First Year Of Dialysis Research Articles

Elderly predialysis care pathways and early morbidity-mortality upon start of dialysis.

The ageing of the population with advanced chronic kidney disease (CKD) increases the complexity of care pathways. Our aim was to identify subgroups of older people according to predialysis care pathways and describe their association with early morbidity-mortality after transition to dialysis. This study included 22,128 incident dialysis patients aged ≥ 75 years during 2009-2017 from the French nationwide registry linked to the National Health Data System. Predialysis care pathways were identified by ascending hierarchical classification based on preselected healthcare use indicators in the previous year. Their association with a composite outcome of death or hospitalization ≥ 50% of the time off dialysis within the first year of dialysis was studied by multivariable logistic regression accounting for demographics, comorbidities, functional status, conditions of dialysis initiation, socioeconomic deprivation index, and home-to-dialysis center travel time. Five care pathway profiles were identified, characterized by limited healthcare use (cluster 1, 28%), non-nephrology ambulatory care (cluster 2, 17%), nephrology ambulatory care (cluster 3, 37%), and a high level of non-nephrology or nephrology hospitalizations (clusters 4 and 5, both 9%). Profile subgroups did not differ according to patient age and comorbidities, but clusters 1, 2 and 4 displayed higher levels of social deprivation. Compared to cluster 3, the odds ratios of primary composite outcome were significantly increased for clusters 1, 4, and 5 (OR (95% CI) of 1.16 (1.08-1.25), 1.17 (1.05-1.32), and 1.12 (1.01-1.25) respectively). Moreover, prolonged hospitalizations were also more common in all groups, compared to cluster 3. Despite similar comorbidity profile, older people with advanced CKD experience very heterogeneous predialysis care pathways, some of which associated with higher burden of hospitalization after the transition to dialysis.

Prevalence and Association of Pruritus and Its Current Treatment During the First Year of Dialysis: A DOMESTICO Study.

Pruritus is common in dialysis patients and associated with impaired health-related quality of life (HRQoL) and sleep disturbances. Its pathophysiology remains unclear resulting in limited treatment options and lack of treatment guidelines. The exact trajectory of pruritus after dialysis initiation nor the state of current medical treatment has been studied. Incident dialysis patients (n=1438), included in the Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes (DOMESTICO), were studied. Outcome parameters were prevalence of pruritus, severity of pruritus and the use of antipruritic medication, repeatedly measured during the first year of dialysis. Associations between treatment, pruritus and quality of life were longitudinally studied using linear mixed models. The prevalence of pruritus ranged from 50.5% to 56.6% during the first year of dialysis. Throughout the year approximately 35% experienced persistent pruritus and 40% fluctuating pruritus. During follow-up 21.5% to 26.5% received medical treatment for pruritus. Emollients were associated with more severe pruritus (adjusted β = 0.31, 95% CI 0.15; 0.48), the remaining treatments did not show any association. Pruritus was significantly associated with lower physical and mental HRQoL (adjusted β = -2.04, 95% CI -2.78; -1.30 and β = -1.73, 95% CI -2.51; -0.94, respectively), irrespective of treatment. During the first year of dialysis, pruritus is highly prevalent, predominantly fluctuating, and associated with impaired HRQoL. The minority of patients received medical treatment; in our study current treatment was not associated with an improvement of pruritus. These results highlight the need for more awareness among clinicians and for the development of effective treatment options.

#2891 Comparing health-related quality of life and symptom burden in patients undergoing twice-weekly versus thrice-weekly haemodialysis

