Incident Hemodialysis Patients Research Articles

#1657 Impact of cumulative fluid and sodium imbalance exposure on cause-specific mortality in hemodialysis

Abstract Background and Aims Even mild fluid overload and prolonged exposure to salt excess showed to be associated with all-cause mortality in hemodialysis patients. This analysis aims to estimate the effect of fluid and sodium imbalance on cause-specific mortality. Method The study followed 68,196 incident hemodialysis patients from 875 clinics in 25 countries for a decade (2010-2020) using the European Clinical Database 5. Fatal events (21,644) were classified through ICD10- codes and free text descriptions into different endpoints: cardiac death (7,926 events)—with subcomponents sudden cardiac death (2,815 events), coronary death (1,705 events) and heart failure death (3,248 events); cerebrovascular death (1,516 events), non-cardiovascular death (10,898 events)—with subcomponents death by sepsis (2,054) or other infection (1,217 events), cancer death (2,095), other non-cardiovascular death (5,532 events) and death of unknown origin (1,304 events). Time-varying cumulative exposure times (in months) of relative fluid overload/-depletion, hypo-/hypernatremia and low dialysate sodium (≤ 138) were assessed and hazard ratios (HR) were calculated using a multivariate Cox model. Results Fluid overload showed the most consistent exposure risk associations for cardiovascular endpoints with strongest associations in cardiac causes (arrythmia death: HR peak at 7.5 (95% CI: 4.2-3.6), heart failure death: HR peak at 4.2 (95% CI: 3.3-5.4) and sudden cardiac death: HR peak at 3.8 (95% CI: 2.6-4.5)). Fluid depletion was less important but consistently associated with all causes of death. By contrast, Hyponatremia showed heterogeneity of cause specific effects. We found slightly stronger associations for non- cardiovascular causes: Death by sepsis (HR peak at 2.3 (95% CI: 1.8-2.8)) or death by other infections (HR peak at 2.1 (95% CI: 1.6-2.7)) showed the strongest cumulative exposure risk association pattern. Hypernatremia was less important with substantially smaller effects and slightly higher associations for non-cardiovascular endpoints. For low dialysate sodium, we observed evidence of heterogeneity in cause specific effects. The risk of death due to heart failure was notably pronounced with low dialysate sodium (HR peak at 5.8 (95% CI: 1.9-17.9)), while other endpoints did not show this effect. Sensitivity analysis in patients with 48 or more months of follow-up indicated that HR in higher exposure categories might be biased downwards due to non-survival of high-risk individuals. Conclusion Cause-specific hazard models confirm the role of fluid and sodium imbalance as independently acting risk factors for mortality. Fluid overload has the most pronounced effect on cardiac death, especially death by heart failure, arrhythmia, or sudden death. In contrast, hyponatremia is a more critical risk factor for non-cardiovascular death, particularly death caused by sepsis or other infections. The significantly increased risk in patients on low dialysate sodium prescriptions is primarily driven by a dramatic increase in risk of death by heart failure.

#529 Educational level and mortality in patients receiving chronic hemodialysis in Lazio Region—Italy

