Machine Learning-Based Prediction of Life-Threatening Complications During Hemodialysis in Hospitalized Patients With Poor General Conditions.

Enrollment parathyroid hormone level is a new marker of survival in hemodialysis and peritoneal dialysis therapy for uremia

Hepatitis B virus (HBV) vaccination is recommended for all individuals with renal failure. Nevertheless, the response rate for this vaccine in hemodialysis (HD) patients is low, ranging from 50% to 80%. The goal of this study was to determine patient characteristics at the initiation of HD that influence HBV vaccine response. Patients new to HD in an urban population in the United States were retrospectively examined. Analyzed patients were HBV antibody and antigen negative and hepatitis C virus antibody negative at the start of HD, who received HBV recombinant vaccine. Nonresponse was defined as failure to seroconvert (>10 UI/L) after six deltoid intramuscular injections of vaccine. Response was defined as a lasting seroconversion (at least two consecutive positive titers) with </=6 injections. Demographic, laboratory, and kinetic modeling data were examined. A total of 33 nonresponders and 64 responders were identified. Univariate analysis demonstrated that nonresponders were older (59 vs. 51 years), had a higher prevalence of diabetes mellitus (DM) (70 vs. 39%), had lower serum albumin levels (3.2 vs. 3.3 g/dL), and had higher dry weights (84 vs. 71 kg) than responders at HD start. In addition, nonresponders had lower normalized protein catabolic rates (0.74 vs. 0.85 g/kg/day) and lower (single-pool) spKt/V(urea)values (0.95 vs. 1.19). Nonresponders had lower serum creatinine levels than responders, despite the greater dry weights. In a multiple logistic analysis model, the presence of DM, age >/= 55 years, body weight >/=80 kg, and normalized protein catabolic rate </=0.75 g/kg/day were associated with HBV vaccination nonresponse. At the end of the vaccination period, nonresponders versus responders continued to have lower serum albumin (3.5 vs. 3.8 g/dL) and creatinine levels (7.8 vs. 10.0 mg/dL) and spKt/V(urea)(1.27 vs. 1.39). Hepatitis B vaccine nonresponders on HD are older, are more likely to have DM, are more malnourished, and have lower spKt/V(urea) than responders. Nonresponders may also have a different body composition with a lower ratio of lean to total body mass.

In Japan, percutaneous endoscopic gastrostomy (PEG) has been used mainly in patients with stroke and dementia, who undertake oral ingestion voluntarily. We have used PEG for patients with various diseases in Saga Medical School Hospital, including postoperative recovery, malignant disease, and neurodegenerative diseases. This study evaluated prognostic factors in these patients regarding long-term survival. We analyzed retrospectively all patients who received PEG at our hospital. During the period of 1998-2007, 84 patients (32 females, 52 males; mean age, 60.3 years, range 20-89 years) were followed for more than 1 year. We analyzed sex, age, total lymphocyte count, serum albumin level, presence of malignant diseases, cerebrovascular diseases, neurodegenerative disorders, poor general condition after surgical procedures, dementia before PEG, pneumonia before PEG, and complications of PEG placement. As for diseases, 23 patients had malignant diseases, 27 had cerebrovascular diseases, 19 had neurodegenerative disorders, 16 were in poor general condition after surgery for nonmalignant diseases, and 12 had dementia. Multivariate analysis indicated that risk factors for 1-year survival were low serum albumin level (≤2.9 g/dL), low lymphocyte count, and complications of malignant diseases. Low serum albumin level, low lymphocyte count, and malignant diseases were risk factors, and only the albumin level was a risk factor in those without malignant diseases. Low serum albumin level was a risk factor for 1-year survival with PEG, which suggests that nutrient management before and during PEG placement should be monitored carefully.

