First Year Of Hemodialysis Research Articles

Survival of HIV infected patients on maintenance hemodialysis in Cameroon: a comparative study

BackgroundThere are conflicting reports on the impact of HIV in the era of combined antiretroviral (c-ART) on survival of patient with ESKD. We aimed to compare the one-year survival of HIV positive patients to that of their HIV negative counterparts with ESKD on maintenance haemodialysis in Cameroon.MethodsThis was a retrospective cohort study conducted in the haemodialysis units of the Douala and Yaoundé General Hospitals. All HIV positive patients treated by maintenance haemodialysis between January 2007 and March 2015 were included. A comparative group of HIV negative patients with ESKD were matched for age, sex, co morbidities, year of dialysis initiation and haemodialysis unit. Relevant data at the time of haemodialysis initiation and during the first year of haemodialysis was noted. Survival was analysed using the Kaplan Meier and Cox regression hazard ratio estimator. A p value < 0.05 was considered statistically significant.ResultsA total of 57 patients with HIV and 57 without HIV were included. Mean age was 46.25 ± 11.41 years, and 52.6% were females in both groups. HIV nephropathy (50.9%) was the main presumed aetiology of ESKD in the HIV group, while chronic glomerulonephritis (33.3%) and diabetes (21.1%) were the main aetiologies in the HIV negative group. At initiation of dialysis, the median CD4 count was 212 cell/mm3 (IQR; 138–455) and 77.2% were receiving c-ART. The proportion of patients who initiated dialysis with a temporary venous catheter was similar in both groups (p = 0.06). After one year on haemodialysis, survival rate was lower in the HIV positive group compared to the HIV negative group (61.4%/78.9%, HR: 2.05; 95% CI: 1.03–4.08; p = 0.042).Kaplan Meier survival curve was in direction of a lower survival in HIV positive group (p = 0.052).ConclusionThe one year survival of HIV positive patients on maintenance haemodialysis in Cameroon seems to be lower compared to their HIV negative counterparts.

Cardiac outcomes after successful kidney transplantation

Aim The aim of this study was to investigate the effects of renal transplantation on cardiac function and morphology in patients with ESRD on regular hemodialysis at the post-transplant period. Background End stage renal disease (ESRD) is considered an overall general health issue related to increased morbidity & mortality. The mortality rate among cases with ESRD who have been experiencing dialysis has been approximately seven times higher than for comparable cases in the general population and has been to a great extent related to cardiovascular causes. Cardiac diseases have been common in cases with chronic kidney disease (CKD). About 75% of cases with CKD who begin dialysis have left ventricular hypertrophy, left ventricle dilatation or diminished left ventricle functional shortening; these cardiac anomalies keep on progressing during the first year of hemodialysis. Besides these changes, impairment of diastolic function has been also expected in these cases. For example, Left ventricular hypertrophy has been a very common pathological condition in cases with ESRD and considered as an independent risk variable for death and cardiac disease. Generally, many risk variables including uremic toxins, fluid retention & chronic volume over-load, anemia, hypoalbuminemia, hyperparathyroidism, arterio-venous fistula and pressure over-load were involved in the pathogenesis for Left Ventricular Hypertrophy in cases with ESRD. Renal transplantation is a well-established treatment for ESRD, allowing most patients to return to a satisfactory quality of life. It is the most acceptable treatment modality for the patients with ESRD, which improves some complications of renal failure such as chronic uremia and volume overload. Methods This cross sectional study was done on 40 kidney transplant recipients enrolled from the patients in the NIUN according to the inclusion and exclusion criteria. We compared echocardiographic findings and some cardiac risk factors after transplantation with those done before transplantation. Results There was highly significant reduction with respect to serum creatinine, blood urea, phosphorus. Comparison of echocardiographic findings between the pre-transplant period and post-transplant period. Ejection fraction (EF) was significantly increased at the post-transplant period while left ventricular systolic dimension (LVSD), left ventricular diastolic dimension (LVDD), and LVH showed a significant decrease after transplantation. Conclusions We have found that cardiac parameters showed significant improvement after transplantation as well as cardiac risk factors including anemia, hyperparathyroidism and volume & pressure overload.