Abstract Background and Aims In 2010, 2.6 million people received Kidney Replacement Treatment (KRT) worldwide. Hemodialysis (HD) is the most commonly used KRT. HD patients have a consistent risk of death. The impact of Educational Level (Edl) on the mortality in HD patients is unclear. This study aims to analyse the association between the Edls and mortality in incident chronic HD patients using the Lazio Regional Dialysis and Transplant Registry. Method A cohort of incident HD patients between 2008 and 2022 was selected. Patients under 18 years old and with a follow-up period shorter than 91 days were excluded. All patients were characterized by sociodemographic and clinical characteristics at the incident date and were followed from the incident date until the earliest of the following dates: death, transplantation, renal function recovery or end of the study (one or three years after initiation). One-year and three-year Crude Mortality Rates*100 Person Years (CMR*100PY) overall and by Edal (low: up to primary school, medium: secondary school, high: university degree and more) were calculated. Cumulative survival estimates at one year and three years since starting HD, were presented as Kaplan-Meier curves by EdL and compared using the log-rank test. Crude and adjusted Hazard Ratios (HR) and respective 95% Confidence Intervals (95% CI) of the association between EdL and one and three-year mortality were calculated using univariate and multivariate Cox regression models (reference category: low EdL). Sociodemographic and clinical characteristics were considered potential confounders or effect modifiers in the adjusted Cox regression models. Results The cohort counted 9,776; 33.5% had a low EdL, 30.7% had a medium, and 35.8% had a high EdL. The mean age decreased with increasing EdL (73 and 65 in low and high EdL, respectively) as the proportion of females (43.0% and 26.0% in low and high EdL, respectively). During the first year of HD, 1,683 deaths occurred, and 3,827 occurred within three years. One-year CMR*100PY were 24.1 (95% CI 22.4-26.0) in low EdL, 17.4 (95% CI: 15.9-19.0) in medium EdL and 15.0 (95% CI: 13.8-16.4) in high ED. The corresponding three-year CMR were 22.7 (95% CI 21.6-23.8), 17.4 (95% CI 16.4-18.4) and 15.1 (95% CI 14.2-16.0). One-year survivals estimates were 78.0% in low EdL, 83.8% in medium and 85.8% in high EdL (log-rank test: p-value < 0.001). The three-years survival estimates were 51.0% in low EdL, 59.3% in medium EdL and 63.7% in high EdL (log-rank test: p-value < 0.001). In one-year mortality the crude HRs were 0.72 (95% CI: 0.64–0.81) and 0.62 (95% CI: 0.55–0.70) of medium and high EdL vs. low EdL respectively; the corresponding adjusted HRs were 0.93 (95% CI: 0.83–1.06) and 0.92 (95% CI: 0.81–1.04) (Fig. 1). Similar results were obtained for three-year mortality: crude HRs were 0.77 (95% CI: 0.71–0.83) and 0.66 (95% CI: 0.62–0.72); adjusted HRs were 0.99 (95% CI: 0.92–1.08) and 0.97 (95% CI: 0.89–1.06), respectively (Fig. 2).). Conclusion Based on the present study, high educational level does not appear to be associated with lower mortality risk at either one-year or three-years. Hemodialysis patients are constantly monitored by National Health Service; this probably cancels the effect of low educational level on mortality. Although EdL is a strong indicator of socioeconomic position, it does not capture all dimensions of disadvantage. The mechanisms that underline the poor prognosis in Haemodialysis patients are complex and further investigations are needed.

#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.

#2654 Erythropoietin hypo-responsiveness in haemodialysis patients, contributing factors and outcome

