Dialysis Facilities Research Articles

Receiving hemodialysis in Hispanic ethnic dense communities is associated with better adherence and outcomes among young patients: a retrospective analysis of the Dialysis Outcomes and Practice Patterns Study

BackgroundHispanic ethnic density (HED) is a marker of better health outcomes among Hispanic patients with chronic disease. It is unclear whether community HED is associated with mortality risk among ethnically diverse patients receiving maintenance hemodialysis.MethodsA retrospective analysis of patients in the United States cohort of the Dialysis Outcomes and Practice Patterns Study (DOPPS) database (2011–2015) was conducted (n = 4226). DOPPS data was linked to the American Community Survey database by dialysis facility zip code to obtain % Hispanic residents (HED). One way ANOVA and Kruskal Wallis tests were used to estimate the association between tertiles of HED with individual demographic, clinical and adherence characteristics, and facility and community attributes. Multivariable Cox proportional hazards models were used to estimate the mortality hazard ratio (HR) and 95% CIs by tertile of HED, stratified by age; a sandwich estimator was used to account for facility clustering.ResultsPatients dialyzing in facilities located in the highest HED tertile communities were younger (61.4 vs. 64.4 years), more commonly non-White (62.4% vs. 22.1%), had fewer comorbidities, longer dialysis vintage, and were more adherent to dialysis treatment, but had fewer minutes of dialysis prescribed than those in the lowest tertile. Dialyzing in the highest HED tertile was associated with lower hazard of mortality (HR, 0.86; 95% CI, 0.72-1.00), but this association attenuated with the addition of individual race/ethnicity (HR, 0.92; 95% CI, 0.78–1.09). In multivariable age-stratified analyses, those younger than 64 showed a lower hazard for mortality in the highest (vs. lowest) HED tertile (HR, 0.66; 95% CI, 0.49–0.90). Null associations were observed among patients ≥ 64 years.ConclusionsTreating in communities with greater HED and racial/ethnic integration was associated with lower mortality among younger patients which points to neighborhood context and social cohesion as potential drivers of improved survival outcomes for patients receiving hemodialysis.

Use of Analog and Human Insulin in a European Hemodialysis Cohort With Type 2 Diabetes: Associations With Mortality, Hospitalization, MACE, and Hypoglycemia

Poor glycemic control may contribute to the high mortality rate in patients with type 2 diabetes receiving hemodialysis. Insulin type may influence glycemic control, and its choice may be an opportunity to improve outcomes. This study assessed whether treatment with analog insulin compared with human insulin is associated with different outcomes in people with type 2 diabetes and kidney failure receiving hemodialysis. Retrospective cohort study. People in the Analyzing Data, Recognizing Excellence and Optimizing Outcomes (AROii) study with kidney failure commencing hemodialysis and type 2 diabetes being treated with insulin within 288 dialysis facilities between 2007 and 2009 across 7 European countries. Study participants were followed for 3 years. People with type 1 diabetes were excluded using an established administrative data algorithm. Treatment with an insulin analog or human insulin. All-cause mortality, major adverse cardiovascular events (MACE), all-cause hospitalization, and confirmed hypoglycemia (blood glucose<3.0mmol/L sampled during hemodialysis). Inverse probability weighted Cox proportional hazards models to estimate hazard ratios for analog insulin compared with human insulin. There were 713 insulin analog and 733 human insulin users. Significant variation in insulin type by country was observed. Comparing analog with human insulin at 3 years, the percentage of patients experiencing end points and adjusted hazard ratios (AHR) were 22.0% versus 31.4% (AHR, 0.808 [95% CI, 0.66-0.99], P=0.04) for all-cause mortality, 26.8% versus 35.9% (AHR, 0.817 [95% CI, 0.68-0.98], P=0.03) for MACE, and 58.2% versus 75.0% (AHR, 0.757 [95% CI, 0.67-0.86], P<0.001) for hospitalization. Hypoglycemia was comparable between insulin types at 14.1% versus 15.0% (AHR, 1.169 [95% CI, 0.80-1.72], P=0.4). Consistent strength and direction of the associations were observed across sensitivity analyses. Residual confounding, lack of more detailed glycemia data. In this large multinational cohort of people with type 2 diabetes and kidney failure receiving maintenance hemodialysis, treatment with analog insulins was associated with better clinical outcomes when compared with human insulin. People with diabetes who are receiving dialysis for kidney failure are at high risk of cardiovascular disease and death. This study uses information from 1,446 people with kidney failure from 7 European countries who are receiving dialysis, have type 2 diabetes, and are prescribed either insulin identical to that made in the body (human insulin) or insulins with engineered extra features (insulin analog). After 3 years, fewer participants receiving analog insulins had died, had been admitted to the hospital, or had a cardiovascular event (heart attack, stroke, heart failure, or peripheral vascular disease). These findings suggest that analog insulins should be further explored as a treatment leading to better outcomes for people with diabetes on dialysis.

