Dialysis Withdrawal Research Articles

Causes and risk factors for peritoneal dialysis withdrawal.

This study intends to investigate the causes and risk factors for withdrawal from peritoneal dialysis (PD) in patients with end stage renal disease (ESRD). Two hundred ninety-three patients admitted to the peritoneal dialysis center in nephrology department for PD treatment were divided into 175 cases in group A (continuous treatment group) and 118 cases in group B (withdrawal group). The proportion of patients in group B whose primary disease was glomerulonephritis was significantly lower than that in group A (p <0.05), whereas the proportion of patients with diabetic nephropathy was significantly higher in group B than in group A (p <0.05). Group A received better emotional support and care services from family members than group B. Family care was mostly severely impaired in patients who died and were lost to follow-up. Diabetes mellitus, level of knowledge regarding PD, depression, and family care are risk factors for withdrawal from PD.

Predialysis serum lactate levels could predict dialysis withdrawal in Type 1 cardiorenal syndrome patients.

SummaryBackgroundRenal replacement therapy (RRT) is an effective rescue therapy for Type 1 cardiorenal syndrome (CRS). Previous studies have demonstrated that type 1 CRS patients with severe renal dysfunction were susceptible to sepsis, and that serum lactate has been correlated with the risk of mortality in patients with sepsis. However, the association between serum lactate level and the prognosis of type 1 CRS patients requiring RRT is unknown.MethodsAn inception cohort of 500 type 1 CRS patients who received RRT in a tertiary-care referral hospital in Taiwan from August 2011 to January 2018 were enrolled. The outcomes of interest were dialysis withdrawal and 90-day mortality. The results were further externally validated using sampling data of type 1 CRS patients requiring dialysis from multiple tertiary-care centers.FindingsThe 90-day mortality rate was 52.8% and the incidence rate of dialysis withdrawal was 34.8%. Lower pre-dialysis lactate was correlated with a higher rate of dialysis withdrawal and lower rate of mortality. Generalized additive model showed that 4.2 mmol/L was an adequate cut-off value of lactate to predict mortality. Taking mortality as a competing risk, Fine-Gray subdistribution hazard analysis further indicated that a low lactate level (≦ 4.2 mmol/L) was an independent predictor for the possibility of dialysis withdrawal, as also shown in external validation. The interaction of quick Sequential Organ Failure Assessment score and lactate was associated with dialysis dependence in a disease severity-dependent manner. Furthermore, the associations between hyperlactatemia and dialysis dependence were consistent in the patients with and without sepsis.InterpretationSerum lactate level is accurate and capable of forecasting the prognosis along with qSOFA severity for clinical decision-making for treating type 1 CRS patients. Further studies are needed to validate our results.FundingThis study was supported by grants from Taiwan National Science Council [104–2314-B-002–125-MY3,106–2314-B-002–166-MY3,107–2314-B-002–026-MY3], National Taiwan University Hospital [106-FTN20,106-P02,UN106–014,106-S3582,107-S3809,107-T02,PC1246,VN109–09,109-S4634,UN109–041], Ministry of Science and Technology of the Republic of China [MOST106–2321-B-182–002,106-2314-B-182A-064,MOST107–2321-B-182–004,MOST107-2314-B-182A-138, MOST108–2321-B-182–003,MOST109–2321-B-182–001, MOST108-2314-B-182A-027], Chang Gung Memorial Hospital [CMRPG-2G0361,CMRPG-2H0161,CMRPG-2J0261, CMRPG-2K0091], and Ministry of Health and Welfare of the Republic of China [PMRPG-2L0011].

Consensus Paper "Palliative renal care"

Palliativmedizinische Aspekte wie Dialysevorenthalt und -abbruch, Einleitung einer konservativen Therapie sowie kooperative Betreuung am Lebensende sind zunehmend Teil der nephrologischen Regelversorgung geworden. Die entsprechende Wissensvermittlung palliativmedizinischer Grundsätze fehlt bislang in Aus- und Weiterbildung. In diesem Konsensuspapier wird für das nephrologische Team eine strukturierte kurrikuläre Weiterbildung zu den Grundprinzipien einer palliativen Betreuung vorgeschlagen.

Dialysis withdrawal in The Netherlands between 2000 and 2019: time trends, risk factors and centre variation.