Abstract Background and Aims Erythropoietin (ESA) resistance or hypo-responsiveness (HR) is a condition when patients do not achieve the desired haemoglobin concentration or require incremental ESA doses to maintain stable Hb concentration. Contributing factors include iron deficiency, inflammation, infection, mineral bone disease (CKD-MBD), insufficient dialysis, malnutrition, and hematologic abnormalities. This study aimed to determine the prevalence of HR in maintenance haemodialysis (HD) population and its contributing factors. The outcome in terms of all-cause mortality and need for hospitalization over 6 months follow-up was studied. Method We prospectively studied 100 maintenance HD patients above 18 years age over one and a half years. Those with a known haematological disorder, malignancy or active infection were excluded. Enrolled patients were classified into 2 groups: 1) Initial ESA Group: Initiated on ESA therapy and had Hb less than 10 gm/dl. These were also incident HD patients. Initial ESA HR for the study was defined as any Hb increase less than 0.8 gm/dl over 1 month after initiating ESA. The ESA dose and modification remained as per current existing practice in the dialysis unit. 2) Subsequent ESA Group: Already receiving ESA therapy and on HD for at least 3 months. Patients on previously stable doses of ESA who required two increments in ESA doses up to 50% beyond the previous dose to maintain Hb were taken as HR. Patients who required Epoetin or equivalent ESA dose of more than 300 IU/kg/week were also included in HR. All underwent anaemia workup at start and monthly haemoglobin estimation. They were also tested for CRP and CKD-MBD. All were followed for 6 months; hospitalization (excluding vascular access) and mortality was noted. The Charlson comorbidity index was used to ensure equitability. Results Seventeen cases were in Initial ESA group and 83 cases were in subsequent ESA group. ESA type was not associated with responsiveness in either group. In the ‘initial’ group, 8/17 were HR. Iron deficiency was noted in 75 and 33 percent of HR vs R patients (p =0.15). Median CRP in HR group was significantly higher at 10 mg/dL (7.4-20.4) as compared to R 2.8mg/dl (1.5-4), p=0.034. Distribution of other bio-chemical parameters was comparable. HR patients had more hospitalizations (62.5% vs 22.2%; p =0.153). In subsequent ESA group 10/83 (12%) cases were HR. Mean average weekly ESA dose (IU/Kg/week) in HR (286 ± 28) was significantly higher than R group (137 ± 44, p <0.0001). Median CRP (mg/dL) in HR was 20.2 (8.8-27.6) and was significantly higher than R 2.6 (1.2-5.4, p=0.0001). Median iPTH (pg/mL) in HR group was 899 (801-1053) significantly higher than R 418 (242-632; p =<0.0001). Mean serum phosphorus (mg/dL) in HR was 6.4 ± 1.7 which was significantly higher as compared to R (5.3 ± 1.6, p value=0.038). Median ALP of 366 (276-408) IU/L in HR was significantly higher than in R 126 (93-196, p=0.0007). Both groups were equitable in adequacy. Hospitalization rate was not (60 vs 30%, p=0.09) different. Mortality rate was significantly higher in HR as compared to R (40% vs 1.4%, p=0.0005). Conclusion The study revealed a substantial occurrence of ESA hypo-responsiveness in HD population. High CRP, signifying inflammation and CKD-MBD turned out to be significant contributors to development of hypo-responsiveness. ESA hypo-responsiveness is associated with higher mortality over short term.

#1647 Clinical insights into incremental hemodialysis: a retrospective analysis of patient persistence and outcomes

