Adult End-stage Renal Disease Patients Research Articles

Association of sociocultural factors with initiation of the kidney transplant evaluation process.

Although research shows that minorities exhibit higher levels of medical mistrust, perceived racism, and discrimination in healthcare settings, the degree to which these underlying sociocultural factors preclude end-stage renal disease (ESRD) patients from initiating kidney transplant evaluation is unknown. We telephone surveyed 528 adult ESRD patients of black or white race referred for evaluation to a Georgia transplant center (N=3) in 2014-2016. We used multivariable logistic regression to examine associations between sociocultural factors and evaluation initiation, adjusting for demographic, clinical, and socioeconomic characteristics. Despite blacks (n=407) reporting higher levels of medical mistrust (40.0% vs 26.4%, P<.01), perceived racism (55.5% vs 18.2%, P<.01), and experienced discrimination (29.0% vs 15.7%, P<.01) than whites (n=121), blacks were only slightly less likely than whites to initiate evaluation (49.6% vs 57.9%, P=.11). However, after adjustment, medical mistrust (odds ratio [OR]: 0.59; 95% confidence interval [CI]: 0.39, 0.91), experienced discrimination (OR: 0.62, 95% CI: 0.41, 0.95), and perceived racism (OR: 0.61; 95% CI: 0.40, 0.92) were associated with lower evaluation initiation. Results suggest that sociocultural disparities exist in early kidney transplant access and occur despite the absence of a significant racial disparity in evaluation initiation. Interventions to reduce disparities in transplantation access should target underlying sociocultural factors, not just race.

Technology-assisted cognitive-behavioral therapy intervention for end-stage renal disease.

Technology-assisted cognitive-behavioral therapy (CBT) interventions have been conducted for symptoms including depression, pain, and fatigue in patients with chronic illnesses but not in end-stage renal disease (ESRD). The purpose of this study was to pilot the feasibility and acceptability of a technology-assisted CBT intervention in ESRD patients on hemodialysis (HD), share design and implementation lessons learned, and provide preliminary results on changes in select patient-reported symptoms. This was a single-center pilot feasibility study of adult ESRD patients on HD. Study eligibility required clinically elevated levels of at least one symptom (depression, pain, or fatigue). Patients met weekly with a CBT therapist for eight sessions, each 45-60 min, during HD sessions via a video-conferencing platform. Symptom questionnaires were completed at baseline and 3 months follow-up. Of 10 patients screened, 100% screened positive for at least one symptom, 100% of eligible patients consented, and eight (of 10) completed the intervention (mean age 59 years, 50% male, 50% African American). Patient adherence and satisfaction was high, and seven of the eight patients completed all eight prescribed sessions. Minimal interference with HD was reported. Preliminary results indicate no statistically significant changes in depression, fatigue, or pain at follow-up. However, there was small improvement in SF-36 Physical Component score [t(7) = -2.60, p = .035], and four of the six patients (67%) with clinically elevated pain at baseline reported improvement at follow-up. A technology-assisted CBT intervention for ESRD patients was feasible, well-accepted, and required minimal additional resources in the HD setting. Larger, adequately powered clinical trials are needed to evaluate the effect on ESRD patient-reported outcomes.

Use of Phosphate Binders in End-Stage Renal Disease: An Experience From a Secondary Care Hospital in United Arab Emirates.