Myocardial changes in incident haemodialysis patients over 6-months: an observational cardiac magnetic resonance imaging study

Patients commencing on haemodialysis (HD) have an increased risk of cardiovascular events in the first year after starting HD compared to those patients established on HD longer. Left ventricular (LV) hypertrophy and abnormal myocardial strain predict mortality. There may be changes in the myocardium of incident HD patients over a 6-month period of HD which may explain changes in cardiovascular risk. We used CMR to consider changes in LV mass, myocardial strain and T1 mapping. We examined changes in pre-dialysis highly sensitive troponin T. 33 patients undergoing HD for <12 months were recruited. Participants underwent CMR at baseline and after 6-months of standard care. 6-months of HD was associated with reduction in LV mass index (Baseline: 78.8 g/m2 follow up: 69.9 g/m2, p = <0.001). LV global longitudinal strain also improved (Baseline: −17.9%, follow up: −21.6%, p = <0.001). Change in T1 time was not significant (Baseline septal T1 1277.4 ms, follow up 1271.5 p = 0.504). Highly sensitive troponin T was lower at follow up (Baseline 38.8 pg/L, follow up 30.8 pg/L p = 0.02). In incident HD patients, 6-months of HD was associated with improvements in LV mass, strain and troponin. These findings may reflect improvement in known cardiac tissue abnormalities found in patients over the first year of HD.

Multi-Disciplinary Vascular Access Care and Access Outcomes in People Starting Hemodialysis Therapy.

Fistulas, the preferred form of hemodialysis access, are difficult to establish and maintain. We examined the effect of a multidisciplinary vascular access team, including nurses, surgeons, and radiologists, on the probability of using a fistula catheter-free, and rates of access-related procedures in incident patients receiving hemodialysis. We examined vascular access outcomes in the first year of hemodialysis treatment before (2004-2005, preteam period) and after the implementation of an access team (2006-2008, early-team period; 2009-2011, late-team period) in the Calgary Health Region, Canada. We used logistic regression to study the probability of fistula creation and the probability of catheter-free fistula use, and negative binomial regression to study access-related procedure rates. We included 609 adults (mean age, 65 [±15] years; 61% men; 54% with diabetes). By the end of the first year of hemodialysis, 102 participants received a fistula in the preteam period (70%), 196 (78%) in the early-team period (odds ratios versus preteam, 1.47; 95% confidence interval, 0.92 to 2.35), and 139 (66%) in the late-team period (0.85; 0.54 to 1.35). Access team implementation did not affect the probability of catheter-free use of the fistula (odds ratio, 0.87; 95% confidence interval, 0.52 to 1.43, for the early; and 0.89; 0.52 to 1.53, for the late team versus preteam period). Participants underwent an average of 4-5 total access-related procedures during the first year of hemodialysis, with higher rates in women and in people with comorbidities. Catheter-related procedure rates were similar before and after team implementation; relative to the preteam period, fistula-related procedure rates were 40% (20%-60%) and 30% (10%-50%) higher in the early-team and late-team periods, respectively. Introduction of a multidisciplinary access team did not increase the probability of catheter-free fistula use, but resulted in higher rates of fistula-related procedures.

Dialysis Access as an Area of Improvement in Elderly Incident Hemodialysis Patients: Results from a Cohort Study from the International Monitoring Dialysis Outcomes Initiative

Background: Commencing hemodialysis (HD) using a catheter is associated with a higher risk of adverse outcomes, and early conversion from central-venous catheter (CVC) to arteriovenous fistula/graft (non-CVC) improves outcomes. We investigated CVC prevalence and conversion, and their effects on outcomes during the first year of HD in a multinational cohort of elderly patients. Methods: Patients ≥70 years from the MONDO Initiative who commenced HD between 2000 and 2010 in Asia-Pacific, Europe, North-, and South-America and survived at least 6 months were included in this investigation. We stratified by age (70-79 years [younger] vs. ≥80 years [older]) and compared access types (at first and last available date) and their changes. We studied the association between access at initiation and conversion, respectively, and all-cause mortality using Kaplan-Meier curve and Cox regression, and predicted the absence of conversion from catheter to non-CVC using adjusted logistic regression. Results: In 14,966 elderly, incident HD patients, survival was significantly worse when using a CVC at all times. In Europe, the conversion frequency from CVC to non-CVC was higher in the younger fraction. Conversion from non-CVC to CVC was associated with worsened outcomes only in the older fraction. Conclusion: These results corroborate the need for early HD preparation in the elderly HD population. Treatment of elderly patients who commence HD with a CVC should be planned considering aspects of individual clinical risk assessment. Differences in treatment practices in predialysis care specific to the elderly as a population may influence access care and conversion rate.

