End-stage Kidney Disease Population Research Articles

#541 Secular trends in CKD and ESKD mortality rates in the United States, 2011–2021

Abstract Background and Aims Patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) have a considerably higher mortality than the general population. Nevertheless, in the United States, mortality rates in the CKD and ESKD populations have declined steadily over the last decade until the onset of the COVID-19 pandemic [1]. Through a quantitative analysis of the age- and time-dependence of mortality rates in renal patient populations in the US, we aimed at quantifying trends in life expectancy between 2011 and 2021. Method We analysed CKD and ESKD mortality rates as reported in the US Renal Data System's (USRDS) Annual Data Report 2023 for the years 2011–2021 [1]. There, CKD mortality rates were determined from a Medicare 5% random sample (CKD stages 4 and 5) for patients aged 65 and above (“CKD 65+”). ESKD mortality rates were obtained from the USRDS database; we analysed data for patients aged 45 and above (“ESKD 45+”). We used fits of analytical functions to the data to hosphorzed their dependence on age and time. This technique enables us to extract quantitative trends in time by tracking fit parameters. Results We found that for each year between 2011 and 2021, mortality rates in the adult CKD and ESKD populations in the US largely conformed to an exponential dependence on patient age, $m = {{m}_0}( t ){{2}^{a/{{\Delta }}a}}$, that is, mortality rates doubled over constant age increments ${{\Delta }}a$. While overall, mortality rates were declining between 2011 and 2019, the age increments over which mortality rates doubled were nearly identical for each year (CKD 65+: ${{\Delta }}a$ = 10.5 ± 0.4 y, ESKD 45+: ${{\Delta }}a$ = 15.1 ± 0.9 y; mean ± SD). Exploiting this simple relationship, we found that the changes in mortality rates over time could largely be reduced to a steady right-shift of an otherwise unchanged mortality curve over time (shown for the ESKD 45+ group in Fig. 1a). By quantifying this right-shift over time, we estimated the gain in 1-year survival probability for different ages (Fig. 1b,c). This gain in survival does not necessarily imply a prolonged time on renal replacement therapy (RRT), e.g., when patients concomitantly start RRT at a later age. The onset of the COVID-19 pandemic in 2020 coincides with an abrupt cessation of these positive trends, reflected by a setback of mortality curves close to those in the year 2016 for the CKD population and to before 2011 for the ESKD population. Conclusion Public health data on CKD and ESKD show systematic dependencies of mortality rates on age and time, which can be revealed using analytical parameterisations of the data. Using this technique, we can capture trends in mortality rates and 1-year survival probability in adult kidney patient populations in the US during the years 2011–2019 and can quantify the abrupt cessation of these trends during the onset of the COVID-19 pandemic. In the CKD population we observed a setback of mortality rates close to those in the year 2016 with the onset of the pandemic. Changes in mortality rates in the ESKD population were more distinct. Specifically in elderly patients (aged 65 and above) 1-year survival dropped abruptly to levels lower than those observed in the previous decade.

#1454 Usefulness of the clinical frailty scale in Dutch patients with end-stage kidney disease

Abstract Background and Aims Frailty is common in end-stage kidney disease (ESKD) patients which may benefit from advance care planning. Currently there are multiple frailty screening instruments available, of which the Frailty Index is commonly used to estimate frailty in ESKD patients. The Clinical Frailty Scale is a less time consuming alternative to estimate frailty. We aimed to investigate the performance of the Clinical Frailty Scale as a screening tool for frailty in an ESKD population. Method A cross-sectional observational study was performed at Kidney Centre Apeldoorn. Included patients received haemodialysis, peritoneal dialysis, pre-dialysis care, or conservative treatment. Frailty was assessed with both the Frailty Index and the Clinical Frailty Scale. The Frailty Index consisted of 38 components considering activities of daily living, physical aspects, psychosocial factors, comorbidities, and functional tests. The functional tests included grip strength, walking speed, and cognitive functioning measured by the Mini Mental State Examination. The Frailty Index was calculated by dividing the number of deficits by the total number of components measured. A patient with a Frailty Index ≥0.25 was considered frail. The Clinical Frailty Scale consisted of nine classes varying from very fit to terminally ill. Patients who scored 4 on the Clinical Frailty Scale were considered vulnerable. Patients with a score ≥5 were considered frail. Nephrologists not familiar with the Clinical Frailty Scale were asked to complete the Clinical Frailty Scale after medical consultation. The sensitivity, specificity and area under the curve (AUC) of the Clinical Frailty Scale were determined. The Frailty Index was used as the golden standard. Results In total, 144 patients were included of whom 60 (41.7%) were frail according to the Frailty Index. The mean age was 67.4 years (SD±13.5) and 56 (38.9%) were female. Overall, 72 patients (50.0%) were treated by haemodialysis, 13 (9.0%) by peritoneal dialysis, 6 (4.2%) received conservative treatment, and 53 (36.8%) were pre-dialysis patients. According to the Frailty Index, 55.6% of the haemodialysis patients were frail compared to 20.8% of the pre-dialysis patients. The Clinical Frailty Scale identified 37 (25.7%) patients as frail and 17 (11.8%) patients as vulnerable. The cut-off point of the Clinical Frailty Scale for vulnerable (≥4) had a sensitivity of 63.3%, a specificity of 81.0%, and AUC of 0.72. The cut-off point of the Clinical Frailty Scale for frail (≥5) had a sensitivity of 50.0%, a specificity of 91.7%, and AUC of 0.71. Conclusion Prevalence of frailty was high in patients with ESKD. Although the Clinical Frailty Scale is a quick and easy tool for the identification of frailty in ESKD patients, the sensitivity of the Clinical Frailty Scale was too low to implement it in daily clinical practice. Sensitivity might be increased by training of nephrologists in using the Clinical Frailty Scale.

