Dialysis-dependent End-stage Renal Disease Patients Research Articles

Incident dementia in kidney transplantation recipients: a matched comparative nationwide cohort study in South Korea.

Recent studies have shown that patients with end-stage renal disease (ESRD) are at elevated risk of dementia. However, whether kidney transplantation (KT) lowers the risk for incident dementia remains unclear. From the Korean National Health Insurance Service database, we identified incident KT recipients aged ≥40 years without any history of dementia between 2007 and 2015. We also established a pair of age-, sex-, and inclusion year-matched control cohorts of patients with incident dialysis-dependent ESRD and members of the general population (GP) without a history of dementia, respectively. Cases of incident all-cause dementia, including Alzheimer disease (AD), vascular dementia (VD), and other kinds of dementia, were obtained from baseline until December 31, 2017. We followed 8,841 KT recipients, dialysis-dependent ESRD patients, and GP individuals for 48,371, 28,649, and 49,149 patient- years, respectively. Their mean age was 52.5 years, and 60.6% were male. Over the observation period, 55/43/19 KT recipients, 230/188/75 dialysis-dependent ESRD patients, and 38/32/14 GP individuals developed all-cause dementia/AD/VD. The risks of incident all-cause dementia, AD, and VD in KT recipients were similar to those in GP (hazard ratio: 0.74 [p = 0.20], 0.74 [p = 0.24], and 0.59 [p = 0.18], respectively) and significantly lower than those in dialysis-dependent ESRD patients (hazard ratio: 0.17 [p < 0.001], 0.16 [p < 0.001], and 0.16 [p < 0.001], respectively). Older age and diabetes mellitus at the time of KT were risk factors for incident all-cause dementia and AD in KT recipients. This is the first study to show a beneficial impact of KT on incident dementia compared to dialysis dependency.

Clinical outcomes after coronary artery bypass grafting in patients with dialysis-dependent end-stage renal disease and an analysis of the related influencing factors

Perioperative and short/mid-term survival rates of dialysis-dependent patients with end-stage renal disease (ESRD), who undergo coronary artery bypass grafting (CABG), and the factors influencing mortality are not well evaluated In China. We retrospectively analyzed the perioperative and postoperative 1-, 3-, and 5-year survival rates of 53 dialysis-dependent ESRD patients who underwent CABG, and compared the factors related to perioperative mortality and all-cause mortality during the postoperative follow-up. Survival rates were expressed as Kaplan–Meier survival curves, and factors influencing the follow-up survival rates were analyzed using the log rank (Mantel–Cox) test. There were eight perioperative deaths, resulting in 15.1% mortality. Intraoperative intra-aortic balloon pump use (P = 0.01), advanced age (P = 0.0027), and high EuroSCORE II score (P = 0.047) were associated with increased perioperative mortality. Forty-five discharged patients were followed from 2 months to 10 years (median, 4.2 years) postoperatively. There were 19 all-cause deaths, including 10 cardiac deaths (10/19, 52.6%). Comparisons between groups indicated that the presence of peripheral artery disease (PAD) increased mortality during follow-up (P = 0.025); 1-, 3-, and 5-year survival rates were 93.3, 79.5, and 66.8%, respectively. The results of the long-rank analysis indicated that the presence of PAD was a risk factor for postoperative survival (log rank χ2 = 4.543; P = 0.033). Dialysis-dependent patients with ESRD had high perioperative mortality and unsatisfactory short- and medium-term survival after CABG. PAD was a risk factor affecting patients’ postoperative survival. Multidisciplinary teamwork is needed to enhance postoperative management and reduce complications, to improve postoperative survival in these patients.

Transcatheter Aortic Valve Replacement Outcomes in End-Stage Renal Disease Patients on Hemodialysis Requiring Midodrine