Association of body weight changes with mortality in incident hemodialysis patients.

Incident hemodialysis patients may experience rapid weight loss in the first few months of starting dialysis. However, trends in weight changes over time and their associations with survival have not yet been characterized in this population. In a large contemporary US cohort of 58 106 patients who initiated hemodialysis during 1 January 2007-31 December 2011 and survived the first year of dialysis, we observed trends in weight changes during the first year of treatment and then examined the association of post-dialysis weight changes with all-cause mortality. Patients' post-dialysis weights rapidly decreased and reached a nadir at the 5th month of dialysis with an average decline of 2% from baseline, whereas obese patients (body mass index ≥30 kg/m 2 ) did not reach a nadir and lost ∼3.8% of their weight by the 12th month. Compared with the reference group (-2 to 2% changes in weight), the death hazard ratios (HRs) of patients with -6 to -2% and greater than or equal to -6% weight loss during the first 5 months were 1.08 (95% confidence interval, 1.02-1.14) and 1.14 (1.07-1.22), respectively. Moreover, the death HRs with 2-6% and ≥6% weight gain during the 5th to 12th months were 0.91 (0.85-0.97) and 0.92 (0.86-0.99), respectively. In patients who survive the first year of hemodialysis, a decline in post-dialysis weight is observed and reaches a nadir at the 5th month. An incrementally larger weight loss during the first 12 months is associated with higher death risk, whereas weight gain is associated with greater survival during the 5th to 12th month but not in the first 5 months of dialysis therapy.

Determinant Effects of Average Fasting Plasma Glucose on Mortality in Diabetic End-Stage Renal Disease Patients on Maintenance Hemodialysis

IntroductionDiabetic kidney disease is an increasingly frequent cause of end-stage renal disease. However, mixed results were shown between glycated hemoglobin and mortality.MethodsWe used the average fasting plasma glucose (FPG) levels to predict mortality rates in long-term hemodialysis patients. We enrolled 46,332 hemodialysis patients with diabetes mellitus, who were registered in the Taiwan Renal Registry Data System between January 2005 and December 2012. The patients were stratified based on the quartiles of average FPG levels measured for the first (1-year FPG) and third years (3-year FPG) of hemodialysis. Survival analysis was conducted via multivariable Cox regression.ResultsAfter the first year of hemodialysis, the mean FPG levels were 103.5 ± 14.5, 144.7 ± 11.5, 189.6 ± 15.2, and 280.8 ± 1.2 mg/dl for the first, second, third, and fourth quartile, respectively. The Kaplan-Meier curve showed an incremental reduction in the survival as FPG levels increased (P < 0.0001). In the Cox regression model, the adjusted hazard ratios were 1.15 (95% CI: 1.10–1.20), 1.30 (95% CI: 1.25–1.36), and 1.45 (95% CI: 1.39–1.51) for the pairwise comparisons between the first quartile and the second, third, and fourth quartile, respectively. Similar trends were observed by 3-year FPG. Patients whose FPG levels increased had a 22% increased risk (95% CI: 1.16–1.29) for all-cause mortality compared with patients whose FPG levels decreased.DiscussionOur results suggest that the average FPG levels are useful predictors of all-cause mortality in dialysis patients. In addition, an increasing trend in average FPG levels indicates poor survival.

The first year on haemodialysis: a critical transition.

The first year following the start of haemodialysis (HD) is associated with increased mortality, especially during the first 90–120 days after the start of dialysis. Whereas the start of dialysis has important effects on the internal environment of the patient, there are relatively few studies assessing changes in phenotype and underlying mechanisms during the transition period following pre-dialysis to dialysis care, although more insight into these parameters is of importance in unravelling the causes of this increased early mortality. In this review, changes in cardiovascular, nutritional and inflammatory parameters during the first year of HD, as well as changes in physical and functional performance are discussed. Treatment-related factors that might contribute to these changes include vascular access and pre-dialysis care, dialysate prescription and the insufficient correction of the internal environment by current dialysis techniques. Patient-related factors include the ongoing loss of residual renal function and the progression of comorbid disease. Identifying phenotypic changes and targeting risk patterns might improve outcome during the transition period. Given the scarcity of data on this subject, more research is needed.