Home-Delivered Medically Tailored Meal Engagement Among Hemodialysis Patients and Providers

Hemodialysis patients face one of the most difficult diets among clinical patient populations. Furthermore, dialysis dietary adherence is generally reported as low with providers generally lacking the time and resources to implement effective behavior change. The purpose of this study was to elucidate measures of patient and provider engagement with home-delivered medically tailored meals (MTMs). We surveyed patients and staff at dialysis centers within the Denver metropolitan area. Surveys focused on 1) patient dietary intake, 2) awareness, support, and utilization of meal programs, and 3) nutritional challenges and barriers (including food security). We surveyed 118 patients (mean age 61.0 ± 14.2 year, 58.5% male, and dialysis vintage of 4.6 ± 4.9 years) and 26 staff across the included dialysis facilities. Patients were 20.3% White/Non-Hispanic, 35.6% Hispanic/Latin and 31.4% Black/African American. Most patients reported eating two meals per day (N=53, 44.9%) and 52.2% reported difficulty with following a kidney diet. The most cited reasons for not following the diet were behavioral or knowledge (38.5%), taste (26.3%), time/convenience (26.9%) and food autonomy (16.9%). Sixty participants (52.2%) reported living in a food desert and 26.3% reported food insecurity. Seventy-one patients (61.2%) were aware of MTMs but only 40.5% had been referred. Most (76.9%) dialysis providers were aware of MTMs but only 15 (57.7%) had actually referred patients to such a service. Black individuals were less likely to be referred for MTMs than White or Hispanics/Latin (29.7% vs 48.1% White and 45.0% Hispanic/Latin) individuals. MTMs represent a potential method to alleviate or bypass some of the many barriers expressed by patients. Our findings reveal a critical need for education around MTMs for both patients and providers. MTMs could potentially demonstrate health kidney dietary patterns that might translate to altered dietary preferences or towards future behavior change.

Setting Up Home Dialysis Programs: Now and in the Future.

Home dialysis utilization has been growing in the United States over the past decade but still lags behind similar socioeconomic nations. More than half of dialysis facilities in the United States either are not licensed to offer home dialysis or, despite a license, have no patients dialyzing at home, and many programs have a relatively small census. Multiple stakeholders, including patients, health care providers, and payers, have identified increased home dialysis use as an important goal. To realize these goals, nephrologists and kidney care professionals need a sound understanding of the key considerations in home dialysis center operation. In this review, we outline the core domains required to set up and operate a home dialysis program in the United States now and in the future.

Association between Physical Frailty and Sleep Disturbances among Patients on Hemodialysis: A Cross-Sectional Study

Introduction: Among patients on hemodialysis (HD), physical frailty and sleep disturbances are not only common but also associated with adverse outcomes. The aim of this study was to evaluate the association between physical frailty and sleep disturbances in patients on HD. Methods: This cross-sectional study was conducted from June 2017 to March 2021, with outpatients receiving HD 3 times a week at two dialysis facilities in Japan. Sleep disturbances were identified with the Athens Insomnia Scale (AIS). Physical frailty was defined using the Fried Frailty Phenotype. Patients were classified as “non-frailty (number of frailty components: 0–2)” or “frailty (3–5).” We examined the association of sleep disturbances with physical frailty and its components by performing a logistic regression analysis. Results: We analyzed 360 patients (mean age 65.6 years; 62% men). Eighty-one patients (23%) were classified into the group with frailty, and the mean AIS score was 5.2 ± 4.2 points. After adjusting for clinical characteristics, increasing the AIS score per 1 point was associated with higher odds of physical frailty (odds ratio, 1.12; 95% confidence interval, 1.05–1.20; p < 0.01). As for the frailty components, exhaustion, low physical activity, and weak grip strength showed an association with sleep disturbances (all p < 0.05). Conclusions: Sleep disturbances were independently associated with physical frailty in patients on HD. Future studies are warranted to investigate the causality between physical frailty and sleep disturbances in this population.

SARS-CoV-2 Infection and Death Rates Among Maintenance Dialysis Patients During Delta and Early Omicron Waves - United States, June 30, 2021-September 27, 2022.