BackgroundPatients with dialysis-dependent end-stage renal disease (ESRD) taking midodrine may be at high risk for poor outcomes following transcatheter aortic valve replacement (TAVR). We evaluated dialysis-dependent ESRD patients taking midodrine. MethodsWe conducted a retrospective analysis of non-clinical trial TAVR patients from February 2012 to December 2020 from 11 facilities in a Western US health system. Patient groups included ESRD patients on midodrine before TAVR (ESRD [+M]), ESRD patients without midodrine (ESRD [−M]), and non-ESRD patients. The endpoints of 30-day and 1-year mortality were represented by Kaplan–Meier survival estimator and compared by log-rank test. ResultsForty-five ESRD (+M), 216 ESRD (−M), and 6898 non-ESRD patients were included. ESRD patients had more comorbid conditions, despite no significant difference in predicted Society of Thoracic Surgeons mortality risk between ESRD (+M) and ESRD (−M) (8.7% vs. 9.2%, p = 0.491). Thirty-day mortality was significantly higher for ESRD (+M) patients vs. ESRD (−M) patients (20.1% vs. 5.6%, p = 0.001) and for ESRD (+M) vs. non-ESRD patients (2.5%, p < 0.001). One-year mortality trended higher for ESRD (+M) vs. ESRD (−M) patients (41.9% vs. 29.8%, p = 0.07), and was significantly higher for ESRD (+M) vs. non-ESRD patients (10.7%, p < 0.001). Compared to ESRD (−M), ESRD (+M) patients had a higher incidence of 30-day stroke (6.7% vs. 1.4%, p = 0.033), 30-day vascular complications (6.7% vs. 0.9%, p = 0.011), and a lower rate of discharge to home (62.2% vs. 84.7%, p < 0.001). In contrast, ESRD (−M) patients had no significant differences from non-ESRD patients for these outcomes. ConclusionsOur experience suggests ESRD patients on midodrine are a higher acuity population with worse survival after TAVR, compared to ESRD patients not on midodrine. These findings may help with risk stratification for ESRD patients undergoing TAVR.

Safety and Tolerability of Remdesivir in Patients with End-stage Renal Disease on Maintenance Hemodialysis.

IntroductionThe use of remdesivir is not recommended in patients with end-stage renal disease (ESRD) with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection unless potential advantage offset disadvantage due to limited safety data. Our objective was to assess the safety of remdesivir in patients with end-stage renal failure and evaluate the outcome of this vulnerable group.MethodologyWe carried out a retrospective observational study in dialysis-dependent ESRD patients with SARS-CoV-2 infection who received a standard 5-day course of remdesivir (powder form) from June 2020 to December 2020. Oxygen requirement, hemogram, inflammatory markers, and liver function tests before and after remdesivir treatment were compared.ResultWe found thirty-nine such patients with mean age of patients 58.79 ± 12.13 years. Diabetes mellitus, hypertension, and cardiac diseases were present in 58.97, 87.17, and 23.07% of patients, respectively. Mean oxygen saturation on admission was 85.41% (±7.73). There were no events of hepatotoxicity, altered behavior, or infusion reaction. There was statistically significant improvement in total leukocyte count, absolute lymphocyte counts, and C-reactive protein (p value <0.001, 0.01, and 0.02, respectively) post remdesivir treatment. A total of 60% of patients had improved oxygenation while 13% of patients had no change in oxygen requirement after completion of remdesivir course. Mortality in our study was 28.21%. We did not find any significant benefit of early remdesivir administration (3–6 days of illness) on mortality or days of hospitalization.ConclusionThe use of remdesivir in end-stage kidney disease is safe. Improvement in oxygenation was significant when baseline oxygen requirement was less. It requires prospective controlled trials with larger population to assess its impact on mortality.How to cite this articleShah MK, Parikh M, Prajapati D, Kute VB, Bhende P, Prajapati A, et al. Safety and Tolerability of Remdesivir in Patients with End-stage Renal Disease on Maintenance Hemodialysis. Indian J Crit Care Med 2022;26(5):619–625.

Outcomes of cardiac surgery in patients with end-stage renal disease: Insights from the Israel national registries.

End-stage renal disease (ESRD) has been shown to be associated with increased mortality in patients undergoing cardiac surgery. We aimed to compare the short- and mid-term mortality after cardiac surgery of patients with dialysis-dependent ESRD (DD-ESRD) to patients with normal renal function (NRF), using national registries: the ESRD registry, the adult cardiac surgery registry (ACSR), and the National Mortality Registry. The study population comprised 8207 adult patients who underwent either isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement (MVR), or CABG + valve-related procedure, between January 2017 and April 2019. Data were retrospectively extracted and reported to the ACSR by the department of medical records of each medical center. One hundred and four DD-ESRD patients (mean age 63.2 ± 8.8 years, 83.7% males) were compared with 8103 NRF patients (mean age 64.9 ± 9.8 years, 77.6% males). Median follow-up for the total cohort was of 32.0 months (IQR; 25.0, 40.0). In DD-ESRD compared to NRF patients, 30-day mortality was higher (14.4% vs. 2.3%, respectively, p = 0.0001) and 4-year survival was significantly lower (44% ± 0.06 vs. 91% ± 0.04, respectively, p = 0.0001). Fifty-three percent of DD-ESRD 30-day mortality was caused by sepsis. Risk factors associated with reduced midterm survival included: DD-ESRD patients (HR = 4.7, 95% CI; 1.2-18.2), MVR procedure (HR = 1.5, 95% CI; 1.04-2.1) and combined CABG + valve-related procedure (HR = 1.6, 95% CI; 1.2-2.04). Preoperative DD-ESRD was associated with a significant increase in 30-day and mid-term mortality after cardiac surgery. The highest mortality rate was observed in valvular and combined procedures.

