Mineral and bone disorders, morbidity and mortality in end-stage renal failure patients on chronic dialysis

Moderate-severe aortic arch calcification and high serum alkaline phosphatase co-modify the risk of cardiovascular events and mortality among chronic hemodialysis patients

BACKGROUND

Patients with end-stage kidney disease undergoing chronic hemodialysis (HD) have an unparalleled risk of vascular calcification (VC) and high alkaline phosphatase (Alk-P) levels. However, whether VC contributed to the cardiovascular risk modified by serum Alk-P levels was not addressed in the population.

METHODS

A retrospective cohort study was conducted on chronic HD patients, between October 1 and December 31, 2018, with aortic arch calcification (AoAC) scores and serum Alk-P levels. Patients were categorized into four groups: non-to-mild AoAC/low Alk-P, non-to-mild AoAC/high Alk-P, moderate-to-severe AoAC/low Alk-P, and moderate-to-severe AoAC/high Alk-P. The Cox proportional hazard model and Kaplan-Meier analysis were used to evaluate the risks of major adverse cardiovascular effects (MACEs) and cardiovascular and all-cause mortality after multivariate adjustment.

RESULTS

Among 376 chronic HD patients recruited, 125 (33%) had non-to-mild AoAC/low Alk-P, 76 (20%) had non-to-mild AoAC/high Alk-P, 89 (24%) had moderate-to-severe AoAC/low Alk-P, and 86 (23%) had moderate-to-severe AoAC/high Alk-P. After 3 years of follow-up, patients with coexisting moderate-to-severe AoAC and high Alk-P had a higher risk of MACEs (aHR 1.76; 95% CI 1.06-2.92), and cardiovascular (aHR 2.49; 95% CI 1.21-5.11) and all-cause mortality (aHR 2.67; 95% CI 1.39-5.13) compared to those with non-to-mild AoAC/low Alk-P even after adjustments for significant clinical variables.

CONCLUSIONS

In chronic HD patients, moderate to severe AoAC co-existed with high Alk-P levels and enhanced the risk of MACEs and cardiovascular and all-cause mortality. Interventions to attenuate these risk factors simultaneously should be emphasized in this population.

Fracture risk prediction & kidney function at different stages of chronic kidney disease: A correlation study

Background & objectives Mineral bone disease commonly occurs in individuals with chronic kidney disease (CKD) and increases fracture risk due to deficiency in bone quality and quantity. The FRAX score attempts to estimate fracture risk better. The primary aim of this study was to evaluate the prediction and correlation of fracture risk with different stages of CKD. Methods This was a correlational study. Data were collected from 95 individuals at different stages of CKD using non-probability consecutive sampling. The clinical and laboratory parameters were compared with the FRAX score in all CKD patients. Results A total of 95 CKD patients with a mean age of 51.42±9.95 yr were selected. Of these, 66.3 per cent between 40-55 yr, 25.3 per cent were 56-70 yr, and 8.4 per cent were ≥70 yr. There were 62 (65.3%) males and 33 (34.7%) females, and more than half (60%) were from rural areas. Age (P<0.001), occupation (P<0.005), and area of residence (P<0.003) showed a significant association with the FRAX score for major osteoporotic fracture risk. The FRAX score for predicting hip fracture risk showed a significant association with factors such as age, occupation, and area of residence, with P values of <0.001, 0.003, and 0.031, respectively. Additionally, the FRAX score for assessing the risk of major osteoporotic fractures demonstrated a significant association with various stages of CKD (P=0.018). Similarly, for hip fracture, there was a significant increase in the risk between stage III and V CKD patients (P=0.038). Interpretation & conclusions Based on the study findings it was found that the FRAX score was significantly associated with different stages of CKD, both for major osteoporotic as well as hip fracture risk.

Effect of intradialytic exercise on bone profile in hemodialysis patients

Background

Chronic kidney disease increases the risk of fractures and altered bone and mineral metabolism. Exercise training could be a non-pharmacological therapeutic intervention. The aim of this work is to evaluate the effect of intradialytic exercise training on bone markers in hemodialysis (HD) patients.

