a diverse HD population, and; (ii) to assess adherence to PA monitor wear amongst HD patients.

METHODS

Clinically stable HD patients from the UK and China wore a SenseWear Armband accelerometer for 7 days. Step count between days (HD, Weekday, Weekend) were compared using repeated measures ANCOVA. Intraclass correlation coefficients (ICCs) determined reliability (≥0.80 acceptable). Spearman-Brown prophecy formula, in conjunction with a priori ≥  80% sample size retention, identified the minimum number of days required for representative PA data.

RESULTS

Seventy-seven patients (64% men, mean ± SD age 56 ± 14 years, median (interquartile range) time on HD 40 (19-72) months, 40% Chinese, 60% British) participated. Participants took fewer steps on HD days compared with non-HD weekdays and weekend days (3402 [95% CI 2665-4140], 4914 [95% CI 3940-5887], 4633 [95% CI 3558-5707] steps/day, respectively, p < 0.001). PA on HD days were less variable than non-HD days, (ICC 0.723-0.839 versus 0.559-0.611) with ≥ 1 HD day and ≥  3 non-HD days required to provide representative data. Using these criteria, the most stringent wear-time retaining ≥ 80% of the sample was ≥7 h.

CONCLUSIONS

At group level, a wear-time of ≥7 h on ≥1HD day and ≥ 3 non-HD days is required to provide reliable PA data whilst retaining an acceptable sample size. PA is low across both HD and non- HD days and future research should focus on interventions designed to increase physical activity in both the intra and interdialytic period.

Inequities in the global representation of sites participating in large, multicentre dialysis trials: a systematic review

Background

The number of dialysis recipients is growing worldwide, making it important that the full range of patient populations are represented in randomised trials. As trial recruitment has not previously been examined at a global level, we compared the location of trial sites recruiting to large multicentre randomised controlled trials (RCTs) in dialysis to the global distribution of dialysis recipients.

Methods

A systematic review (2007–2016) was conducted to identify RCTs enrolling ≥100 dialysis patients from ≥2 sites. The number and location of sites were extracted from manuscripts and trial registration. The proportion of sites from each International Society of Nephrology global region was divided by the proportion of the global dialysis population in that region to determine a ‘representation index’ (RI), where 1.0 indicated that the number of sites was proportionate to the number of dialysis recipients in that region.

Results

We identified 180 RCTs, recruiting from 6172 sites in 54 countries. Eastern and Central Europe had the highest RI at 2.45. Other well-represented regions were Western Europe (2.20), North America (2.06), and Russia and newly independent states (1.36). Africa had the lowest RI at 0.05, followed by South Asia (0.08), Latin America (0.15), Middle East (0.27), North-East Asia (0.41), and South-East Asia and Oceania (0.62).

Conclusions

Regions of the world with growing numbers of dialysis patients are poorly represented in large, multicentre RCTs. Efforts to boost trial participation in these regions are required to ensure that generalisable and relevant information is available to local healthcare providers.

[Studies of the Various Chronic Kidney Failure Rat Models and Hemodialysis Mini-pig Model for the Evaluation of Anti-hyperphosphatemia Drugs]

Animal models of chronic kidney failure (CKF) have been developed for the pharmacodynamic evaluation of various phosphate binders that are used clinically to treat hyperphosphatemia in patients with chronic kidney disease. However, these models represent different disease states and severities, depending on the experimental conditions and are not clearly defined for pharmacological evaluation. In addition, experimental models have not yet been established for artificial dialysis. The purpose of this study was to confirm the utility of the various rat models of CKF and the mini-pig model of hemodialysis as models of hyperphosphatemia for pharmacodynamic evaluation. Various rat models of pre-dialysis CKF (oral adenine dosing, 5/6 resection, and ligation nephrectomy model) were evaluated through determinations of serum and urinary parameters (osmolality, creatinine, and phosphorus), pathological observations of kidney, and the phosphorus-absorbing properties of lanthanum carbonate (La) formulations. The rat and mini-pig models were compared based on each evaluation index. In the oral adenine dosing model, serum phosphorus increased markedly and the area under the serum phosphorus concentration-time curve (phosphorus AUC) decreased in a dose-dependent manner with the administration of La formulations. In contrast, a significant decrease in serum phosphorus AUC, a prolongation of the dialysis interval, and an improvement in dialysis efficiency were observed after administration of La formulations to the mini-pig hemodialysis model. Furthermore, the results of bioequivalence studies between two La formulations (Fosrenol and SW670, a generic formulation) suggested that the rat and mini-pig models are useful and precise as pre-dialysis and dialysis models, respectively.

