Physical Function and Clinical Outcomes in Hemodialysis Patients: China Dialysis Outcomes and Practice Patterns Study

The influencing factors of the erythropoietin resistance index and its association with all-cause mortality in maintenance hemodialysis patients

Anemia is a common complication of chronic kidney disease with major option treatment of erythropoiesis-stimulating agents (ESAs). This study aimed to investigate the influencing factors of erythropoietin resistance index (ERI) and its association with mortality in maintenance hemodialysis (MHD) patients. Patients enrolled from China Dialysis Outcomes and Practice Patterns Study (DOPPS) 5 were included. ERI was calculated as follows: ESA (IU/week)/weight (kg, post-dialysis)/hemoglobin level (g/dL). The Cox regression model was used to analyze the influencing factors on survival outcomes. Stepwise multivariate logistic regression was used to identify the related risk factors, and subgroup analyses were performed. A total of 1270 MHD subjects (687 males and 583 females) were included, with an average age of 60 (49.0, 71.0) years. All subjects were divided into two groups by the median ERI of 14.03. Multivariate logistic regression showed that dialysis vintage (OR 0.957, 95% CI: 0.929-0.986), white blood cells (OR 0.900, 95% CI: 0.844-0.960), high flux dialyzer use (OR 0.866, 95% CI: 0.755-0.993), body mass index (OR 0.860, 95% CI: 0.828-0.892), males (OR 0.708, 95% CI: 0.625-0.801), and albumin (OR 0.512, 95% CI: 0.389-0.673) had a negative association with high ERI baseline (all p < 0.05). There were 176 (13.9%) deaths in total including 89 cardiac/vascular deaths during follow-up. Cox regression analysis showed that ERI was positively associated with all-cause mortality, especially in some subgroups. ERI was associated with increased all-cause mortality in MHD patients, indicating the possibility of death prediction by ERI. Patients with high ERI warrant more attention.

The impact of malnutrition on the effectiveness of intradialytic exercise in hemodialysis patients: amulticenter cohort study

PURPOSE

Low physical function can be effectively improved via intradialytic exercise. However, the association between the effects of intradialytic exercise on physical function and malnutrition severity has not been studied extensively. This study aimed to investigate the impact of nutritional status severity on physical function in patients undergoing hemodialysis with low physical function to whom intradialytic exercise was prescribed.

METHODS

The participants were patients with decreased mobility [walking speed < 1.0 m/s and/or Short Physical Performance Battery (SPPB) < 12] who had been undergoing hemodialysis thrice a week for 6 months and performing intradialytic exercise program. Patients were divided into groups based on the Geriatric Nutritional Risk Index (GNRI) [Non-malnutrition group (GNRI > 98), Gentle/slim malnutrition group (GNRI ≤ 98, GNRI ≥ 92), Mild malnutrition group (GNRI < 92, GNRI ≥ 82), Severe malnutrition group (GNRI < 82)]. The primary outcomes were Grip strength, isometric knee extension strength (IKES), SPPB, and 10-m walking speed measured at baseline and at 6 months. Statistical analyses were performed using a linear mixed-effects model with the intention-to-treat analysis, including within-group analysis and between-group comparison.

RESULTS

A total of 805 participants were included in the study. Within-group comparisons showed significantly improved IKES, 10-m walking speed, and SPPB improved, except in the Severe malnutrition group. Grip strength significantly improved in the Gentle/slim and mild malnutrition groups. Between-group comparison with controls showed that the improvement in Grip strength was significantly bigger in the Gentle/slim malnutrition group [0.98 (0.15 to 1.82) kg] than in the non-malnutrition group. However, IKES in the Severe malnutrition group [- 5.14 (- 9.18 to - 1.10) %] less significantly improve than that in the non-malnutrition group. No significant differences were found in the other indices.

CONCLUSION

In patients with severe malnutrition, the changes in IKES scores resulting from Intradialytic exercise were significantly smaller than those observed in non-malnourished patients. Therefore, it is necessary to initiate suitable nutritional and exercise therapy based on the severity of malnutrition.

Clinical Outcomes in Patients on Hemodialysis with Congestive Heart Failure

Introduction

Congestive heart failure (CHF) is one of the common complications in patients with end-stage kidney disease. In the general population, CHF increases the risk of the death. However, there is no well-designed relevant study in the Chinese hemodialysis (HD) population addressing the risks associated with CHF. The aim of this study was to explore the impact of CHF on clinical outcomes in HD patients.

Methods

Data from a prospective cohort study, the China Dialysis Outcomes and Practice Patterns Study (DOPPS) 5 (2012-2015), were analyzed. Demographic data, comorbidities, lab data, and death records were extracted. CHF was defined by the diagnosis records upon study inclusion. Our primary outcome was all-cause and cardiovascular (CV) mortality; secondary outcomes were all-cause and cause-specific hospitalization risk. Associations between CHF and outcomes were evaluated using Cox regression models. Stepwise multivariate logistic regression was used to identify the related risk factors, and subgroup analyses were carried out.