Abstract Background and Aims Incremental haemodialysis has been proposed as an alternative to standard thrice-weekly haemodialysis for incident patients with significant residual kidney function. Definition is not unique, but it is mostly intended as twice weekly dialysis. Its diffusion is not known since there are no public registers in Europe, but it is adopted in some dialysis facilities, while in others is not, with geographical differences. In our centre incremental haemodialysis in adopted for some patients, based on the clinical judgement, without a strict protocol. We retrospectively analysed clinical outcomes of the incident patients of the last 36 months, to understand which patients may benefit more from this approach, how long it is viable and the clinical outcomes. Method Retrospective observational analysis of incident patients of the last 36 months, without serious rapidly evolving disease. Focus was on persistence in twice-weekly dialysis, nutritional parameters, residual kidney function, hospital admissions and economic considerations. 36 patients started haemodialysis with a 2-times per week schedule while 13 with full dose dialysis. At baseline, there were no significant differences on age, sex, serum albumin or vascular access. 5 patients in full dose group were anuric for bilateral nephrectomy or rapidly progressive kidney disease, while all patients in incremental group had significant residual kidney function (average creatinine clearance: 7.1 ml/min). Results During the follow up period, 19/36 patients’ weekly dialysis sessions were incremented to three after a median time of 280 days, and 17/36 were still on 2-dialysis with a median follow-up time of 228 days. The reason for transition to three dialysis per week was residual kidney function loss except for a case of pericarditis. Persistence in incremental dialysis was >80% at 6 months and 44% at 1 year (Fig. 1a). We observed a significantly reduced persistence in patients with low ultrafiltration at 2nd month of dialysis (<1.7% of weight per session – 1 kg for a 60 kg patient-) and a reduced persistence with pre-dialysis systolic blood pressure <150 mmHg at 2nd month (Fig. 1b-c). Persistence was not different in more frail patients (elderly, dialyzed with a central venous line or with lower baseline albumin). Serum albumin increase was higher in patients in incremental haemodialysis at 6 months, with a borderline statistically significant difference, and similar at 1 year (Fig. 2a-b). The average weight was stable in both groups (Fig. 2). Hospital admissions were lower in the incremental group, and number of days of hospitalization per 1000 patients’ days were lower (24 vs 41 days). Thanks to the incremental approach, about 1600 dialysis sessions were avoided for the patients included in the analysis, with significant reduction of economic impact for the public healthcare and the possibility to treat more patients. Data was insufficient to make conclusions on kidney function preservation. Conclusion Incremental approach is valid in our experience. These data give useful information on how long we can expect patients to persist in 2-weekly dialysis and on which patients might benefit more and longer of this approach. The patients with better volume control, which reflect in adequate blood pressure control and low ultrafiltration rate, show a significantly longer persistence in incremental dialysis. The approach is valid also for frail patients. We also found better albumin and lower hospital admission rates that could be related with a reduced health-care exposition and better overall patients’ well-being, with adequate uremic symptoms control. The reduction on the hospital admissions has been already observed, while the albumin better rise is a new finding and should be confirmed in a randomized or at least larger study. Waiting for the results of the on-going randomized clinical trials, incremental haemodialysis might be the new standard-of-care for a subset incident haemodialysis patients.

#1899 Transitional care clinic for incident hemodialysis patients : the Singapore experience

Abstract Background and Aims The period of transition from chronic kidney disease (CKD) to End stage kidney disease (ESKD) presents significant morbidity and mortality risk to the patients. This higher mortality risk is largely contributed by cardiovascular factors and infection. The last 2 decades have seen a remarkable succession of programs to improve outcome in incident dialysis patients. One such initiative is the use of ‘fistula first’ policy. In Singapore, pre-emptive access creation among ESKD patients continues to be low, with up to 80% of incident dialysis patients being commenced on hemodialysis (HD) via a dialysis catheter. Ensuring that incident dialysis patients have definitive vascular access, early referral to transplantation and adequate psychosocial support, amongst other factors, is an important consideration in their journey towards improved health outcomes. In order to achieve this, meticulous care coordination and a multifaceted approach is required. This realization is what led to the inception of our transition care clinic (TCC) in 2019. Conducted bi-monthly by a multidisciplinary team of nephrologists and renal coordinators, with inputs from pharmacists and medical social workers as needed, the TCC engages patients within 4-6 weeks post-hospital discharge. Its focus includes vascular access, dietary and fluid compliance, blood pressure control, HD adherence, transplantation referral, and medication reconciliation. Method A retrospective analysis of 314 ESKD patients who initiated HD between September 2019 and September 2022 compared outcomes between TCC attendees (n=164) and non-attendees Results TCC attendees exhibited a lower 1- year mortality rate (p=0.002) and higher rates for vascular access creation within first 6 months (p=0.001) as compared to non-attendees. However, no statistical differences were observed in hospitalization rates in the first year (p=0.760) and kidney transplantation referrals (p=0.20) between the two groups. Conclusion While notable improvements were observed in mortality rates and vascular access creation, there was no significant difference in hospitalization rates or kidney transplantation referrals between the two groups. In spite of the limitations due to its retrospective nature, this study clearly demonstrates the effectiveness of TCC in enhancing patient outcomes during the critical initial phase of hemodialysis. The study highlights the importance of setting up, refinement and expansion of such services in improving the outcome of this vulnerable patient group.