Linagliptin and cardiorenal outcomes in Asians with type 2 diabetes mellitus and established cardiovascular and/or kidney disease: subgroup analysis of the randomized CARMELINA® trial

Objective

Linagliptin, a dipeptidyl peptidase-4 inhibitor, demonstrated cardiovascular and renal safety in type 2 diabetes mellitus (T2DM) patients with established cardiovascular disease (CVD) with albuminuria and/or kidney disease in the multinational CARMELINA^® trial. We investigated the effects of linagliptin in Asian patients in CARMELINA^®.

Methods

T2DM patients with HbA1c 6.5-10.0% and established CVD with urinary albumin-to-creatinine ratio (UACR) > 30 mg/g, and/or prevalent kidney disease (estimated glomerular filtration rate [eGFR] 15-< 45 ml/min/1.73 m² or ≥ 45-75 with UACR > 200 mg/g), were randomized to linagliptin or placebo added to usual care. The primary endpoint was time to first occurrence of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke (3-point MACE).

Results

Of the 6979 patients, 555 (8.0%) were Asians living in Asia. During a median follow-up of 2.2 years, 3-point MACE occurred in 29/272 (10.7%) and 33/283 (11.7%) of linagliptin and placebo patients, respectively (hazard ratio [HR] 0.90; 95% confidence interval [CI] 0.55-1.48), consistent with the overall population (HR 1.02; 95% CI 0.89-1.17; P value for treatment-by-region interaction: 0.3349). Similar neutrality in Asian patients was seen for other cardiorenal events including the secondary kidney endpoint of death from renal failure, progression to end-stage kidney disease, or ≥ 40% eGFR decrease (HR 0.96; 95% CI 0.58-1.59). Linagliptin was associated with a nominal decrease in the risk of hospitalization for heart failure (HR 0.47; 95% CI 0.24-0.95). Overall in Asian patients, linagliptin had an adverse event rate similar to placebo, consistent with the overall population.

Conclusions

Linagliptin showed cardiovascular and renal safety in Asian patients with T2DM and established CVD with albuminuria and/or kidney disease.

Patient and provider factors associated with enrolment in the pre-end-stage renal disease pay-for-performance programme in Taiwan: a cross-sectional study

OBJECTIVE

The incidence and prevalence of end-stage renal disease (ESRD) in Taiwan have been ranked the highest worldwide. Therefore, the National Health Insurance Administration has implemented the pre-ESRD pay-for-performance (P4P) programme since November 2006, which had significantly reduced the incidence of dialysis and all-cause mortality. This study aimed to identify the factors associated with the enrolment in the pre-ESRD P4P programme.

DESIGN

Cross-sectional study.

SETTING

The National Health Insurance research database 2007-2012 in Taiwan.

PARTICIPANTS

Patients with prevalent pre-ESRD aged more than 18 years between January 2007 and December 2012 were enrolled. Patient demographics and hospital characteristics between P4P and non-P4P groups were compared. A logistic regression model was used to analyse the factors associated with P4P enrolment, and a generalised estimating equation was used to verify the results.

PRIMARY OUTCOME MEASURE

Enrolment in the pre-ESRD P4P programme.