Persons receiving maintenance dialysis are at increased risk for SARS-CoV-2 infection and its severe outcomes, including death. However, rates of SARS-CoV-2 infection and COVID-19-related deaths in this population are not well described. Since November 2020, CDC's National Healthcare Safety Network (NHSN) has collected weekly data monitoring incidence of SARS-CoV-2 infections (defined as a positive SARS-CoV-2 test result) and COVID-19-related deaths (defined as the death of a patient who had not fully recovered from a SARS-CoV-2 infection) among maintenance dialysis patients. This analysis used NHSN dialysis facility COVID-19 data reported during June 30, 2021-September 27, 2022, to describe rates of SARS-CoV-2 infection and COVID-19-related death among maintenance dialysis patients. The overall infection rate was 30.47 per 10,000 patient-weeks (39.64 among unvaccinated patients and 27.24 among patients who had completed a primary COVID-19 vaccination series). The overall death rate was 1.74 per 10,000 patient-weeks. Implementing recommended infection control measures in dialysis facilities and ensuring patients and staff members are up to date with recommended COVID-19 vaccination is critical to limiting COVID-19-associated morbidity and mortality.

The Association of Dialysis Facility Payer Mix With Access to Kidney Transplantation

Insurance coverage for patients with end-stage kidney disease has shifted toward more commercially insured patients at dialysis facilities. The associations among insurance status, facility-level payer mix, and access to kidney transplantation are unclear. To determine the association of dialysis facility commercial payer mix and 1-year incidence of wait-listing for kidney transplantation, and to delineate the association of commercial insurance at the patient vs facility level. This retrospective population-based cohort study used data from the United States Renal Data System from 2013 to 2018. Participants included patients aged 18 to 75 years initiating chronic dialysis between 2013 and 2017, excluding patients with a prior kidney transplant or with major contraindications to kidney transplant. Data were analyzed from August 2021 and May 2023. Dialysis facility commercial payer mix, calculated as the proportion of patients with commercial insurance per facility. The primary outcome was patients added to a waiting list for kidney transplant within 1 year of dialysis initiation. Multivariable Cox regression, censoring for death, was used to adjust for patient-level (demographic, socioeconomic, and medical) and facility-level factors. A total of 233 003 patients (97 617 [41.9%] female patients; mean [SD] age, 58.0 [12.1] years) across 6565 facilities met inclusion criteria. Participants included 70 062 Black patients (30.1%), 42 820 Hispanic patients (18.4%), 105 368 White patients (45.2%), and 14 753 patients (6.3%) who identified as another race or ethnicity (eg, American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Islander, and multiracial). Of 6565 dialysis facilities, the mean (SD) commercial payer mix was 21.2% (15.6 percentage points). Patient-level commercial insurance was associated with increased incidence of wait-listing (adjusted hazard ratio [aHR], 1.86; 95% CI, 1.80-1.93; P < .001). At the facility-level and before covariate adjustment, higher commercial payer mix was associated with increased wait-listing (fourth vs first payer mix quartile [Q]: HR, 1.79; 95% CI, 1.67-1.91; P < .001). However, after covariate-adjustment, including adjusting for patient-level insurance status, commercial payer mix was not significantly associated with outcome (Q4 vs Q1: aHR, 1.02; 95% CI, 0.95-1.09; P = .60). In this national cohort study of patients newly initiated on chronic dialysis, although patient-level commercial insurance was associated with higher access to the kidney transplant waiting lists, there was no independent association of facility-level commercial payer mix with patients being added to waiting lists for transplant. As the landscape of insurance coverage for dialysis evolves, the potential downstream impact on access to kidney transplant should be monitored.