Background Dialysis withdrawal is a common cause of death in dialysis-dependent patients. This study aims to describe dialysis withdrawal practice in The Netherlands, focussing on time trends, risk factors and centre variation.MethodsData were retrieved from the Dutch registry of kidney replacement therapy patients. All patients who started maintenance dialysis and died in the period 2000–2019 were included. The main outcome was death after dialysis withdrawal; all other causes of death were used for comparison. Time trends were analysed as unadjusted data (proportion per year) and the year of death was included in a multivariable logistic model. Univariable and multivariable analyses were performed to identify factors associated with withdrawal. Centre variation was compared using funnel plots.ResultsA total of 34 692 patients started dialysis and 18 412 patients died while on dialysis. Dialysis withdrawal was an increasingly common cause of death, increasing from 18.3% in 2000–2004 to 26.8% in 2015–2019. Of all patients withdrawing, 26.1% discontinued treatment within their first year. In multivariable analysis, increasing age, female sex, haemodialysis as a treatment modality and year of death were independent factors associated with death after dialysis withdrawal. Centre variation was large (80.7 and 57.4% within 95% control limits of the funnel plots for 2000–2009 and 2010–2019, respectively), even after adjustment for confounding factors.ConclusionsTreatment withdrawal has become the main cause of death among dialysis-dependent patients in The Netherlands, with large variations between centres. These findings emphasize the need for timely advance care planning and improving the shared decision-making process on choosing dialysis or conservative care.

Integrated renal-palliative care in Germany- Results from a survey on end of life care in a non-profit provider.

Palliative care-related problems in end-stage renal patients are similar to those of cancer patients. While the literature on renal palliative care is growing, real-world data on practice patterns of an integrated palliative care approach (IPCA) in Germany are lacking. An anonymous survey of end of life care (ELC; conservative treatment, dialysis withdrawal, decision making) was mailed to head physicians of adult renal centers (N = 198) including 13structured questions and 1 open question for more detailed information on the current state of ELC. Afree text analysis of the quality of established care and further requirements was provided. Responses were received from 122 centers (62%) with 14,197 dialysis and 159,652 renal outpatients. Of the 122 centers 86 provided detailed responses to the open question and 4 different thematic patterns could be identified: centers with successfully established ELC (N = 17, 20%, group1), those where intensified training and education were required (N = 19, 22%, group2), centers which required structural improvement to establish IPCA (N = 39, 45%, group3) and those which did not require further supportive measures (N = 11, 13%, group4). Physician's age, sex, years of working in renal medicine, center size, and proportion of dialysis withdrawal and conservative treatment were not significantly different between the groups. Despite equal general conditions, only 20% reported successfully established IPCA. Two out of three centers requested specific measures to establish or improve palliative care. Implementation of IPCA is hampered by educational and structural constraints. These real-world data suggest that structural determinants and soft skills (e.g. team motivation, leadership) can influence ICPA.

Temporal changes and risk factors for death from early withdrawal within 12 months of dialysis initiation-a cohort study.

BackgroundMortality risk is high soon after dialysis initiation in patients with kidney failure, and dialysis withdrawal is a major cause of early mortality, attributed to psychosocial or medical reasons. The temporal trends and risk factors associated with cause-specific early dialysis withdrawal within 12 months of dialysis initiation remain uncertain.MethodsUsing data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the temporal trends and risk factors associated with mortality attributed to early psychosocial and medical withdrawals in incident adult dialysis patients in Australia between 2005 and 2018 using adjusted competing risk analyses.ResultsOf 32 274 incident dialysis patients, 3390 (11%) experienced death within 12 months post-dialysis initiation. Of these, 1225 (36%) were attributed to dialysis withdrawal, with 484 (14%) psychosocial withdrawals and 741 (22%) medical withdrawals. These patterns remained unchanged over the past two decades. Factors associated with increased risk of death from early psychosocial and medical withdrawals were older age, dialysis via central venous catheter, late referral and the presence of cerebrovascular disease; obesity and Asian ethnicity were associated with decreased risk. Risk factors associated with early psychosocial withdrawals were underweight and higher socioeconomic status. Presence of peripheral vascular disease, chronic lung disease and cancers were associated with early medical withdrawals.KEY LEARNING POINTSWhat is already known about this subject?dialysis withdrawal is a major cause of death in patients with kidney failure, and international registry reports suggested temporal increase in withdrawal-related mortality; andrisk factors associated with mortality from dialysis withdrawal were older age, Caucasian ethnicity, late nephrologist referral and haemodialysis as initial dialysis modality.What this study adds?the proportion of early mortality from dialysis withdrawal has remained unchanged in Australia since 2005;the annual proportion of early mortality attributed to medical withdrawals consistently surpassed the proportion of psychosocial withdrawals; andearly mortality attributed to psychosocial and medical withdrawals was associated with similar risk factors.What impact this may have on practice or policy?recognizing the patient at risk of early mortality attributed to dialysis withdrawal may better inform the shared decision-making process, empower patient-focused treatment choices and facilitate advanced care planning.ConclusionsDeath from dialysis withdrawal accounted for >30% of early deaths in kidney failure patients initiated on dialysis and remained unchanged over the past two decades. Several shared risk factors were observed between mortality attributed to early psychosocial and medical withdrawals.

