Initiation Of Dialysis Therapy Research Articles

Comparison of Patient Survival Between Hemodialysis and Peritoneal Dialysis Among Patients Eligible for Both Modalities

Although peritoneal dialysis (PD) costs less to the health care system compared to in-center hemodialysis (HD), it is an underused therapy. Neither modality has been consistently shown to confer a clear benefit to patient survival. A key limitation of prior research is that study patients were not restricted to those eligible for both therapies. Retrospective cohort study. All adult patients developing end-stage renal disease from January 2004 to December 2013 at any of 7 regional dialysis centers in Ontario, Canada, who had received at least 1 outpatient dialysis treatment and hadcompleted a multidisciplinary modality assessment. HD or PD. Mortality from any cause. Among all incident patients with end-stage renal disease (1,579 HD and 453 PD), PD was associated with lower risk for death among patients younger than 65 years. However, after excluding approximately one-third of all incident patients deemed to be ineligible for PD, the modalities were associated with similar survival regardless of age. This finding was also observed in analyses that were restricted to patients initiating dialysis therapy electively as outpatients. The impact of modality on survival did not vary over time. The determination of PD eligibility was based on the judgment of the multidisciplinary team at each dialysis center. HD and PD are associated with similar mortality among incident dialysis patients who are eligible for both modalities. The effect of modality on survival does not appear to change over time. Future comparisons of dialysis modality should be restricted to individuals who are deemed eligible for both modalities to reflect the outcomes of patients who have the opportunity to choose between HD and PD in clinical practice.

Insights From the 2016 Peer Kidney Care Initiative Report: Still a Ways to Go to Improve Care for Dialysis Patients

Although outcomes improved during the past decade for patients receiving maintenance dialysis, gains were few in certain key areas, as highlighted in the 2016 Peer Kidney Care Initiative Report. Overall incidence rates of dialysis therapy initiation in adults remained relatively stable (∼42 per 100,000 US population, 2009-2013), but rates varied more than 2-fold, from 26 to 54, across US geographic regions. Hospitalization rates in incident patients decreased from 261 hospitalizations per 100 patient-years in 2003 to 207 in 2012, but observation stay rates increased from 40 to 67, attenuating the decline in hospitalizations by half. Decreases in prevalent patient hospitalizations for heart failure, from 15.6 per 100 patient-years in 2004 to 9.5 in 2013, were partially offset by increases in hospitalizations for volume overload, from 3.0 in 2004 to 6.1 in 2013. Prevalent patient rates of hospitalizations for arrhythmias (∼4.6 per 100 patient-years) did not improve during the past decade, whereas sudden cardiac death as a proportion of total cardiovascular deaths increased from 53% to 73%. Hospitalization rates for pneumonia/influenza, at about 8.3 per 100 patient-years in prevalent patients, did not decrease during this period, while hospitalization rates for bacteremia/sepsis increased from 8.6 to 12.0. If decreases in mortality rates are to be sustained, novel approaches to these challenges will berequired.

Uric Acid and the Risks of Kidney Failure and Death in Individuals With CKD

Serum uric acid concentrations increase in chronic kidney disease (CKD) and may lead to tubular injury, endothelial dysfunction, oxidative stress, and intrarenal inflammation. Whether uric acid concentrations are associated with kidney failure and death in CKD is unknown. Prospective observational cohort study. 3,885 individuals with CKD stages 2 to 4 enrolled in the Chronic Renal Insufficiency Cohort (CRIC) between June 2003 and September 2008 and followed up through March2013. Baseline uric acid concentrations. Kidney failure (initiation of dialysis therapy or transplantation) and all-cause mortality. During a median follow-up of 7.9 years, 885 participants progressed to kidney failure and 789 participants died. After adjustment for demographic, cardiovascular, and kidney-specific covariates, higher uric acid concentrations were independently associated with risk for kidney failure in participants with estimated glomerular filtration rates (eGFRs)≥ 45mL/min/1.73m2 (adjusted HR per 1-standard deviation greater baseline uric acid, 1.40; 95% CI, 1.12-1.75), but not in those with eGFRs<30mL/min/1.73m2. There was a nominally higher HR in participants with eGFRs of 30 to 44mL/min/1.73m2 (adjusted HR, 1.13; 95% CI, 0.99-1.29),butthis did not reach statistical significance.The relationship between uric acid concentrationand all-cause mortality was J-shaped (P=0.007). Potential residual confounding through unavailable confounders; lack of follow-up measurements to adjust for changes in uric acid concentrations over time. Uric acid concentration is an independent risk factor for kidney failure in earlier stages of CKD and has a J-shaped relationship with all-cause mortality in CKD. Adequately powered randomized placebo-controlled trials in CKD are needed to test whether urate lowering may prove to be an effective approach to prevent complications and progression of CKD.