Fatty Acids and Other Risk Factors for Sudden Cardiac Death in Patients Starting Hemodialysis

Background: Little is known about risk factors for sudden cardiac death in hemodialysis patients during the high-risk first year of dialysis. We therefore undertook to identify such risk factors in a nationally representative cohort and were able to include baseline levels of blood fatty acids, some of which influence arrhythmogenicity and sudden cardiac death risk. Design: The study cohort included 100 patients who died of sudden cardiac death during the first year of hemodialysis and 300 frequency-matched controls. Using the elastic net statistical method, numerous demographic and clinical characteristics were included with baseline total serum levels for 11 major fatty acids (model 1) and with serum phospholipid fractions of these same fatty acids (model 2). Final models included only covariates that had a non-zero coefficient. Results: In model 1, serum albumin [odds ratio (95% CI): 0.55 (0.33-0.93); p = 0.03] and total serum long-chain n-3 docosapentaenoic acid [0.70 (0.51-0.97); p = 0.03] were inversely associated with the odds of sudden cardiac death, while the total serum saturated fatty acid level had a direct association [1.01 (1.00-1.02); p = 0.03]. In model 2, serum albumin and docosapentaenoic acid remained inversely associated with sudden cardiac death in a similar manner as in model 1. Pulse pressure also had an inverse association [0.96 (0.93-1.00); p < 0.05]. Conclusions: Several factors, including blood content of docosapentaenoic acid and saturated fatty acids, were associated with the odds of sudden cardiac death during year one of hemodialysis. These results raise the possibility that dietary modification may reduce sudden death risk.

Fish oil for prevention of sudden death in hemodialysis patients?

Friedman et al. report that hemodialysis patients with the highest levels of n-3 fatty acids had impressively low odds of sudden cardiac death. The study is limited by a small sample size, and the analysis relies on only a single baseline measurement of blood levels. Recent randomized evidence indeed fails to support that n-3 fatty acids may prevent sudden death in nonrenal patients. More evidence is needed to advocate fish oil in this setting.

Inverse relationship between long-chain n-3 fatty acids and risk of sudden cardiac death in patients starting hemodialysis

Experimental and clinical evidence suggests that long chain n-3 fatty acids may protect against sudden cardiac death, the leading cause of mortality in hemodialysis patients. Here we investigated whether long chain n-3 fatty acids have a protective relationship with sudden cardiac death in 100 patients who died of sudden cardiac death during the first year of starting hemodialysis and 300 patients who survived. Individuals were selected from a nationally representative cohort of over 1000 U.S. hemodialysis units in 2004–2005. The odds of sudden cardiac death were calculated by quartile of long chain n-3 fatty acids levels over the first year. There was a significant inverse relationship between long chain n-3 fatty acids and the risk of sudden cardiac death even after adjusting for relevant co-morbid conditions, biochemical values, and dietary fats. The odds of sudden cardiac death at 1 year for the second, third, and fourth quartile groups of long chain n-3 fatty acids were 0.37, 0.22, and 0.20, respectively, compared to the lowest quartile. This significant inverse relationship was maintained even during the highest-risk first few months on hemodialysis. Thus, long chain n-3 fatty acids are strongly and independently associated with a lower risk of sudden cardiac death in hemodialysis patients throughout the first year of hemodialysis.

L-Carnitine Treatment in Incident Hemodialysis Patients

L-carnitine levels decrease rapidly and steadily with duration of hemodialysis, and carnitine depletion can impair response to recombinant human erythropoietin (rHuEPO). The study hypothesis was that L-carnitine supplementation during the first year of hemodialysis would improve this response. From October 2006 through March 2010, this multicenter, randomized, double-blinded study assigned 92 incident hemodialysis patients to receive placebo or 1 g of intravenous L-carnitine after each dialysis session for 1 year. The primary outcome measure compared the groups for rHuEPO resistance index (EPO-RI), defined as weekly rHuEPO doses (IU/kg body weight divided by hemoglobin level) (g/dl). In the L-carnitine group, carnitine concentration increased from a mean ± SD of 79 ± 51 µmol/L to 258 ± 137 µmol/L; in the placebo group, it declined from 68 ± 25 µmol/L to 53 ± 24 µmol/L (interaction group × time, P<0.001). Carnitine deficiency affected about 30% of the patients in the placebo group during the study period. EPO-RI varied from 15.8 ± 11.3 to 9.5 ± 5.8 IU/kg per g/dl in the placebo group and from 20.6 ± 12.8 to 15.6 ± 15.9 IU/kg per g/dl in the L-carnitine group, for a mean variation of -3.94 ± 12.5 IU/kg per g/dl and -2.98 ± 15.5 IU/kg per g/dl, respectively (P=0.7). After adjustment for baseline characteristics, the EPO-RI course was similar in each group (difference between groups, P=0.10; interaction group × time, P=0.9). Carnitine levels decrease by about 11% ± 33% during the first year of hemodialysis. Treatment of incident hemodialysis patients with L-carnitine does not improve their response to rHuEPO.