Epidemiology of nursing home dialysis patients-A hidden population.

IntroductionDialysis patients are often discharged from hospitals to skilled nursing facilities (SNFs), but little has been published about their natural history.MethodsUsing electronic medical record data, we conducted a retrospective cohort study of nursing home patients treated with in‐SNF hemodialysis from January 1, 2018 through June 20, 2020 within a dialysis organization across eight states. A dialytic episode began with the first in‐SNF dialysis and was ended by hospitalization, death, transfer, or cessation of treatment. The clinical characteristics and natural history of these patients and their dialytic episodes are described.FindingsFour thousand five hundred and ten patients experienced 9274 dialytic episodes. Dialytic episodes had a median duration of 18 days (IQR: 8–38) and were terminated by a hospitalization n = 5747 (62%), transfer n = 2638 (28%), death n = 568 (6%), dialysis withdrawal n = 129 (1.4%), recovered function n = 2 (0.02%), or other cause n = 6 (0.06%). Increased patient mortality was associated with advancing age, low serum creatinine, albumin, or sodium, and low pre‐dialytic systolic blood pressure (sBP). U‐shaped relationships to mortality were observed for intradialytic hypotension frequency and for post‐ > pre‐hemodialysis sBP frequency. Prescription of dialysis five times weekly in the first 2 weeks was associated with better survival in the first 90 days (HR 0.77, CI 0.62–0.96; p < 0.02).DiscussionProvision of in‐SNF dialysis by an external dialysis organization enables discharge from the acute care setting for appropriate treatment with increased nursing contact time in an otherwise under‐resourced environment. SNF ESRD patient clinical characteristics and outcomes are extensively characterized for the first time.

FC 118DIALYSIS WITHDRAWAL IN THE NETHERLANDS BETWEEN 2000-2020: TIME TRENDS AND CENTRE VARIATION

Abstract Background and Aims Treatment withdrawal is an important cause of death among dialysis-dependent patients. Widely variable withdrawal rates were reported in studies using varying designs and definitions in culturally different regions of the world, limiting comparability of individual studies. Cessation of life-prolonging treatment is a well-accepted option in the Netherlands, however it is unclear if these premises result in higher dialysis withdrawal rates and if this effect is generalisable. This study aims to describe dialysis withdrawal practice in the Netherlands, focussing on time trends and practice variation between centres. Method Patient data was retrieved from RENINE, the Dutch national registration which includes nearly all patients requiring dialysis for at least 28 days. All patients who initiated maintenance dialysis from January 1, 2000, to December 31, 2020, and died within this period were included for analysis. Since the primary aim of this study concerned cause of death on dialysis, data of patients in whom dialysis was stopped due to kidney transplantation or recovery of kidney function, were excluded. Main outcome was death by dialysis withdrawal, as registered by the treating physician using ERA-EDTA codes. Other causes of death were used as comparison. Time trends for dialysis withdrawal were first analysed as unadjusted data (proportion per year). Univariable logistic regression analyses were then used to identify factors associated with dialysis withdrawal, including year of death in five-year strata. A multivariable model was subsequently used to determine risks, adjusting for factors associated with dialysis withdrawal. Centre variation was compared visually by using funnel plots. Results A total of 34.692 patients commenced maintenance dialysis of which 20.389 died. After applying exclusion criteria, a cohort of 18.412 patients was used for analysis. Dialysis withdrawal was an increasingly common cause of death, increasing from 13.5% in 2000 to 31.2% in 2019 (22.1% overall). In multivariable analysis, increasing age, female sex, increasing dialysis vintage, haemodialysis as treatment modality, and year of death were independent factors associated with death by dialysis withdrawal. Centre variation was large, even after correction for confounding factors (36.6% outside 95% control limits). Conclusion Treatment withdrawal has become the main cause of death in the Netherlands among dialysis-dependent patients during 2000-2020. Large practice variations were observed between centres, even after correction for confounding factors. These findings emphasize the need for timely advance care planning and urge treating health care professionals to better inform their patients when choosing to start dialysis or not.

MO171BARRIERS TO RENAL SUPPORTIVE CARE IN SINGAPORE: A SURVEY BASED STUDY OF NEPHROLOGISTS, GERIATRICIANS AND PALLIATIVE PHYSICIANS