Carpal tunnel syndrome (CTS) is the most common mononeuropathy in patients with end-stage renal disease (ESRD). The association between chronic inflammation and CTS in hemodialysis (HD) patients has rarely been investigated. HD patients with a high normalized protein catabolic rate (nPCR) and low serum albumin level likely have adequate nutrition and inflammation. In this study, we assume that a low serum albumin level and high nPCR is associated with CTS in HD patients. We recruited 866 maintenance hemodialysis (MHD) patients and divided them into 4 groups according to their nPCR and serum albumin levels: (1) nPCR <1.2 g/kg/d and serum albumin level <4 g/dL; (2) nPCR ≥1.2 g/kg/d and serum albumin level <4 g/dL; (3) nPCR <1.2 g/kg/d and serum albumin level ≥4 g/dL; and (4) nPCR ≥1.2 g/kg/d and serum albumin level ≥4 g/dL. After adjustment for related variables, HD duration and nPCR ≥1.2 g/kg/d and serum albumin level <4 g/dL were positively correlated with CTS. By calculating the area under the receiver-operating characteristic curve, we calculated that the nPCR and HD duration cut-off points for obtaining the most favorable Youden index were 1.29 g/kg/d and 7.5 years, respectively. Advance multivariate logistic regression analysis revealed that in MHD patients, nPCR ≥1.29 g/kg/d and serum albumin <4 g/dL, and also HD duration >7.5 years were associated with CTS. A high nPCR and low serum albumin level, which likely reflect adequate nutrition and inflammation, were associated with CTS in MHD patients.

In British Columbia, multidisciplinary predialysis clinics encourage patients to consider independent modalities of renal replacement therapy (RRT) such as peritoneal dialysis (PD) 'first'. Despite up to 50% of patients choosing PD, PD incidence rates are ~30%. We explored the relationship between predialysis RRT choice and arteriovenous fistula (AVF) creation prior to hemodialysis (HD) start with particular focus on the group of patients who despite PD choice actually commence HD, and thus may contribute to 'suboptimal' HD starts without AVF creation. We conducted a retrospective cohort study of all patients starting dialysis between 31 December, 2006 and 31 December 2008 in the province of British Columbia. Inclusion criteria were >3 months predialysis nephrology follow-up, at least one predialysis RRT education session and maintenance on dialysis for a minimum of 3 months (to ensure chronic dialysis). Patients with any prior history of RRT were excluded. There were 508 patients included in the study: 127 (25%) patients chose HD, 114 (22%) PD, 13 (3%) pre-emptive transplant, 5 (1%) conservative management and 249 (49%) had no documented modality decision. Of those who chose HD, 94% commenced HD. For those who chose PD, 64% commenced PD and 36% HD. In the undecided group, 68% started HD and 32% PD. For those patients who chose PD predialysis, the presence of cardiovascular disease [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.02-5.43] and lower serum albumin levels (OR 0.92, 95% CI 0.86-0.98) were associated with failure to commence PD. Predialysis AVF creation rates were 79% of those who chose and started HD, 39% of those who chose PD but started HD and 50% of those in the undecided group who commenced HD. AVF creation rates prior to HD start were lower in those patients with no documented dialysis modality choice and in those who failed to commence PD. Cardiovascular disease and lower serum albumin levels were associated with failure to start PD. Further work to ensure the efficacy of RRT modality choice pathway and to better predict those patients who will fail to commence PD is necessary, so that dialysis start can be 'optimized' with AVF creation in high-risk groups.

BACKGROUND: Peripheral artery occlusive disease (PAOD) is prevalent in patients receiving hemodialysis (HD) and influences their mortality. However, few studies have identified PAOD risk factors among patients receiving HD. Heme oxygenase-1 (HO-1) has recently been found to be a risk factor for vascular disease and guanidinium thiocyanate (GT) repeat polymorphism in the HO-1 gene promoter has been shown to affect its activity. This study was initiated to evaluate the risk factors for PAOD and mortality in patients receiving HD, including potential associations with polymorphism in HO-1 gene promoter.METHODS: Data for this study were collected as part of a 1-year, prospective, multicenter, observational study. We enrolled 342 patients under regular dialysis from 7 HD centers in northern Taiwan. The ankle brachial pressure index (ABI) ＜ 0.9 indicated a diagnosis of PAOD. Clinical data were obtained from medical records. The (GT)n repeat length polymorphism in the HO-1 gene promoter was assayed according to the standard procedure. We defined (GT)n repeat length ＜ 28 as short repeat (S) and repeat length ≥ 28 as long repeat (L).RESULTS: One hundred and five patients (30.7%) were diagnosed with PAOD. Multivariate analysis revealed that old age (1.038 [1.016-1.060], P = 0.0005), diabetes (2.38 [1.425-3.984], P = 0.0009), and history of stroke (3.83 [1.577-9.346], P = 0.003) were independent risk factors for PAOD. In contrast, the incidence of history of hepatitis B (0.215 [0.068-0.675], P = 0.0084) and calcium (mg/dL) × phosphorous (mg/dL) product (Ca × IP) ＞ 60 (0.373 [0.149-0.931], P = 0.0345) were lower in PAOD patients. Compared with patients without PAOD (NPAOD) during the 1-year follow-up period, patients with PAOD had higher rates of mortality (17.27% vs. 2.16%, P ＜ 0.0001) and rehospitalization (25.45% vs. 12.12%, P = 0.0019). The average (GT)n repeat length ≥ 28 was more common in PAOD than in NPAOD patients (41.9% vs. 30.8%, P = 0.049). There were six independent risk factors of mortality, including old age (HR = 1.071 [1.019-1.126], P = 0.007), PAOD diagnosis (HR = 1.071 [1.019-1.126], P = 0.007), history of stroke (HR = 4.132 [1.443-11.765], P = 0.0082) and diabetes (HR = 4.444 [1.203-16.393], P = 0.0253), presence of HO-1 SL genotype (HR = 7.54 [1.578-36.036], P = 0.0114), and lower serum albumin level (HR = 16.129 [5.076-52.632], P ＜ 0.0001).CONCLUSIONS: PAOD diagnosed by the ABI test was an independent risk factor for mortality in HD patients, and the occurrence of PAOD in patients receiving HD was associated with the longer GT repeat polymorphism in the HO-1 gene promoter. Additionally, HO-1 SL genotype was associated with 1-year mortality. Further study is required to understand the mechanisms underlying the role of HO-1 in the development of PAOD in patients receiving HD.