What to do with foundation therapies for heart failure for patients with end-stage kidney disease on haemodialysis.

There is a significant burden of cardiovascular disease morbidity and mortality in the end-stage kidney disease population, driven by traditional and non-traditional risk factors. Despite its prevalence, heart failure is difficult to diagnose in the dialysis population due to overlapping clinical presentations, limitations of investigations, and the impact on the cardiorenal axis. 'Foundation therapies' are the key medications which improve patient outcomes in heart failure with reduced ejection fraction and include beta-blockers, renin-angiotensin-aldosterone system inhibitors and sodium-glucose cotransporter-2 inhibitors. They are underutilised in the dialysis population due to the exclusion of chronic kidney disease patients from major trials and legitimate clinical concerns e.g. hyperkalaemia, intradialytic hypotension and residual kidney function preservation. A coordinated cardiorenal multidisciplinary approach can guide appropriate diagnostic considerations (biomarkers interpretation, imaging, addressing unique complications of kidney disease), optimise dialysis management (prescription length, frequency and ultrafiltration targets) and when at euvolaemia facilitate the stepwise introduction of appropriate foundation therapies.

Age- and Race-Specific Changes in ESKD Incidence over Four Decades.

ESKD incidence has changed substantially in the past four decades, but differences by age and race have been unexplored. Using data from the United States Renal Data System, we found that ESKD incidence rose for Black and White teenagers, adults, and older adults for two decades beginning in 1980. Growth in incidence slowed for most groups by 1993, and by 2006, the annual percent change (APC) in ESKD incidence had declined for all groups, except White adults, for whom rates continued to rise. By 2019, ESKD incidence among Black and White adolescents nearly returned to 1980 levels, but no other group achieved that degree of improvement. Nonetheless, the ESKD incidence rate among Black American patients exceeds that of White patients in every age group. Distinct patterns in ESKD incidence among patients of different age, sex, and racial groups are shown. These findings could reflect changes in dialysis acceptance rates, access to preventive health care, incidence of diabetes mellitus, implementation of evidence-based guidelines for treatment of CKD, or other unrecognized factors. There may be population-specific opportunities to change the growth of the US ESKD population and address current racial disparities. Substantial changes in ESKD incidence over four decades among Black and White Americans of different ages have been incompletely explored. We analyzed United States Renal Data System data from 1980 to 2019 to determine ESKD incidence trends among Black and White adolescent (13-17 years), adult (18-64 years), and older adult (≥65) populations. We used the National Cancer Institute Joinpoint Regression Program to estimate annual percent change (APC) in ESKD incidence and to define points in time where a statistically significant change in APC slope occurred for each group. ESKD incidence rose after 1980 for all groups, although the trends differed ( P < 0.001). Growth in incidence slowed for most by 1993, and by 2006, the APC in ESKD incidence had declined for all groups, except White adults, for whom rates continued to rise ( P < 0.05). By 2019, ESKD incidence among Black and White adolescents nearly returned to 1980 levels, but no other group achieved that degree of improvement. Nonetheless, the ESKD incidence among Black American patients exceeds that of White patients in every age group. Distinct patterns in ESKD incidence among patients of different age, sex, and racial groups are shown. These findings could reflect changes in dialysis acceptance rates, access to preventive health care, incidence of diabetes mellitus, implementation of evidence-based guidelines for treatment of CKD, or other unrecognized factors. This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2024_03_13_ASN0000000000000310.mp3.