Abstract Background and Aims Renal supportive care is a patient-centred approach to management of advanced chronic kidney disease, especially in elderly patients. Adoption of renal supportive care in Asian countries has been slow. This study aims to investigate the barriers towards renal supportive care as perceived by physicians in Singapore. Method An online survey was sent out to all practising and training nephrologists, geriatricians and palliative physicians in Singapore public hospitals between October 1st and October 30th 2020. Responses were compiled and analysed. Results Out of 365 surveys sent, 75 nephrologists, 43 geriatricians and 28 palliative care physicians responded, accounting for a 40% response rate. Most of the participants managed 16 to 30 chronic kidney disease patients in a week. Older patients aged &amp;gt;75 years accounted for at least 30% of the chronic kidney disease cohort managed by 72% of respondents. Most agreed that renal supportive care aims to improve quality of life in chronic kidney disease (97.9%) and can be implemented alongside life-prolonging treatments such as dialysis (83.6%). However, only 51.4% recognised a distinction between renal supportive care and palliative care. Fewer nephrologists compared to geriatricians received prior palliative care training (54.7% vs 93.0%) or were certified advanced care planning facilitators (33.3% vs 67.4%). All respondents agreed that nephrologists should be aware of basic principles of palliative care, and 89.7% felt that palliative care should be incorporated into nephrology training. Most were comfortable holding discussions regarding dialysis withholding and withdrawal (93.8% and 87.7% respectively), and managing symptoms of pain (74.7%), breathlessness (87.0%) and anticipated symptoms after dialysis withdrawal (78.8%). Fewer physicians were comfortable with managing symptoms of pruritus (65.1%) and restless legs syndrome (56.2%). Majority (60%) did not feel confident in providing spiritual support as part of end-of-life care. Main barriers to renal supportive care included inadequate time during clinic consults to address the patients’ needs (87%), reliance on family members to make decisions (69.2%), inadequate palliative training during fellowship (67.1%) and inadequate community support services (55.5%). Some cited lack of awareness and acceptability of renal supportive care amongst patients and relatives in Singapore’s Asian cultural context. Most felt that encouraging advanced care planning discussions earlier in the course of chronic kidney disease (80.8%), having dedicated renal supportive care services in hospital (78.1%) and including palliative care rotation as part of training (69.2%) could potentially increase uptake of renal supportive care in Singapore. Conclusion Nephrologists, geriatricians and palliative physicians in Singapore recognise the value of renal supportive care, but are faced with barriers such as patients’ and family’s resistance toward renal supportive care as well as inadequate palliative training. A unique model of renal supportive care with the patient as well as family’s involvement early in the decision-making process is likely to be better perceived in Asian countries. Incorporation of palliative care training in the nephrology fellowship curriculum should be considered.

POS-672 CONSERVATIVE AND PALLIATIVE CARE OF PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE

The number of patients with advanced chronic kidney disease who opt for supportive therapy or withdraw from dialysis is increasing world widely. In our research we verified the knowledge of legal regulations, the attitude towards conservative therapy, dialysis withdrawal and palliative care in patients with advanced chronic kidney disease in Slovenia. The research was performed among nephrologists and nephrology fellows using an electronic survey based on modified European research »European Renal Best Practice Survey«. Forty-one nephrologists and nephrology fellows of the Slovenian Society of Nephrology participated in the research, 59% were female, the majority (55%) aged 35 to 50 with more than 10 years of service (57%) in the inpatient setting (50%). 39% of the participants knew that the right to palliative care in our country has a legal background and 32% were familiar with the legal possibility of advanced patients will on intensity of treatment. According to participants opinion, 79% of their patients were not familiar with the option of advanced will although the great majority of participants were familiar with the definition of patient autonomy. 11% of participants reported withdrawal from dialysis on the request of the patient. In 86% of participants the decision on dialysis withdrawal was based on the proposition of the patient or his relatives (76%) after detailed consultation with other nephrologists. Only 48% of nephrologists would respect the patient advanced will to withdraw from dialysis if his relatives opposed. 84% of the participants believed that health professionals are not familiar enough with the organization of palliative care in their region, although 57% of their patients were discharged in their home environment. 59% of nephrologists attended education on the topic of palliative care, mostly on national meetings (88%). We need to improve the knowledge of nephrologists on supportive and palliative care in nephrology, their communication skills and knowledge on legal patients’ rights to be able to fully respect autonomy of patients, based on timely extensive education of patients considering their therapeutic options and advanced will.

Risk factors for peritoneal dialysis withdrawal due to peritoneal dialysis-related peritonitis