Abstract Background and Aims Patients with kidney failure who initiate haemodialysis (HD) have traditionally followed a thrice-weekly, 4-hour schedule. Recently, incremental dialysis (i.e. initiating HD with lower frequency and/or treatment duration) has been advocated. It has been suggested that residual kidney function is better preserved, while mortality is similar when initiating dialysis with a twice versus thrice weekly schedule. It remains unclear which impact initiating dialysis twice a week has on health-related quality of life (HRQoL) in the short and long term. Therefore, the aim of this study was first to investigate the impact of following a twice-weekly dialysis schedule on the mental and physical HRQoL and symptom burden compared to thrice-weekly dialysis during the first year of dialysis. Second, to investigate the long term impact on mental and physical HRQoL and symptom burden of patients who solely started on a twice-weekly versus thrice-weekly schedule. Method Data were obtained from the ongoing multicentre, prospective, observational Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes (DOMESTICO). This study longitudinally compares HRQoL between home and in-center dialysis. For this analysis, incident HD patients > 18 years were included, if they started on a twice-weekly or thrice-weekly schedule. Mental and physical HRQoL was measured using the validated 12-item Short Form Health Survey (SF12, summary scores ranging from 0 to 100). Symptom burden was measured using the dialysis symptom index (DSI), consisting of 30 items on dialysis-related symptoms, these symptoms are reported using a 5-point Likert scale. The overall burden score, ranging from 0 to 150, was calculated by summing every symptom and its severity. The first aim was longitudinally analysed using linear mixed models, using measures at 3, 6 and 12 months after start dialysis. The second aim was cross-sectionally analysed at 1, 2 and 3 years after dialysis initiation using linear regression models. All models were adjusted for possible confounders. Results A total of 1007 patients were included, of whom 205 started on a twice-weekly schedule and 802 on a thrice-weekly schedule. The total population had a mean age of 64 ± 15 years and 35% were women. There was no significant difference in baseline characteristics between twice-weekly and thrice-weekly dialysis. At baseline mental and physical HRQoL for patients on twice-weekly dialysis were 45.9 ± 9.5 and 36.0 ± 10.7, respectively. In thrice-weekly dialysis this was 45.8 ± 10.3 and 35.0 ± 9.7. The symptom burden score at baseline was 33.0 ± 19.6 for twice-weekly and 34.0 ± 21.7 for thrice-weekly patients. As shown in Table 1, there were no significant differences in HRQoL or symptom burden over the first year of dialysis when comparing twice-weekly with thrice weekly HD. In Table 2 the long-term cross-sectional analyses show that starting with a twice-weekly schedule results in physical and mental HRQoL scores gradually becoming lower, with a statistically significant decrease in physical HRQoL score at 3 years after start dialysis (ß = −0.825, 95% CI −14.11; −2.38). There was no significant difference in symptom burden between the two schedules. Conclusion We found no differences in HRQoL or symptom burden during the first year of dialysis comparing incident patients on a twice-weekly versus thrice-weekly hemodialysis schedule. Conversely, starting on a twice-weekly dialysis schedule appears to be associated with a lower HRQoL, especially physical HRQoL, in the longer term. Following our results, physicians should be cautious of the possible negative effects on HRQoL when prescribing a twice-weekly dialysis schedule.

Serum Phosphorus Management with Sucroferric Oxyhydroxide as a First-Line Phosphate Binder within the First Year of Hemodialysis.

Sucroferric oxyhydroxide (SO), a non-calcium, chewable, iron-based phosphate binder (PB), effectively lowers serum phosphorus (sP) concentrations while reducing pill burden relative to other PBs. To date, SO studies have largely examined treatment-experienced, prevalent hemodialysis populations. We aimed to explore the role of first-line SO initiated during the first year of dialysis. We retrospectively analyzed deidentified data from adults receiving in-center hemodialysis who were prescribed SO monotherapy within the first year of hemodialysis as part of routine clinical care. All patients continuing SO monotherapy for 12 months were included. Changes from baseline in sP, achievement of sP ≤5.5 and ≤4.5 mg/dL, and other laboratory parameters were analyzed quarterly for 1 year. The overall cohort included 596 patients, 286 of whom had a dialysis vintage ≤3 months. In the 3 months preceding SO initiation, sP rapidly increased (mean increases of 1.02 and 1.65 mg/dL in the overall cohort and incident cohort, respectively). SO treatment was associated with significant decreases in quarterly sP (mean decreases of 0.26-0.36; p < 0.0001 for each quarter and overall). While receiving SO, 55-60% of patients achieved sP ≤5.5 mg/dL and 21-24% achieved sP ≤4.5 mg/dL (p < 0.0001 for each quarter and overall vs. baseline). Daily PB pill burden was approximately 4 pills. Serum calcium concentrations increased and intact parathyroid hormone concentrations decreased during SO treatment (p < 0.0001 vs. baseline). Among patients on hemodialysis, initiating SO as a first-line PB resulted in significant reductions in sP while maintaining a relatively low PB pill burden.

Hypoglycemia and Mortality Risk in Incident Hemodialysis Patients

BackgroundHypoglycemia is a frequent occurrence in chronic kidney disease (CKD) patients due to alterations in glucose and insulin metabolism. However, there are sparse data examining the predictors and clinical implications of hypoglycemia including mortality risk among incident hemodialysis patients. MethodsAmong 58,304 incident hemodialysis patients receiving care from a large national dialysis organization over 2007-2011, we examined clinical characteristics associated with risk of hypoglycemia, defined as a blood glucose concentration <70 mg/dL, in the first year of dialysis using expanded case-mix+laboratory logistic regression models. We then examined the association between hypoglycemia during the first year of dialysis with all-cause mortality using expanded case-mix+laboratory Cox models. ResultsIn the first year of dialysis, hypoglycemia was observed among 16.8% of diabetic and 6.9% of non-diabetic incident hemodialysis patients. In adjusted logistic regression models, clinical characteristics associated with hypoglycemia included younger age, female sex, African-American race, presence of a central venous catheter, lower residual renal function, and longer dialysis session length. In the overall cohort, patients who experienced hypoglycemia had a higher risk of all-cause mortality risk (reference: absence of hypoglycemia): adjusted HR (95%CI) 1.08 (1.04, 1.13). In stratified analyses, hypoglycemia was also associated with higher mortality risk in the diabetic and non-diabetic subgroups: adjusted HRs (95% CI’s) 1.08 (1.04-1.13), and 1.17 (0.94-1.45), respectively. ConclusionsHypoglycemia was a frequent occurrence among both diabetic and non-diabetic hemodialysis patients, and was associated with higher mortality risk. Further studies are needed to identify approaches that reduce hypoglycemia risk in the hemodialysis population.