Elevation of Highly Sensitive Cardiac Troponin T Among End-Stage Renal Disease Patients Without Acute Coronary Syndrome.

BackgroundIn end-stage renal disease (ESRD), troponin T concentrations can be elevated even without cardiac ischaemia, which hampers the diagnosis of acute myocardial infarction (AMI). The objectives of our study were to determine the proportion of dialysisdependent ESRD patients without acute coronary syndrome (ACS) but with highly sensitive cardiac troponin T (hs-cTnT) levels above the 99th percentile upper reference limit and to evaluate the range of hs-cTnT among this population.MethodsA cross-sectional study was conducted at the haemodialysis (HD) unit of a tertiary hospital in Malaysia from January 2018 to February 2019. Dialysis-dependent ESRD patients were included and those with a recent history of ACS (within 30 days) were excluded. Pre-dialysed serum hs-cTnT levels were measured using Cobas e411. The upper limit of the 99th percentile value for troponin T was 14 ng/L.ResultsA total of 150 patients were recruited as study participants. The majority were female (62%) and of Malay ethnicity (94%), and the mean (SD) age was 45.19 (16.36) years old. The hs-cTnT range (min, max) was 11.39–738.30 ng/L and the median (interquartile range [IQR]) of hs-cTnT was 59.20 (83.41) ng/L. Elevated hs-cTnT levels were observed in 149/150 (99%) of the study participants (54/55 [98.2%] of the patients were on HD, and 95/95 [100.0%] of the patients were on continuous ambulatory peritoneal dialysis).ConclusionThis study supports prior research showing that even without ACS, most ESRD patients have elevated concentrations of cardiac troponin. Furthermore, our study illustrates the need to revisit the use of absolute troponin values when making a diagnosis of ACS in ESRD patients.

Evaluation of the relationship between blood cell parameters and vascular calcification in dialysis-dependent end-stage renal disease patients.

Coronary artery calcification is an acceptable tool for cardiovascular risk assessment in end-stage renal disease (ESRD) population. We aimed to identify the association and predictive value of components of blood cell parameters with coronary and thoracic aorta vascular calcification (VC) in ESRD population on dialysis. All ESRD patients receiving hemodialysis or peritoneal dialysis aged between 18 and 60 years were included in the study. Exclusion criteria comprised patients with active infection or inflammatory disease, autoimmune disease, congestive heart failure, angina pectoris and/or documented coronary artery disease, thyroid disease, and hepatic dysfunction. Agatston scoring was used for the evaluation of coronary aorta calcification (CAC) score (CACS) and thoracic aorta calcification (TAC) score (TACS). Compared to participants with no VC, those who had VC were statistically significantly older (P <0.001) and had higher neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) (P = 0.02 and <0.001, respectively). On multivariate logistic regression analysis, increasing age (P = 0.00) and higher PLR (P = 0.04) were associated with an increased likelihood of exhibiting VC (CAC or TAC). There was a positive correlation between CACS and age (rs = 0.495, P = 0.00). A statistically significant positive correlation existed between TACS and age (rs = 0.516, P = 0.00). Similarly, a positive correlation was found between NLR, PLR, and TACS (rs = 0.334, P = 0.001, and rs = 0.438, P = 0.00, respectively). On multivariate linear regression analysis, increased age and red cell distribution width were found to be significant predictors of log(n) TACS. PLR of 135 gave a sensitivity of 80% and a specificity of 50% for predicting VC. Being a cost-effective and easily available investigation, the utilization of the correlation of NLR and PLR with CAC and TAC appears promising, particularly in the age group of 30-60 years.