BackgroundPeritoneal dialysis has become commonly used for renal replacement therapy; however, some patients withdraw from peritoneal dialysis due to complications, including peritoneal dialysis-related peritonitis, resulting in the low number of patients on peritoneal dialysis. Risk factors for peritoneal dialysis withdrawal due to peritoneal dialysis-related peritonitis are less certain. This retrospective study aimed to investigate these risk factors. MethodsWe retrospectively analyzed clinical characteristics, laboratory data, and causative microorganisms of 204 episodes of peritoneal dialysis-related peritonitis between 2007 and 2018 at our institution. ResultsOf the 204 episodes, 38 resulted in withdrawal from peritoneal dialysis due to peritoneal dialysis-related peritonitis. The number of peritonitis episodes per patient-year and the incidence of cardiovascular disease were significantly higher in the withdrawal group. Similarly, this group had low levels of serum creatinine, urea nitrogen, serum albumin, alanine aminotransferase, cholinesterase and high C-reactive protein, and second dialysate cell counts after antibiotic administration. Multivariate logistic regression analysis revealed that serum albumin (odds ratio: 0.465; 95% confidence interval: 0.249–0.868; P=0.016) and cardiovascular disease (odds ratio: 2.508; 95% confidence interval: 1.184–5.315; P=0.016) exhibited significant differences. ConclusionsThe results of this study suggest that hypoalbuminemia and the presence of cardiovascular disease were independent risk factors for withdrawal from peritoneal dialysis due to peritoneal dialysis-related peritonitis.

The Prevalence and Severity of Chronic Pain in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Background:Chronic pain is a common and distressing symptom reported by patients with chronic kidney disease (CKD). Clinical practice and research in this area do not appear to be advancing sufficiently to address the issue of chronic pain management in patients with CKD.Objectives:To determine the prevalence and severity of chronic pain in patients with CKD.Design:Systematic review and meta-analysis.Setting:Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity.Patients:Adults with glomerular filtration rate (GFR) category 3 to 5 CKD including dialysis patients and those managed conservatively without dialysis.Measurements:Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of pain, and severity of pain.Methods:Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library, last searched on February 3, 2020. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of overall chronic pain, musculoskeletal pain, bone/joint pain, muscle pain/soreness, and neuropathic pain and the I2 statistic was computed to measure heterogeneity. Random effects models were used to account for variations in study design and sample populations and a double arcsine transformation was used in the model calculations to account for potential overweighting of studies reporting either very high or very low prevalence measurements. Pain severity scores were calibrated to a score out of 10, to compare across studies. Weighted mean severity scores and 95% confidence intervals were reported.Results:Sixty-eight studies representing 16 558 patients from 26 countries were included. The mean prevalence of chronic pain in hemodialysis patients was 60.5%, and the mean prevalence of moderate or severe pain was 43.6%. Although limited, pain prevalence data for peritoneal dialysis patients (35.9%), those managed conservatively without dialysis (59.8%), those following withdrawal of dialysis (39.2%), and patients with earlier GFR category of CKD (61.2%) suggest similarly high prevalence rates.Limitations:Studies lacked a consistent approach to defining the chronicity and nature of pain. There was also variability in the measures used to determine pain severity, limiting the ability to compare findings across populations. Furthermore, most studies reported mean severity scores for the entire cohort, rather than reporting the prevalence (numerator and denominator) for each of the pain severity categories (mild, moderate, and severe). Mean severity scores for a population do not allow for “responder analyses” nor allow for an understanding of clinically relevant pain.Conclusions:Chronic pain is common and often severe across diverse CKD populations providing a strong imperative to establish chronic pain management as a clinical and research priority. Future research needs to move toward a better understanding of the determinants of chronic pain and to evaluating the effectiveness of pain management strategies with particular attention to the patient outcomes such as overall symptom burden, physical function, and quality of life. The current variability in the outcome measures used to assess pain limits the ability to pool data or make comparisons among studies, which will hinder future evaluations of the efficacy and effectiveness of treatments. Recommendations for measuring and reporting pain in future CKD studies are provided.Trial registration:PROSPERO Registration number CRD42020166965

Nephrologists' Perspectives on Decision Making About Life-Sustaining Treatment and Palliative Care at End of Life: A Questionnaire Survey in Korea.

Background: Nephrologists commonly engage in decision making regarding the withholding or withdrawal of dialysis and palliative care in patients at end of life (EoL). However, these issues remain an unsolved dilemma for nephrologists. Objective: To explore nephrologists' perceptions on the decision-making process about withholding or withdrawing dialysis and palliative care in Korea. Design: A nationwide 25-item questionnaire online survey via e-mail. Setting/Subjects: A total of 369 Korean nephrologists completed the survey. Results: The proportions of respondents who stated that withholding or withdrawing dialysis at EoL is ethically appropriate were 87.3% and 86.2%, respectively. A total of 72.4% respondents thought that withdrawal of dialysis in a maintenance dialysis patient is ethically appropriate. Responses regarding patient features that should be considered to withhold or withdraw dialysis were as follows: dialysis intolerance (84.3%), poor performance status (74.8%), patient's active request (47.2%), age (28.7%), very severe dementia (27.1%), and several comorbidities (16.5%). Among those nephrologists who responded to the question about the minimum age, at which dialysis should be withheld or withdrawn, most specified an age between 80 and 90 years (94.3%). Fifty-eight percent of respondents stated that terminally ill dialysis patients should be allowed to use palliative care facilities. In addition, a number of nephrologists thought that adequate palliative care facilities, specific treatment guidelines, enough time to manage patients, financial support, and adequate medical experts are necessary. Conclusions: Korean nephrologists thought that withholding or withdrawing dialysis at EoL is ethically appropriate, even in maintenance dialysis patients. Therefore, consensus guidelines for palliative care after withholding or withdrawal of dialysis are needed.