Early outcomes of peritoneal dialysis in a middle-income country: A retrospective cohort study of a large dialysis network in Colombia.

The first year of dialysis is critical given the significant risk for complications following dialysis initiation. We analysed complications during the first year among incident peritoneal dialysis (PD) patients. This retrospective cohort study comprised adult kidney failure patients starting PD in Baxter Renal Care Services in Colombia, receiving their first PD catheter between 1 January 2017 and 31 December 2020 and were followed up for up to 1 year. We analysed incidence, causes and factors associated with complications using logistic regression and transfer to haemodialysis (HD) using the Fine-Gray regression model. Among 4743 patients receiving their first PD catheter: 4628 (97.6%) of catheter implantations were successful; 377 (7.9%) patients experienced early complications. The incidence rate of complications during the year was 0.51 events per patient-year (95% CI: 0.48-0.54). Age, obesity and urgent start were associated with higher probability of complications after catheter implantation. The cumulative incidence of transfer to HD within 1 year of PD initiation was 10.1% [95% CI: 9.2-11.1%]. The hazard function for transfer to HD showed an accelerating pattern during the first month followed by progressive decrease during the first year. In this large population of incident PD patients, there is a high primary catheter placement success rate. Urgent start, age ≥65 years, obesity, centre size ≥150 PD patients and diabetes were risk factors associated with early complications. The follow-up of the cohort from day 1 of PD treatment showed that the risk for transfer to HD was higher during the first month.

Health-related quality of life and symptom burden in patients on haemodialysis.

Patients on haemodialysis (HD) generally experience poor health-related quality of life (HRQoL) and a broad range of physical and mental symptoms, but it is unknown whether this differs between younger and older patients. We aimed to describe the trajectories of HRQoL and symptom burden of patients <70 and ≥70years old and to assess the impact of symptom burden on HRQoL. In incident Dutch HD patients, HRQoL and symptoms were measured with the 12-item Short Form Health Survey and Dialysis Symptom Index. We used linear mixed models for examining the trajectories of HRQoL and symptom burden during the first year of dialysis and linear regression for the impact of symptom burden on HRQoL. In 774 patients, the trajectories of physical HRQoL, mental HRQoL and symptom burden were stable during the first year of dialysis. Compared with patients <70years of age, patients ≥70years reported similar physical HRQoL {mean difference -0.61 [95% confidence interval (CI) -1.86-0.63]}, better mental HRQoL [1.77 (95% CI 0.54-3.01)] and lower symptom burden [-2.38 (95% CI -5.08-0.32)]. With increasing symptom burden, physical HRQoL declined more in older than in younger patients (β=-0.287 versus -0.189, respectively; P-value for interaction=.007). For mental HRQoL, this decrease was similar in both age groups (β=-0.295 versus -0.288, P=.847). Older HD patients generally experience a better mental HRQoL and a (non-statistically significant) lower symptom burden compared with younger patients. Their physical HRQoL declines more rapidly with increasing symptom burden.

#6113 SCRATCHING THE SURFACE? A LONGITUDINAL OBSERVATIONAL STUDY ON PRURITUS AND ITS CURRENT TREATMENT IN INCIDENT DIALYSIS PATIENTS