ABSTRACTObjective:Hyperphosphatemia in end-stage renal disease (ESRD) is associated with many serious patient-level consequences including cardiovascular events and mortality. The purpose of this study was to investigate the use of phosphate binders in ESRD patients on maintenance hemodialysis.Materials and Methods:The study was a prospective observational cohort study including adult ESRD patients undergoing hemodialysis at a secondary hospital in United Arab Emirates. Patient characteristics were compared as per type of phosphate binder used. Bivariate and multivariate multinomial logistic regression analyses were carried out to determine variables that were independently associated with use of different phosphate binders.Results:Phosphate binders used at our study site were sevelamer, calcium carbonate, and a combination of sevelamer and calcium carbonate. Bivariate multinomial logistic regression analysis revealed that serum phosphorous (odds ratio [OR]: 0.14, 95% confidence interval [CI]: 0.04–1.09, P = 0.047; OR: 0.10, 95% CI: 0.03–0.89, P = 0.042), calcium (OR: 0.11, 95% CI: 0.02–0.86, P = 0.041; OR: 0.22, 95% CI: 0.01–0.96, P = 0.012), and calcium–phosphorous product (OR: 0.20, 95% CI: 0.06–0.64, P = 0.008; OR: 0.16, 95% CI: 0.05–0.54, P = 0.003) levels were significantly lower in patients on sevelamer per se as well as in patients on combination therapy, respectively when compared to calcium carbonate per se. Multivariate multinomial logistic regression analysis revealed that in sevelamer and combination groups, cardiovascular diseases (OR: 0.12, 95% CI: 0.02–0.65, P = 0.022; OR: 0.10, 95% CI: 0.01–0.88, P = 0.038) were significantly lesser compared to calcium carbonate group after being adjusted for other variables in the model.Conclusion:We observed that hyperphosphatemia and related events in our study population were better controlled by sevelamer per se and combination therapy than calcium carbonate per se. Further large scale, multicenter studies are required to confirm and establish these findings.

Relationship between serum sclerostin, vascular sclerostin expression and vascular calcification assessed by different methods in ESRD patients eligible for renal transplantation: a cross-sectional study.

Vascular calcification (VC) is known to be prevalent in patients with end-stage renal disease (ESRD). Sclerostin has been identified to be involved in the cross-talk between the kidney, vasculature, and bone. The aims of the present study were to evaluate vessel sclerostin expression and its correlation with VC, as well as serum sclerostin levels. A total of 51 adult ESRD patients undergoing living donor renal transplant (RT) were enrolled in this study. Serum sclerostin levels were measured by enzyme-linked immunosorbent assays. The thoracic aorta calcification (TAC) was measured by computed tomography (CT). The aortic calcification area index (ACAI) was used to evaluate the severity of TAC. During the RT surgery, the internal iliac arteries were collected and paraffin-embedded in 40 patients, followed by immunohistochemical staining for sclerostin expression and von Kossa-staining for vascular medial calcification degree. The prevalence rate of TAC detected by CT was 58.82%. The positive rates of the internal iliac arterial calcification and vessel sclerostin expression were both 45%. Vessel sclerostin was strongly co-localized with medial calcification. Multivariate analyses revealed that only serum sclerostin was significantly associated with the presence of TAC, the severity of TAC and the positive expression of vessel sclerostin. Kappa test showed that the consistency of the two different calcification assessment methods, as well as the consistency of vessel sclerostin expression and von Kossa-staining were high. Furthermore, the cutoff points of serum sclerostin for vessel sclerostin expression, the presence of VC evaluated by CT and that evaluated by pathology were 1599.92pg/mL, 2475.52pg/mL, and 2116.23pg/mL, respectively. The two methods, namely CT and pathology, to evaluate VC were highly consistent. Serum sclerostin was an independent determinant of positive expression of vessel sclerostin and VC in ESRD patients eligible for RT.

Abstract MP10: Increasing Obesity Prevalence in the United States End-stage Renal Disease Population

Background: Obesity has become a national epidemic, and is associated with increased risk for comorbid diseases including end-stage renal disease (ESRD). Among ESRD patients, obesity may improve dialysis-survival but decreases likelihood of transplantation, and as such, obesity prevalence may directly impact growth of the incident dialysis population. Methods: Incident adult ESRD patients with complete body mass index (BMI, kg/m 2 ) data were identified from the United States Renal Data System from 01/01/1995-12/31/2010 (n=1,822,598). Data from the Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention (n=4,303,471) represented the US population when weighted. Trends in BMI and obesity classes I (BMI of 30-34.9), II (BMI of 35-39.9), and III (BMI ≥40) were examined by year of dialysis initiation. Trends in median BMI slope were compared between the ESRD and US populations using linear regression. Results: Median BMI of ESRD patients in 1995 was 24.2 as compared to 28.0 in 2010, a 15.7% increase, while the US population’s median BMI increased from 24.2 in 1995 to 25.6 in 2010, a 5.8% increase. Comparable trends were noted with respect to prevalence of obesity classes I, II, and III (Table). BMI increase among the ESRD population was significantly more rapid than among the US population (β: 0.15, 95% CI: 0.14-0.17, p&lt;0.001) (Figure). Conclusion: The median BMI of ESRD patients and prevalence of obesity among ESRD patients is increasing more rapidly than the US population. Given the increased dialysis-survival and decreased likelihood of transplantation associated with obesity, healthcare costs will likely increase, and thus, future research should be directed at examining medical expenditures.