#5743 ALTERNATIVES TO DAYTIME IN-CENTER HEMODIALYSIS AND EMPLOYMENT AMONG PATIENTS WITH KIDNEY FAILURE

Abstract Background and Aims Maintaining employment is a priority for many patients with kidney failure. In addition to its economic benefits, employment is associated with physical and psychological wellbeing. Yet, only 30-35% of working aged patients with advanced chronic kidney disease in the United States (US) report employment prior to starting dialysis and many patients stop working at the onset of kidney failure. While access to a dialysis treatment schedule outside of working hours may help patients to remain employed, the effects of alternative dialysis options on employment after starting dialysis are not well understood. Method We analyzed data from the US National Dialysis Registry to determine whether access to nearby facilities offering evening dialysis shifts and home dialysis increases the likelihood that patients are able to continue working after they start dialysis. Our cross-sectional analysis included working-aged patients (ages 18-54) receiving dialysis in US facilities in 2016. We combined information reported at the levels of individual patients and dialysis facilities. In a negative binomial regression model, we examined the associations among exposures of interest (the presence of facilities offering home dialysis and/or evening dialysis shifts in a patient's locality) and the number of employed working-aged adults at each dialysis facility. The multivariable regression model adjusted for observed patient, dialysis facility, and geographic characteristics, including patient health and demographic characteristics, information about individual patient employment at the onset of dialysis, local unemployment rates, and the number of working-aged patients at a given dialysis facility. Results We identified 4,860 US dialysis facilities with information about patient employment in 2016. Median employment among working-aged adults at these facilities was 17.9% (interquartile range 8.8% to 28.6%). In multivariable, fully adjusted, regression models, the presence of at least one facility offering an evening dialysis shift in a county was associated with a 5% increase in the relative rate of maintaining employment among all working-aged patients receiving dialysis in the county (risk ratio (rr) 1.05; 95% Confidence Interval (CI) 1.01 to 1.09; p = 0.02). The presence of at least one facility offering home dialysis in a county was associated with a 26% increase in the relative rate of maintaining employment (RR 1.26; 95% CI 1.18 to 1.34; p&amp;lt;0.001). The likelihood of employment did not increase with additional facilities in a county offering home dialysis. Conclusion Access to dialysis schedules outside of regular working hours – evening dialysis shifts and home dialysis – is associated with increased employment among patients with kidney failure. Efforts to increase access to these alternative dialysis treatments could help patients to continue working.

#3648 INDIVIDUALIZED ANEMIA THERAPY IMPROVES HEMOGLOBIN OUTCOMES AND DECREASES EPOETIN BETA DRUG EXPOSURE IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Anemia is a common complication in hemodialysis (HD) patients. Its treatment with erythropoiesis-stimulating agents (ESAs) is challenging due to a nonlinear dose-response relationship and time delays between ESA administration and hemoglobin (Hgb) response. Anemia treatment protocols are frequently used in clinical settings. However, high variability of patient-specific disease characteristics complicate attainment and maintenance of desired Hgb levels. We developed a novel fully personalized ESA dose recommendation tool and present clinical results of a multi-center, randomized controlled trial (RCT) using this software. Method We conducted an RCT in adult HD patients in six dialysis facilities in the US. Patients were randomized 1:1 and treated with our personalized ESA dose recommendation tool for twenty-six weeks (intervention group) or continued to be treated using an anemia protocol that was used as part of standard of care in those clinics (control group). The recommendation tool utilized a physiology-based model of anemia to estimate patient-specific physiological key characteristics, such as red blood cell lifespan, to create a patient-individual model from recent routine clinical data (gender, height, weight, Hgb measurements, and ESA treatment). These key characteristics and model-based outcome predictions were used to generate patient-specific ESA dose recommendations to stabilize Hgb levels in a target window of 10–11 g/dL. Dose recommendations were disseminated to the anemia managers of patients enrolled in the study for evaluation and further decision-making (Figure 1). This procedure was repeated biweekly with updated clinical data. Results Ninety-six patients were enrolled in the RCT. Patients were included in the statistical analysis when they remained in the clinical study for at least 30 days (n = 45 control group, n = 46 intervention group). We evaluated outcome measures showing efficacy and efficiency of the treatment in achieving target Hgb levels. Hgb-related outcomes were significantly different between the two study groups, with an improved Hgb control in the intervention arm, manifesting in a reduction of the Hgb distance to target by more than 30%. Epoetin-beta utilization in the intervention group was decreased by over 20%, while iron-related parameters showed no difference between the two arms (Table 1). Acceptance rate of dose recommendations was high; roughly 95% of the recommendations were accepted and implemented by the clinical staff. Conclusion A therapy software for personalized anemia management was developed for use with epoetin beta. The model-based ESA dose recommendation tool was evaluated in a clinical RCT in HD patients. Hgb control improved significantly in the group using the novel software tool, while ESA usage decreased, thus providing more efficient anemia management for the individual patient while reducing epoetin-beta drug exposure.