The effect of frequent hemodialysis on nutrition and body composition: Frequent Hemodialysis Network Trial

We investigated the effects of frequency of hemodialysis on nutritional status by analyzing the data in the Frequent Hemodialysis Network Trial. We compared changes in albumin, body weight and composition among 245 patients randomized to 6- or 3-times per week in-center hemodialysis (Daily Trial) and 87 patients randomized to 6-times per week nocturnal or 3-times per week conventional hemodialysis, performed largely at home (Nocturnal Trial). In the Daily Trial, there were no significant differences between groups in changes in serum albumin or the equilibrated protein catabolic rate by 12 months. There was a significant relative decrease in pre-dialysis body weight of 1.5 ± 0.2 kg in the 6 times per week group at one month, but this significantly rebounded by 1.3 ± 0.5 kg over the remaining 11 months. Extracellular water decreased in the 6 times per week compared to the 3 per week hemodialysis group. There were no significant between-group differences in phase angle, intracellular water or body cell mass. In the Nocturnal Trial, there were no significant between-group differences in any study parameter. Any gain in “dry” body weight corresponded to increased adiposity rather than muscle mass but was not statistically significant. Thus, frequent in-center hemodialysis reduced extracellular water but did not increase serum albumin or body cell mass while frequent nocturnal hemodialysis yielded no net effect on parameters of nutritional status or body composition.

Body weight change during the first year of HEMODIALYSIS is influenced by the dry weight quest

Fluid overload, high blood pressure (BP) and nutrition disturbances may improve after HD onset. However HD patients remain exposed to a high risk of death. We report the relationship between the dry weight quest and nutritional markers on the survival in incident HD patients. Among a cohort including 308 patients stating HD therapy 251 (age=65,8±14,8 y.o.; F/M=93/158; diabetes=36%) survived at least one year after dialysis onset and were followed for an average of 44,9 months. During the first 8 weeks, the prescribed BW decreased by 6.5±5.6% and then started to increase again. From Week 8 (W8) to W52, the BW change (Δ) was+1,9±7,4% (extremes:–24,6 to+28,2%). Serum albumin and nPNA changed respectively by+7.8 and+11.4%. (+7.6% vs–3.6%, p=0.0001). The initial W8-W1 BW Δ (expressed as % of the BW at HD onset) was significantly correlated with the systolic BP Δ at W26 and W52 (respectively p=0.0007 and 0.0033). It was also inversely correlated with the Δ in serum albumin and nPNA (p=0.002 and 0.04) but not with BW Δ between W8 and W52. The W52W8-BW Δ and the W52-W1-systolic BP Δ were significantly correlated (r=–0,14, p=0.03). When the patients were split in two groups according the median of systolic BP change (–20.8 vs +7.8%), the W52W8 BW Δ was significantly higher in the group of the larger systolic BP decrease (+3.3 vs +0.6%, p=0.004). Hence weight gain during the first year of HD treatment that is a strong predictor of survival in our experience (reported in another abstract) is influenced by the dry weight quest. In our practice, the systolic BP decrease is related to fluid removal and is associated with better patient survival, opposite to the reverse epidemiology concept. Further studies using bioimpedance are necessary to confirm that an optimal fluid status may improve the nutritional status in HD patients.