Assessment of Hemorrhagic Risk in Maintenance Hemodialysis Population using Different Clinical Tools

BACKGROUND: End stage kidney disease (ESKD) patients receiving maintenance hemodialysis (HD) face an elevated bleeding risk. There are the factors such as body mass index (BMI), comorbidities, and medications such as antiplatelet, anticoagulants, and nonsteroidal anti-inflammatory drugs that increase the bleeding risk. The validity of bleeding risk assessment tools in the ESKD population needs to be studied. MATERIALS AND METHODS: This was a prospective, observational study in a HD unit at a tertiary care teaching hospital in Ajman. Sixty adult patients on regular maintenance HD sessions were included in the study. Severity of bleeding was categorized based on the World Health Organization (WHO) classification. Each patient’s risk of bleeding was assessed monthly using 9 different bleeding risk assessment tools (HASBLED, ATRIA, HEMORR2HAGES, ORBIT, IMPROVE, OBRI, S2TOP-BLEED, intracranial-B2 LEED3S, and Glasgow Blatchford Score for gastrointestinal bleeding) for 6 months’ period. Patients were categorized into low- and high-risk groups according to their risk scores. The predictive power of risk assessment tools was assessed by calculating its sensitivity and specificity. Receiver operating characteristic (ROC) curve was plotted, and the area under the curve was estimated for each risk assessment tool. Logistic regression model was also done using the SPSS software version 29. RESULTS: The mean age of the study group was 56 years, and the average BMI was 27 kg/m2. A total of 20 bleeding events were reported among ten patients (16.7%). The WHO category 1 and WHO category 2 bleeding were observed in 15 and 5 bleeding events, respectively. None had category 3 or 4 bleeding. Bleeding risk was found to be associated with ethnicity and obesity but not to other patient demographic factors or medication use. Based on sensitivity, specificity, positive predictive value, negative predictive value, and the area under the ROC curve, HEMORR2HAGES score showed better prediction of bleeding risk compared to the other tools used. CONCLUSION: In conclusion, most of the risk assessment tools showed poor predictive value in the maintenance HD population. Existing bleeding risk tools may not be helpful in dialysis patients. A more valid bleeding risk tool needs to be developed for the ESKD patient population.

High-Dimensional Fixed Effects Profiling Models and Applications in End-Stage Kidney Disease Patients: Current State and Future Directions.

Profiling analysis aims to evaluate health care providers, including hospitals, nursing homes, or dialysis facilities among others with respect to a patient outcome, such as 30-day unplanned hospital readmission or mortality. Fixed effects (FE) profiling models have been developed over the last decade, motivated by the overall need to (a) improve accurate identification or "flagging" of under-performing providers, (b) relax assumptions inherent in random effects (RE) profiling models, and (c) take into consideration the unique disease characteristics and care/treatment processes of end-stage kidney disease (ESKD) patients on dialysis. In this paper, we review the current state of FE methodologies and their rationale in the ESKD population and illustrate applications in four key areas: profiling dialysis facilities for (1) patient hospitalizations over time (longitudinally) using standardized dynamic readmission ratio (SDRR), (2) identification of dialysis facility characteristics (e.g., staffing level) that contribute to hospital readmission, and (3) adverse recurrent events using standardized event ratio (SER). Also, we examine the operating characteristics with a focus on FE profiling models. Throughout these areas of applications to the ESKD population, we identify challenges for future research in both methodology and clinical studies.