Quality of Life of Patients on Maintenance Hemodialysis in Relation to Hemoglobin Level: A Multicenter Study from a Developing Country

Background: Anemia is common in patients with end stage renal disease (ESRD) and is associated with impaired quality of life (QOL). This study was done to evaluate the QOL of ESRD patients on maintenance hemodialysis (MHD) with different levels of hemoglobin (Hb).Methods: This cross-sectional study was conducted from January to December 2013 on 135 adult ESRD patients on MHD for ?4 months, at hemodialysis units of three tertiary care hospitals in Dhaka, Bangladesh. The patients were divided into three groups based on Hb levels (Group 1: Hb &lt;9 gm/dl, n=45, 33%; Group 2: Hb 9-11 gm/dl, n=53, 39% and Group 3: Hb &gt;11 gm/dl, n=37, 28%), provided their Hb levels were stable [ie. maintained with erythropoietin (EPO) or blood transfusion (BT) or both] over the previous four months. Subjects were interviewed by principal investigator using Kidney Disease Quality of Life Short Form Tool (KDQOL-SF-36 version 1.3) consisting of two domains with 38 questions with each item put on a 0 to 100 range, higher scores indicating better QOL.Results: The mean age was 50+12 years with male predominance (male:female = 1.5:1). Mean duration of hemodialysis was 12±11.8 months (range 9 to 66 months). The average QOL score was 50. Comparison of QOL parameters between the three groups showed that symptoms/problems, effects of kidney disease, burden of kidney disease, cognitive function, quality of social interaction and sleep in the kidney disease specific domain as well as pain, emotional well-being, social function and energy/fatigue scale scores in the general health related domain were significantly higher in the group 2 and group 3 than group 1 patients (each with p&lt;0.001). Comparison of QOL parameters between anemia correction measures like EPO (n=65, 48.2%), BT (n=42, 31.1%) or both (n=28, 20.7%) showed that the group receiving EPO alone had better QOL [symptom/ problem (p 0.043), burden of kidney disease (p 0.000), sexual function (p 0.000), pain (p 0.008) and energy/ fatigue (p 0.036)] compared to those getting BT or even BT plus EPO.Conclusion: Patients were found to have better QOL with higher Hb levels. The overall QOL can be improved significantly by correction of anemia.Birdem Med J 2017; 7(3): 198-204

Pharmacokinetic and pharmacogenetic analysis of immunosuppressive agents after laparoscopic sleeve gastrectomy.

Severe obesity has been shown to limit access to renal transplantation in patients with end-stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (LSG) has been performed in the ESRD population to assist in achieving waitlist and transplant eligibility. Little is known about how LSG impacts the bioequivalence of tacrolimus products and immunosuppression pharmacokinetics. This was a prospective, open-label, single-dose, crossover, two-period pharmacokinetic (PK) study. The purpose of this study was to assess single-dose PK of immediate-release tacrolimus (IR-TAC), extended-release tacrolimus (ER-TAC), and mycophenolic acid (MPA) in adult ESRD patients post-LSG. Twenty-three subjects were included in the 24-hour PK assessments. The ratio of geometric means between ER-TAC and IR-TAC was 103.5% (90% CI; 89.6%-119.6%) for AUC0-24 and 92.5% (90% CI; 80.4%-106.4%) for Cmax . PK parameters were similar between ER-TAC and IR-TAC, except for Cmin (P=.004) and Cmax (P=.04). MPA AUC0-24 was similar when given with either ER-TAC or IR-TAC (P=.32). Patients expressing CYP3A5*1 genotypes had lower tacrolimus AUC0-24 values vs those with CYP3A5*3/*3 (IR-TACP<.001; ER-TACP=.008). Genotype did not impact MPA PK. Dose modification of immunosuppressants post-LSG may not be necessary aside from standard therapeutic drug monitoring.