Abstract Background and Aims Chronic kidney disease-associated pruritus (CKD-aP) is a common condition in dialysis patients. It is associated with impaired health-related quality of life (HRQoL) and sleep disturbances. The pathophysiology remains unclear resulting in limited treatment options and lack of treatment guidelines. The exact course of CKD-aP after dialysis initiation has not been identified nor the state of current medical treatment. Therefore, the aim of this study was to assess presence and severity of CKD-aP during the first year of dialysis, and to assess how it is currently medically managed. Method Data were used from the ongoing multicentre, prospective, observational Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes (DOMESTICO). This study longitudinally compares HRQoL between different dialysis modalities. Incident dialysis patients (&amp;gt; 18 years) were included, if they completed a HRQoL questionnaire around initiation. Pruritus was assessed using the Dialysis Symptom Index (DSI), using a 5-point Likert scale. Medication data were retrieved from electronic patient files. Outcome parameters were prevalence, severity of pruritus and the use of antipruritic medication, both systemic and topical, all measured at dialysis initiation and after 3,6 and 12 months. The association between pruritus and treatment was studied using logistic regression analysis and adjusted for potential confounders. Results A total of 643 patients were included, 70.8% started with hemodialysis and 29.2% with peritoneal dialysis. The mean (SD) age was 64.0 years (13.8) and 68.3% were men. At dialysis initiation 53.5% of all patients suffered from pruritus with a fluctuation in prevalence following the first year of dialysis (Fig. 1). During the first year 35.7% of the patients had persistent itching, 35.5% had fluctuating itching and 28.8% never experienced itching. There was a small increase in number of patients without itching at 3 months followed by an increase in number of patients with ‘quite some itch’ to ‘severe itch’ over the next months (Fig. 2). At 6 months after start dialysis 10.8% of the dialysis patients received topical antipruritic treatment, 17.2% received systemic antipruritic treatment and 3.3% received both topical and systemic treatment. The majority of patients with topical antipruritic treatment received emollients (58.9%) followed by cutaneous steroids (37.6%). Systemic steroids were the most used systemic antipruritic treatment (58.7%), followed by antihistamines (20.4%) and gabapentoids (17.4%). Patients treated with topical agents at 6 months showed an odds ratio of 3.48 (95%CI: 1.11 – 10.91) on severe itching compared to patients without treatment. Furthermore, patients with systemic antipruritic treatment and with both systemic and topical treatment showed an odds ratio of 1.40 (95%CI: 0.48 – 4.03) and 1.52 (95%CI: 0.41 – 5.70) compared to patients without treatment respectively. Conclusion CKD-aP is highly prevalent in incident dialysis patients. The presence of CKD-aP is fluctuating during the first year of dialysis, with a third of patients experiencing intermittent itching. Starting dialysis may have a small beneficial effect on presence and severity of CKD-aP, but this is lost over time with moderate to severe CKD-aP increasing over the following months. Approximately a third of the patients received treatment for CKD-aP, predominantly as systemic treatment. The use of topical antipruritic treatment is associated with more severe CKD-aP at six months after start dialysis. These findings emphasize the need for further research on the pathophysiology and optimal treatment in dialysis patients.

Severe infections in peritoneal dialysis and home hemodialysis patients: An inception cohort study.

Infections are the most common non-cardiovascular cause of death among dialysis patients. Earlier studies have shown similar or higher risk of infectious complications in peritoneal dialysis (PD) compared to hemodialysis (HD) patients, but comparisons to home HD patients have been rare. We investigated the risk of severe infections after start of continuous ambulatory PD (CAPD) and automated PD (APD) as compared to home HD. All adult patients (n = 536), who were on home dialysis at day 90 from starting kidney replacement therapy (KRT) between 2004 and 2017 in Helsinki healthcare district, were included. We defined severe infection as an infection with C-reactive protein of 100 mg/l or higher. Cumulative incidence of first severe infection was assessed considering death as a competing risk. Hazard ratios were estimated using Cox regression with propensity score adjustment. The risk of getting a severe infection during the first year of dialysis was 35% for CAPD, 25% for APD and 11% for home HD patients. During five years of follow-up, the hazard ratio of severe infection was 2.8 [95% CI 1.6-4.8] for CAPD and 2.2 [95% CI 1.4-3.5] for APD in comparison to home HD. Incidence rate of severe infections per 1000 patient-years was 537 for CAPD, 371 for APD, and 197 for home HD patients. When excluding peritonitis, the incidence rate was not higher among PD than home HD patients. CAPD and APD patients had higher risk of severe infections than home HD patients. This was explained by PD-associated peritonitis.

#6847 HEALTH-RELATED QUALITY OF LIFE AND SYMPTOM BURDEN IN YOUNGER AND OLDER HAEMODIALYSIS PATIENTS: A PROSPECTIVE COHORT STUDY

Abstract Background and Aims Patients on haemodialysis generally report poor health-related quality of life (HRQoL) and a broad range of physical and emotional symptoms, but it is unknown if this differs between younger and older patients. We aimed to describe the trajectories of HRQoL and symptom burden of patients &amp;lt; 70 and ≥ 70 years old after dialysis initiation and to assess the impact of symptom burden on HRQoL. Method Incident Dutch haemodialysis patients were included between December 1st, 2017, and January 19th, 2019. HRQoL and symptom were measured with the 12-item Short Form Health Survey (range 0-100, higher scores indicate better HRQoL) and the Dialysis Symptom Index (range 0-150, higher scores indicate more symptoms and/or higher severity). Questionnaires were taken at the start of dialysis and after 3, 6 and 12 months. We used (multilevel) linear regression to examine the trajectories of HRQOL and symptom burden, and the impact of symptom burden on HRQoL. Results In 774 patients, the trajectories of physical HRQoL, mental HRQoL and symptom burden were stable. Compared with patients aged &amp;lt; 70 years, patients ≥ 70 years reported similar physical HRQoL (crude mean difference -0.61, 95% CI -1.86; 0.63, p = .33) but slightly better mental HRQoL (1.77, 95% CI 0.54; 3.01, p = .005) and lower symptom burden (-2.38, 95% CI -5.08; 0.32, p = .08) during the first year of dialysis. With increasing symptom burden, physical HRQoL declined more in older than in younger patients (β -.287 versus β -.189, respectively, p-value for interaction = .007). For mental HRQoL, this decrease was similar (β -.295 versus -.288, p-value for interaction = .847). Conclusion Older haemodialysis patients generally experience better mental HRQoL and a (non-statistically significant) lower symptom burden in the first year after dialysis initiation, compared to younger patients. However, their physical HRQoL declines more rapidly with increasing symptom burden, compared to younger patients.