Objective To investigate cerebrovascular lesions on maintenance hemodialysis (MHD) patients, including types of cerebrovascular disease, and cognitive function changes. Methods A cross-sectional study was applied. A total of 270 MHD patients at hemodialysis center of Peking Union Medical College Hospital were screened, and finally 117 cases were enrolled. Demographic information, aboratory data, MRI and MRA data were collected and assessed. Cognitive function was evaluated with C-MMSE (Chinese mini mental test examination) and C-MoCA (Chinese montreal cognitive assessment). The related factors were selected by Spearman correlation analysis, multiple linear regression and logistic regression analysis. Results The patients' average age was (56.0±12.5) years, average hemodialysis age was (73.5±60.8) months. Only 5.1% patients had clinical history of cerebral infarction or hemorrhage. Pre-hemodialysis blood pressure was (142.7/80.3±18.2/12.9) mmHg, Post-hemodialysis blood pressure was (130.2/79.1±23.4/14.9) mmHg. A total of 18.8% patients had intra-hemodialysis hypotension, spKt/V was (1.45±0.25). MR results showed that 12.0% patients had cerebral artery stenosis, 5.1% patients had cortical infarcts, 39.3% patients had lacunar infarcts, 47.0% patients had microbleeds, 7.7% patients had chronic hematoma, 52.1% patients had abnormal brain whiter matter lesions (WMLs). In cognitive function evaluation, 20.9% patients had abnormal C-MMSE scores, but 65.2% patients had abnormal C-MoCA results. Multiple linear regression showed age (b=0.059, P<0.01), dialysis age (b=0.005, P<0.05) were associated with WMLs in MHD patients. Intra-hemodialysis hypotension was an independent risk factor of lacunar infarcts (b=2.123, P<0.01) and microbleeds (b=3.531, P<0.01). Low serum albumin level was an independent risk factor of cognitive decline (b=0.314, P<0.05). Logistic regression analysis showed pre-hemodialysis systolic blood pressure was an independent risk factor of cortical infarcts [OR=1.088, 95%CI (1.018-1.152), P<0.05]. Gender, dialysis age and pre-dialysis serum TCO2 level were related with chronic hematoma. Conclusions WMLs is related with dialysis voltage. Lacunar infarcts and mirobleeds are related with intra-hemodialysis hypotension. Lacunar infarcts, WMLs and nutritional status are contributed to decline of cognition in MHD patients. Key words: Renal dialysis; Cerebrovascular disorders; Neurobehavioral manifestations

Frequent Hemodialysis Network (FHN) randomized trials: Study design

Heart Failure Severity Scoring System and Medical- and Health-Related Quality-of-Life Outcomes: The HEMO Study