Absolute interdialytic weight gain is more important than percent weight gain for intradialytic hypotension in heavy patients

Few published reports have mentioned the difference between absolute interdialytic weight gain (IDWG) and IDWG/DW (IDWG%), and subsequent effects on daily dialysis. The aim of present study was to evaluate the difference between absolute IDWG and IDWG% in new haemodialysis patients. We retrospectively reviewed the records of 255 patients who recently received conventional haemodialysis for at least 1 year at the same centre from 1997 to 2008. The first 4 weeks after starting haemodialysis was defined as the pre-study period. Data were collected for 5-56 weeks. IDWG% value remained relatively constant in the first year of haemodialysis despite most patients having certain residual renal function. For haemodialysis outcomes, both absolute IDWG and IDWG% were significantly correlated with intradialytic hypotension (IDH) in men and heavy women. After dividing patients into four strata, which according to the gender and the median dry weight, stepwise multivariate linear regression analysis showed that absolute IDWG, rather than IDWG%, was an independent risk factor for IDH in heavy men (Beta = 0.585, P < 0.001) and heavy women (Beta= 0.458, P < 0.001). Absolute IDWG, rather than IDWG%, is an independent risk factor for IDH in heavy haemodialysis patients. Therefore, higher absolute IDWG needs to be strictly controlled despite the corresponding IDWG% possibly being relatively small in heavy haemodialysis patients.

Persistently low intact parathyroid hormone levels predict a progression of aortic arch calcification in incident hemodialysis patients

Recent observational studies have found that low intact parathyroid hormone (iPTH) is related with mortality in hemodialysis patients and these findings may be considered to be the result of accelerated cardiovascular calcifications in adynamic bone disease. This study was aimed to determine the relationship between persistently low iPTH and aortic arch calcification (AAC) in incident hemodialysis patients. From January 2004 to December 2008, a total of 94 incident hemodialysis patients were enrolled in this study. They were divided into three groups according to the changing patterns of iPTH during the first year of hemodialysis. ACC was scored on posterior-anterior plain chest X-rays using a specific scale at the initiation of dialysis and followed till May 2011. The median follow-up periods were 46.9 months. The prevalence of baseline AAC and its progression were the highest in the persistently low iPTH group. Also, all-cause mortality was the highest in this group. Age, baseline calcification score and persistently low iPTH independently contributed to the progression of calcification by multivariate logistic regression analyses (HR 1.083, 95% CI 1.023-1.147, P = 0.006; HR 3.320, 95% CI 1.023-10.789, P = 0.046; HR 5.207, 95% CI 1.027-26.412, P = 0.046, respectively). Also, mortality was relatively higher in calcification progressor compared to non-progressor (39.3, 18.2%, P = 0.030). Persistently low iPTH was an independent risk factor for both AAC and mortality in incident hemodialysis patients.

Metabolic control and vascular diseases under oral antidiabetic drug versus insulin therapy and/or diet alone during the first year of hemodialysis in type 2 diabetic patients with ESRD

Uremic type 2 diabetic patients on hemodialysis need various types of antidiabetic therapies. The aim of the present study was to identify differences between patients on oral antidiabetic drug therapy or insulin substitution or diet therapy alone during their first year of hemodialysis. Sixty-four type 2 diabetic patients who had started hemodialysis (HD) at our dialysis center between 2003 and 2007 were included in the study. Kidney-transplanted patients (n = 1) and those with chronic infectious or malignant diseases (n = 4) were excluded. Patients were divided into three groups according to their antidiabetic therapy: group 1 consisted of patients on oral antidiabetic drug therapy (n = 12), group 2 of those on insulin therapy (n = 42), and group 3 of those being treated with diet alone (n = 10). At the start of HD and 12 months later, we measured fasting plasma glucose (FPG), HbA1c, the incidence of hypoglycemia (n/patient/month), cholesterol, triglycerides, body weight, and insulin requirements in the insulin-treated group. C-peptide was only measured at the start of dialysis. We evaluated changes in antidiabetic therapy during the first year on dialysis, and the prevalence of vascular disease in each group at the start of HD. FPG and HbA1c values were similar in all groups at the start of HD and after 1 year. Hypoglycemia occurred more frequently in insulin-treated patients; however, the difference was not significant. Cholesterol levels were similar in all groups, whereas triglycerides were significantly lower in insulin-treated patients (138 ± 28 vs. 176 ± 46 mg/dl; P < 0.05). Body weight was similar in all groups. No significant change in body weight was observed in any group after 12 months on dialysis. At the start of HD, C-peptide levels were lower in insulin-treated patients than in the other groups (1.8 ± 0.9 ng/ml vs. 2.2 ± 1.1 and 2.4 ± 1.1 ng/ml; P < 0.05). During the first 12 months on HD, two patients from group 1 were shifted to group 3 (diet alone), while four patients could reduce their drug dosage (33%). However, two subjects became insulin-dependent. In group 2, insulin therapy could be terminated in two cases, while the insulin dose could be reduced in 20 patients (48%). In group 3, one patient was switched to oral antidiabetic therapy. The prevalence of vascular disease was slightly higher in group 3 (NS). Within 1 year after the start of HD, the dose of sulfonylurea as well as insulin could be reduced in a large majority of patients. Metabolic control was similar in all groups. Only triglycerides were significantly lower in group 2. The frequency of hypoglycemia and the prevalence of vascular disease were just slightly higher in the group on insulin therapy.

