Clinical Outcomes In Hemodialysis Patients Research Articles

Association of Clinic Vascular Access Monitoring Practices with Clinical Outcomes in Hemodialysis Patients

Background: Early identification of access dysfunctions may be associated with improved patient outcomes. We examined whether patient outcomes were associated with vascular access monitoring practices in an incident dialysis cohort. Methods: We conducted a national prospective cohort study and analyzed 363 hemodialysis patients who had a first permanent vascular access (arteriovenous fistula or graft) by 6 months after the start of dialysis. Multivariate methods were used to examine associations between monitoring practices and 6-month Kt/V (reaching Kt/V ≧1.2), access intervention, access failure, and 2-year septicemia and all-cause hospitalization and mortality. Results: Patients who received monitoring weekly or more often (49%) were more likely to have an access intervention (adjusted RH = 1.40, 95% CI, 1.07–1.84) than those who received monitoring less frequently. Additionally, patients treated at clinics that reported performing regular access monitoring (80% of patients) were less likely to be hospitalized for septicemia (IRR = 0.35, 95% CI, 0.21–0.61) or for any cause (IRR = 0.77, 95% CI, 0.60–0.99). There were no statistically significant differences between patients exposed to different vascular access monitoring practices in access failure, achievement of Kt/V, or survival. Conclusion: Frequent monitoring of dialysis access may initially increase the number of interventions but is beneficial to longer-term outcomes, including septicemia-related and all-cause hospitalization.

Association of aminothiols with the clinical outcome in hemodialysis patients: comparison of chromatography and immunoassay for homocysteine determination

Controversial results on hyperhomocysteinemia and cardiovascular risk in hemodialysis (HD) could be due in part to the methodology used for homocysteine (Hcy) determination. The aim of this study was to compare the influence of the method used for Hcy determination (chromatography or immunoassay) with regard to the association of Hcy with cardiovascular mortality rate in HD patients in a 3-year prospective study. A total of 162 patients undergoing HD were included in a cohort study. Baseline Hcy levels were measured by HPLC and fluorescence polarization immunoassay (FPIA). Cysteine and cysteinylglycine were determined simultaneously with Hcy measurement by HPLC. Hcy levels obtained with both methods were highly correlated (r(2)=0.927, p<0.0001). An increased relative risk (RR) for cardiovascular mortality (n=31) was found between the highest against lowest tertile of Hcy for both HPLC (RR 2.74, 95% CI 1.07-7.02; p<0.05) and FPIA (RR 2.76, 95% CI 0.99-7.70; p=0.05). Interestingly, increased cysteine (> or =452 micromol/L) and cysteinylglycine (> or =36.6 micromol/L) levels were associated with a decreased RR of non-cardiovascular death (n=26) (RR 0.27, 95% CI 0.09-0.79; p=0.02) for cysteine and (RR 0.28, 95% CI 0.09-0.90; p=0.03) for cysteinylglycine when compared to the first tertile. This study demonstrated an increased risk of cardiovascular mortality in HD patients with Hcy values in the third tertile, independent of the method used. HPLC offers the advantage of simultaneous determination of other aminothiols that appear to be associated with non-cardiovascular mortality.

Hemodialysis Complications

Hemodialysis Complications

Appetite and inflammation, nutrition, anemia, and clinical outcome in hemodialysis patients

Malnutrition-inflammation complex syndrome, an outcome predictor in maintenance hemodialysis (MHD) patients, may be related to anorexia. We examined whether subjectively reported appetite is associated with adverse conditions and increased morbidity and mortality in MHD patients. A cohort of 331 MHD outpatients was asked to rate their recent appetite status on a scale from 1 to 4 (very good, good, fair, and poor appetite, respectively). Anemia indexes and nutritional and inflammatory markers-including serum concentrations of C-reactive protein, tumor necrosis factor alpha, and interleukin 6-were measured. The malnutrition-inflammation score was used to evaluate the malnutrition-inflammation complex syndrome, and the SF36 questionnaire was used to assess quality of life (QoL). Mortality and hospitalization were followed prospectively for up to 12 mo. Patients were aged 54.5 +/- 14.4 y. Diminished appetite (fair to poor) was reported by 124 patients (38%). Hemoglobin, protein intake, and QoL scores were progressively lower, whereas markers of inflammation, malnutrition-inflammation scores, and the required erythropoietin dose were higher across the worsening categories of appetite. The adjusted odds ratios of diminished versus normal appetite for increased serum tumor necrosis factor alpha and C-reactive protein concentrations were significant. Significant associations between a poor appetite and an increased rate of hospitalization and mortality were observed. The hazard ratio of death for diminished appetite was 4.74 (95% CI: 1.85, 12.16; P = 0.001). Diminished appetite (anorexia) is associated with higher concentrations of proinflammatory cytokines and higher levels of erythropoietin hyporesponsiveness and poor clinical outcome, including a 4-fold increase in mortality, greater hospitalization rates, and a poor QoL in MHD patients. Appetite status may yield significant insight into the clinical status of dialysis patients.