Effects of Higher Quality of Care on Initiation of Long-term Dialysis in Patients With CKD and Diabetes

The burden of diabetes-related chronic kidney disease (CKD) on individuals and society is increasing, shifting attention toward improving the quality of care for patients with CKD and diabetes. We assessed the quality of CKD care and its association with long-term dialysis, acute kidney injury (AKI), and death. Retrospective cohort study (2004-2011). Adults in Taiwan with incident CKD enrolled in the Longitudinal Cohort of Diabetes Patients. 3 CKD-care quality indicators based on medical and pharmacy claims data were studied: prescription of renin-angiotensin system inhibitors, testing for proteinuria, and nutritional guidance. Each was examined individually, and all were summed into an overall quality score. The primary outcome was initiation of long-term dialysis therapy. Secondary outcomes were hospitalization due to AKI and death from any cause. Using instrumental variables related to the quality indicators to minimize both unmeasured and measured confounding, we fit a 2-stage residual inclusion model to estimate HRs and 95% CIs for each outcome. Among the 63,260 patients enrolled, 43.9% were prescribed renin-angiotensin system inhibitors, 60.6% were tested for proteinuria, and 13.4% received nutritional guidance. During a median follow-up of 37.9 months, 1,471 patients started long-term dialysis therapy, 2,739 patients were hospitalized due to AKI, and 4,407 patients died. Higher overall quality scores were associated with lower hazards for long-term dialysis in instrumental variable analyses (HR of 0.62 [95% CI, 0.40-0.98] per 1-point greater score) and hospitalization due to AKI (HR of 0.69 [95% CI, 0.50-0.96] per 1-point greater score). The hazard for all-cause death was nonsignificantly lower (HR of 0.80 [95% CI, 0.62-1.03] per 1-point greater score). Potential misclassification and uncontrolled confounding by indication. Our findings suggest potential opportunities to improve long-term outcomes among patients with diabetes and CKD by improving the quality of their CKD care.

Unrecognized Fibrinogen A α-Chain Amyloidosis: Results From Targeted Genetic Testing

Fibrinogen A α-chain (AFib) amyloidosis results from autosomal-dominant mutations in the gene encoding AFib (FGA). Patients with this disorder typically present with proteinuria. Isolated cases of AFib amyloidosis, carrying the FGA p.Glu545Val variant, were identified in the district of Braga, in northwest Portugal. This observation led us to hypothesize that this disorder might be an unrecognized cause of kidney disease in that region and prompted us to carry out targeted genetic testing for the p.Glu545Val variant in the local hemodialysis population and family members of identified cases. Case series. 3 groups of participants: (1) kidney biopsy registry, n=4; (2) hemodialysis facility, n=122 of 267 patients; and (3) genetically at-risk individuals; n=69 of 167 family members. Kidney disease, kidney disease progression, and survival. The p.Glu545Val variant was identified in all 4 patients of the biopsy registry, 12 of 122 (9.8%) hemodialysis patients tested, and 34 of 69 (49%) relatives tested. These 50 cases belonged to 13 unrelated families with kidney disease or amyloidosis identified in 61% of probands. 35 individuals presented with hypertension at a mean of 51.0±10.4 years. Of these, 30 developed kidney disease at a mean of 56.7±12.0 years, and 21 initiated dialysis therapy at a mean of 61.4±11.3 years. Heart, liver, spleen, colon, and ileum were involved along the progression of the disease. Kidney disease was formerly attributed to hypertension in 25% of patients with AFib amyloidosis undergoing hemodialysis. Retrospective data collection for patients with amyloidosis previously diagnosed. AFib amyloidosis appears to be an under-recognized disorder in Braga, Portugal, where we found a high frequency of the FGA p.Glu545Val variant. Due to the nonspecific nature of its major clinical features, the diagnosis of AFib amyloidosis should have a high index of suspicion, particularly in populations in which hypertension is prevalent.

Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality

Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown. Observational study. 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years. Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to≥160mmHg in 10-mmHg increments) and 5 (<60 to≥90mmHg in 10-mmHg increments) categories, respectively, and as continuous measures. Postdialysis all-cause mortality, assessed over different follow-up periods (ie,<3, 3-<6, 6-<12, and≥12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access. Mean predialysis SBP and DBP were 141.2±16.1 (SD) and 73.7±10.6mmHg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP<140mmHg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95% CI, 1.96-2.93), 1.99 (95% CI, 1.66-2.40), 1.35 (95% CI, 1.13-1.62), 0.98 (95% CI, 0.78-1.22), and 0.76 (95% CI, 0.57-1.00) for SBP<120, 120 to<130, 130 to<140, 150 to<160, and≥160 (vs 140-<150) mmHg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality. Results cannot be inferred to show causality and may not be generalizable to women or the general US population. Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality.

Frequency of Early Predialysis Nephrology Care and Postdialysis Cardiovascular Events

Patients with kidney failure are at a high risk for cardiovascular events. Predialysis nephrology care has been reported to improve postdialysis survival, but its effects on postdialysis major adverse cardiovascular events (MACEs) have not been comprehensively studied. Observational cohort study. We used data from the National Health Insurance Research Database in Taiwan. Adult patients who initiated maintenance dialysis therapy in 1999 to 2010 were enrolled. We created 3 subtypes of predialysis nephrology care based on the time between the first nephrology visit and the initiation of dialysis therapy: early frequent (duration≥ 6 months; at least 1 nephrology visit every 3 months), early infrequent (duration≥ 6 months,<1 nephrology visit every 3 months), and late (duration< 6 months). MACE was defined using the primary diagnosis in hospitalization records of acute myocardial infarction, acute heart failure, acute stroke, or sudden death. We investigated the associations of different subtypes of nephrology care with postdialysis 1-year MACEs. Among the 60,329 eligible patients, 24,477 (40.6%) had early frequent, 12,763 (21.2%) had early infrequent, and 23,089 (38.3%) had late nephrology care. Compared to the late-nephrology-care group, the early-frequent group was associated with an ∼10% lower risk for 1-year MACEs (HR of 0.89 [95% CI, 0.82-0.96] for first MACE and relative risk of 0.91 [95% CI, 0.84-0.98] for recurrent MACEs). However, the early-infrequent-care group had similar risks for MACEs as the late group (HR of 0.95 [95% CI, 0.86-1.05] for first MACE and relative risk of 0.94 [95% CI, 0.86-1.02] for recurrent MACEs). Lack of physical and biochemical information because of inherent limitations from administrative claims data. Early frequent nephrology care for 6 or more months before the initiation of long-term dialysis therapy may improve 1-year postdialysis major cardiovascular outcomes.

System-Level Barriers and Facilitators for Foregoing or Withdrawing Dialysis: A Qualitative Study of Nephrologists in the United States and England

Despite a growing body of literature suggesting that dialysis does not confer morbidity or mortality benefits for all patients with chronic kidney failure, the initiation and continuation of dialysis therapy in patients with poor prognosis is commonplace. Our goal was to elicit nephrologists' perspectives on factors that affect decision making regarding end-stage renal disease. Semistructured, individual, qualitative interviews. Participants were purposively sampled based on age, race, sex, geographic location, and practice type. Each was asked about his or her perspectives and experiences related to foregoing and withdrawing dialysis therapy. Interviews were audiotaped, transcribed, and analyzed using narrative and thematic analysis. We conducted 59 semistructured interviews with nephrologists from the United States (n=41) and England (n=18). Most participants were 45 years or younger, men, and white. Average time since completing nephrology training was 14.2±11.6 (SD) years. Identified system-level facilitators and barriers for foregoing and withdrawing dialysis therapy stemmed from national and institutional policies and structural factors, how providers practice medicine (the culture of medicine), and beliefs and behaviors of the public (societal culture). In both countries, the predominant barriers described included lack of training in end-of-life conversations and expectations for aggressive care among non-nephrologists and the general public. Primary differences included financial incentives to dialyze in the United States and widespread outpatient conservative management programs in England. Participants' views may not fully capture those of all American or English nephrologists. Nephrologists in the United States and England identified several system-level factors that both facilitated and interfered with decision making around foregoing and withdrawing dialysis therapy. Efforts to expand facilitators while reducing barriers could lead to care practices more in keeping with patient prognosis.