Antiplatelet Therapy and Vascular-Access Patency

Current predictions estimate that by the year 2020, more than 750,000 people in the United States alone will have end-stage renal disease and over 500,000 will require hemodialysis.1 The success of hemodialysis depends on a well-functioning vascular access, which may be considered the patient's lifeline. However, creating and maintaining a vascular access are challenging and costly. In the first year of hemodialysis, care of the vascular access represents the leading cause of hospitalizations; overall costs are over $1 billion annually.2,3 The Dialysis Access Consortium (DAC) Study Group has taken the lead in advancing clinical knowledge of dialysis access dysfunction . . .

Greater First-Year Survival on Hemodialysis in Facilities in Which Patients Are Provided Earlier and More Frequent Pre-nephrology Visits

The aim of this study was to evaluate the relation between pre-nephrology visit (PNV) and 1-yr patient survival after hemodialysis (HD) induction. Data were analyzed from 8500 incident HD patients (on HD <or=30 d) in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases I and II. A visit to a nephrologist at least 1 mo before starting HD was regarded as PNV. Cox regression was used to estimate the adjusted hazard ratio (AHR) for mortality in the first year of HD in both patient- and facility-level analyses. All models were adjusted for age, sex, race, socioeconomic factors, cause of ESRD, 14 comorbid conditions, hemoglobin, serum albumin, and serum creatinine; accounted for facility clustering effects; and were stratified by country. In patient-level analysis, PNV was associated with significantly lower risk for death (AHR 0.57; P < 0.0001). Facility-level analysis also showed a significant lower risk for death in facilities with greater prevalence of PNV in both continuous models (AHR 0.92 per 10% greater facility mean %PNV; P < 0.0004) and in categorical models (AHR 0.71 for facilities with >90% of patients receiving PNV [first quartile] compared with facilities with <71% of patients receiving PNV [fourth quartile]; P = 0.001). These results provide not only patient-level but also facility practice evidence that PNV is related to improved patient survival during the first year after initiation of HD, indicating the possible mortality benefits with more increased attention to PNV.

El FGF23 en la insuficiencia renal crónica y el postrasplante renal

Phosphatonins are regulatory factors of phosphate metabolism and the FGF23 is the best studied of them. This has produced a change in our understanding in mineral metabolism and specifically of phosphate regulation. FGF23 is a 251-amino acid factor that differs from other FGF family members by having a 71-amino acid extension on the carboxyl-terminal end of the molecule that is specific for this factor. It is primarily produced by osteocytes in bone. It has a central role in phosphate homeostasis regulation, producing phosphaturia, and in vitamin D metabolism, inhibiting its production by suppression of renal 1 Alfa hydroxylase. It is believed to have an important place in the pathogenesis of early secondary hyperparathiroidism related to chronic renal insufficiency by inhibiting renal synthesis of 1,25(OH)2D in response to its increment in blood produced to increase renal phosphate excretion and maintain phosphate balance. In CRF its serum levels seem to be independent predictors of progression to terminal renal failure. In dialysis patients the determination of its serum levels would allow to predict the results of therapy with calcitriol in the treatment of secondary hyperparathyroidism; they also seem to be independent predictors of the risk of mortality during the first year of hemodialysis. Its serum levels have also been related to the development of vascular calcifications of hand arteries but not with aortic calcifications. The exposure to excessive levels of FGF23 in the early postransplant period seems to be strongly associated with postransplant hypophophatemia more than to PTH or other phosphatonins.