Results

Of 1,411 patients without missing CHF history information, 24.1% (340) had CHF diagnosis at enrollment. The overall mortality rates were 21.8% versus 12.0% (p < 0.001) in patients with and without CHF during follow-up, respectively. CHF was associated with higher all-cause mortality (adjusted HR: 1.72, 95% confidence interval [CI]: 1.17-2.53, p = 0.006), and the association with CV death was of similar magnitude (HR: 1.60, 95% CI: 0.91-2.81, p = 0.105). CHF patients had more episodes of hospitalization due to heart failure (HR: 2.93, 95% CI: 1.49-5.76, p < 0.01). However, compared with patients without CHF, the all-cause hospitalization risk was not much higher in CHF patients (HR: 1.09, 95% CI: 0.90-1.33, p = 0.39). Subgroup analysis found that the effect of CHF on all-cause mortality was stronger for male patients, patients with residual renal function, the elderly (≥60 years of age), patients with arteriovenous fistulae vascular accesses, nondiabetic patients, low-flux dialyzer users, and inadequately dialyzed patients (standardized Kt/V <2).

Conclusion

In HD patients, CHF was found to be associated with a higher risk of all-cause mortality and cause-specific hospitalization risk. Further research is needed to identify opportunities to improve care for HD patients combined with CHF.

Thrombocytopenia predicts mortality in Chinese hemodialysis patients- an analysis of the China DOPPS

BACKGROUND

Hemodialysis (HD) patients have a higher mortality rate compared with general population. Our previous study revealed that platelet counts might be a potential risk factor. The role of platelets in HD patients has rarely been studied. The aim of this study is to examine if there is an association of thrombocytopenia (TP) with elevated risk of all-cause mortality and cardiovascular (CV) death in Chinese HD patients.

METHODS

Data from a prospective cohort study, China Dialysis Outcomes and Practice Patterns Study (DOPPS) 5, were analyzed. Demographic data, comorbidities, platelet counts and other lab data, and death records which extracted from the medical record were analyzed. TP was defined as the platelet count below the lower normal limit (< 100*109/L). Associations between platelet counts and all-cause and CV mortality were evaluated using Cox regression models. Stepwise multivariate logistic regression was used to identify the independent associated factors, and subgroup analyses were also carried out.

RESULTS

Of 1369 patients, 11.2% (154) had TP at enrollment. The all-cause mortality rates were 26.0% vs. 13.3% (p < 0.001) in patients with and without TP. TP was associated with higher all-cause mortality after adjusted for covariates (HR:1.73,95%CI:1.11,2.71), but was not associated with CV death after fully adjusted (HR:1.71,95%CI:0.88,3.33). Multivariate logistic regression showed that urine output < 200 ml/day, cerebrovascular disease, hepatitis (B or C), and white blood cells were independent impact factors (P < 0.05). Subgroup analysis found that the effect of TP on all-cause mortality was more prominent in patients with diabetes or hypertension, who on dialysis thrice a week, with lower ALB (< 4 g/dl) or higher hemoglobin, and patients without congestive heart failure, cerebrovascular disease, or hepatitis (P < 0.05).

CONCLUSION

In Chinese HD patients, TP is associated with higher risk of all-cause mortality, but not cardiovascular mortality. Platelet counts may be a useful prognostic marker for clinical outcomes among HD patients, though additional study is needed.

Current status of the assessment of sarcopenia, frailty, physical performance and functional status in chronic kidney disease patients

PURPOSE OF REVIEW

Low physical function, frailty, and sarcopenia are common complications of chronic kidney disease (CKD). In this article, we review the epidemiology and pathogenesis of low physical function, as well as its associations with adverse outcomes in CKD patients. Additionally, we present various traditional and novel methods for assessment of physical function in CKD patients.

RECENT FINDINGS

In nondialysis dependent (NDD) and dialysis-dependent CKD patients, the prevalence of low physical function, frailty, and sarcopenia are substantially higher than in the general population. The potential mechanisms of low physical function, frailty, and sarcopenia in CKD patients are due to various factors including underlying kidney disease, co-existing comorbidities, and certain therapeutic interventions utilized in CKD. Increasing evidence has also uncovered the ill effects of impaired physical function on clinical outcomes in CKD patients.

SUMMARY

Routine assessment of physical function is an under-utilized yet important component in the management of CKD patients. Future studies are needed to determine how prescription of exercise and increased daily physical activity can be tailored to optimize the health and well-being of NDD and dialysis-dependent CKD patients in pursuit of successful aging.