Results

Forty adult patients on regular HD participated in the study. Twenty of which completed 3 months supervised intradialytic cycling exercise program and 20 served as controls. At baseline, there was no difference between both groups regarding age, sex, physical performance, and laboratory studies performed. After 3 months, the exercise group showed significant improvement in short performance battery test (SPBT) total score (P<0.001) associated with significant decrease in serum parathormone (PTH) (P=0.01) and increase in serum alkaline phosphatase (ALP) and bone specific alkaline phosphatase (BALP) (P<0.05 and P<0.001 respectively). Controls did not show similar change in SPBT or laboratory studies. There was no significant change in serum calcium or phosphorus in both groups. A significant positive correlation was observed between SPBT scores post-exercise and both BALP and ALP levels (r=0.432, P=0.01 and r=0.645, P<0.01 respectively). Also, an inverse relation was observed between SPBT and PTH (r=−0.503, P=0.01).

Conclusion

Intradialytic cycling exercise program resulted in significant increase in physical performance associated with decrease in serum PTH and increase in BALP and ALP in HD patients. This indicates the positive influence of exercise not only on physical performance in dialysis patients but also on bone metabolism.

Patient-centered Pharmacist Care in the Hemodialysis Unit: a quasi-experimental interrupted time series study

BACKGROUND

Nonadherence to medications by patients requiring hemodialysis (HD) leads to unfavorable clinical outcomes. Limited data exist to demonstrate the effect of incorporating patient-centered interventions using concepts of medication therapy management and motivational interview by pharmacists on pharmacoadherence in patients requiring HD. Therefore, we assessed the impact of patient-centered pharmacist care on pharmacoadherence and its outcomes in patients requiring HD.

METHODS

Adult patients who had received outpatient HD for at least 3 months were enrolled. The study was conducted from October 2016 to April 2017. Pharmacists interviewed the patients at month 1, 2, 4 and 6, and the intervention (comprehensive review) occurred at months 3 and 5. The primary outcome was the change in pharmacoadherence as assessed by pre-HD serum phosphate levels and the differences in the number of medications between patient' self-report and medications records at the electronic healthcare records (EHRs). The secondary outcomes included changes in systolic blood pressure (SBP), glycosylated hemoglobin levels, serum low-density lipoprotein (LDL) levels, and the prevalence and types of medication-related problems (MRPs).

RESULTS

Seventy-two patients were enrolled. Their median age was 59 (interquartile range: 47-67.5) years, and 53% were men. Pre- and post-intervention pharmacoadherence, as indicated by serum phosphate levels and the differences in the number of medications between patient' self-report and the medication records at the EHRs, did not significantly differ (p = 0.682 and 0.348, respectively). Mean SBP and mean LDL did not significantly change post-intervention. The median number of MRPs declined between Months 3 and 5 (p = 0.002): the prevalence of MRPs at Month 3 was 44.9% (95 confidence interval [CI]: 40.4-49.3) and decreased to 29.8% (95 CI: 25.6-34.3) at Month 5. Drug use without indication was the most frequent MRP (23.9%).

CONCLUSIONS

Patient-centered pharmacist care did not result in significant changes in pharmacoadherence. However, its clinical utility as a tool to identify and mitigate MRPs in patients requiring HD is indisputable.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03576404 (retrospectively registered on July 3rd, 2018).

Health-related quality of life in end-stage renal disease patients, using the Missoula-Vitas quality of life index: a multicenter study

Background and aims

Assessment of Health-related Quality of Life in chronic hemodialysis patients (CHD) is a predictive indicator of the outcome of the disease, including mortality and hospitalization. Regular surveys of the quality of life (QoL) in CHD patients have been conducted worldwide, using various, internationally validated and standardized tools, including the Missoula-VITAS Quality of Life Index scale (MVQOLI). The aim of this study was to examine the reliability and validity of the Bulgarian version of the Missoula-VITAS Quality of Life Index-15 (B-MVQOLI-15) and QoL in CHD patients using this instrument.

Methods

Our study was designed as multi-center cross-sectional. It incorporated 263 end-stage renal disease (ESRD) patients on CHD from across the country and applied the B-MVQOLI-15. Internal consistency and convergent validity of the index were assessed. Non-parametric methods were used to evaluate the impact of demographic factors on the different dimensions scores and on the total score. The relationship between the total QoL score, the total MVQOLI-15 score and dimensions scores were measured based on Spearman's rho Correlation Coefficient.