#4245 CATHETER-ASSOCIATED BLOODSTREAM INFECTIONS IN A HOSPITAL DIALYSIS UNIT – SEASONAL INFLUENCE AND COVID-19 PANDEMIC

Abstract Background and Aims Catheter-associated bloodstream infections (CRBSI) are an important source of morbidity and mortality among patients receiving hemodialysis through a central venous catheter (CVC). Despite of the efforts to choose the arteriovenous fistula as the first vascular access, a large proportion of end stage kidney disease population initiates dialysis using these catheters. Thus, efforts to prevent catheter-associated bloodstream infections remain important. The aim of our study is to analyze the outcomes of the episodes of CRBSI in our dialysis unit. Secondly, we evaluated the seasonal distribution and the possible impact of infection-control measures implemented during COVID-19 pandemic. Method We conducted a single-center retrospective observational study of all cases of tunneled dialysis catheter-associated bacteremia that need hospitalization during a nine-year period (January 2013 – December 2022). Results A total of 67 episodes of catheter-associated bloodstream infections in 52 hemodialysis patients were registered. This translates into a total of 2 episodes per 1000 catheter-days. Among all patients, the mean age was 68.5 years, 74.6% were men and 25.4% women. Five patients (9.6%) had any type of immunosuppressive treatment. Nearly 88% used a tunneled jugular catheter as definite vascular access and the remainder used a femoral one. Eighteen of all episodes (26.9%) occurred during the first thirty days of catheter implantation. Ten of all patients (19.2%) suffer at least a second infection during the follow-up period, without differences in clinical and demographic characteristics. The microbial etiology of the infections were Gram-positive organisms in 67.2% and, within these, 83% were Staphylococcus Aureus. The catheter had to be removed in 65.7% of all cases and there were significant difference (p&amp;lt;0.01) between Gram negative infections (preservation of 70%, successfully treated with prolonged antibiotic therapy) and Gram positive ones (preservation 12%, 3 cases of S. epidermidis and 2 cases of S. Aureus due to limited vascular tree). Admission to the intensive care unit was required in five patients and there were only two cases of endocarditis as metastasic complication. There was no death related to CRBSI. About the seasonal distribution, the majority of episodes occurs in summer and spring (43.3% and 23.9% respectively), whereas in autumn and winter there were fewer cases registered (16.4% and 16.4% in both). Despite of the increasing use of CVC as definite vascular access in our dialysis unit (almost 60%), the rate of CRBSI has been declining in parallel over the years. Since 2018, we reported less than 0.5 episodes per 1000 catheter-days. Conclusion This study shows a low frequency of CRBSI compared to previous studies. Among all episodes, the predominant infecting organism was methicillin-sensitive Staphylococcus Aureus (14.7% were methicillin-resistant). The early catheter removal, especially in aggressive strains as S. Aureus, reflects a low number of serious complications, with uncommon metastatic infections and no death directly related to CRBSI. A large proportion of infections were in summer; it may be attributable to hiring of less experienced professionals. We identified a substantial decline in rates of CRBSI coincident with COVID-19 pandemic. Nevertheless, this reduction was apparent beginning nearly two years before pandemic. This suggests that factors other than changes in infection-control practices during the pandemic are partially responsible of that.

Differences in Long-Term Outcomes in End-Stage Kidney Disease Patients with Chronic Limb-Threatening Ischemia

End-stage kidney disease (ESKD) is a risk factor for peripheral arterial disease and major adverse limb events following infra-inguinal bypass. Despite comprising an important patient population, ESKD patients are rarely analyzed as a subgroup and are underrepresented in vascular surgery guidelines. This study aims to compare the long-term outcomes of patients with and without ESKD undergoing endovascular peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI). CLTI patients with and without ESKD from 2007-2020 were identified in the Vascular Quality Initiative PVI dataset. Patients with prior bilateral interventions were excluded. Patients undergoing femoral-popliteal and tibial interventions were included. Mortality, reintervention, amputation, and occlusion rates at 21months following intervention were examined. Statistical analyses were completed with the t-test, chi-square, and Kaplan-Meier curves. The ESKD cohort was younger (66.4±11.8 vs. 71.6±12.1years, P<0.001) with higher rates of diabetes (82.2 vs. 60.9%, P<0.001) the non-ESKD cohort. Long-term follow-up was available for 58.4% (N=2,128 procedures) of ESKD patients and 60.8% (N=13,075 procedures) of non-ESKD patients. At 21months, ESKD patients had a higher mortality (41.7 vs. 17.4%, P<0.001) and a higher amputation rate (22.3 vs. 7.1%, P<0.001); however, they had a lower reintervention rate (13.2 vs. 24.6%, P<0.001). CLTI patients with ESKD have worse long-term outcomes at 2years following PVI than non-ESKD patients. Mortality and amputation are higher with ESKD, while the reintervention rate is lower. Development of guidelines within the ESKD population has the potential to improve limb salvage.