The Use of Putative Dialysis Initiation Time in Comparative Outcomes of Patients with Advanced Chronic Kidney Disease: Methodological Aspects.

The latest data from the United States Renal Data Systems show over 134,000 individuals with end-stage kidney disease (ESKD) starting dialysis in the year 2019. ESKD patients on dialysis, the default treatment strategy, have high mortality and hospitalization, especially in the first year of dialysis. An alternative treatment strategy is (non-dialysis) conservative management (CM). The relative effectiveness of CM with respect to various patient outcomes, including survival, hospitalization, and health-related quality of life among others, especially in elderly ESKD or advanced chronic kidney disease patients with serious comorbidities, is an active area of research. A technical challenge inherent in comparing patient outcomes between CM and dialysis patient groups is that the start of follow-up time is "not defined" for patients on CM because they do not initiate dialysis. One solution is the use of putative dialysis initiation (PDI) time. In this work, we examine the validity of the use of PDI time to determine the start of follow-up for longitudinal retrospective and prospective cohort studies involving CM. We propose and assess the efficacy of estimating PDI time using linear mixed effects model of kidney function decline over time via simulation studies. We also illustrate how the estimated PDI time can be used to effectively estimate the survival distribution.

Rates of Medicare Enrollment Among Dialysis Patients After Implementation of Medicare Payment Reform and the Affordable Care Act Marketplace

Medicare finances health care for most US patients with end-stage kidney disease (ESKD), regardless of age. The 2011 Medicare prospective payment system (PPS) for dialysis reduced reimbursement for hemodialysis, and the 2014 Patient Protection and Affordable Care Act (ACA) Marketplace increased patient access to new private insurance options, potentially influencing organizations that provide health care, such as hospitals, nursing homes, and dialysis facilities, to adjust their payer mix away from Medicare sources. To describe Medicare enrollment trends among patients with incident ESKD in 2006 to 2016. This retrospective cohort study involved US patients aged 18 to 64 years who were not enrolled in Medicare at dialysis initiation in 2006 to 2016, with 1-year follow-up through 2017. Data analysis was conducted April 2021 to June 2022. The exposure of interest was a 3-category indicator of time, whether patients initiated dialysis before policies were enacted (2006-2010), in the first years of the Medicare ESKD PPS (2011-2013), or during the Medicare ESKD PPS and implementation of the ACA Marketplace (2014-2016). Patient-level Medicare enrollment through the first year of dialysis. Logistic regression and Cox models were used to examine associations of time, patient characteristics, and Medicare enrollment, adjusting for patient demographic, clinical, and market-level characteristics. Of 335 157 patients aged 18 to 64 years with ESKD not actively enrolled in Medicare when they initiated dialysis in 2006 to 2016, the mean (SD) age was 49.9 (10.8) years, 198 164 (59.1%) were men, 188 290 (56.2%) were White, and 313 622 (93.6%) received in-center hemodialysis. New Medicare enrollment was higher in 2006 to 2010 (110 582 patients [73.1%]) than after the Medicare ESKD PPS and ACA Marketplace in 2014 to 2016 (55 382 patients [58.5%]). In adjusted analyses, declining Medicare enrollment was associated with implementation of 2011 Medicare ESKD PPS and 2014 ACA policies and was disproportionately lower among younger, racially minoritized, and ethnically Hispanic patients. There was declining Medicare enrollment among new dialysis patients associated with the 2011 Medicare ESKD PPS and 2014 ACA Marketplace that raise concerns about benefits and harms to patients and payers and continued disparities in kidney care. As the dialysis payer mix moves toward higher proportions of patients not covered by Medicare, it will be important to understand the implications for health care system and patient outcomes.