#2652 Hemoglobin excursion outside of the target range and their associations with all-cause mortality in hemodialysis patients

Abstract Background and Aims Based on earlier analyses (Mermelstein et al., ASN Renal Week 2023), where we found an improved survival with hemoglobin levels above the currently targeted range of 10 to 11 g/dL quantified as an area under the excursion curve, we hypothesized an independent association between all-cause mortality hazard ratio and a) the number of excursions, and b) the number of days outside of the target range. Method We explored this relationship in a retrospective cohort study of incident hemodialysis patients receiving erythropoietin stimulating agent (ESA) commencing treatment Fresenius Kidney Care clinics in the US. We included patients who were given a long-acting erythropoietin stimulating agent within 90 days of dialysis initiation, considered the first six months as baseline and the following 18 months as the follow-up period. Only patients with at least 5 hemoglobin values over the first 75 days were included. We calculated the ‘area under the curve’ (AUC) above and below the target hemoglobin range of 10-11 g/dL for each patient during the baseline period, as well as days below and above range, and number of excursions below and above range. Cox proportional hazard models additionally adjusted for age, race, sex, diabetes, serum albumin, and phosphate were developed, and the hazard ratio estimates depicted in a forest plot. Results We studied 62,181 patients (57% male, 39% diabetic, mean baseline hgb 10.42 ± 0.72 g/dL, baseline AUC above target 44.36 ± 49.44 g/dL * days and 78.06 ± 86.26 g/dL * days below target). Forest plot of the HR estimates showed an increased risk of death with AUC below the lower limit of the target range (i.e. 10 g/dL), which also held true both for number of excursions and days exposed to lower hgb levels). Conversely, AUC, conversions and days spent at hgb levels higher than the upper limit of the target range (i.e. 11 g/dL), associated with a significant survival advantage. Conclusion In an effort to validate the robustness of our previously shown association between higher hgb levels and survival advantage, and to corroborate the accuracy of the utilized AUC quantification method, we separated both components of the AUC, namely into time and magnitude and quantified the independent associations with the risk of death. This allowed to discern between the associations of both to the risk of death. Consistent with the earlier results, avoiding levels below 10 g/dL and aiming for levels above the upper limit of 11 g/dL, seems to be beneficial for the anemia management of incident hemodialysis patients treated with a long-acting ESA.

#2155 Evaluating the health-related quality of life of patients undergoing haemodialysis: highlights from a multicentric nationwide study

Abstract Background and Aims Haemodialysis (HD) represents the most common renal replacement therapy for end-stage renal disease worldwide. Despite recent advances in HD the health-related quality of life (HRQoL) should be monitored in conjunction with clinical variables to optimize a comprehensive treatment. Method From June to July 2022, all patients from 47 clinics were included. Among other key relevant clinical variables, HRQoL was assessed by using the Kidney Disease Quality of Life Short Form (KDQOL-SF™ 1.3).It`s generic part is summarised in the physical component summary (PCS) and mental component summary (MCS). The specific part evaluates 11 domains: symptom/problem list; effects of kidney disease on daily life; burden of kidney disease; work status; cognitive function; quality of social interactions; sexual function; sleep; social support; dialysis staff encouragement; and patient satisfaction. All scores range from 0 (worst) to 100 (best). To ensure comparability of results, mean ± SD values are outlined, even though non-parametric tests were used to test associations. Results A total of 3,595 patients (67.3% male) completed the KDQOL (out of 4259 HD patients treated during study period). Most of them (67.18%) were over 60yo of age, and 65.67% had a severe comorbidity index score. In addition, 50.54% had a native AV fistula and only 3.92% were incident HD. PCS scores reported were higher in over 75yo (47.68 ± 10.63) rather than normative population (40.16 ± 11.62), indicating an overall good physical function. However, MCS values (33.17 ± 9.36) were indicative of substantial impact. Gender differences were noted across almost all disease-specific and generic domains (all p < 0.05). Severe comorbidity scores were associated with lower scores in certain renal specific domains and MCS. Finally, incident HD patients reported lower satisfaction and poorer perceived overall health (p-values = 0.001). Conclusion Although PCS scores reported were reasonable, a remarkable impact on mental health was found. Moreover, a differential impact of patient's HRQoL was captured based on gender and other variables highlighting the need of individualised evaluation and management of HD patients.