Real-world evaluation of patiromer utilization and its effects on serum potassium in veterans with end stage kidney disease

Hyperkalemia (serum potassium [K+] ≥5.1) is life-threatening in patients diagnosed with end stage kidney disease (ESKD). Patiromer is approved for the treatment of hyperkalemia, although its role in hyperkalemic patients with ESKD is not well understood. This study describes real-world patiromer utilization in an ESKD population and its corresponding association with serum K+ level changes. The study population was comprised of US veterans with an outpatient dispensing of patiromer and 2 or more International Classification of Diseases diagnostic codes for ESKD. A treatment course of patiromer was defined by serial dispensing events without a 30-day gap. Patiromer utilization was described by duration, average dose, persistence, and proportion of days covered during patiromer course. Mean serum K+ values were described for baseline and 3 follow-up intervals during the 180-day follow-up period. There were 458 patients with ESKD included in the study. On average, patients had 1.24 (95% CI: 1.20-1.29) patiromer courses. Half of the population discontinued their first patiromer course within 30 days, while approximately 10% of patients remained persistent at the end of the 180-day period and 102 (22.3%) patients started a second course during the 180-day follow up period. Average serum K+ concentrations during baseline and the 3 evaluation intervals during the 180-day follow-up were 5.91 mEq/L (5.85-5.97), 4.94 mEq/L (4.86-5.03), 4.89 mEq/L (4.8-4.98) and 4.88 mEq/L (4.8-4.96). Few patients remained persistent on their initial course of patiromer at the end of follow-up, but approximately 20% of patients initiated a second treatment episode after a 30-day gap in treatment during the 180-day follow-up period. Nonetheless, average serum K+ in ESKD patients were sustainably reduced by approximately 1 mEq/L during follow-up.

Assessment of the Association of Vitamin D and the Risk of Tuberculosis among End-Stage Kidney Disease Population.

We investigated the role of vitamin D in the risk of tuberculosis (TB) among patients with end-stage kidney disease (ESKD). The retrospective cohort was conducted with data of 20,985 patients with kidney disease and 20,985 controls without kidney disease (1:1 matching on age of cohort entry and sex) in the duration of 1997-2010 from the Taiwan National Health insurance database. Then, by a case-cohort study, among 20,985 kidney disease, 3194 ESKD patients were identified with matched 3194 non-ESKD patients. Multivariate analyses revealed a significant association between kidney disease and tuberculosis (adjusted incidence rate ratio (IRR) 1.57 (1.33-1.86)), and the risk increased after 3 years of follow-up the (adjusted IRR 3.79 (2.55-5.62)), but after more years of follow-up no significance was observed. We also found that ESKD increases the risk of tuberculosis (adjusted IRR 3.67 (2.27-5.93)). However, vitamin D usage was not related with the tuberculosis risk in ESKD patients (p &gt; 0.1783). Our study showed increased risk of tuberculosis in kidney disease and ESKD patients, and vitamin D was not beneficial in ESKD.

A Trauma-Informed Care Model: Addressing Adverse Childhood Experiences in Patients with End-Stage Kidney Disease

In the healthcare field, there has been increased recognition of the long-term consequences that adverse childhood experiences (ACEs) have on the health and well-being of people. It is imperative that a trauma-informed care (TIC) approach is utilized in the treatment of patients with end-stage kidney disease (ESKD) because of high rates of non-adherence and health risk behaviors. The purpose of this article is to explore current nephrology practices and TIC approaches utilized in the healthcare field. A TIC approach, through a health-belief model lens specific to the ESKD population, can be introduced by providers to better assess and treat patients. Implications for practice include standardization of TIC in social work practice, better outcomes for patients, and ongoing research considerations.

FC 111: A Comorbidity Index and Pretransplant Physical Status Predict Survival in Older Kidney Transplant Recipients

Abstract BACKGROUND AND AIMS Regardless of age, kidney transplantation (KT) is considered the optimal treatment for patients with end-stage kidney disease (ESKD). In the increasing elderly ESKD population, KT should be reserved for carefully selected candidates who are expected to experience favorable outcomes. We aimed to prospectively evaluate pre-transplant recipient factors that may predict post-transplant patient survival and can eventually guide therapeutic decisions in elderly with ESKD. METHOD Recipient factors were evaluated in KT candidates aged ≥65 years, who were enlisted for KT between January 2013 and November 2016 at the Norwegian national transplant centre. Pretransplant comorbidity was assessed at waitlisting, according to the Liu Comorbidity Index (LCI). Self-reported health-related quality of life was assessed using the Kidney Disease Quality of Life Short Form version 1.3 (KDQOL-SF). The Cox proportional hazard regression was used to evaluate predictors of patient survival. RESULTS We included 289 waitlisted candidates, of whom 192 received a deceased brain-dead donor kidney. Mean age at KT was 72 (4.1) years, 133 (69%) were male, 47 (24%) were transplanted preemptively and 80% received an expanded criteria donor organ. During a median observation time of 4.6 (3.2–6.3) years post-KT, 66 recipients died. LCI ≤ 3 was observed in 136 recipients (71%), between 4–6 in 39 recipients (20%) and 17 recipients (9%) had LCI ≥ 7. Elevated LCI ≥ 4 predicted poor patient survival, and was associated with a 2.2-times increase in mortality risk (Figure 1). In recipients with LCI ≥ 4, dialysis ≥2 years comprised a 2.5-fold higher mortality risk, compared with recipients on dialysis ≤2 years (Figure 2). Self-reported pretransplant physical function was also proven to be a significant positive predictor of survival, with scores ≤60 being associated with a 2-fold increase in mortality risk. CONCLUSION The implementation of LCI and a physical function score during the evaluation of older kidney transplant candidates may improve the selection and thereby optimize post-transplant outcomes.