MO874: Incidence of Severe Infections in Home Haemodialysis and Peritoneal Dialysis Patients

Abstract BACKGROUND Dialysis patients have a more than ten-fold risk of dying from infections compared with general population. In earlier studies, the risk of infections was similar in peritoneal dialysis (PD) and haemodialysis (HD), but comparison to home HD has not been performed. Our aim was to study the incidence of severe infections after start of home HD as compared with continuous ambulatory PD (CAPD) and automated PD (APD). METHODS We included all 536 adult patients, who were on home dialysis at day 90 from start of kidney replacement therapy (KRT) between 2004 and 2017 in Helsinki healthcare district. Severe infections were identified from patients’ laboratory data as a plasma C-reactive protein over 100 mg/L and confirmed from the patient data system. The cumulative incidence of the first severe infection was estimated considering death as a competing risk event. Hazard ratios of first severe infection were assessed using Cox regression with propensity score adjustment. Incidence rate (IR) and ratios (IRR) of all severe infection episodes were calculated. RESULTS The probability of getting a severe infection during the first year of dialysis was 35% for CAPD, 25% for APD and 11% for home HD patients. During a 5-year follow-up, the hazard ratio of severe infection was 2.8 [95% confidence interval (95% CI) 1.6–4.8] for CAPD and 2.2 (95% CI 1.4–3.5) for APD in comparison to home HD with adjustment for propensity scores. IR of infections/100 patient-years was 54 for CAPD, 37 for APD and 20 for home HD patients. The IR of peritonitis was 37 for CAPD and 25 for APD patients. When infection episodes caused by peritonitis were excluded, the IR of severe infections was not higher among PD than home HD patients. CONCLUSION The risk of severe infection was considerably lower among home HD than PD patients. This difference was mainly explained by the peritonitis episodes among the PD patients.

MO886: Outcomes in Incident Patients Treated With Incremental Haemodialysis as Compared With Thrice-Weekly Haemodialysis and Peritoneal Dialysis: The Geneva Experience

Abstract BACKGROUND AND AIMS Preservation of residual kidney function (RKF) in maintenance haemodialysis (HD) patients is associated with better survival and quality of life. RKF may be better preserved with an incremental HD (frequency &amp;lt; 3x/week) regimen in patients starting HD. Since 2013, incremental HD is routinely used at our centre. METHOD Incremental HD was implemented in incident HD patients with a urine output of &amp;gt;600 mL/day, a urea clearance (KRU) ≥2 mL/min and an interdialytic weight gain &amp;lt; 2.5 kg. Patients were clinically assessed every week and a 24-h urine collection was ordered every other month in order to measure RKF. RESULTS From January 2013 to December 2020, 296 patients started chronic dialysis, with 162 on thrice-weekly HD, 63 on incremental HD and 71 on peritoneal dialysis (PD). Patients on incremental HD did not differ from those on thrice-weekly HD or PD in terms of age, gender and comorbidity score. Diuresis, eGFR and KRU at incremental HD initiation were 1842 ± 749 mL/day, 6.7 ± 3.1 mL/min and 4.0 ± 1.8 mL/min, respectively. Among patients on incremental HD, four could retrieve a sufficient RKF to become dialysis-independent and two were transplanted. Among the 57 remaining patients on incremental HD, median duration until transition to a thrice-weekly HD regimen or death was 10 (6–20) months. Within the first year of dialysis, median survival and hospital-free days were higher in patients starting with incremental HD as compared with thrice-weekly HD: 91% versus 77%, P = 0.02 and 348 (316–362) versus 338 (295–354) days; P = 0.03. CONCLUSION These preliminary results show that incremental HD can be implemented in incident HD patients as long as regular clinical and RKF assessments are found adequate. A median duration of 10 months before transition to thrice-weekly HD can be expected in this setting. Results of randomised clinical trials assessing long-term survival and quality of life in incremental HD are awaited prior to its large-scale implementation.

Diagnosis of tuberculosis in dialysis and kidney transplant patients.

Background and objectivesIn patients with chronic kidney disease the risk of developing Tuberculosis is increased, while the presentation is often atypical making the diagnosis more difficult. The aim of this study is to describe the presentation of Tuberculosis in dialysis and kidney transplant patients, including the range of diagnostic approaches and the utility of different sample types.Design, setting, participants, and measurementsIn this retrospective study, case records of dialysis and kidney transplant patients were reviewed, including all those treated for Tuberculosis between January 2009 and December 2020.ResultsOver 12 years, there were 143 cases of Tuberculosis in 141 patients (aged 17–86, 50.4% male). Tuberculosis was most common in Asian patients (64%) and those receiving hemodialysis (82%), particularly during the first year after dialysis initiation (54% of dialysis cases). Non‐pleural/pulmonary disease accounted 40% of cases, and non‐organ‐specific presenting features were prominent including fever, lymphadenopathy, and weight loss. The diagnosis was confirmed microbiologically or histologically in 87 cases (61%), with low sensitivity observed for many types of samples including sputum (18%) and pleural fluid (12%). Higher sensitivity was observed with tissue samples including bronchoscopic lymph node aspiration (75%) and other lymph node sampling (92%). In the 52 cases where drug sensitivities were available, resistance to a first line treatment, most commonly isoniazid, was seen in 12 cases (23%). Furthermore, 1‐ and 5‐year survival from diagnosis were 78% and 61%, respectively. Baseline variables independently associated with poorer survival were age (OR 1.8 per decade, 95% CI 1.4–2.3), weight loss over 10% (OR 1.9, 95% CI 1.0–3.5), and a non‐confirmed diagnosis (OR 1.6, 95% CI 1.2–2.1).ConclusionsTuberculosis is common in dialysis and kidney transplant patients, particularly during the first year of dialysis. Short‐term mortality is high, but the diagnostic sensitivity of many types of samples is low, so that diagnosis is difficult, with treatment often initiated without confirmation. These data highlight the importance of judgment and clinical experience with this complex patient group.