RESULTS

In total, 82 991 patients were enrolled in the programme, with a 45.6% participation rate. Patients who were males (adjusted OR (AOR)=0.89, 95% CI=0.86 to 0.91) and employed (AOR=0.95, 95% CI=0.92 to 0.97) had a significantly lower probability to be enrolled in the programme. Older patients (66-75 years old, AOR=1.23, 95% CI=1.14 to 1.33) and those with higher Charlson Comorbidities Index (CCI 5+, AOR=4.01, 95% CI=3.55 to 4.53) tended to be enrolled in the programme, while those in the 76+ years age group were not (AOR=1.03, 95% CI=0.95 to 1.13). Hospitals located in the central (AOR=1.48, 95% CI=1.05 to 2.08) and Kao-Ping regions (AOR=1.62, 95% CI=1.18 to 2.22) also tended to enrol patients in the pre-ESRD P4P programme. Enrolment rates increased over time.

CONCLUSION

Pre-ESRD patients of the female gender, greater age and more comorbidities were more likely to be enrolled in the pre-ESRD P4P programme. Healthcare providers and health authorities should focus attention on patients who are male, younger and with less comorbidities to improve the healthcare quality and equality for all pre-ESRD patients.

Diabetes in developing countries

There has been a rapid escalation of type 2 diabetes (T2D) in developing countries, with varied prevalence according to rural vs urban habitat and degree of urbanization. Some ethnic groups (eg, South Asians, other Asians, and Africans), develop diabetes a decade earlier and at a lower body mass index than Whites, have prominent abdominal obesity, and accelerated the conversion from prediabetes to diabetes. The burden of complications, both macro- and microvascular, is substantial, but also varies according to populations. The syndemics of diabetes with HIV or tuberculosis are prevalent in many developing countries and predispose to each other. Screening for diabetes in large populations living in diverse habitats may not be cost-effective, but targeted high-risk screening may have a place. The cost of diagnostic tests and scarcity of health manpower pose substantial hurdles in the diagnosis and monitoring of patients. Efforts for prevention remain rudimentary in most developing countries. The quality of care is largely poor; hence, a substantial number of patients do not achieve treatment goals. This is further amplified by a delay in seeking treatment, "fatalistic attitudes", high cost and non-availability of drugs and insulins. To counter these numerous challenges, a renewed political commitment and mandate for health promotion and disease prevention are urgently needed. Several low-cost innovative approaches have been trialed with encouraging outcomes, including training and deployment of non-medical allied health professionals and the use of mobile phones and telemedicine to deliver simple health messages for the prevention and management of T2D.

Effect of do-not-resuscitate orders on patients with sepsis in the medical intensive care unit: a retrospective, observational and propensity score-matched study in a tertiary referral hospital in Taiwan

OBJECTIVE

The aim of this study was to determine whether do-not-resuscitate (DNR) orders affect outcomes in patients with sepsis admitted to intensive care unit (ICU).

DESIGN

This is a retrospective observational study.

PARTICIPANTS

We enrolled 796 consecutive adult intensive care patients at Kaohsiung Chang Gung Memorial Hospital, a 2700-bed tertiary teaching hospital in southern Taiwan. A total of 717 patients were included.

MAIN MEASURES

Clinical factors such as age, gender and other clinical factors possibly related to DNR orders and hospital mortality were recorded.

KEY RESULTS

There were 455 patients in the group without DNR orders and 262 patients in the group with DNR orders. Within the DNR group, patients were further grouped into early (orders signed on intensive care day 1, n=126) and late (signed after day 1, n=136). Patients in the DNR group were older and more likely to have malignancy than the group without DNR orders. Mortality at days 7, 14 and 28, as well as intensive care and hospital mortality, were all worse in these patients even after propensity-score matching. There were higher Charlson Comorbidity Index in the emergency room, but better outcomes in those with early-DNR orders compared with late-DNR orders.

CONCLUSIONS

DNR orders may predict worse outcomes for patients with sepsis admitted to medical ICUs. The survival rate in the early-DNR order group was not inferior to the late-DNR order group.