426 Background: Patients with maintenance hemodialysis (HD) have been recognized as a high risk group for cancer. The aim of this study was to verify the incidence and oncological outcomes of patients on maintenance hemodialysis with renal cell carcinoma (RCC) compared with RCC patients without renal dysfunction. Methods: We have been carried out annual screening for renal mass for the hemodialysis patients.The oncological outcome of pT1N0M0 RCC detected by annual screening of CT imaging were retrospectively reviewed in 1217 patients with HD between January 2002 and December 2010 at Oyokyo kidney Research Institute and Hirosaki University Hospital, Hirosaki, Japan. Overall and cancer specific survival was compared with age matched 106 of pT1N0M0 RCC patients without renal dysfunction who performed radical nephrectomy at the same periods. Results: Among the hemodialysis patients, 14 RCCs were incidentally detected by screening CT examinations and RCC detection rate in HD patients was 0.27% per year. Total 119 pT1N0M0 RCC patients (13 with HD group, 106 normal kidney function group) were incidentally detected by regular abdominal CT imaging without symptoms. There were no significant differences on age and gender between HD and normal kidney function group. Cancer specific survival after tumor diagnosis was not different, but overall survivals were significantly superior in patients without renal dysfunction compared to those with chronic renal failure (P &lt; 0.0001). Cancer specific and Overall 5-year survival was 95% and 96% in patients without renal dysfunction, 92% and 54% in those with chronic renal failure. Conclusions: There was no significant difference in cancer specific survival of pT1 RCC between the two groups. However, overall survival was significantly worse in HD patients. Oncological effectiveness of annual CT screening for the HD patients was not evident in the present retrospective study.

Background: As symptomatic intradialytic hypotension in the hemodialysis (HD) patient is often a sudden event whose onset cannot be predicted by means of extemporary measures, continuous blood pressure (BP) measurement would be far more useful. We tested a new continuous noninvasive BP monitoring system, Harmonized Alert Sensing Technology (HASTE), which, by means of the analysis of the finger pulse wave, obtained from an O₂ sensor, estimates a beat-to-beat systolic pressure value (Esys) and supplies a continuous read-out. The study aim sought to verify the reliability of this non-invasive instrument in continuously providing systolic pressure values during HD. Methods: We studied 18 patients during HD treatment, initially comparing the Esys with the invasive blood pressure measurement (SYS). Subsequently, the Esys derived from the O₂ sensor in the arm with the shunt (S) and the arm without (N), respectively, were both compared with the cuff measurement. Results: The mean difference between SYS and Esys was 0.7 ± 13.3 mm Hg (p < 0.01; r = 0.80). There was a mean difference of 0.2 ± 21.9 mm Hg (p = NS; r = 0.67) between Esys(N) and Esys(S). The correlation was not statistically significant even between Esys(N) or Esys(S) versus the cuff measurement, respectively. Patient movement compromised the accuracy of the estimations made using the O₂ sensor in the non-fistula arm. Conclusions: A good correlation between the data estimated by HASTE compared with invasive BP suggests that the instrument may prove useful for continuously monitoring the blood pressure trends during the dynamic hemodialysis situation. However, its sensibility needs to be improved in order to be used indifferently in both arms with a view to achieving real intradialytic hypotension prevention.

Oxidative stress (OS) is considered a significant risk factor for the development of anemia in patients treated by regular hemodialysis (HD). Moreover, OS represents a risk factor for the development of erythropoietin (EPO) resistance in these patients. The aim of this study was to examine the role of OS regarding EPO resistance development in patients treated by regular HD. 96 patients treated with standard HD and on-line hemodiafiltration were included in this study. The patients were treated with short-acting and long-acting EPOs for anemia. The concentration of superoxide anion radical, hydrogen peroxide, thiobarbituric acid reactive substances, and nitric oxide in the form of nitrites and the activity of catalase, superoxide dismutase and reduced glutathione were measured in patients' blood spectrophotometrically. Standard biochemical analysis, inflammatory markers, nutritional status, HD parameters, and erythropoietin resistance index were also determined. Patients with resistance to short-acting EPO had significantly lower concentration of hemoglobin in the blood and hematocrit value, a significantly higher serum ferritin concentration, and significantly lower catalase activity in erythrocytes than patients without EPO resistance. Patients with resistance to long-acting EPO have a significantly lower hemoglobin concentration in the blood, hematocrit values, and serum concentration of prealbumin and vitamin D, as well as significantly higher concentration of C-reactive protein, superoxide anion, and hydrogen peroxide concentration than those without resistance. OS significantly contributes to EPO resistance development. OS, higher ferritin and CRP levels, lower hemoglobin, hematocrit and prealbumin levels, and vitamin D deficiency represent significant risk factors for EPO resistance development in HD patients.