MO891: Poor Tolerability of the Standard, Extended, 48h Ambulatory Blood Pressure Monitoring in Haemodialysis Patients

Abstract BACKGROUND AND AIMS Ambulatory blood pressure monitoring (ABPM), extended to 44h or 48h for the diagnosis of hypertension in end-stage kidney disease (ESKD) patients, is recommended by Consensus Documents of the American Society of Nephrology and the European Renal Association. About 10%–20% of individuals in the general population report sleeping problems and other symptoms during 24 h ABPM. Because the longer recording period (44 or 48 h versus 24 h), the notorious sleeping disturbances and the high symptom burden of the ESKD population, the feasibility of the technique may be limited in this population. However, the large-scale tolerability of ABPM in the haemodialysis population, has never been investigated. METHOD We performed an international survey of feasibility and tolerability of 48 h ABPM in six centres in three European countries. These centres are led by motivated clinical nephrologists, all members of the EURECA-m working group. 48 h ABPM recording was proposed to a large, representative sample of the whole dialysis population of these centres. Well validated instruments (AAMI/ESH/ISO) were applied in all centres. As recommended by the European Society of Hypertension guidelines, recordings were made at 15-min intervals during the day and 30 min during the night. Reasons for refusal to undergo the test were accurately registered. A tolerability (symptoms) questionnaire and a specific questionnaire for sleep evaluation were administered to all participants who underwent 48h ABPM. Reasons for not completing of the ABPM monitoring were systematically recorded. RESULTS In the whole haemodialysis population of participating centres including 735 patients, 440 (60%) were invited to participate in the study. Among these patients, 119 (27%) refused to undergo ABPM recording. Reasons for refusal were fear of discomfort (n = 30, 25%), measurement too long (n = 22, 18%), logistic problems (n = 17, 14%), previous negative experience (n = 13, 11%), clinical reasons (n = 12, 10%), other reasons (n = 25). Among the 321 patients who performed the 48h ABPM recording, 29 (9%) did not complete it and the main reason for interrupting the recording were discomfort [12 patients (41%)], followed by device failure [10 patients (34%)]. Among symptoms developed during the ABPM study, frequent interruption of sleeping because of noise or discomfort was reported by 32% of patients, followed by itching (24%) and pain during the measurements (20%). The detailed list of symptoms, is reported in the Table 1. CONCLUSION Overall, about 25% of haemodialysis patients consider 48h ABPM a laborious and discomforting test and prejudicially refuse to undergo it. Among patients who undergo 48h ABPM, itching and interruption of sleeping are complained by about 1/3 of patients. These figures are substantially higher than those reported in studies in the general population and in hypertensive patients and point to peculiar barriers at applying extended ABPM recordings in the haemodialysis population. Studies applying more tolerable instruments and a minimum set of measurements over a shorter time, with a reduced number of measurements overnight, are clinical research priority for extending the use of ABPM in the haemodialysis population.

Presentation and Outcomes of Patients With End-Stage Kidney Disease Hospitalized With COVID-19 at a Tertiary Center in Riyadh, Kingdom of Saudi Arabia.