Contributors, risk associates, and complications of frailty in patients with chronic kidney disease: a scoping review.

Frailty exhibits diverse influences on health-related outcomes and represents a surrogate of increased susceptibility to harmful injuries. Patients with chronic kidney disease (CKD) are at a higher risk of accelerated biologic aging, and, in this population, the concept of frailty emerges as an instrumental measurement of physiologic reserves. However, a comprehensive description of known independent contributors to, and risk associates of, frailty in these patients remain unavailable. In the present review, original studies up to 28 February 2019 that assessed frailty in patients with all stages of CKD were retrieved and reviewed, with results extracted and summarized. By pooling 62 original investigations, 58.1% and 49.1% used cohort and cross-sectional designs, respectively. Dialysis-dependent end-stage renal disease patients (n = 39; 62.9%) were the most commonly examined population, followed by those with nondialysis CKD (n = 12; 19.4%) and those receiving renal transplantation (n = 11; 17.7%). Contributors to frailty in CKD patients included sociodemographic factors, smoking, CKD severity, organ-specific comorbidities, depression, hypoalbuminemia, and low testosterone levels. Conversely, the development of frailty was potentially associated with the emergence of cardiometabolic, musculoskeletal, and cerebral complications; mental distress; and a higher risk of subsequent functional and quality-of-life impairment. Moreover, frailty in CKD patients increased healthcare utilization and consistently elevated mortality among affected ones. Based on the multitude of contributors to frailty and its diverse health influences, a multifaceted approach to manage CKD patients with frailty is needed, and its potential influences on outcomes besides mortality need to be considered.

Beneficial effect of statins in patients receiving chronic hemodialysis following percutaneous coronary intervention: A nationwide retrospective cohort study

The cardiovascular diseases are the leading cause of mortality in end-stage renal disease (ESRD) patients. However, roles of statins are still controversial in dialysis-dependent ESRD patients regardless of having proven coronary artery occlusive disease. The aim of this study was to examine the benefit of statin following percutaneous coronary intervention (PCI) in ESRD patients who have proven coronary artery occlusive disease. This study was based on the National Health Insurance Service-National Sample Cohort in South Korea. We included 150 ESRD patients on chronic hemodialysis who underwent PCI with stenting between 2002 and 2013. The primary outcome was a composite of myocardial infarction, stroke, and all-cause mortality. Multivariate time-dependent Cox regression analysis were performed, and statin therapy after PCI was treated as a time-dependent variable. During 3.15 ± 2.71 (mean ± standard deviation) years of follow-up, there were 82 patients with primary outcome. The adjusted hazard ratio for statin use was 0.54 [0.33–0.90] compared to no statin use. This study showed that statin has significant benefit on reducing adverse events risk in dialysis-dependent ESRD patients after PCI.

Outcomes of basilic vein transposition at 1 year of follow-up

Background: In dialysis-dependent end-stage renal disease patients, arteriovenous access (AV access) is the chief mode of hemodialysis access. Basilic vein transposition (BVT) is an alternative in patient with failed multiple AV access. The aim of the study is to assess the outcomes of BVT at 1 year of follow-up. Materials and Methods: This prospective, nonrandomized, observational study was conducted in the Department of Vascular Surgery at Sir Ganga Ram Hospital, New Delhi. Forty consenting patients with end-stage renal failure on maintenance hemodialysis having no other options utilizing superficial veins of the upper limb for AV access formation were included. All the complications, secondary interventions and patency rates were calculated at 1 year of follow-up. Statistical analysis was performed using Chi-square test, and patency rates were assessed using Kaplan–Meier survival curve. Results: Most of the patients were in the age group of 51–70 year with the mean age of 51.98 year. The mean basilic vein diameter was 2.84 mm. Fistula thrombosis was the most common complication and was seen in 17.5% cases followed by limb edema in 13% of cases. Re-interventions (fistula thrombectomy, balloon angioplasty etc.) were performed in 27.5% of the patients. The primary patency rate and secondary patency rate at 1 year of follow-up were 77.5% and 85%, respectively. Conclusions: BVT is a feasible and suitable surgical option to provide a durable and autogenous AV access to end-stage renal disease patients requiring maintenance hemodialysis.