Epidemiology of cardiovascular death in kidney failure: An Australian and New Zealand cohort study using data linkage.

AimCardiovascular mortality risk evolves over the lifespan of kidney failure (KF), as patients develop comorbid disease and transition between treatment modalities. Absolute cardiovascular death rates would help inform clinical practice and health‐care provision, but are not well understood across a continuum of dialysis and transplant states. We aimed to characterize cardiovascular death across the natural history of KF using a lifespan approach.MethodsWe performed a population‐based cohort study of incident patients commencing kidney replacement therapy in Australia and New Zealand. Cardiovascular deaths were identified using data linkage to national death registers. We estimated the probability of death and kidney transplant using multi‐state models, and calculated rates of graft failure and cardiovascular death across demographic factors and comorbidities.ResultsAmong 60 823 incident patients followed over 381 874 person‐years, 25% (8492) of deaths were from cardiovascular disease. At 15 years from treatment initiation, patients had a 15.2% probability of cardiovascular death without being transplanted, but only 2.3% probability of cardiovascular death post‐transplant. Females had a 3% lower probability of cardiovascular death at 15 years (15.3% vs. 18.6%) but 4% higher probability of non‐cardiovascular death (54.5% vs. 50.8%). Within the first year of dialysis, cardiovascular mortality peaked in the second month and showed little improvement across treatment era.ConclusionDespite improvements over time, cardiovascular death remains common in KF, particularly among the dialysis population and in the first few months of treatment. Multi‐state models can provide absolute measures of cardiovascular mortality across both dialysis and transplant states.

Utilizing diabetes mellitus risk assessment tool in screening of hemodialysis patients at risk of diabetes mellitus

Background: Hamad General Hospital is the main provider of hemodialysis (HD) in Qatar, for approximately 650 patients per year. Over 60% of these patients have Diabetes Mellitus (DM) and 55% of them suffer from end stage renal disease (ESRD). 2% of ESRD patients develop DM after their first year of dialysis. The aims of this quality improvement study were early DM detection, risk factors modifications, and reduction of diabetes complications in our patients. Methods: A risk assessment tool was adapted to identify the risk level of HD patients to develop DM. They were screened to determine their risk score across 8 categories. Six categories (gender, history of gestational diabetes, family history of high blood pressure, diabetes, physical activity and smoking) were scored 0 to 1, age was scored 0 to 3, and relationship between weight and height scored 1 to 3. (Overall score range: 1-12). Patients were classified into two groups: a low-risk group (score &lt; 5) and a high-risk group (score ≥ 5). Patients were referred to different medical specialties for further management according to the risk factor and a lifestyle modification management plan was set individually. Results: 189 non-diabetic dialysis patients were screened in the first quarter of 2020, their mean age was 51 years-old, and 69% were male. Forty-three percent of patients were found to be at high risk of developing DM. The most important risk factors were family history (55%), obesity (40%), age &gt;60 years (32%), low physical activity (14%), and smoking (11%). Thirty-seven percent of patients were referred to the obesity clinic, 10% to the smoking cessation clinic, 5% to physiotherapy, and 100% of patients were referred to the multidisciplinary care. Conclusion: Screening for diabetes is pivotal for early detection and risk factor modification in dialysis patients. We recommend quarterly data assessment and evaluation so patients can be managed according to the findings.

Evolution of Vascular Access Use among Incident Patients during the First Year on Hemodialysis: A National Cohort Study.