Initial Session Duration and Mortality Among Incident Hemodialysis Patients

The association of dialysis session duration with mortality in patients undergoing maintenance hemodialysis is unclear. We compared mortality rates of patients treated in dialysis facilities that used initial session durations of either ≥ 4 versus 3 hours for all incident patients. Retrospective cohort study. Patients with end-stage renal disease beginning maintenance hemodialysis therapy in January 2006 to December 2010 and followed up through December 2012, including 39,172 patients in 852 facilities who initiated treatment for ≥ 4 hours and 47,721 patients in 631 facilities who initiated treatment for 3 hours. Initial session duration of ≥ 4 hours versus 3 hours. 2- and 1-year mortality rates. Total numbers of deaths observed within 2 years after initiating dialysis therapy were 8,945 in the ≥ 4-hour group and 15,624 in the 3-hour group. The corresponding numbers of deaths observed within 1 year were 5,492 and 10,372, respectively. The 2-year adjusted HR in the ≥ 4-hour versus 3-hour group was 0.79 (95% CI, 0.73-0.86). The corresponding 1-year adjusted HR was 0.77 (95% CI, 0.70-0.84). Results were robust when analyses were restricted to specific subgroups of patients classified by age, sex, race, and select clinical characteristics. We did not observe hemodialysis duration in sessions subsequent to initiation. We only included patients treated in facilities with uniform session length (at initiation) for all their patients. Furthermore, we lacked information for dialysis dosage and patients' baseline residual kidney function. Patients in facilities routinely initiating hemodialysis therapy for ≥ 4 hours may have substantially lower mortality as compared with patients in facilities initiating for only 3 hours of treatment.

Serious Fall Injuries Before and After Initiation of Hemodialysis Among Older ESRD Patients in the United States: A Retrospective Cohort Study

Because initiation of dialysis therapy often occurs in the setting of acute illness and may signal worsening health and functional decline, we examined whether rates of serious fall injuries among older hemodialysis patients differ before and after dialysis therapy initiation. Retrospective cohort study of claims data from the 2 years spanning dialysis therapy initiationamong patients initiating dialysis therapy in 2010 to2012. Claims from 81,653 Medicare end-stage renal disease beneficiaries aged 67 to 100 years. Post- versus pre-dialysis therapy initiation periods, defined as on or after versus before dialysis therapy initiation. Serious fall injuries were defined using diagnostic codes for falls in combination with fractures, brain injuries, or joint dislocation. Incidence rate ratios (overall and stratified) for post- versus pre-dialysis therapy initiation periods were estimated using generalized estimating equation models with a negative binomial link. Overall, 12,757 serious fall injuries occurred in the pre- and post-dialysis therapy initiation periods. Annual rates of serious fall injuries were 64.4 (95% CI, 62.7-66.2) and 107.8 (95% CI, 105.4-110.3) per 1,000 patient-years, respectively, in the pre- and post-dialysis therapy initiation periods (incidence rate ratio, 1.62; 95% CI, 1.56-1.67). Relative rates of serious fall injuries in the post- vs pre-dialysis initiation periods were of greater magnitude among patients who were younger (<75 years), had pre-end-stage renal disease nephrology care, had albumin levels > 3g/dL, were able to walk and transfer, did not need assistance with activities of daily living, and were not institutionalized compared with relative rates among their counterparts. Potential misclassification due to the use of claims data and survival bias among those initiating hemodialysis therapy. Among older Medicare beneficiaries receiving hemodialysis, serious fall injuries are common, the post-dialysis initiation period is a high-risk time for falls, and dialysis therapy initiation may be an important time to screen for fall risk factors and implement multifactorial fall prevention strategies.

Dietary protein intake and chronic kidney disease

High-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration. This can cause damage to glomerular structure leading to or aggravating chronic kidney disease (CKD). Hence, a low-protein diet (LPD) of 0.6-0.8 g/kg/day is often recommended for the management of CKD. We reviewed the effect of protein intake on incidence and progression of CKD and the role of LPD in the CKD management. Actual dietary protein consumption in CKD patients remains substantially higher than the recommendations for LPD. Notwithstanding the inconclusive results of the 'Modification of Diet in Renal Disease' (MDRD) study, the largest randomized controlled trial to examine protein restriction in CKD, several prior and subsequent studies and meta-analyses appear to support the role of LPD on retarding progression of CKD and delaying initiation of maintenance dialysis therapy. LPD can also be used to control metabolic derangements in CKD. Supplemented LPD with essential amino acids or their ketoanalogs may be used for incremental transition to dialysis especially on nondialysis days. The LPD management in lieu of dialysis therapy can reduce costs, enhance psychological adaptation, and preserve residual renal function upon transition to dialysis. Adherence and adequate protein and energy intake should be ensured to avoid protein-energy wasting. A balanced and individualized dietary approach based on LPD should be elaborated with periodic dietitian counseling and surveillance to optimize management of CKD, to assure adequate protein and energy intake, and to avoid or correct protein-energy wasting.