Association between Helicobacter pylori and end-stage renal disease: A meta-analysis.

AIMTo investigate the prevalence and association of Helicobacter pylori (H. pylori) with end-stage renal disease (ESRD).METHODSSA comprehensive literature search was completed from inception until October 2016. Studies that reported prevalence, relative risks, odd ratios, hazard ratios or standardized incidence ratio of H. pylori among ESRD patients were included. Participants without H. pylori were used as comparators to assess the association between H. pylori infection and ESRD. Pooled risk ratios and 95%CI was calculated using a random-effect model. Adjusted point estimates from each study were combined by the generic inverse variance method of DerSimonian and Laird.RESULTSOf 4546 relevant studies, thirty-seven observational studies met all inclusion criteria. Thirty-five cross-sectional studies were included in the analyses to assess the prevalence and association of H. pylori with ESRD. The estimated prevalence of H. pylori among ESRD patients was 44% (95%CI: 40%-49%). The pooled RR of H. pylori in patients with ESRD was 0.77 (95%CI: 0.59-1.00) when compared with the patients without ESRD. Subgroup analysis showed significantly reduced risk of H. pylori in adult ESRD patients with pooled RR of 0.71 (95%CI: 0.55-0.94). The data on the risk of ESRD in patients with H. pylori were limited. Two cohort studies were included to assess the risk of ESRD in patients with H. pylori. The pooled risk RR of ESRD in patients with H. pylori was 0.61 (95%CI: 0.03-12.20).CONCLUSIONThe estimated prevalence of H. pylori in ESRD patients is 44%. Our meta-analysis demonstrates a decreased risk of H. pylori in adult ESRD patients.

First-Year Waitlist Hospitalization and Subsequent Waitlist and Transplant Outcome.

Frailty is associated with inferior survival and increased resource requirements among kidney transplant candidates, but assessments are time-intensive and costly and require direct patient interaction. Waitlist hospitalization may be a proxy for patient fitness and could help those at risk of poor outcomes. We examined United States Renal Data System data from 51 111 adult end-stage renal disease patients with continuous Medicare coverage who were waitlisted for transplant from January 2000 to December 2011. Heavily admitted patients had higher subsequent resource requirements, increased waitlist mortality and decreased likelihood of transplant (death after listing: 1-7 days: hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.20-1.28; 8-14 days: HR 1.49, 95% CI 1.42-1.56; ≥15 days: HR 2.07, 95% CI 1.99-2.15; vs. 0 days). Graft and recipient survival was inferior, with higher admissions, although survival benefit was preserved. A model including waitlist admissions alone performed better (C statistic 0.76, 95% CI 0.74-0.80) in predicting postlisting mortality than estimated posttransplant survival (C statistic 0.69, 95% CI 0.67-0.73). Although those with a heavy burden of admissions may still benefit from kidney transplant, less utility is derived from allografts placed in this population. Current kidney allocation policy, which is based in part on longevity matching, could be significantly improved by consideration of hospitalization records of transplant candidates.

Prevalence and severity of pain in adult end-stage renal disease patients on chronic intermittent hemodialysis: a systematic review.