#3914 TRAJECTORY OF ANTHROPOMETRIC INDICATOR AND CLINICAL EVENTS AMONG PATIENTS ON HEMODIALYSIS

Abstract Background and Aims Low values for anthropometric indicators are risk factors for adverse clinical outcomes among patients on hemodialysis (HD). Anthropometric parameters are time-dependent; thus, reliance on only baseline measurements may not sufficiently capture important patient outcomes. Nonetheless, little is known about the associations between the trajectory of anthropometric indicators and prognosis. We examined associations between a one-year change in anthropometric indicators and hospitalization and mortality rates in patients undergoing HD. Method This retrospective study collected data from outpatients undergoing HD at two dialysis facilities between April 2018 and March 2022. The five anthropometric measurements were evaluated, including body mass index (BMI), mid-upper arm circumference (MUAC), mid-arm muscle circumference (MAMC), triceps skinfold (TSF), and calf circumference (CC). We defined baseline which was the date of the first measurement of anthropometric assessments. Thereafter, we evaluated their trajectories over one year. Change in anthropometric indicators over the 1-year was calculated by subtracting the baseline value from the second assessment value. Patients were divided into 2 groups according to a one-year change in anthropometric indicators: no decline (≥0) and decline (&amp;lt;0). The outcomes were all-cause death and the number and duration of all-cause hospitalizations. Death and hospitalizations were determined using the facilities’ records. Negative binomial regressions were used to examine the associations between anthropometric changes and clinical outcomes. Results We included 283 patients (mean age, 67.3 years; 60.4% males). During the follow-up period (median, 2.7 years), 30 deaths and 200 hospitalizations occurred. When considering anthropometric measurements trajectories as continuous variables, increasing BMI per 1 standard deviation (incident rate ratio [IRR]: 0.87; 95% confidence interval [CI]: 0.85–0.90), MUAC (IRR: 0.94; 95% CI: 0.88–0.99), TSF (IRR: 0.92; 95% CI: 0.84–0.99), and MAMC (IRR: 0.99; 95% CI: 0.98–0.99) were associated with a lower risk of all-cause hospitalizations and death regardless of their value at any one point in time. However, the CC trajectory was not associated with clinical events (IRR: 0.94; 95% CI: 0.83–1.07). Similarly, when the anthropometric changes were considered in the categorical models, the group with BMI decline (IRR: 1.36, 95% CI: 1.30–1.43), MUAC decline (IRR: 1.14, 95% CI: 1.02–1.28), TSF decline (IRR: 1.27, 95% CI: 1.05–1.53), and MAMC decline (IRR: 1.11, 95% CI: 1.03–1.19) had a higher risk of the clinical outcome than the no decline group. A significant association was not detected for CC decline (IRR: 0.93, 95% CI: 0.84–1.03) (Table 1). Conclusion We observed that decreasing BMI, MUAC, TSF, and MAMC over time were independently associated with clinical events. Routinely assessing these simple measures in clinical practice may be a useful management strategy for the prognostic stratification of patients undergoing HD.

#4088 IMPACT OF DYSMAGNESEMIA ON ATRIAL FIBRILLATION IN MAINTENANCE HAEMODIALYSIS PATIENTS: A NATIONWIDE STUDY

Abstract Background and Aims The dose-response relationship between serum magnesium (sMg) and atrial fibrillation (AF) and the contribution of dysmagnesemia to AF remain unknown among haemodialysis patients. Method This was a nationwide cross-sectional study on the Japanese Society for Dialysis Therapy registry as of the end of 2019. Eligible participants were adult patients undergoing haemodialysis thrice a week. The main exposure was sMg, categorised into seven categories (≤1.5, &amp;gt;1.5-≤2, &amp;gt;2-≤2.5, &amp;gt;2.5-≤3, &amp;gt;3-≤3.5, &amp;gt;3.5-≤4, and ≥4.0 mg/dL). The outcome was AF reported by dialysis facilities. The independent contribution to AF was assessed via logistic regression to generate population-attributable fractions, assuming a causal relationship between sMg and AF. Results A total of 165,926 patients from 2,549 facilities were analyzed. The prevalence of AF was 7.9%. Compared with the reference (&amp;gt;2.5-≤3 mg/dL), lower sMg was associated with increased AF (adjusted ORs [95%CI] of 1.49 [1.19-1.85], 1.24 [1.17-1.32], and 1.11 [1.06-1.16] for sMg of ≤1.5, &amp;gt;1.5-≤2.0, and &amp;gt;2.0-≤2.5 mg/dl categories, respectively). The slightly high sMg was associated with fewer AF (adjusted OR 0.87 [95%CI 0.79-0.96] for sMg of &amp;gt;3.0-≤3.5 mg/dl). The adjusted population-attributable fraction of lower sMg and higher and lower sMg for AF was 7.4% and 6.9%, respectively. Conclusion An association does indeed exist between lower sMg and AF, with the fewest percentages of AF at sMg levels above the reference range for the general population. Dysmagnesemia may be an important contributor to AF among adult haemodialysis patients. Further longitudinal studies are warranted to determine whether correction of sMg reduces the incidence of AF.