Infants Requiring Maintenance Dialysis: Outcomes of Hemodialysis and Peritoneal Dialysis

The impact of different dialysis modalities on clinical outcomes has not been explored in young infants with chronic kidney failure. Cohort study. Data were extracted from the ESPN/ERA-EDTA Registry. This analysis included 1,063 infants 12 months or younger who initiated dialysis therapy in 1991 to2013. Type of dialysis modality. Differences between infants treated with peritoneal dialysis (PD) or hemodialysis (HD) in patient survival, technique survival, and access to kidney transplantation were examined using Cox regression analysis while adjusting for age at dialysis therapy initiation, sex, underlying kidney disease, and country of residence. 917 infants initiated dialysis therapy on PD, and 146, on HD. Median age at dialysis therapy initiation was 4.5 (IQR, 0.7-7.9) months, and median body weight was 5.7 (IQR, 3.7-7.5) kg. Although the groups were homogeneous regarding age and sex, infants treated with PD more often had congenital anomalies of the kidney and urinary tract (CAKUT; 48% vs 27%), whereas those on HD therapy more frequently had metabolic disorders (12% vs 4%). Risk factors for death were younger age at dialysis therapy initiation (HR per each 1-month later initiation, 0.95; 95% CI, 0.90-0.97) and non-CAKUT cause of chronic kidney failure (HR, 1.49; 95% CI, 1.08-2.04). Mortality risk and likelihood of transplantation were equal in PD and HD patients, whereas HD patients had a higher risk for changing dialysis treatment (adjusted HR, 1.64; 95% CI, 1.17-2.31). Inability to control for unmeasured confounders not included in the Registry database and missing data (ie, comorbid conditions). Low statistical power because of relatively small number of participants. Despite a widespread preconception that HD should be reserved for cases in which PD is not feasible, in Europe, we found 1 in 8 infants in need of maintenance dialysis to be initiated on HD therapy. Patient characteristics at dialysis therapy initiation, prospective survival, and time to transplantation were very similar for infants initiated on PD or HD therapy.

Referral for Kidney Transplantation and Indicators of Quality of Dialysis Care: A Cross-sectional Study

Dialysis facility performance measures to improve access to kidney transplantation are being considered. Referral of patients for kidney transplantation evaluation by the dialysis facility is one potential indicator, but limited data exist to evaluate whether referral is associated with existing dialysis facility quality indicators. Cross-sectional study. 12,926 incident (July 2005 to September 2011) adult (aged 18-69 years) patients treated at 241 dialysis facilities with complete quality indicator information from US national registry data linked to transplantation referral data from all 3 Georgia kidney transplantation centers. Facility performance on dialysis quality indicators (high, intermediate, and low tertiles). Percentages of patients referred within 1 year of dialysis therapy initiation at dialysis facility. Overall, a median of 25.4% of patients were referred for kidney transplantation within 1 year of dialysis therapy initiation. Higher facility-level referral was associated with better performance with respect to standardized transplantation ratio (high, 28.6%; intermediate, 25.1%; and low, 22.9%; P=0.001) and percentage waitlisted (high, 30.7%; intermediate, 26.8%; and low, 19.2%; P<0.001). Facility-level referral was not associated with indicators of quality of care associated with dialysis therapy initiation, including percentage of incident patients being informed of transplantation options. For most non-transplantation-related indicators of high-quality care, including those capturing mortality, morbidity, and anemia management, better performance was not associated with higher facility-level transplantation referral. Potential ecologic fallacy and residual confounding. Transplantation referral among patients at dialysis facilities does not appear to be associated with overall quality of dialysis care at the facility. Quality indicators related to kidney transplantation were positively associated with, but not entirely correspondent with, higher percentages of patients referred for kidney transplantation evaluation from dialysis facilities. These results suggest that facility-level referral, which is within the control of the dialysis facility, may provide information about the quality of dialysis care beyond current indicators.