ObjectivesUnderstanding the epidemiology of pain in patients on hemodialysis (HD) is crucial for further improvement in managing pain. The aim of this study was to systematically review available evidence on the prevalence and severity of pain in adult end-stage renal disease patients on chronic intermittent HD.Materials and methodsWe carried out a systematic review of the literature and developed a comprehensive search strategy based on search terms on pain and HD. We searched the databases MEDLINE, Scopus, PsycINFO, and CINAHL from the earliest date of each database to July 24, 2014. Manuscripts in all languages were taken into consideration. Two authors performed each step independently, and all disagreements were resolved after discussion with the third author. The quality of studies was estimated using the STROBE checklist and Cochrane risk-of-bias tool.ResultsWe included 52 studies with 6,917 participants. The prevalence of acute and chronic pain in HD patients was up to 82% and 92%, respectively. A considerable number of patients suffered from severe pain. Various locations and causes of pain were described, with most of the studies reporting pain in general, pain related to arteriovenous access, headache, and musculoskeletal pain.ConclusionThe findings of this systematic review indicate high prevalence of pain in HD patients and considerable gaps and limitations in the available evidence. Pain in this population should be recognized as a considerable health concern, and the nephrology community should promote pain management in HD patients as a clinical and research priority to improve patients’ quality of life and pain-related disability.

A comprehensive approach to assess the costs of renal replacement therapy for end-stage renal disease in France: the importance of age, diabetes status, and clinical events.

In the current pressured economic context, and to continue to treat the growing number of patients with high-quality standards, the first step is to have a better understanding of the costs related to end-stage renal disease (ESRD) treatment according to various renal replacement therapy, age, diabetes status, and clinical events. In order to estimate the direct costs of all adult ESRD patients, according to (RRT) modality, patient condition, and clinical events, data from the French national health insurance funds were used. The mean monthly costs for the 47,862 stable prevalent patients (73% of the population) varied substantially according to treatment modality (from 7300€ for in-center hemodialysis to 1100€ for a functioning renal graft) and to clinical event (8300€ for the first month of dialysis, 11,000€ for the last month before death, 22,800€ for the first month after renal transplantation). Mean monthly costs varied according to diabetic status and to age to a lesser extent. These results demonstrate, for the first time in France and in Europe, the importance of a dynamic view of renal care and the bias likely when comparing treatments in cross-sectional studies.

Longitudinal Changes in Body Composition in Patients After Initiation of Hemodialysis Therapy: Results From an International Cohort

In patients with advanced kidney disease, metabolic and nutritional derangements induced by uremia interact and reinforce each other in a deleterious vicious circle. Literature addressing the effect of dialysis initiation on changes in body composition (BC) is limited and contradictory. The aim of this study was to evaluate changes in BC in a large international cohort of incident hemodialysis patients. A total of 8,227 incident adult end-stage renal disease patients with BC evaluation within the initial first 6 months of baseline, defined as 6 months after renal replacement therapy initiation, were considered. BC, including fat tissue index (FTI) and lean tissue index (LTI), were evaluated by Body Composition Monitor (BCM, Fresenius Medical Care, Bad Homburg, Germany). Exclusion criteria at baseline were lack of a BCM measurement before or after baseline, body mass index (BMI) < 18.5 kg/m(2), presence of metastatic solid tumors, treatment with a catheter, and prescription of less or more than 3 treatments per week. Maximum follow-up was 2 years. Descriptive analysis was performed comparing current values with the baseline in each interval (delta analysis). Linear mixed models considering the correlation structure of the repeated measurements were used to evaluate factors associated with different trends in FTI and LTI. BMI increased about 0.6 kg/m(2) over 24 months from baseline. This was associated with increase in FTI of about 0.95 kg/m(2) and a decrease in LTI of about 0.4 kg/m(2). Female gender, diabetic status, and low baseline FTI were associated with a significant greater increase of FTI. Age > 67 years, diabetes, male gender, high baseline LTI, and low baseline FTI were associated with a significant greater decrease of LTI. With the transition to hemodialysis, end-stage renal disease patients presented with distinctive changes in BC. These were mainly associated with gender, older age, presence of diabetes, low baseline FTI, and high baseline LTI. BMI increases did not fully represent the changes in BC.

Factors Influencing Quality of Life in Adult End-Stage Renal Disease Patients Undergoing Hemodialysis.