Although the arteriovenous fistula (AVF) confers superior benefits over central venous catheters (CVCs), utilization rates remain low among prevalent patients on hemodialysis (HD). The goal of this study was to determine the evolution of vascular access type in the first year of dialysis and identify factors associated with conversion from CVC to a functioning AVF. We studiedadult patients (n=610) who began HD between the January 1, 2015 and December 31, 2016 and were treated for at least 90 days, using data from the National Kidney Disease Clinical Patient Management System in the Irish health system. Prevalence of vascular access type was determined at days 90 and 360 after dialysis initiation and at 30-day intervals. Multivariable logistic regression explored factors associated with CVC at day 90, and Cox regression evaluated predictors of conversion from CVC to AVF on day 360. CVC use was present in 77% of incident patients at day 90, with significant variation across HD centers (from 63% to 91%, P<0.001), which persisted after case-mix adjustment. From day 90 to day 360, AVF use increased modestly from 23% to 41%. Conversion from CVC to AVF increased over time, but the likelihood was lower for older patients (for age >77 years versus referent, adjusted hazard ratio [HR], 0.43; 95% CI, 0.19 to 0.96), for patients with a lower BMI (per unit decrease in BMI, HR, 0.95; 95% CI, 0.93 to 0.98), and varied significantly across HD centers (from an HR of 0.25 [95% CI, 0.08 to 0.74] to 2.09 [95% CI, 1.04 to 4.18]). CVCs are the predominant type of vascular access observed during the first year of dialysis, with low conversion rates from CVC to AVF. There is substantial center variation in the Irish health system that is not explained by patient-related factors alone.

Global Dialysis Perspective: Brunei Darussalam.

Brunei Darussalam is a small country in Southeast Asia, with a population of less than half a million people. Hemodialysis (HD) first began in the country in 1968, using single-patient Dylade model B proportioning machines with heat sterilization and Kiil dialyzers (1,2). Scribner arteriovenous shunts were inserted into patients’ legs by nephrologists. Interestingly, patients were required to manage their own dialysis, which usually extended to 10 hours each session, independent of nursing staff. There were stringent criteria for patient selection. Since the open-door policy was set out in 1985, the incidence and prevalence of KRT have increased significantly (Figure 1). Figure 1. Incidence and prevalence of KRT . Brunei has some of the world’s highest KRT incidence and prevalence. In 2018, the incidence and prevalence of KRT were 380 and 1769 per million population, respectively (Table 1), placing Brunei in the top five globally for incidence and in the top nine for prevalence of patients on KRT (3). The Brunei Dialysis and Transplant Registry was created in 2011 to enable a systematic collection of KRT data. The registry has enabled our nephrology services to be benchmarked against international registries, and it is unique as it captures all patients on KRT in the country. However, in our Brunei Dialysis and Transplant Registry, patients who were incident were excluded if death happened within 2 weeks of starting KRT, rather than the more commonly defined 90 days in other national registries, which might explain the disproportionately higher incidence compared with prevalence in Brunei. In 2019, the mean and median ages of death were 61.3 and 62 years, respectively. About 25% of the mortality happened within the first year of dialysis. The top cause of mortality was infection (28%), followed by cardiovascular death (23%). Hospitalization data are not available. View this table: Table 1. Annual trend of kidney …

Cerebral Perfusion in Hemodialysis Patients: A Feasibility Study.

Background:Patients on hemodialysis (HD) are known to exhibit low values of regional cerebral oxygenation (rSO2) and impaired cognitive functioning. The etiology of both is currently unknown.Objective:To determine the feasibility of serially monitoring rSO2 in patients initiating HD. In addition, we sought to investigate how rSO2 is related to hemodynamic and dialysis parameters.Design:Prospective observational study.Setting:Single-center tertiary academic teaching hospital in Ontario, Canada.Participants:Six patients initiating HD were enrolled in the study.Methods:Feasibility was defined as successful study enrollment (>1 patient/month), successful consent rate (>70%), high data capture rates (>90%), and assessment tolerability. Regional cerebral oxygenation monitoring was performed 1 time/wk for the first year of dialysis. A neuropsychological battery was performed 3 times during the study: before dialysis initiation, 3 months, and 1 year after dialysis initiation. The neuropsychological battery included a traditional screening tool: the Repeatable Battery for the Assessment of Neuropsychological Status, and a robot-based assessment: Kinarm.Results:Our overall consent rate was 33%, and our enrollment rate was 0.4 patients/mo. In total 243 rSO2 sessions were recorded, with a data capture rate of 91.4% (222/243) across the 6 patients. Throughout the study, no adverse interactions were reported. Correlations between rSO2 with hemodynamic and dialysis parameters showed individual patient variability. However, at the individual level, all patients demonstrated positive correlations between mean arterial pressure and rSO2. Patients who had more than 3 liters of fluid showed significant negative correlations with rSO2. Less cognitive impairment was detected after initiating dialysis.Limitation:This small cohort limits conclusions that can be made between rSO2 and hemodynamic and dialysis parameters.Conclusions:Prospectively monitoring rSO2 in patients was unfeasible in a single dialysis unit, due to low consent and enrollment rates. However, rSO2 monitoring may provide unique insights into the effects of HD on cerebral oxygenation that should be further investigated.Trial Registration:Due to the feasibility nature of this study, no trial registration was performed.