Daytime sleepiness in stable hemodialysis patients

Background: Patients frequently sleep during hemodialysis (HD), a behavior often attributed to treatment-related fatigue and/or simple boredom. The possibility that this behavior reflects a more pervasive underlying increase in daytime sleepiness has never been systematically examined. Thus, we studied a sample of HD patients on an off-dialysis day to establish the presence or absence of daytime sleepiness independent of effects of treatment, quantify its severity, and identify associated demographic, metabolic, and sleep-related variables. Methods: Forty-six stable HD patients underwent polysomnography, followed the next day (a nondialysis day) by the Multiple Sleep Latency Test (MSLT; low score = greater sleepiness), a measure of physiological daytime sleepiness. Subjects also completed the Epworth Sleepiness Scale (ESS; high score = greater sleepiness), a measure of subjective daytime sleepiness. Results: One third (n = 15) of subjects had MSLT scores suggesting abnormal levels of physiological daytime sleepiness, and six subjects had scores consistent with severe, pathological sleepiness. Thirty percent (n = 14) had significant subjective daytime sleepiness as measured by the ESS. However, MSLT and ESS scores were unrelated. Higher indices of sleep apnea (r = −0.324; P = 0.028) and brief arousals (r = −0.370; P = 0.009) correlated significantly with increased physiological, but not subjective, sleepiness. Longer nocturnal sleep latencies (r = 0.350; P = 0.017) and greater percentage of rapid-eye-movement sleep (r = 0.302; P = 0.042) were associated with decreased physiological sleepiness. Other major demographic, metabolic, and sleep-related variables did not correlate with MSLT scores, and none of the variables examined were related to ESS scores. Conclusion: Daytime sleepiness is common in HD patients and may be severe despite the absence of obvious clinical risk factors for the condition. Thus, research designed to identify cost-effective indicators of daytime sleepiness and evaluate the detrimental effects of sleepiness on clinical outcomes in HD patients is warranted. Am J Kidney Dis 41:394-402.

Iron administration and clinical outcomes in hemodialysis patients.

To evaluate the impact of parenteral iron administration on the survival and rate of hospitalization of US hemodialysis patients, a nonconcurrent cohort study of 10,169 hemodialysis patients in the United States in 1994 was conducted. The main outcome measures were patient survival and rate of hospitalization. After adjusting for 23 demographic and comorbidity characteristics among 5833 patients included in multivariable analysis, bills for <or=10 vials of iron over 6 mo showed no adverse effect on survival (adjusted relative risk [RR] = 0.93; 95% confidence interval [CI], 0.84 to 1.02; P = 0.14) when compared with none, but bills for >10 vials showed a statistically significant elevated rate of death (adjusted RR = 1.11; 95% CI, 1.00 to 1.24; P = 0.05). Bills for <or=10 vials of iron over 6 mo also showed no significant association with hospitalization (adjusted RR = 0.92; 95% CI, 0.83 to 1.03; P = 0.15), but bills for >10 vials showed statistically significant elevated risk (adjusted RR = 1.12; 95% CI, 1.01 to 1.25; P = 0.03). Prescribing iron in quantities of <or=10 vials over 6 mo had no association with an elevated risk of death or rate of hospitalization. More intensive dosing was associated with diminished survival and higher rates of hospitalization, even after extensive adjustment for baseline comorbidity. Although these potential risks may be offset by the known elevations in morbidity and mortality associated with anemia, these findings indicate that caution is warranted when prescribing >10 vials (1000 mg) of iron dextran over a period of 6 mo.