The population of individuals with end-stage renal disease (ESRD) in Korea is increasing rapidly, yet comprehensive research on the quality of life (QOL) of this population undergoing hemodialysis is scarce. The purpose of this study was to identify the factors influencing QOL of Korean hemodialysis patients with ESRD. This study was a cross-sectional survey. Data were drawn from a convenience sample of 141 patients aged >18 years receiving maintenance hemodialysis in a general hospital. Data were collected by a self-administrated survey conducted from June 15 to July 25, 2012. The questionnaire included basic subject data, QOL, fatigue, perceived health status, and emotional status. The mean QOL score was 3.09 or "above average" as measured by the World Health Organization's (1993) Quality of Life Assessment. Significant differences were observed for basic subject data including educational level, occupation, monthly income, medical expense assistance, and family living situation. Significant negative correlations were found between QOL and fatigue and between anxiety and depression, but a significant positive correlation was found with perceived health status. The factors influencing QOL were fatigue and depression, marital status (married), and medical expense assistance (from self or parents). The results of this study indicate that, to improve the QOL in patients with ESRD, comprehensive intervention is necessary to assess and manage depression and fatigue. Social mediation is needed to enhance the QOL of patients with ESRD who lack familial and economic support, those who are single, or those who cannot afford medical expenses either by themselves or with the help of their parents.

The role of diabetes mellitus and hypertension in chronic kidney disease.

*Corresponding author: Seyed Seifollah Beladi-Mousavi, Chronic Renal Failure Research Center, Department of Internal Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Email: beladimusavi@yahoo.com With interest, we read the article by Hernandez et al. about increasing awareness of chronic kidney disease and aging (1). We agree with the authors of the article that, the diabetes mellitus and hypertension are the leading causes of chronic kidney disease (CKD). Over the last decade, different kinds of glomerulonephritis (GN) were the leading causes of CKD in the world, too. However, possibly due to lifestyle changes and increasing prevalence of obesity, diabetes and hypertension and because of more available aggressive treatment of GN, it is well established that diabetes and hypertension are now the primary causes of CKD in developed countries (2-6). However, it seems that there is an important difference between causes of end-stage renal disease (ESRD) in developed and developing countries. In contrast to the United States and other developed countries, in developing countries, the cause of ESRD among significant percent of patients is the unknown etiology possibly due to late presentation and late referral of patients with CKD to the specialists (7-12). For example, in a report from Iran, Beladi-Mousavi et al. evaluated the cause of CKD among 1000 adult ESRD patients from January 1999 to March 2010. Although according to the result of this study, diabetic nephropathy and hypertensive nephrosclerosis were the most common causes of ESRD, however in the significant number of the patients (n=242, 24.2%), the causes of ESRD were unknown (8). The results of other studies which have done in Iran, for example Haghighi et al. in 2002 (7), Malekmakan et al. in 2009 (11) and Salahi et al. in 2004 (12) were also similar. In some developing countries like Iran, the significant percent of patients with CKD are presented to the nephrologist with the severe symptoms of uremia and late stage of the disease. Unfortunately at this time, determining the primary causes of CKD is not possible. Renal biopsy is also not helpful and it cannot determine the cause of CKD at the end-stage of the disease. Regardless of the causes of CKD, histologic findings of kidney biopsy at the late stage of CKD are glomerulosclerosis, tubular atrophy and interstitial fibrosis and therefore renal biopsy is not helpful. In addition, in most of the patients with CKD, the sizes of kidneys are gradually decreased and kidney biopsy is not possible at the end stage. It is associated with increment risk and therefore kidney biopsy not recommended (13,14). In conclusion, although the diabetic nephropathy and hypertensive nephrosclerosis are also the most common Seyed Bahman Ghaderian1, Seyed Seifollah Beladi-Mousavi2’*

Associations of ECG interval prolongations with mortality among ESRD patients evaluated for renal transplantation.

It is unknown whether prolongation of electrocardiogram (ECG) intervals is associated with mortality in end-stage renal disease (ESRD) patients evaluated for renal transplantation. We examined the relationship between 12-lead ECG interval measurements (PR >200 ms, QRS >110 ms, or QTC >450 ms) and the presence of none, 1, and 2 or more ECG interval prolongations with all-cause mortality in 930 adult ESRD patients evaluated for renal transplantation from August 2006 to October 2008 and followed through November 2010. A total of 108 (11.6%) patients died after a median follow-up of 3.1 years. A stepwise increase in all-cause mortality occurred among adult ESRD patients with prolongation of 1, and 2 or more ECG intervals. In adjusted analyses, the rate of death in patients with at least 1 ECG interval prolongation was 69% higher than that of patients with no ECG prolongations (HR=1.69; 95% CI: 1.05-2.73). Patients with 2 or more ECG interval prolongations had a 2.5-fold increased likelihood of dying vs. patients with no ECG interval prolongations (HR 2.53, 95% CI 1.38-4.82). ECG interval prolongations are associated with higher mortality in patients evaluated for renal transplantation. The ECG is a potentially important evaluative tool for risk assessment in this population.