#6780 EFFECTS OF ISONATREMIC DIALYSIS ON INTERDIALYTIC WEIGHT GAIN RELYING ON AN AUTOMATED SODIUM CONTROL ALGORITHM: INTERIM ANALYSIS OF DISON-IRC STUDY

Abstract Background and Aims Sodium (Na) is a major determinant of extracellular fluid volume and osmolarity homeostasis. Chronic fluid overload (FO) is present in 30 to 50% of hemodialysis patients (HD). HD patients are mostly treated with fixed dialysate Na concentration irrespective of plasma Na concentration. This fixed approach tends to displace patient's osmolar set point and stimulates thirst and weight gain. An automated personalized dialysate Na alignment to patient's natremia to avoid unwanted diffusive Na gain and tonicity change induced by HD seems preferable. Several studies exploring individualized dialysate Na prescription have reported inconsistent results. In this prospective interventional multicenter study, we aimed to explore the impact of dialysate Na individualization through isonatremic HD on interdialytic weight gain (IDWG) (primary outcome) and dialytic HD-related symptoms (secondary outcome). For this purpose, we have used the automated “Na Control” option for adjusting dialysate Na to minimize dialysate-plasma sodium gradient and deliver an isonatremic dialysis. Method This is a longitudinal study comparing 2 periods: Period-1 = observational phase (2 months) → Period-2 = isonatremic phase by activation of “Na Control” in isonatremic mode (2 months) → comparison of IDWG between both periods. The embedded “sodium control” option in HD machine was used in all cases of Period-2 to actively align dialysate sodium concentration to natremia and quantify net sodium mass transfer. Results are expressed as mean±SD or median [25th-75th]. Results We present preliminary results obtained through 6 dialysis facilities including 51 patients, 33 (64.7%) females, 75 [65-81] years old, dry weight 71.9 [60.5-78.0] kg. Main findings are as follows: Firstly, an excellent agreement was observed between plasma Na concentrations, measured (laboratory) and estimated (machine) from HD monitor (mean difference before dialysis: 0.05, after dialysis: 0.62); Secondly, plasma Na estimated was as follows: before dialysis plasma Na (137.6 [136.2-139.0] vs 137.2 [136.0-139.3] and after dialysis plasma Na (139.0 [137.6-139.7] vs 137.1 [135.7-138.9]) in Period-1 and Period-2 respectively; Thirdly, the primary outcome (IDWG) as well as the diffusive Na balance were significantly reduced by isonatremic dialysis condition (IDWG: 2.17±0.92 versus 1.95±0.86 kg, p&amp;lt;0,0001; diffusive Na balance (3.9 [1.9-5.1] versus 0.7 [0.0-2.7] g of Na, p&amp;lt;0.0001). Conclusion Isonatremic dialysis condition automatically driven by “Na control” embedded In HD monitor was confirmed safe and easily implemented in clinical workflow. In addition, these preliminary results show that isonatremic dialysis improved dialysis patient perception and significantly reduced IDWG.

#4866 PREVALENCE AND SEVERITY OF CHRONIC KIDNEY DISEASE ASSOCIATED PRURITUS IN A DIALYSIS NETWORK IN WEST GERMANY

Abstract Background and Aims Chronic kidney disease-associated pruritus (CKD-aP) is a troubling and in some cases debilitating problem for patients with CKD and end-stage renal disease with potential impact on patients’ quality of life (QoL). Frequency of CKD-aP with at least a medium intensity has been reported to be present in approximately 40% of dialysis dependent patients in European countries and 26% in Germany. This work intended to update prevalence and disease severity in a large dialysis network in West Germany. Method We performed a cross-sectional study addressing maintenance dialysis patients (both hemodialysis and peritoneal dialysis) in 23 dialysis facilities in West Germany with a total of approximately 1,500 dialysis patients. After ethical approval, a questionnaire was distributed to all dialysis patients asking for presence of pruritus and if present about itch duration, dialysis vintage, pruritus severity, communication patterns, therapeutic attempts and impact on quality of life (QoL). Pruritus intensity was assessed using the worst itch numeral rating scale (WI-NRS). Results From May to July 2022, 919 patients completed and returned the questionnaire. 31.9% were female, 55.4% male and 12.7% did not disclose their gender. Overall, 223 (23.7%) reported presence of pruritus of any severity with 90.1% having pruritus for at least 6 weeks duration. 159 (17.4%) of all patients reported at least moderate itch intensity (WI-NRS ≥4) and 70 (7.7%) a severe itch intensity (WI-NRS ≥7). Dialysis vintages of &amp;lt;1 year, 1–2 years, 2–4 years and &amp;gt;4 years were reported by 15.8%, 16.2%, 25.7% and 36.9% of patients with pruritus, respectively. Approx. 71% of all patients with any intensity of pruritus reported to be unaware of origin of pruritus, the remainder gave various reasons with a majority mentioning CKD or dialysis associated reasons. 62 of the 223 with pruritus (27.8%) reported having received treatments of which 14 (22.6%) stated no, 27 (43.5%) partial and 17 (27.4%) good response. Most frequent therapy category mentioned was emollients (14) with a mixed effect: 4 reported no effect, 6 some and 2 a good effect. Of those having received antihistamines, all reported good response (4). 132 (59.2%) of patients with pruritus communicated the presence with someone, 89 of those (67.4%) with their nephrologist. Of the 223 patients with pruritus 214 (96.0%) reported any stage of impact on their QoL in at least one of the categories sleep, social life, household, or work. Highest frequency given was in social life (180/223) and lowest frequency in sleep disturbances (74/223). Conclusion Prevalence of CKD-aP of at least medium intensity was lower than previously reported for Germany, continuing the previous trend seen in DOPPS for decreasing prevalences. The patient awareness of association of pruritus to CKD is still low. A positive correlation of itch prevalence in CKD may exist to dialysis vintage. Compared to DOPPS data from 2015, fewer patients communicated itch at all but in case the nephrologist was most frequently addressed. Treatment attempts seem to be still rare and were conducted only in a minority of patients with CKD-aP. Impact of CKD-aP on QoL was usually present.