Depression among Chronic Kidney Diseases Patients Receiving Hemodialysis

Background: Chronic Kidney Disease (CKD) is a progressive irreversible loss of renal function over a period of months or years. When kidney disease progresses, it may eventually lead to kidney failure, which requires dialysis or a kidney transplant to maintains life. Hemodialysis is used for patients who require short term dialysis (days to weeks) and for patients with advanced CKD and End Stage renal Disease (ESRD) who require long term or permanent renal replacement therapy. Hemodialysis significantly and adversely affects the lives of patients, both physically and psychologically. Depression is the most common psychological condition among patients with ESRD. Depression in dialysis patients not only effect mortality, but increased rate of hospitalizations and dialysis withdrawal is also very common.&#x0D; Methods: A descriptive cross sectional research design was carried out to identify the depression level of chronic kidney disease patients receiving Hemodialysis in Western Regional Hospital, Pokhara using Beck Depression Inventory among forty six patients.&#x0D; Results: The study findings revealed that majority of the patients (84.8%) has various degree of depression i.e. mild (21.7%), moderate (30.8%) and severe (32.6%). Only fifteen percent of patient has no depression. There was no statistical association between the level of depression and socio-demographic variables. It can be concluded that the prevalence of depression is high among patients receiving Hemodialysis.&#x0D; Conclusion: The prevalence of depression is high among patients receiving Hemodialysis. It is effective to provide mental health services to the CKD patients receiving Hemodialysis which help them better psychologically adaptation to their disease and improve their quality of life.

Clinical features and long-term outcomes of Chinese patients with scleroderma renal crisis.

To investigate the clinical features, treatments, and long-term outcomes of Chinese patients with scleroderma renal crisis (SRC). We retrospectively reviewed the clinical and laboratory data of 538 patients with systemic sclerosis (SSc) at our center from January 2009 to December 2016, including 29 SRC and 509 SSc without SRC patients. The treatments and long-term outcomes of patients with SRC were also retrospectively analyzed. The prevalence of SRC was 5.4% in our cohort. Male gender (odds ratio [OR] =4.194 [95% CI 1.494-11.773]), glucocorticoid exposure (OR=3.666 [1.484-9.056]), pericardial effusion (OR=11.180 [4.515-27.681]), and myocardial involvement (OR=7.958 [1.664-38.064]) were associated with an increased risk of development of SRC. Despite the wide use of angiotensin-converting enzyme inhibitors, the permanent dialysis rate of patients with SRC was 48.3%. Sixteen patients died during follow-up, and the estimated 1- and 5-year survival rates of patients with SRC were 62.1% and 47.3%, respectively. Withdrawal of dialysis (5 patients) and myocardial complications (3 patients) were the main causes of death in patients with SRC. Patients with serum creatinine level >500µmol/L before treatment (log rank test 5.051, P=0.025) and/or those who needed dialysis at the onset of SRC (log rank test 12.870, P<0.001) showed poorer prognosis. SRC is a rare but severe complication in patients with SSc. Male gender, glucocorticoid exposure, pericardial effusion, and myocardial involvement were risk factors in the development of SRC. Withdrawal of dialysis and myocardial complications were the main causes of death in Chinese patients with SRC.

Systemic sclerosis and end-stage renal disease: study of patient characteristics, follow-up and outcomes in France.

Scleroderma renal crisis (SRC), the most frequent renal complication of Systemic Sclerosis (SSc), can lead to end-stage renal disease (ESRD),most frequently, but not exclusively, because ofscleroderma renal crisis (SRC). The main objectives of our study using data extracted from the French renal epidemiology and information network (REIN) registry, were to describe the characteristics and outcomes in an incident French cohort of SSc patients requiring renal replacement therapy (RRT) compared with a matched RRT patient sample. Between 2002 and 2014, 120 incident SSc patients started RRT in France. SSc was significantly associated with higher mortality (HR 1.95; 95% CI 1.41-2.71; p = 0.001) in comparison with matched controls. Among SSc patients in dialysis, besides age, the only risk factor independently associated with mortality was the inability to walk without help (HR 2.34, CI 95% 1.37-4.02, p = 0.002). Dialysis withdrawal was reported for 22 (18.3%) of the SSc patients compared to 15 (6.3%) for the controls. Patients with SSc have less access to transplantation waiting list (HR 0.21; CI 95% 0.11-0.41, p < 0.001) and to kidney transplantation (KTR) (HR 0.22; 95% CI 0.12-0.43; p < 0.001). During the follow-up, 6 of the 27 patients (22.2%) registered on KTR waiting list died compared to 69 of the 93 (74.2%) patients who were not on the waiting list. The prognosis for SSc patients requiring RRT is still poor, with a significantly higher mortality and lower registration on kidney transplant waiting-list compared to matched controls.