Clinical Factors and Outcomes of Dialysis-Dependent End-Stage Renal Disease Patients with Emergency Department Septic Shock

BackgroundInfection is the second leading cause of death in end-stage renal disease (ESRD) patients. Prior investigations of acute septic shock in this specific population are limited. ObjectiveWe aimed to evaluate the clinical presentation and factors associated with outcome among ESRD patients with acute septic shock. MethodsWe reviewed patients prospectively enrolled in an emergency department (ED) septic shock treatment pathway registry between January 2014 and May 2016. Clinical and treatment variables for ESRD patients were compared with non-ESRD patients. A second analysis focused on ESRD septic shock survivors and nonsurvivors. ResultsAmong 4126 registry enrollees, 3564 (86.4%) met inclusion for the study. End-stage renal disease was present in 3.8% (n = 137) of ED septic shock patients. Hospital mortality was 20.4% and 17.1% for the ESRD and non-ESRD septic shock patient groups (p = 0.31). Septic shock patients with ESRD had a higher burden of chronic illness, but similar admission clinical profiles to non-ESRD patients. End-stage renal disease status was independently associated with lower fluid resuscitation dose, even when controlling for severity of illness. Age and admission lactate were independently associated with mortality in ESRD septic shock patients. ConclusionESRD patients comprise a small but important portion of patients with ED septic shock. Although presentation clinical profiles are similar to patients without ESRD, ESRD status is independently associated with lower fluid dose and compliance with the 30-mL/kg fluid goal. Hyperlactatemia is a marker of mortality in ESRD septic shock.

Levosimendan Use Increases Cardiac Performance after Coronary Artery Bypass Grafting in End-Stage Renal Disease Patients.

The effect of levosimendan on myocardial performance has not been studied in dialysis-dependent end-stage renal disease patients who have undergone coronary artery bypass grafting (CABG) surgery. Our aim was to investigate the effect of levosimendan on postoperative hemodynamic effects in end-stage renal disease patients undergoing CABG operation. We performed 58 elective isolated CABG operations in end-stage renal disease patients. The study group received levosimendan at a slow bolus dose of 3 µg/kg, followed by a 24-hour infusion of 0.03-0.05 µg/kg/kg/min. (study group [SG]: n = 25). The remaining patients received a placebo (control group [CG]: n = 33). The mean left ventricular ejection fraction of both groups was similar (44.6 ± 55.4% versus 42.8 ± 53.9%). Hemodynamic data were collected at the end, at 1 hour after CPB, and thereafter at 6, 12, and 24 hours in the ICU. Preoperatively, at the end of the operation, at 1 hour after CPB, and thereafter at 6, 12, and 24 hours in the ICU, blood samples from the peripheral vein were collected for cardiac troponin-I (c-TnI) and lactate levels. Norepinephrine if needed started during the rewarming period in both groups. One patient in SG (4%) and 4 patients (12.1%) in CG died postoperatively (P &lt; .01). Cardiac output and cardiac index values did not change early after weaning from extracorporeal circulation, and they were nearly similar during the next 6 hours in both groups. In SG, cardiac output and cardiac index significantly improved at 6 hours, and were stable at the end of 24 hours (P &lt; .001). Hemodynamic parameters were nearly similar after the operation, and did not change significantly at the end of 24 hours in CG. Hemodynamic improvement caused a significant reduction in systemic and pulmonary artery vascular resistance index in SG (P &lt; .002). Pulmonary capillary wedge pressure decreased significantly in SG (P &lt; .034). Cumulative inotrope dose requirement and intraaortic balloon pump use were significantly lower in SG. In addition, blood lactate and cTnI levels were significanly lower in SG (P &lt; .044). No important adverse effect was detected during levosimendan infusion. Because levosimendan at a dose of 0.03-0.05 μg/kg/min increased myocardial performance significantly in the postoperative period, it can be used safely in end-stage renal disease patients undergoing isolated CABG. The requirement of vasopressors were lower in SG.