One-year impact of COVID-19 pandemic on renal replacement therapy and kidney transplantation in a tertiary center in Southern Brazil.

Patients on renal replacement therapy (RRT) and kidney transplant recipients (KTR) present multiple factors that may increase the risk of death from coronavirus disease 2019 (COVID-19). This study aimed to evaluate the incidence and impact of COVID-19 in RRT patients and KTRs. Between March 2020 and February 2021, we monitored the RRT population of thirteen dialysis facilities that refer patients for transplantation to our center, a tertiary hospital in Southern Brazil. In the same period, we also monitor COVID-19 incidence and mortality in our KTR population. Demographical, clinical, and COVID-19-related information were analyzed. We evaluated 1545 patients in the dialysis centers, of which 267 (17.4%) were infected by COVID-19 and 53 (19.9%) died. Among 275 patients on the kidney transplant waiting list, 63 patients (22.9%) were infected and seven (11.1%) died. COVID-19 was the leading cause of death (29.2%) among patients on the waiting list. Within the population of 1360 KTR, 134 (9.85%) were diagnosed with COVID-19 and 20 (14.9%) died. The number of kidney transplants decreased by 56.7% compared with the same period in the previous twelve months. In the study period, patients on RRT and KTRs presented a high incidence of COVID-19 and high COVID-19-related lethality. The impact on the patients on the transplant waiting list was less pronounced. The lethality rate observed in both cohorts seems to be related to age, comorbidities, and disease severity.

Heparin-induced Anaphylaxis shock.

Introduction: Anaphylaxis is a fatal condition that can be easily managed if discovered early. Only a few examples of anaphylaxis-like reactions caused by heparin have been documented, and immediate-type hypersensitivity reactions to heparin are extremely uncommon. Case Presentation: We report a case of a 53-yearold gentleman known to have an End Stage Renal Disease (ESRD) on Hemodialysis for two years, who went to the dialysis facility in his usual state of health. After two hours of dialysis, a new lock of taurolidine/heparin was installed; one minute later, the patient started to vomit and became restless, blood pressure dropped to 60/47 mmHg, and urticarial hives and a reddish rash developed on his skin, covering his trunk and limbs. He was immediately given three doses of epinephrine intramuscularly, which he did not respond to. Therefore, an epinephrine infusion was started. IV hydrocortisone and diphenhydramine were given for symptomatic relief. The patient was shifted to the emergency department, where he became vitally stable and returned to baseline. Heparininduced anaphylaxis was assumed based on the quick response to the above medications. Conclusion: This case can be added to the growing literature regarding this rare reaction, and more studies should be done to understand the nature of the reaction better. We recommend that the healthcare team becomes vigilant of heparin as a possible cause of anaphylaxis.

Walking aids and complicated orthopedic diseases are risk factors for falls in hemodialysis patients: an observational study

BackgroundAging and an increased fall risk have been demonstrated in hemodialysis patients at home and in a facility. However, studies investigating the cause of falls to prevent fractures in dialysis rooms are scarce. This study aimed to explore the related factors for accidental falls statistically in dialysis facilities for future fall prevention.MethodsThis study included 629 hemodialysis patients with end-stage renal disease. The patients were divided into two groups: the fall and non-fall groups. The main outcome was the presence or absence of falls in the dialysis room. Univariate and multivariate logistic analyses were performed; multivariate analysis was conducted using covariates significantly correlated in the univariate analysis.ResultsA total of 133 patients experienced falling accidents during the study period. The multivariate analysis indicated that the use of walking aid (p < 0.001), orthopedic diseases (p < 0.05), cerebrovascular disease, and age were significantly correlated with falls.ConclusionsIn the dialysis clinic, patients who use walking aids and have complicated orthopedic or cerebrovascular conditions are at a high risk of falling in the dialysis room. Therefore, establishing a safe environment may help prevent falls, not only for these patients but also among other patients with similar conditions.