SUN-286 HEMODIALYSIS IN EDERLY PATIENTS

When dialysis was a scarce resource worldwide, patients of advanced age were often excluded. However, this has changed dramatically. Haemodialysis (HD) of elderly patients has become routine. As a consequence of the aging of the dialysis population, new issues have emerged. HD in elderly and very elderly patients has important differences from younger patients, and an understanding of these issues is critical in effectively guiding their care. Until recently, many studies used a cut-off of 65-year-old (or even younger) as a definition of elderly, grouping all patients over that age. We choose in our study to select patients above 60-year-old as elderly patients. We collected data of patients over 60-year-old who underwent dialysis in our dialysis centre for a period of three months. Our data collection items contain patient identity, his personal medical information, the clinical exam before dialysis, laboratory test before dialysis and evolution during dialysis and after. We used the dialysis registry in the nephrology unit to gather data. Patients who underwent few sessions of dialysis less than 3 months in the dialysis unit were excluded. Patients discharged from hospitalization to their dialysis unit with a normal follow up were included. Our primary end point in this cohort is three months’ survival of the patients. Secondary end points were characteristics of this group, dialysis tolerance and dialysis withdrawal. We use IBM Statistics SPSS v.21 to analyse our data. Our cohort collected data of fifty patients who underwent dialysis in our centre who were above 60 years of age. The gender ratio was 28/22 (56%/44%) (male vs female). The age repartition is as following: 52% are between 60 and 69 year old, 38% between 70 and 79 year old, 8% between 80 and 89 year old and 2% (one patient) above 90 years of age (diagram 1). The most of our patients came from three main units: emergency unit and intensive care unit (ICU) and resuscitation unit with respectively 34%, 10% and 10% (table 1) of the patients hospitalized in these units. Another important part of our patients (12%) are coming from home for their dialysis; these patients moved to the Marrakech for any reasons, or have recently settled down. The Charleson comorbidity score (CCS) was evaluated in our cohort. We found that most of our patients had a CCS 5 or 6 respectively 36% and 34% (table 2). Other clinical and biological exams are summarized in the table 3Tabled 1Clinical dataBiological examsMean (min - max)Hypertension60%Urea (g/l)2.7 (0.5 - 5)Diabetes2% (T1), 50% (T2)Creatinine (mg/l)108 (15 - 231)Cardiac disease46%Calcium (mg/l)76.3 (46 - 98)Anemia72%Phosphorus (mg/l)83.2 (47 - 139)Oedema36%CRP (mg/l)139 (6 - 519)Dehydration12%Haemoglobin (g/dl)8.9 (3.5 – 14.5)Diuresis32% (anuric) 28% (Oliguric)Potassium (mmol/l)5.3 (2.9 – 8.2)Pulmonary crackles26%Sodium (mEq/l)135 (122 - 163)Bicarbonates (mmol/l)12 (5 - 23) Open table in a new tab The mortality rate in our cohort was under the rate described in other cohorts. Most of our patients are from emergency units and the CVVH would be suitable for such patients. Unfortunately they can't because it's not available.

Factors Associated with Elective Withdrawal of Maintenance Hemodialysis: A Case-Control Analysis

Background: Associations of demographic factors with elective dialysis withdrawal and setting of death, patterns of illness trajectories preceding death, and how illness trajectories, particularly worsening putative disability, are associated with elective withdrawal are poorly understood. Methods: Using United States Renal Data System data, we performed a case-control analysis of hemodialysis patients who died in 2010–2015. A disability proxy score characterized disability; logistic regression identified characteristics associated with death from withdrawal and with death setting; and group-based trajectory models characterized the trajectory of disability in the months preceding death. Results: We identified 14,571 (9.2%) patients who withdrew and 144,305 (90.8%) who died of a non-withdrawal cause. Women were more likely than men to withdraw (OR 1.19, 95% CI 1.15–1.24). The most rural patients were more likely to withdraw than the most urban (OR 1.37, 95% CI 1.25–1.50). Medicaid coverage (a marker for impoverishment) was associated with less withdrawal (OR 0.90, 95% CI 0.86–0.94). Disability proxy score was strongly related to withdrawal: the OR for patients in the highest score category was 31.16 (95% CI 28.40–34.20) versus those with a score of 0. Women and whites (vs. blacks) were overrepresented in the worst, versus better, proxy disability score trajectory. In-hospital death and death in the intensive care unit were more common in women and minorities than in men and whites, but less common in the most rural patients. Conclusions: Important differences separate patients who electively withdraw from those who die of non-withdrawal causes. Worsening disability, in particular, may be a marker for withdrawal.