A Clinical Risk Prediction Tool for 6-Month Mortality After Dialysis Initiation Among Older Adults

Information on an individual's risk for death following dialysis therapy initiation may inform the decision to initiate maintenance dialysis for older adults. We derived and validated a clinical risk prediction tool for all-cause mortality among older adults during the first 6 months of maintenance dialysis treatment. Prediction model using retrospective administrative and clinical data. We linked administrative and clinical data to define a cohort of 2,199 older adults (age≥ 65 years) in Alberta, Canada, who initiated maintenance dialysis therapy (excluding acute kidney injury) in May 2003 to March2012. Demographics, laboratory data, comorbid conditions, and measures of health system use. All-cause mortality within 6 months of dialysis therapy initiation. Predicted mortality by logistic regression with 10-fold cross-validation. 375 (17.1%) older adults died within 6 months. We developed a 19-point risk score for 6-month mortality that included age 80 years or older (2 points), glomerular filtration rate of 10 to 14.9mL/min/1.73m2 (1 point) or≥15mL/min/1.73m2 (3 points), atrial fibrillation (2 points), lymphoma (5 points), congestive heart failure (2 points), hospitalization in the prior 6 months (2 points), and metastatic cancer (3 points). Model discrimination (C statistic= 0.72) and calibration (Hosmer-Lemeshow χ2=10.36; P=0.2) were reasonable. As examples, a score< 5 equated to<25% of individuals dying in 6 months, whereas a score > 12 predicted that more than half the individuals would die in the first 6 months. The tool has not been externally validated; thus, generalizability cannot be assessed. We used readily available clinical information to derive and internally validate a 7-variable tool to predict early mortality among older adults after dialysis therapy initiation. Following successful external validation, the tool may be useful as a clinical decision tool to aid decision making for older adults with kidney failure.

A Dynamic Predictive Model for Progression of CKD

Predicting the progression of chronic kidney disease (CKD) is vital for clinical decision making and patient-provider communication. We previously developed an accurate static prediction model that used single-timepoint measurements of demographic and laboratory variables. Development of a dynamic predictive model using demographic, clinical, and time-dependent laboratory data from a cohort of patients with CKD stages 3 to5. We studied 3,004 patients seen April 1, 2001, to December 31, 2009, in the outpatient CKD clinic of Sunnybrook Hospital in Toronto, Canada. Age, sex, and urinary albumin-creatinine ratio at baseline. Estimated glomerular filtration rate (eGFR), serum albumin, phosphorus, calcium, and bicarbonate values as time-dependent predictors. Treated kidney failure, defined by initiation of dialysis therapy or kidney transplantation. We describe a dynamic (latest-available-measurement) prediction model using time-dependent laboratory values as predictors of outcome. Our static model included all 8 candidate predictors. The latest-available-measurement model includes age and the latter 5 variables as time-dependent predictors. We used Cox proportional hazards models for time to kidney failure and compared discrimination, calibration, model fit, and net reclassification for the models. We studied 3,004 patients, who had 344 kidney failure events over a median follow-up of 3 years and an average of 5 clinic visits. eGFR was more strongly associated with kidney failure in the latest-available-measurement model versus the baseline visit static model (HR, 0.44 vs 0.65). The association of calcium level was unchanged, but male sex and phosphorus, albumin, and bicarbonate levels were no longer significant. Discrimination and goodness of fit showed incremental improvement with inclusion of time-dependent covariates (integrated discrimination improvement, 0.73%; 95% CI, 0.56%-0.90%). Our data were derived from a nephrology clinic at a single center. We were unable to include time-dependent changes in albuminuria. A latest-available-measurement predictive model with eGFR as a time-dependent predictor can incrementally improve risk prediction for kidney failure over a static model with only a single eGFR.