Recognizing Local Champions in Infection Prevention and Control.

Recognizing Local Champions in Infection Prevention and Control.

Vital Signs: Health Disparities in Hemodialysis-Associated Staphylococcus aureus Bloodstream Infections — United States, 2017–2020

IntroductionRacial and ethnic minorities are disproportionately affected by end-stage kidney disease (ESKD). ESKD patients on dialysis are at increased risk for Staphylococcus aureus bloodstream infections, but racial, ethnic, and socioeconomic disparities associated with this outcome are not well described. MethodsSurveillance data from the 2020 National Healthcare Safety Network (NHSN) and the 2017–2020 Emerging Infections Program (EIP) were used to describe bloodstream infections among patients on hemodialysis (hemodialysis patients) and were linked to population-based data sources (CDC/Agency for Toxic Substances and Disease Registry [ATSDR] Social Vulnerability Index [SVI], United States Renal Data System [USRDS], and U.S. Census Bureau) to examine associations with race, ethnicity, and social determinants of health. ResultsIn 2020, 4,840 dialysis facilities reported 14,822 bloodstream infections to NHSN; 34.2% were attributable to S. aureus . Among seven EIP sites, the S. aureus bloodstream infection rate during 2017–2020 was 100 times higher among hemodialysis patients (4,248 of 100,000 person-years) than among adults not on hemodialysis (42 of 100,000 person-years). Unadjusted S. aureus bloodstream infection rates were highest among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) hemodialysis patients. Vascular access via central venous catheter was strongly associated with S. aureus bloodstream infections (NHSN: adjusted rate ratio [aRR] = 6.2; 95% CI = 5.7–6.7 versus fistula; EIP: aRR = 4.3; 95% CI = 3.9–4.8 versus fistula or graft). Adjusting for EIP site of residence, sex, and vascular access type, S. aureus bloodstream infection risk in EIP was highest in Hispanic patients (aRR = 1.4; 95% CI = 1.2–1.7 versus non-Hispanic White [White] patients), and patients aged 18–49 years (aRR = 1.7; 95% CI = 1.5–1.9 versus patients aged ≥65 years). Areas with higher poverty levels, crowding, and lower education levels accounted for disproportionately higher proportions of hemodialysis-associated S. aureus bloodstream infections. Conclusions and implications for public health practiceDisparities exist in hemodialysis-associated S. aureus infections. Health care providers and public health professionals should prioritize prevention and optimized treatment of ESKD, identify and address barriers to lower-risk vascular access placement, and implement established best practices to prevent bloodstream infections.

Century-Long Trends in the Financing and Ownership of American Health Care.

Who pays for health care-and who owns it-determine what care is delivered, who receives it, and who profits from it. We examined trends in health care ownership and financing over a century. We used multiple historical and current data sources (including data from the American Medical Association, the American Hospital Association, government publications and surveys, and analyses of Medicare Provider of Services files) to classify health care provider ownership as: public, private (for-profit), and private (not-for-profit). We used US Census data to classify physicians' employers as public, not-for-profit, or for-profit entities or "self-employed." We combined estimates from the official National Health Expenditures Accounts with other data sources to determine the public vs. private share of health care spending since 1923; we calculated a "comprehensive" public share metric that accounted for public subsidization of private health expenditures, mostly via the tax exemption for employer-sponsored insurance plans or government purchase of such plans for public employees. For-profit ownership of most health care subsectors has risen in recent decades and now predominates in several (including nursing facilities, ambulatory surgical facilities, dialysis facilities, hospices, and home health agencies). However, most community hospitals remain not-for-profit. Additionally, over the past century, a growing share of physicians identify as employees. Meanwhile, the comprehensive taxpayer-financed share of health care spending has increased dramatically from 9% in 1923 to 69% in 2020, with taxpayer-financed subsidies to private expenditures accounting for much of the recent growth. American health care is increasingly publicly financed yet investor owned, a trend accompanied by rising costs and, recently, worsening population health. A reassessment of the US mode of health care financing and ownership appears warranted.

How Do the ASCEND Study Findings Help Us as Dialysis Patients?

How Do the ASCEND Study Findings Help Us as Dialysis Patients?