Survival Advantage of Kidney Transplantation Over Dialysis in Patients With Hepatitis C

The clinical outcomes of hepatitis C infection in kidney transplantation and maintenance dialysis patients remain controversial. Here, we conducted a systematic review and meta-analysis that aimed at comparing 5-year mortality rates between waiting list and kidney transplantation patients with hepatitis C infections. We searched Medline, EMBASE, and Scopus databases published since inception to June 2011 and found nine studies with 1734 patients who were eligible for pooling. Eligible studies were cohort studies that analyzed adult end-stage renal disease patients with hepatitis C virus infection and compared death rates between waiting list and kidney transplantation. The crude risk ratio of death along with its 95% confidence interval was estimated for each study. Data were independently extracted by two reviewers. The pooled risk ratio of death at 5 years by using a random-effect model was 2.19 (95% confidence interval, 1.50-3.20), which significantly favored the kidney transplantation when compared with the waiting list. There was evidence of heterogeneity of death rates across studies (χ(2) = 22.6; df = 8; P = 0.004). From the metaregression model, age and male gender could be the source of heterogeneity or variation of treatment effects. A major cause of death in the waiting list was cardiovascular diseases, whereas infection was a major cause in the transplant group. There was no evidence of publication bias suggested by an Egger test. This systematic review suggested that hepatitis C virus-infected patients who remain on dialysis are at higher risk of death when compared with those who received kidney transplantations.

Residual renal function in children treated with chronic peritoneal dialysis.

Residual renal function (RRF) in patients with end-stage renal disease (ESRD) receiving renal replacement therapy is defined as the ability of native kidneys to eliminate water and uremic toxins. Preserved RRF improves survival and quality of life in adult ESRD patients treated with peritoneal dialysis. In children, RRF was shown not only to help preserve adequacy of renal replacement therapy but also to accelerate growth rate, improve nutrition and blood pressure control, reduce the risk of adverse myocardial changes, facilitate treatment of anemia and calcium-phosphorus balance abnormalities, and result in reduced serum and dialysate fluid levels of advanced glycation end-products. Factors contributing to RRF loss in children treated with peritoneal dialysis include the underlying renal disease such as hemolytic-uremic syndrome and hereditary nephropathy, small urine volume, severe proteinuria at the initiation of renal replacement therapy, and hypertension. Several approaches can be suggested to decrease the rate of RRF loss in pediatric patients treated with chronic peritoneal dialysis: potentially nephrotoxic drugs (e.g., aminoglycosides), episodes of hypotension, and uncontrolled hypertension should be avoided, urinary tract infections should be treated promptly, and loop diuretics may be used to increase salt and water excretion.

Comparative clinical outcomes between pediatric and young adult dialysis patients

Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initiative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children (<18 years) and young adults (18-24 years) with prevalent end stage renal disease (ESRD), we performed a cross-sectional analysis of data collected by the Mid-Atlantic Renal Coalition, in conjunction with the 2007 and 2008 ESRD Clinical Performance Measures Projects. Data on all enrolled pediatric dialysis patients, categorized into three age groups (0-8, 9-12, 13-17 years), and on a random sample of 5% of patients ≥ 18 years in ESRD Network 5 were examined for two study periods: hemodialysis (HD) data were collected from October to December 2006 and from October to December 2007 and peritoneal dialysis (PD) data were collected from October 2006 to March 2007 and from October 2007 to March 2008. In total, 114 unique patients were enrolled the study, of whom 41.2% (47/114) were on HD and 58.8% (67/114) on PD. Compared to the pediatric patients, young adults were less likely to achieve the KDOQI recommended serum phosphorus levels and serum calcium × phosphorus product values, with less than one-quarter demonstrating values at or below each goal. Multivariate analysis revealed that both young adults and 13- to 17-year-olds were less likely to achieve target values for phosphorus [young adults: odds ratio (OR) 0.04, 95% confidence interval (95% CI) 0.01-0.19, p < 0.001; 13- to 17-year-olds: OR 0.17, 95% CI 0.04-0.77, p = 0.02] and calcium × phosphorus product (young adults: OR 0.01, 95% CI 0.002-0.09, p < 0.001; 13- to 17-year-olds: OR 0.09, 95% CI 0.02-0.56, p = 0.01) than younger children. In summary, there are significant differences in clinical indices between pediatric and young adult ESRD patients.

Vascular Access Recirculation in Hemodialysis Patients With Two Noncuffed, Single‐lumen, Jugular Catheters in the Same Jugular Vein

Having achieved excellent results with single-lumen temporary hemodialysis catheters as a long-term vascular access in our center, in this study we examined the amount of vascular access recirculation in the case of using two single-lumen catheters in a single jugular vein. In 11 adult end-stage renal disease patients on chronic hemodialysis (HD), vascular access recirculation was studied using a thermodilution technique during dialysis at our center. The vascular access in all patients consisted of two pre-curved, 15 cm-long, 8-Fr catheters inserted in the right jugular vein. Recirculation measurements were performed with the blood flow set to 250 mL/min in all patients. In five patients, additional measurements were performed with the blood flow set to 200 mL/min. During 16 HD procedures, 55 recirculation measurements were taken. The rate of recirculation was <15% in 50 measurements, between 15% and 20% in four measurements, and >20% in one measurement. The average recirculation rate during a single procedure was <15% in 10 patients, and 16.2% in one patient. We did not find any significant differences in the recirculation rates measured either at higher or lower blood flow rates. The clinical importance of vascular access recirculation was noted in a single patient. Vascular access recirculation in hemodialysis patients with two single-lumen catheters in the same jugular vein is mostly acceptable. Some measures for preventing clinically important recirculation are also suggested.

Population pharmacokinetic model for human growth hormone in adult patients in chronic dialysis compared with healthy subjects

Objective To develop a population pharmacokinetic (PK) model of recombinant human growth hormone (rhGH) treatment in patients with end-stage renal disease (ESRD) and healthy volunteers (HVs), to support future study design. Design This was an open, non-randomized, single-centre parallel-group study lasting 8–9 days. Various compartment models with first-order and Michaëlis-Menten absorption and elimination were explored. Eleven adult ESRD patients and 10 matched HVs received 50 μg/kg/day rhGH (subcutaneous (s.c.) injection) for 8 or 7 days, respectively. Blood samples were drawn every 30 min for 24 h following dosing on Days 0, 7 and 8 (ESRD patients). Influence of the covariates subject group (ESRD/HV), gender, weight, and dialysis flow-rate on model parameters was examined. Results The final model was one-compartmental with Michaëlis-Menten absorption and elimination. The following estimates were obtained: maximum absorption rate (VMA) – 11.3 μg/kg/h (both groups); amount of drug corresponding to half-maximum absorption rate (KMA) – 1.06 and 18.8 μg/kg (ESRD patients and HVs, respectively; P < 0.001); maximum elimination rate (VM) – 9.37 and 13.0 μg/kg/h (ESRD patients and HVs, respectively; P < 0.001); amount of drug corresponding to half-maximum elimination rate – 18.9 μg/kg (both groups). Significant differences in KMA and VM between HVs and ESRD patients corresponded to higher absorption and lower elimination rates in ESRD, but all GH profiles were back to baseline by 20–22 h and no overall accumulation occurred. Simplified posterior predictive checks indicated that the model satisfactorily captured PK. All non-compartmental estimates for AUC 0–24h and C max lay within 95% confidence limits of the simulated distributions. Conclusions A population PK model was established, which showed acceptable performance for trial-simulation purposes.