#1085 Prediction models for hospitalization in patients with advanced chronic kidney disease: systematic review, external validation and development study

Abstract Background and Aims Hospitalization is a common complication in patients with advanced chronic kidney disease (CKD). Predicting hospitalization would be beneficial for clinicians and patients. Clinicians may be assisted in adequate healthcare planning by being able to anticipate hospitalizations. Additionally, patients have indicated wanting more information about their risk of hospitalization. By providing patients a personal indication of their risk of hospitalization, they better know what to expect of the future which can foster a feeling of control. Especially for incident dialysis patients this might help, as they enter a new and to them still largely unknown stage of their disease. Moreover, if a patient knows they have a high risk of hospitalization, they may better cope with the hospitalization if it occurs, as it is less unexpected. Therefore, we aimed to 1) identify and give an overview of current prediction models for hospitalization in CKD patients, 2) externally validate these models, and 3) develop a new model if no well-performing models were identified. Method We performed a systematic review in PubMed to identify prediction models for hospitalization, length of stay (LOS), and readmission. Identified models were appraised using the Prediction model Risk of Bias Assessment Tool. We targeted three external validations in hemodialysis (HD), peritoneal dialysis (PD), and pre-dialysis patients in a Dutch dialysis and European pre-dialysis cohort. Prediction models were externally validated on discrimination (C-statistic) and calibration (calibration plot, slope, and calibration-in-the-large). We developed a Fine-Gray model for hospitalization within one year in patients initiating HD, taking into account the competing risk of death. Informed by model performance, we also investigated Cox and logistic regression as modeling strategies. We performed a sensitivity analysis, redefining the outcome to be predicted as the 1-year risk of hospitalization of 3 days or longer. Results From the systematic search, we identified 17 models in 6 studies. All models were developed in the USA or in China. Two models predicted hospitalization rate in incident PD patients and 3 models predicted 30-day readmission in maintenance HD patients and in CKD stage 3-5 patients not on dialysis discharged after a heart failure hospitalization. The risk of 1 and 6 hospitalizations within one year in prevalent HD patients were predicted by one model each. Prolonged LOS in PD patients was predicted by ten models. All models were of low quality with a high risk of bias. The most common shortcomings were using future information to make predictions, inadequate handling of missing data, and model overfitting. Due to underreporting and unavailability of predictors, we could only externally validate 3 models. These models were poorly calibrated and had poor discrimination. We developed a new model in 1,020 incident HD patients predicting 1-year risk of hospitalization. We used age, cardiovascular disease, diabetes mellitus, malignancy, estimated glomerular filtration rate, and body mass index as predictors, selected based on literature and clinical expertise. The model discriminated poorly (C-statistic, 95% confidence interval [CI]; 0.55, 0.53-0.58), also in targeted external validations in 620 PD patients (0.55, 0.52-0.58) and 1,718 pre-dialysis patients (0.52, 0.52-0.54). Calibration was poor for all models. Using different modelling strategies, model performance did not improve. In the sensitivity analysis, discrimination improved but was still low (HD population: 0.58, 0.55-0.62; PD population: 0.59, 0.54-0.63; pre-dialysis: 0.55, 0.52-0.57). Conclusion Hospitalizations are important but difficult to predict for patients with advanced CKD. Current models are insufficient to predict hospitalizations. We offer two main suggestions to improve future predictions of hospitalizations. First, the outcome of hospitalization should be more specific (e.g., cardiovascular hospitalizations) to reduce outcome heterogeneity. Second, the selection of predictors should be extended with more patient-centered factors, such as patient-reported outcomes.