The aim of this cross-sectional study was to compare health-related quality of life (HRQOL) of Russian hemodialysis (HD) patients with the general population and international data, and to determine factors influencing HRQOL. One thousand forty-seven HD patients from 6 dialysis centers were studied (576 male, age 43.5 +/- 12.5 years, HD duration 55.0 +/- 47.2 months). Health-related quality of life was evaluated by SF-36. Self-appraisal Depression Scale (W. Zung), State-Trait Anxiety Inventory, and Level of Neurotic Asthenia Scale were used. Hemodialysis patients scored significantly lower than the general Russian population in the majority of SF-36 scales. The only exception was the Mental Health score, which was even better than the general population. The Mean physical component score (PCS) of HD patients was 36.9 +/- 9.7, and the mental component score was (MCS) 44.2 +/- 10.5. In multiple linear regression analysis, increasing age, HD duration, depression level and number of days of hospitalization in the past 6 months were significant independent predictors of low PCS along with a low level of serum albumin. Advancing age was also a predictive factor for low MCS along with increase of HD duration, depression level, trait anxiety, and level of asthenia. As far as we know, this is the first study to report on HRQOL of a large sample of Russian HD patients performed using SF-36. Compared with the general population, Russian HD patients had significantly lower scores on the majority of SF-36 scales, especially in the physical domain. The mean PCS and MCS were comparable with European data for HD patients. A number of demographic, clinical, and psychological variables affect HRQOL.

Blood loss from the access cannulation site during hemodialysis (HD) treatment is inevitable. Nevertheless, during HD, excessive blood loss from the cannulation site is not uncommon. The clinical characteristics associated with it and whether such blood loss could impact on patient outcomes is unknown. This pilot study aims to identify the prevalence and risk factors associated with excessive bleeding (≥ 4 mL/session) from dialysis access cannulation site during regular HD treatments. Stable end-stage renal disease patients receiving maintenance HD via arteriovenous fistula (AVF) or graft (AVG) were included in this study (N = 361). They were closely monitored for one month for the occurrence of excessive access bleeding during each HD session. A total of 4152 sessions of HD were performed during the study period and 143 patients (39.6%) had at least one episode of excessive bleeding from the vascular access (≥ 4 mL/session). Individuals experiencing excessive bleeding episodes had a significantly lower hemoglobin level, higher rate of diabetes, central venous stenosis, longer dialysis vintage, lower serum albumin level, longer hemostasis time and higher AVG and anti-platelet agent use (all P < 0.05). In the multivariable logistic regression model, longer dialysis vintage, central venous stenosis, lower hemoglobin level, and AVG usage were independently associated with occurrence of excessive access bleeding. AVG users also clustered with other risk factors for excessive access bleeding. Our study identified the novel associations between excessive cannulation site bleeding with dialysis vintage, anemia and AVG usage. The significance and impact of long-term chronic, intermittent bleeding from dialysis access should be further explored.

It has been reported that (123)I-metaiodobenzylguanidine (MIBG) scintigraphy can predict the poor prognosis in patients with dilated cardiomyopathy (DCM). However, the prognostic significance of MIBG is still unknown in patients with other heart diseases. In this study, we compared the prognosis and MIBG findings in various heart diseases. Consecutive 565 patients undergoing MIBG scintigraphy were enrolled (392 men, 52 +/- 16 years). Indications were that 127 had ischemic heart disease (IHD), 120 DCM, 101 hypertrophic cardiomyopathy (HCM), 21 hypertensive heart disease (HHD), 58 volume-load valvular disease (VVD), 38 pressure-load valvular disease (PVD), and 101 ventricular tachycardia or fibrillation (VTF). Heart-to-mediastinum ratio (H/M) and washout rate (WR) of MIBG were evaluated. Cardiac events were defined as sudden cardiac death, heart failure, and acute ischemic event (follow-up, 22.7 +/- 17.0 months). A total of 106 cardiac events including 40 cardiac deaths occurred. Cox hazard model analysis showed that in the IHD, HCM, and DCM groups, H/M and WR were associated with cardiac death, but not in the HHD, PVD, VVD, or VTF groups. Only death and congestive heart failure (CHF) episodes were related to H/M and WR. On the other hand, fatal arrhythmia, myocardial infarction, or angina pectoris were not related to H/M and WR. The data indicated that WR or H/M may predict death and CHF but does not predict fatal arrhythmia or acute ischemic event. MIBG WR and H/M were associated with heart failure, sudden death, and cardiac death events, and were useful to predict the prognosis in DCM, HCM, and IHD. In contrast, fatal arrhythmia events were not associated with MIBG indices, and thus it does not appear to be useful in predicting cardiac events in patients with VTF.