Indication for Dialysis Initiation and Mortality in Patients With Chronic Kidney Failure: A Retrospective Cohort Study

Initiation of maintenance dialysis therapy for patients with chronic kidney failure is a period of high risk for adverse patient outcomes. Whether indications for dialysis therapy initiation are associated with mortality in this population is unknown. Retrospective cohort study. 461 patients who initiated dialysis therapy (hemodialysis, 437; peritoneal dialysis, 24) from January 1, 2004, through December 31, 2012, and were treated in facilities operated by a single dialysis organization. Follow-up for the primary outcome was through December 31,2013. Clinically documented primary indication for dialysis therapy initiation, as categorized into 4 groups: laboratory evidence of kidney function decline (reference category), uremic symptoms, volume overload or hypertension, and other/unknown. All-cause mortality. During a median follow-up of 2.4 years, 183 (40%) patients died. Crude mortality rates were 10.0 (95% CI, 6.8-14.7), 12.7 (95% CI, 10.2-15.7), 21.7 (95% CI, 16.4-28.6), and 12.2 (95% CI, 6.8-14.7) deaths/100 patient-years among patients initiating dialysis therapy primarily for laboratory evidence of kidney function decline, uremic symptoms, volume overload or hypertension, and other/unknown reason, respectively. Following adjustment for demographic variables, coexisting illnesses, and estimated glomerular filtration rate, initiation of dialysis therapy for uremic symptoms, volume overload or hypertension, or other/unknown reasons was associated with 1.12 (95% CI, 0.72-1.77), 1.69 (95% CI, 1.02-2.80), and 1.28 (95% CI, 0.73-2.26) times higher risk, respectively, for subsequent mortality compared to initiation for laboratory evidence of kidney function decline. Possibility of residual confounding by unmeasured variables; reliance on clinical documentation to ascertain exposure. Patients initiating dialysis therapy due to volume overload may have increased risk for mortality compared with patients initiating dialysis due to laboratory evidence of kidney function decline. Further studies are needed to identify and test interventions that might reduce this risk.

Patient Perspectives on the Choice of Dialysis Modality: Results From the Empowering Patients on Choices for Renal Replacement Therapy (EPOCH-RRT) Study

Little is known about factors that are important to patients with advanced kidney disease and their perspectives at the time they choose a dialysis modality. EPOCH-RRT, a study supported in part by the Patient-Centered Outcomes Research Institute (PCORI), was designed to assist patients with this choice by identifying such factors and effectively provide relevant information. Cross-sectional study, designed and conducted in collaboration with a multistakeholder advisory panel that included patients, caregivers, and health care professionals. 180 patients with advanced chronic kidney disease (CKD; estimated glomerular filtration rate< 25mL/min/1.73m2), either non-dialysis-dependent (NDD-CKD; n=65) or on dialysis therapy (hemodialysis [HD], n=77; or peritoneal dialysis, n=38), recruited across the United States through social media and in-person contacts. Semistructured telephone interviews including open- and closed-ended questions. Mixed methods, integrating quantitative and qualitative approaches; themes identified through content analysis of interview transcripts by 2 independent coders. Themes most often reported as important were keeping as much independence as possible, quality and quantity of life, and flexibility in daily schedule. Other factors (eg, concern about the way they look) differed across patient subgroups based on age, sex, and NDD-CKD/dialysis modality. Among patients who had initiated dialysis therapy, almost half (47%) the HD patients believed that the decision to be treated by HD had largely not been their choice; this was only reported by 3% of peritoneal dialysis patients. Recruitment through social media and willingness to participate in lengthy telephone interviews resulted in a select sample that may not be representative of the broader advanced CKD population; therefore, generalizability of findings cannot be determined. Incorporation of patient priorities in care improves health outcomes. Given the perceived limited role in the choice of dialysis treatment, our findings support the need for interventions to improve shared decision making on dialysis treatment options, targeting both patients and clinicians.

Inguinal hernia in hemodialysis versus peritoneal dialysis patients: a case-control study

Inguinal hernia is common in dialysis patients, especially peritoneal dialysis (PD) patients; however, no previous reports have assessed the incidence, type, treatments, and risk factors of inguinal hernia in hemodialysis (HD) patients. We retrospectively evaluated the differences in these factors between HD and PD patients. A total of 2287 HD and 410 PD patients treated between March 2006 and December 2013 were enrolled. The incidence, type (indirect, direct, or combined), and hernioplasty of inguinal hernia as well as demographic characteristics of HD and PD patients were compared. The incidence of inguinal hernia was lower in HD (0.7 %) than in PD patients (5.9 %) (P < 0.001), and these incidences were higher among men (P = 0.007 and P < 0.001, respectively). Of the 16 HD and 24 PD patients with inguinal hernia, 14 and 21 (both 88 %) underwent hernioplasty. Among them, PD patients demonstrated a higher proportion of indirect hernia (91 %) than HD (47 %) patients (P = 0.003). No recurrence was observed in either group. In a multivariate logistic regression model, PD and male sex were risk factors for inguinal hernia (both P < 0.001). In this study, indirect inguinal hernia was more frequent in PD patients than in HD patients. Male sex and PD are risk factors for inguinal hernia in dialysis patients. Tension-free hernioplasty for inguinal hernia was effective in both HD and PD patients. Our findings can help inform clinicians when selecting the dialysis modality (HD or PD) prior to the initiation of dialysis therapy and guide clinical management practices for inguinal hernias in dialysis patients.