Comments on O’Brien et al.: Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients

Dear Editor, We read with interest the article by O’Brien et al. [1] on the prevalence and outcome of patients with cirrhosis admitted to British ICUs. While the authors raise important points regarding the high mortality of decompensated cirrhosis and the increasing burden placed on critical care services by such patients, we feel their interpretation should not go unchallenged as there are several major limitations to the analysis that mitigate their bold and nihilistic conclusions. Firstly, as the authors themselves partly acknowledge, chronic renal failure is clearly not the same as hepatic failure. The outcome for patients with dialysis dependent endstage renal disease (ESRD) admitted to the ICU is surprisingly good, is better than that of patients admitted with acute kidney injury and has frequently been reported to be little different from that of the general ICU population [2]. In addition, a treatment does exist that directly addresses the underlying organ failure in ESRD, but no such equivalent is available for hepatic failure. We do not believe therefore that the authors’ argument that the two conditions are comparable for the sake of their analysis can be in anyway justified. The second shortcoming of the paper relates to its use of the Intensive Care National Audit & Research Centre (ICNARC) database. This brings with it several major problems in terms of data availability. The ICNARC and Acute Physiology and Chronic Health Evaluation II (APACHE II) models do not collect parameters that quantify either the presence or severity of liver disease. This limits the utility of these models to predict outcome in patients with liver disease, likely explaining why the ICNARC and APACHE II scores were higher for dialysis-dependent ESRD patients compared with patients with cirrhosis and significantly under-predicting mortality for this latter group. In contrast, evidence does exist that the Sequential Organ Failure Assessment (SOFA) score (which includes bilirubin as one of its parameters) performs better than APACHE II score in predicting outcome in patients with cirrhosis admitted to the ICU [3]. A further weakness of the article is the inability to identify the specific reason for ICU admission. For example, variceal bleeding is the commonest reason for ICU admission in many series [3], and ICU mortality has been demonstrated to have fallen threefold between 1980 and 2000 [4]. However, there is no way to interpret the authors’ data in the absence of specific admission data. It is undeniable that mortality in patients with cirrhosis who develop multiple organ failure is high and that the development of sepsis is a grave prognostic sign, but we would challenge the assertion that we should seek to identify earlier those patients with a poor prognosis so we can exclude them from critical care. Rather, our focus should be to more rapidly identify sepsis and organ dysfunction and admit such patients earlier to critical care units to prevent further deterioration in organ function with its associated increase in mortality risk. Such an approach, which is in direct contrast to the prognostic pessimism proposed by the authors, may then begin to deliver the improvement in outcome seen in severe sepsis in recent years [5] and produce further increases in survival in patients with cirrhosis above the 5 % reduction in mortality over time that the authors report.

Improved Long-Term Survival of Dialysis Patients after Near-Total Parathyroidectomy

Severe secondary hyperparathyroidism, which is associated with life-threatening complications, can develop in dialysis-dependent end-stage renal disease patients. The aim of this study was to compare short- and long-term mortality in dialysis patients who underwent near-total parathyroidectomy (NTPTX) and matched nonoperated controls. We identified 150 dialysis patients who underwent NTPTX (1993-2009) at our institution and compared them with 1,044 nonoperated control patients identified in the US Renal Data System registry, matched for age, sex, race, diabetes as cause of kidney failure, years on dialysis, and dialysis modality. Survival outcomes were estimated using multivariable Cox proportional hazards models with stratification on the matching sets, adjusted for cardiovascular comorbidities, smoking, inability to ambulate/transfer, and payor status. During a follow-up of a mean of 3.6 years (range 0.1 month to 16.4 years), NTPTX patients had a significant reduction in the long-term risk of all-cause death (hazard ratio = 0.68; 95% CI, 0.52-0.89; p = 0.006) compared with controls. Thirty-day mortality rates for NTPTX patients and controls were 246 vs 105 per 1,000 person-years (p = 0.21). In adjusted analyses, NTPTX patients had a 37% reduced risk of all-cause death and a 33% reduced risk of cardiovascular death compared with controls. A durable reduction in mean parathyroid hormone was observed after NTPTX; from 1,776 ± 1,416.6 pg/mL to 301 ± 285.7 pg/mL (p < 0.0001). In our center, NTPTX in dialysis patients was associated with a significant reduction in long-term risk of death compared with matched control patients, without a significantly increased short-term risk.