BackgroundPatients with end-stage kidney disease (ESKD) are disproportionately vulnerable to COVID-19 and its complications due to the older age and significant burden of comorbid conditions. Data about the impact of COVID-19 on the ESKD population in the Kingdom of Saudi Arabia is scarce, and this study aims to bridge this gap.MethodThis is a retrospective cohort study that included ESKD patients who were receiving either in-center hemodialysis (HD) or peritoneal dialysis (PD) for at least three months and were hospitalized due to COVID-19 at King Abdulaziz Medical City in Riyadh (KAMC) between March 2020 and March 2021. Of note, the in-center hemodialysis means that the patients come to the dialysis center three times per week to receive their dialysis sessions, as home hemodialysis is not available at our center. Multivariate logistic regression was performed to explore the association of clinical characteristics and laboratory parameters with ICU admission and mortality.ResultsA total of 104 patients were included in the analysis. The mean age was 62.6 (SD=17.4) years, 101 (97%) were on HD, predominantly through a central venous catheter (72%), and 53 patients (51%) were male. Patients with COVID-19 were either asymptomatic (42%) or had mild symptoms (37%), mainly cough and fever. At the time of admission, 37 patients (36%) had extrapulmonary symptoms, and 13 patients (12%) had altered mental status. Normal chest X-ray (48%), followed by bilateral lung infiltrates (24%), and unilateral lung infiltrate (11%) were the most common radiological findings. We did not observe any thromboembolic events. Twenty patients (19%) required ICU admission and 19 patients (18%) died during hospitalization. Predictors for in-hospital mortality were: 1) the need for inotropes (adjusted OR: 53.01, p=0.006), 2) age (adjusted OR: 1.07, p=0.019), and 3) C-reactive protein (CRP) level on admission (adjusted OR: 1.02, p=0.04). We did not find any strong predictor for ICU admission.ConclusionOur study demonstrated that COVID-19 carries significant mortality and morbidity in the ESKD population. Age, inotropic support requirement and elevated CRP on admission predicted mortality in our population. The high rate of adverse outcomes of COVID-19 among ESRD patients calls for strict implementation of preventive measures, including vaccination, social distancing, and universal masking at the level of both the healthcare providers and patients. Further studies are needed to assess the association of COVID-19 and hypercoagulability ESKD population.

A Comorbidity Index and Pretransplant Physical Status Predict Survival in Older Kidney Transplant Recipients: A National Prospective Study.

Background.Kidney transplantation (KT) is considered the best treatment for end-stage kidney disease (ESKD). In the increasing elderly ESKD population, KT should be reserved for carefully selected candidates who are expected to experience favorable outcomes. We aimed to prospectively evaluate pretransplant recipient factors that may predict patient survival and can eventually guide therapeutic decisions in elderly with ESKD.Methods.Recipient factors were evaluated in KT candidates aged ≥65 y. Comorbidity was assessed at waitlisting according to the Liu comorbidity index (LCI). Health-related quality of life outcomes were measured using the Kidney Disease Quality of Life Short Form, version 1.3. The Cox proportional hazard regression was used to evaluate predictors of patient survival.Results.We included 192 recipients, with a mean age of 72.1 (4.1) y, who were transplanted with kidneys from deceased brain-dead donors. During a median observation period of 4.6 (3.2–6.3) y, 66 recipients died. Elevated LCI consistently predicted poor patient survival. In recipients with LCI ≥4, dialysis >2 y comprised a 2.5-fold increase in mortality risk compared with recipients on dialysis ≤2 y. Self-reported pretransplant physical function was also proven to be a significant positive predictor of survival.Conclusion.The implementation of LCI and a physical function score during the evaluation of older kidney transplant candidates may improve the selection and thereby optimize posttransplant outcomes.

Hemodialysis Catheters: Update on Types, Outcomes, Designs and Complications.

Hemodialysis catheters (HDCs) are an essential part of kidney replacement therapy. While these catheters are considered only the bridge to long-term vascular access such as arteriovenous fistulas and grafts, they are associated with significant morbidity and mortality and subsequent increased health care expenditures. However, despite these risks, a large proportion of end stage kidney disease population initiates dialysis using these catheters. The pathogenicity of HDCs stems from its invasive nature to the venous vasculature tree resulting in both mechanical and infectious complications. Therefore, the wide use these catheters in dialysis population and the associated complications necessitated continuous innovations in the catheter material, design, and placement techniques. This review provides an update on the catheter types, catheter tip designs, and the new technologies and innovations aimed to improve the catheter functionality and mitigate its related complications.

POS-941 THE EFFECTIVENESS OF COVID-19 VACCINE IN REDUCING THE SEVERITY AND MORTALITY RATE AMONG THE END STAGE KIDNEY DISEASE WITH COVID-19

In late 2019, a novel coronavirus causing severe acute respiratory syndrome (SARS-CoV-2) emerged in Wuhan, China and rapidly spread throughout the world causing coronavirus disease (COVID-19). End-stage kidney disease (ESKD) populations are vulnerable group with high mortality when contracted COVID-19. We aimed to determine the effects of vaccine on the severity and mortality rate of COVID-19 infection among ESKD population in Malaysia.