Urine Potassium Excretion, Kidney Failure, and Mortality in CKD

Low urine potassium excretion, as a surrogate for dietary potassium intake, is associated with higher risk for hypertension and cardiovascular disease in a general population. Few studies have investigated the relationship of urine potassium with clinical outcomes in chronic kidney disease (CKD). Longitudinal cohort study. The MDRD (Modification of Diet in Renal Disease) Study was a randomized controlled trial (N= 840) conducted in 1989 to 1993 to examine the effects of blood pressure control and dietary protein restriction on kidney disease progression in adults aged 18 to 70 years with CKD stages 2 to 4. This post hoc analysis included 812 participants. The primary predictor variable was 24-hour urine potassium excretion, measured at baseline and at multiple time points (presented as time-updated average urine potassium excretion). Kidney failure, defined as initiation of dialysis therapy or transplantation, was determined from US Renal Data System data. All-cause mortality was assessed using the National Death Index. Median follow-up for kidney failure was 6.1 (IQR, 3.5-11.7) years, with 9 events/100 patient-years. Median all-cause mortality follow-up was 19.2 (IQR, 10.8-20.6) years, with 3 deaths/100 patient-years. Baseline mean urine potassium excretion was 2.39±0.89 (SD) g/d. Each 1-SD higher baseline urine potassium level was associated with an adjusted HR of 0.95 (95% CI, 0.87-1.04) for kidney failure and 0.83 (95% CI, 0.74-0.94) for all-cause mortality. Results were consistent using time-updated average urine potassium measurements. Analyses were performed using urine potassium excretion as a surrogate for dietary potassium intake. Results are obtained from a primarily young, nondiabetic, and advanced CKD population and may not be generalizable to the general CKD population. Higher urine potassium excretion was associated with lower risk for all-cause mortality, but not kidney failure.

Predialysis Cardiovascular Disease Medication Adherence and Mortality After Transition to Dialysis.

Medication nonadherence is a known risk factor for adverse outcomes in the general population. However, little is known about the association of predialysis medication adherence among patients with advanced chronic kidney disease and mortality following their transition to dialysis. Observational study. 32,348 US veterans who transitioned to dialysis during 2007 to2011. Adherence to treatment with cardiovascular drugs, ascertained from pharmacy database records using proportion of days covered (PDC) and persistence during the predialysis year. Post-dialysis therapy initiation all-cause and cardiovascular mortality, using Cox models with adjustment for confounders. Mean age of the cohort was 72±11 (SD) years; 96% were men, 74% were white, 23% were African American, and 69% had diabetes. During a median follow-up of 23 (IQR, 9-36) months, 18,608 patients died. Among patients with PDC>80%, there were 14,006 deaths (mortality rate, 283 [95% CI, 278-288]/1,000 patient-years]); among patients with PDC>60% to 80%, there were 3,882 deaths (mortality rate, 294 [95% CI, 285-304]/1,000 patient-years); among patients with PDC≤60%, there were 720 deaths (mortality rate, 291 [95% CI, 271-313]/1,000 patient-years). Compared with patients with PDC>80%, the adjusted HR for post-dialysis therapy initiation all-cause mortality for patients with PDC>60% to 80% was 1.12 (95% CI, 1.08-1.16), and for patients with PDC≤60% was 1.21 (95% CI, 1.11-1.30). In addition, compared with patients showing medication persistence, adjusted HR risk for post-dialysis therapy initiation all-cause mortality for patients with nonpersistence was 1.11 (95% CI, 1.05-1.16). A similar trend was detected for cardiovascular mortality and in subgroup analyses. Large number of missing values; results may not be generalizable to women or the general US population. Predialysis cardiovascular medication nonadherence is an independent risk factor for postdialysis mortality in patients with advanced chronic kidney disease transitioning to dialysis therapy. Further studies are needed to assess whether interventions targeting adherence improve survival after dialysis therapy initiation.