Perioperative Outcomes of Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma in Patients With Dialysis‐Dependent End‐Stage Renal Disease

The aims of this study were: (i) to analyze the perioperative outcomes of laparoscopic radical nephrectomy for renal cell carcinoma in patients with dialysis-dependent end-stage renal disease and (ii) to reveal perioperative management problems that are unique to these patients. Between June 2004 and June 2011, laparoscopic radical nephrectomy was performed in 39 patients who had renal cell carcinoma and dialysis-dependent end-stage renal disease. The operative outcomes of these patients were compared with the operative outcomes of 104 non-end-stage renal disease patients with sporadic renal cell carcinoma who underwent laparoscopic radical nephrectomy during the same period. Laparoscopic surgery was completed in thirty-eight end-stage renal disease patients. One patient was converted to open surgery because of an intraoperative injury to the inferior vena cava. This patient was excluded from the analysis. The mean operative time was 240 min; blood loss, 157 mL; and postoperative hospital stay, 9.6 days. Postoperative complications were observed in six patients, as follows: retroperitoneal hematoma and abscess in one patient, thrombosis of the arteriovenous fistula in three patients, pneumonia in one patient, and gastrointestinal bleeding in one patient. Eleven patients required blood transfusions. There was no significant difference between the end-stage renal disease patients and the non-end-stage renal disease patients in the mean operative time or the amount of blood loss. In conclusion, laparoscopic radical nephrectomy is feasible for dialysis-dependent end-stage renal disease patients, as well as for non-end-stage renal disease patients; however, end-stage renal disease patients may have a higher probability of experiencing non-life-threatening complications.

EVALUATION OF INTERNAL JUGULAR VEIN THROMBOSIS IN DIALYSIS PATIENTS WITH LARGE TUNNELED CATHETERS.

Purpose To evaluate the prevalence of internal jugular vein thrombosis in patients with large diameter (16 French) tunneled dialysis catheters to determine if the larger diameter catheters are associated with increased thrombosis rates. Methods and Materials A retrospective chart review of dialysis-dependent end-stage renal disease patients at the Memphis VAMC was performed to identify patients who had received tunneled internal jugular catheters for hemodialysis. Since 2002, large-diameter, 16 French Ash-Split catheters have been primarily used. Eligible patients were those with 16 French catheters placed from January 1, 2002, to October 1, 2006. A total of 60 patients were identified. Additional information obtained from patient records included catheter site placement, number of catheters placed in each site, history of hypertension, history of diabetes mellitus, and number of catheter-related infections. Results All of the 60 patients were men. A diagnosis of hypertension was present in 85% (51 of 60) and diabetes mellitus was present in 35% (21 of 60). These percentages are similar to the overall prevalence of hypertension and diabetes mellitus seen in ESRD patients at this center. In 7 of the 60 patients in the study, bilateral internal jugular veins were used for tunneled catheter placement; thus, the total number of access sites was 67. Thrombosis was present in 16.4% (11 of 67) of the total number of catheter access sites. Of the total number of thromboses present, 63.6% (7 of 11) were in the right internal jugular vein and 36.4% (4 of 11) in the left internal jugular vein. Also, of the 11 thromboses present, 82% (9 of 11) of the occlusions were associated with catheter-related infections. Conclusion Previous studies have reported the prevalence of internal jugular thrombosis in patients with standard dialysis catheters (14.5 French) to be around 10 to 25%. The prevalence of thrombosis demonstrated in this study shows no increased rate of thrombosis with larger catheters. There was an extremely high frequency of catheter-related infections in patients with thrombosis.

Elevated Fasting Total Plasma Homocysteine Levels and Cardiovascular Disease Outcomes in Maintenance Dialysis Patients

There is an excess prevalence of hyperhomocysteinemia in dialysis-dependent end-stage renal disease (ESRD) patients. Cross-sectional studies of the relationship between elevated total homocysteine (tHcy) levels and prevalent cardiovascular disease (CVD) in this patient population suffer from severe methodologic limitations. No prospective investigations examining the association between tHcy levels and the subsequent development of arteriosclerotic CVD outcomes among maintenance dialysis patients have been reported. To assess whether elevated plasma tHcy is an independent risk factor for incident CVD in dialysis-dependent ESRD patients, we studied 73 maintenance peritoneal dialysis or hemodialysis patients who received a baseline examination between March and December 1994, with follow-up through April 1, 1996. We determined the incidence of nonfatal and fatal CVD events, which included all validated coronary heart disease, cerebrovascular disease, and abdominal aortic/lower-extremity arterial disease outcomes. After a median follow-up of 17.0 months, 16 individuals experienced at least one arteriosclerotic CVD event. Cox proportional-hazards regression analyses, unadjusted and individually adjusted for creatinine, albumin, and total cholesterol levels, total/HDL cholesterol ratio, dialysis adequacy/residual renal function, baseline CVD, and the established CVD risk factors (ie, age, sex, smoking, hypertension, diabetes/glucose intolerance, and dyslipidemia) revealed that tHcy levels in the upper quartile (> or = 27.0 mumol/L) versus the lower three quartiles (< 27.0 mumol/L) were associated with relative risk estimates (hazards ratios, with 95% confidence intervals for the occurrence of (pooled) nonfatal and fatal CVD ranging from 3.0 to 4.4; 95% confidence intervals (1.1-8.1) to (1.6-12.2). We conclude that the markedly elevated fasting tHcy levels found in dialysis-dependent ESRD patients may contribute independently to their excess incidence of fatal and nonfatal CVD outcomes.