Causes of Death in End-Stage Kidney Disease: Comparison between the United States Renal Data System and a Large Integrated Health Care System

Introduction: Using a large diverse population of incident end-stage kidney disease (ESKD) patients from an integrated health system, we sought to evaluate the concordance of causes of death (CODs) between the underlying COD from the United States Renal Data System (USRDS) registry and CODs obtained from Kaiser Permanente Southern California (KPSC). Methods: A retrospective cohort study was performed among incident ESKD patients who had mortality records and CODs reported in both KPSC and USRDS databases between January 1, 2007, and December 31, 2016. Underlying CODs reported by the KPSC were compared to the CODs reported by USRDS. Overall and subcategory-specific COD agreements were assessed using Cohen’s weighted kappa statistic (95% CI). Proportions of positive and negative agreement were also determined. Results: Among 4,188 ESKD patient deaths, 4,118 patients had CODs recorded in both KPSC and USRDS. The most common KPSC CODs were circulatory system diseases (35.7%), endocrine/nutritional/metabolic diseases (24.2%), genitourinary diseases (12.9%), and neoplasms (9.6%). Most common USRDS CODs were cardiac disease (46.9%), withdrawal from dialysis (12.6%), and infection (10.1%). Of 2,593 records with causes listed NOT as “Other,” 453 (17.4%) had no agreement in CODs between the USRDS and the underlying, secondary, tertiary, or quaternary causes recorded by KPSC. In comparing CODs recorded within KPSC to the USRDS, Cohen’s weighted kappa (95% CI) was 0.20 (0.18–0.22) with overall agreement of 36.4%. Conclusion: Among an incident ESKD population with mortality records, we found that there was only fair or slight agreement between CODs reported between the USRDS registry and KPSC, a large integrated health care system.

Healthcare utilization and expenditure among individuals with end-stage kidney disease in Taiwan

The prevalence of end-stage kidney disease (ESKD) in Taiwan has been increasing in recent decades. ESKD care and medical expenditures constitute an important part of the entire healthcare system. This study analyzed data collected from the National Health Insurance (NHI) Research Database from 2010 to 2018. The annual medical cost increased by approximately 4% both in the entire Taiwanese population and in its ESKD population. The total medical expenditure in the ESKD population from 2010 to 2018 increased from 48.03 to 65.65 billion reimbursement points, with dialysis treatments costing higher than non-dialysis treatments. ESKD outpatient and inpatient costs accounted for 10.4%-11.1% and 4.8%-5.6% of the entire NHI expenditure, respectively. The leading cause of inpatient costs was circulatory diseases, accounting for 29.3% of the total ESKD inpatient costs in 2018. Furthermore, percutaneous coronary intervention had the highest cost followed by simple percutaneous transluminal angioplasty. In 2018, the hemodialysis population had the highest average monthly cost of 73 thousand points per person, while the kidney transplant population had the lowest average monthly cost of 39 thousand points per person. Medical expenditure, including both inpatient and outpatient costs, of the ESKD population continued to grow from 2010 to 2018. The non-dialysis cost in the ESKD population was mainly for cardiovascular disease management and vascular access care, for which prevention will always be challenging.

Mortality rate of end-stage kidney disease patients in Taiwan

End-stage kidney disease (ESKD) is a global burden that reflects each country's unique condition. We used the National Health Insurance Research Database (NHIRD) of Taiwan to decipher changes in the mortality and international survival rates and to determine the effectiveness of the pre-end-stage renal disease care program (pre-ESRD care program) to guide future health policies for ESKD.We conducted a retrospective cohort analysis of the NHIRD data along with records from the catastrophic illness certificate program of ESKD patients from 2010 to 2018.From 2010 to 2018, the annual dialysis-related mortality rate in Taiwan increased from 10.6 to 11.8 deaths per hundred patient-years. The mortality rate for patients below 40 years appears to be decreasing, reflecting the improved quality of care for ESKD patients. Patients above 75 years showed increasing mortality, indicating the prolonged survival and aging of the ESKD population. Patients undergoing dialysis who participated in the pre-ESRD care program had a higher post-dialysis initiation life expectancy than those who did not participate. Among the program enrollees, the post-dialysis initiation life expectancy was higher in patients who had participated for more than one year. Taiwan has one of the highest ESKD patient survival rates globally.From 2010 to 2018, the reduced mortality in young patients and aging of the ESKD population might indicate that the quality of care in Taiwan for ESKD has improved. Furthermore, a better survival rate after dialysis initiation was observed in the pre-ESRD care program participants.