Haemodialysis withdrawal in Australia and New Zealand: a binational registry study.

Withdrawal from dialysis is an increasingly common cause of death in patients with end-stage kidney disease (ESKD). As most published reports of dialysis withdrawal have been outside the Oceania region, the aims of this study were to determine the frequency, temporal pattern and predictors of dialysis withdrawal in Australian and New Zealand patients receiving chronic haemodialysis. This study included all people with ESKD in Australia and New Zealand who commenced chronic haemodialysis between 1 January 1997 and 31 December 2016, using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Competing risk regression models were used to identify predictors of dialysis withdrawal mortality, using non-withdrawal cause of death as the competing risk event. Among 40447 people receiving chronic haemodialysis (median age 62 years, 61% male, 9% Indigenous), dialysis withdrawal mortality rates increased from 1.02 per 100 patient-years (11% of all deaths) during the period 1997-2000 to 2.20 per 100 patient-years (32% of all deaths) during 2013-16 (P < 0.001). Variables that were significantly associated with a higher likelihood of haemodialysis withdrawal were older age {≥70 years subdistribution hazard ratio [SHR] 1.77 [95% confidence interval (CI) 1.66-1.89]; reference 60-70 years}, female sex [SHR 1.14 (95% CI 1.09-1.21)], white race [Asian SHR 0.56 (95% CI 0.49-0.65), Aboriginal and Torres Strait Islander SHR 0.83 (95% CI 0.74-0.93), Pacific Islander SHR 0.47 (95% CI 0.39-0.68), reference white race], coronary artery disease [SHR 1.18 (95% CI 1.11-1.25)], cerebrovascular disease [SHR 1.15 (95% CI 1.08-1.23)], chronic lung disease [SHR 1.13 (95% CI 1.06-1.21)] and more recent era [2013-16 SHR 3.96 (95% CI 3.56-4.48); reference 1997-2000]. Death due to haemodialysis withdrawal has become increasingly common in Australia and New Zealand over time. Predictors of haemodialysis withdrawal include older age, female sex, white race and haemodialysis commencement in a more recent era.

SAT-037 STUDY PROTOCOL FOR THE SYMPTOM MONITORING WITH FEEDBACK TRIAL (SWIFT): A NOVEL REGISTRY-BASED CLUSTER RANDOMISED TRIAL AMONG ADULTS WITH END-STAGE KIDNEY DISEASE MANAGED ON HAEMODIALYSIS

Women and men on haemodialysis frequently experience symptoms of severe or overwhelming pain, fatigue, nausea, cramping, itching, trouble sleeping, and depression that contribute to poor quality of life. A focus on laboratory biomarkers of lower relevance to patients, may have resulted in missed opportunities to intervene and reduce symptoms and improve health-related quality of life. Recent trials in other clinical settings have shown that active symptom management can improve overall survival. The aim of this trial is to determine whether regular symptom monitoring with feedback to the renal team can improve health-related quality of life and overall survival among adults with end-stage kidney disease (ESKD) managed with facility-haemodialysis. Using a novel ANZDATA registry-based cluster randomised trial design, with adults receiving haemodialysis, the proposed trial will test the hypothesis that: 1) three-monthly symptom monitoring using the IPOS-Renal tool with feedback to clinicians improves health-related quality of life (measured by the EQ-5D), dialysis duration and frequency, and cause-specific mortality compared with usual care; and 2) electronic capture of patient-reported outcomes within a clinical quality registry is cost-effective. A two-arm design of 160 clusters (~3072 individuals) has 90% power to detect a 7% clinically meaningful increase in health-related quality of life (primary endpoint); and 80% power to detect an 11% reduction in deaths from dialysis withdrawal (secondary endpoint). The SWIFT pilot study commencing in December 2018 will assess the feasibility and acceptability of the intervention to patients and clinicians including feedback of how data was used. Funding for the SWIFT pilot study was awarded from Kidney Health Australia in July 2018. Ethics approval was received in August 2018, and the electronic patient reported outcome measures were developed in Qualtrics software, with a novel QR reader interface to link with the ANZDATA registry. Preliminary user testing suggested the recording of quality of life and symptom scores within defined response categories is straight forward, however has identified issues with the touch screen interface on tablet computers for the EQ-5D visual analogue scale. The findings from SWIFT may result in improved quality of life, lower symptom burden (both severity and number of symptoms), and lower rates of dialysis withdrawal with the potential to change practice in haemodialysis care. Of significance, SWIFT provides a template for registry-based randomised trial of health services interventions; ongoing bi-national monitoring of patient-reported outcome measures; and infrastructure for economic evaluation of subsequent interventions.