Results

The total MVQOLI-15 score in the study was 16.44, which is slightly above the middle of the index scale. The patients with higher education were less satisfied with the level of their symptom control compared to patients with lower education. However, high education patients seem to manage better with everyday life compared to those with low education. Men seem to feel more satisfied than women when fulfilling their daily activities (P=0.026). Retired patients and unemployed expressed more satisfaction, compared to the employed (P=0.021). Also, patients on dialysis for over 5 years had lower QoL scores (P=0.043).

Conclusions

B-MVQOLI-15 is a reliable instrument to measure QoL in Bulgarian patients with CHD. The majority of CHD patients rate their QoL as "Fair". Four of all five dimensions positively affect the QoL of CHD patients. The most important dimensions positively affecting the QoL of CHD patients were: interpersonal relationships and transcendent factors. Future studies are necessary to assess the adequacy of the delivered dialysis, the level of medico-social care and the needs of ESRD patients treated with CHD in order to improve their QoL.

CD62P and P10 as predictive markers for assessing the efficacy of hemodialysis in treating end-stage renal disease

BACKGROUND

CD62P is a platelet α-granule membrane protein, and P10 is a platelet membrane glycoprotein thrombospondin. To better understand the effects of hemodialysis (HD), we have conducted this study to investigate CD62P and P10 in assessing the efficacy of HD in treating patients with end-stage renal disease (ESRD).

METHODS

The case group consisted of 111 patients suffering ESRD treated with regular HD and the control group enrolled 117 healthy subjects. Before and after HD treatment, a series of parameters were observed, based on which, CD62P and P10 levels were detected in the patients in two groups before and after HD therapy. The correlation analysis analyzed the correlations of CD62P and P10 markers with serum creatinine (Scr), blood urea nitrogen (BUN), and subjective score; and logistic regression analysis was performed to reveal factors affecting the efficacy of HD.

RESULTS

BUN, Scr, serum phosphorus, intact parathyroid hormone (iPTH), fibrinogen, and β2-microglobulin (β2-MG) decreased while hemoglobin, albumin, and activated partial thromboplastin time increased in the patients suffering ESRD; patients presented with improvements in subjective symptoms and an increase in dry weight. CD62P and P10 levels were lower in post-treatment patients. CD62P and P10 positively correlated with Scr, BUN and subjective score; post-treatment CD62P and P10 levels, BUN, hemoglobin, albumin, triglyceride, iPTH, β2-MG, and fibrinogen were correlated with the efficacy of HD.

CONCLUSION

CD62P and P10 might be correlated to the efficacy of HD in treating ESRD, in turn providing predictive markers for assessing the ability of HD in treating ESRD.

Long-term effects of low calcium dialysates on the serum calcium levels during maintenance hemodialysis treatments: A systematic review and meta-analysis

Hypercalcemia and hyperparathyroidism in patients receiving maintenance hemodialysis (MHD) can cause the progression of cardiovascular diseases (CVD) and mineral bone disorders (MBD). The KDIGO recommends the dialysates with a calcium (Ca) concentration of 1.25–1.5 mmol/L for MHD treatments, but the optimal concentration remains controversial. Here, we conducted a systematic review and a meta-analysis of seven randomized controlled trials examining a total of 622 patients to investigate the optimal concentration for MHD for 6 months or longer. The dialysates with a low Ca concentration (1.125 or 1.25 mmol/L) significantly lowered the serum Ca and raised the intact parathyroid hormone levels by 0.52 mg/dL (95% confidence interval, 0.20–0.85) and 39.59 pg/mL (14.80–64.38), respectively, compared with a high Ca concentration (1.50 or 1.75 mmol/L). Three studies showed that a low concentration was preferred for lowering arterial calcifications or atherosclerosis in different arteries, but one study showed that coronary arterial calcifications increased with a low concentration. Two studies showed contradictory outcomes in terms of MBD. Our meta-analysis showed that a dialysate with a low Ca concentration lowered the serum Ca levels in patients receiving long-term MHD, but further studies are needed to determine the optimal Ca concentration in terms of CVD and MBD.