Hyperhomocysteinemia in end-stage renal disease: Prevalence, etiology, and potential relationship to arteriosclerotic outcomes

The end-stage renal disease (ESRD) population requiring chronic maintenance dialysis or renal transplantation is growing at an exponential rate, with over 62,000 incident (newly developed ESRD) cases reported per year in the United States [1]. This patient population experiences an excess morbidity and mortality due to arteriosclerotic cardiovascular disease (CVD) outcomes [1—5]. Specifically, event rates for myocardial infarction and stroke are 5to 10-fold higher in ESRD versus general populations [1—5]. Traditional CVD risk factors, such as smoking, hypertension, glucose intolerance/diabetes, and dyslipidemia [6], despite their widespread prevalence [7], are relatively limited predictors of CVD-specific morbidity and mortality in the ESRD population [7—111. Wu [10], for example, reported that the two-year cumulative incidence of de novo coronary heart disease (CHD) in ESRD patients undergoing chronic peritoneal (18.0%) or hemodialysis (15.0%), exceeded the six-year cumulative incidence (12.7%) of de novo CHD among original Framingham Study cohort participants similarly free of baseline CHD, and frequency matched to the dialysis patients for prevalence of the established CVD risk factors. Recently, controlled evidence [12] has been provided that hyperhomocysteinemia, that is, elevated total plasma levels of the atherothrombotic sulfur amino acid homocysteine [13, 14], occurs more commonly than any of the traditional CVD risk factors in ESRD patients on maintenance dialysis. Initial follow-up data further suggest that the markedly elevated fasting plasma total homocysteine (tHcy) levels found in these dialysis-dependent ESRD patients contributes independently to their excess incidence of fatal and non-fatal CVD outcomes [15]. Confirmation of these prospective findings in more sizable ESRD cohorts is urgently required. This review will first place hyperhomocysteinemia in the context of the other established amino acid abnormalities characteristic of ESRD. What is known from studies of general and ESRD populations about the prevalence and pathogenesis of hyperhomocysteinemia will then be summarized, followed by discussions of the epidcmiological and experimental evidence linking hyper-

The anemia of end-stage renal disease: Hematopoietic progenitor cell response

Patients with the anemia of end-stage renal disease (ESRD) fail to display an appropriate compensatory increase in red cell production. In order to investigate the extent to which the impaired erythropoietic response is determined at the progenitor cell level, we determined the frequencies of marrow colony-forming cells in 11 anemic and 3 non-anemic, dialysis-dependent ESRD patients and 10 healthy individuals. In addition, we measured serum levels of erythropoietin (Epo) by radioimmunoassay. There were no significant differences (P greater than 0.1) between normal and ESRD groups in the frequencies of primitive or late erythroid (BFU-E and CFU-E, respectively), granulocyte-macrophage, and megakaryocyte progenitors, CFU-E/BFU-E ratios, or serum Epo levels. In contrast, 5 non-uremic patients with chronic anemia comparable in severity to the anemic ESRD patients had serum Epo levels and CFU-E/BFU-E ratios that were significantly increased (P less than 0.05 and P less than 0.001, respectively) in comparison to the normal controls and ESRD patients. Pre-dialysis serum and plasma from both ESRD groups were as supportive of autologous erythroid and non-erythroid colony growth in vitro as normal serum and plasma; inhibition was not observed. We conclude that the relative numbers of erythroid and non-erythroid progenitors and the majority of serum Epo levels are unchanged from normal in patients with the anemia of ESRD. However, their normal CFU-E/BFU-E ratio reflects an inadequate compensatory erythropoietic response due to their inability to appropriately increase Epo production in response to anemia. Inhibitors of autologous erythroid colony formation were not detected in ESRD serum.(ABSTRACT TRUNCATED AT 250 WORDS)