Relationship between high-density lipoprotein cholesterol and mortality in elderly hemodialysis patients: Data from the Korean Society of Geriatric Nephrology Retrospective Cohort

BackgroundThe association between high-density lipoprotein (HDL) cholesterol levels and mortality in elderly patients undergoing hemodialysis is not well established. Thus, this study investigated HDL levels and mortality in elderly Korean patients undergoing hemodialysis. MethodsWe recruited 1860 incident hemodialysis patients aged > 70 years from a retrospective cohort of the Korean Society of Geriatric Nephrology. The primary outcome measure was the all-cause mortality. ResultsThe mean age of the cohort was 77.8 years and 1049 (56.4%) were men. When we grouped the patients into HDL cholesterol tertiles, the T1 group (HDL level <30 mg/dL in men and <33 mg/dL in women) had a higher proportion of patients with end-stage kidney disease due to diabetic nephropathy. During the median follow-up period of 3.1 years, 1109 (59.7%) deaths occurred. In a multivariable Cox regression model, the T1 group had significantly higher risk of mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.10-1.50; p=0.002) compared to the T3 group. A nonlinear analysis using a restrictive spline curve showed that low HDL cholesterol levels were associated with increased HR when HDL cholesterol levels were < 40 mg/dL; however, there was no association between HDL cholesterol and mortality when HDL cholesterol levels were > 40 mg/dL. Triglyceride/HDL ratio was not significantly associated with risk of mortality (HR per 1 log increase, 1.08; 95% CI, 0.99-1.18; p=0.069). ConclusionsLow HDL cholesterol levels are associated with an increased risk of mortality in elderly patients undergoing hemodialysis. However, there was no significant relationship between HDL cholesterol levels and mortality when levels were below 40 mg/dL. Therefore, low HDL cholesterol levels may be a useful risk factor for predicting mortality in elderly patients undergoing hemodialysis.

External validation of the 2-year mortality prediction tool in hemodialysis patients developed using a Bayesian network

Abstract Background and hypothesis In recent years, a number of predictive models have appeared to predict the risk of medium-term mortality in haemodialysis patients, but only one, limited to patients aged over 70, has undergone sufficiently powerful external validation. Recently, using a national learning database and an innovative approach based on Bayesian networks and 14 carefully selected predictors, we have developed a clinical prediction tool to predict all-cause mortality at 2 years in all incident haemodialysis patients. In order to generalise the results of this tool and propose its use in routine clinical practice, we carried out an external validation using an independent external validation database. Methods A regional, multicenter, observational, retrospective cohort study was conducted to externally validate the tool for predicting 2-year all-cause mortality in incident and prevalent hemodialysis patients. This study recruited a total of 142 incident and 697 prevalent adult hemodialysis patients followed up in one of the 8 AURAL Alsace dialysis centers. Results In Incident patients, the 2-year all-cause mortality prediction tool had an area under the receiver curve of 0.73, an accuracy of 65%, a sensitivity of 71%, a specificity of 63%. In prevalent patients, the performance for the external validation were similar in terms of AUC-ROC, accuracy, and specificity but was lower in term of sensitivity. Conclusion The tool for predicting all-cause mortality at 2 years, developed using a Bayesian network and 14 routinely available explanatory variables, obtained satisfactory external validation in incident patients, but sensitivity was insufficient in prevalent patients.

Development of a prognostic risk score to predict early mortality in incident elderly Japanese hemodialysis patients.

Information of short-term prognosis after hemodialysis (HD) introduction is important for elderly patients with chronic kidney disease (CKD) and their families choosing a modality of renal replacement therapy. Therefore, we developed a risk score to predict early mortality in incident elderly Japanese hemodialysis patients. We analyzed data of incident elderly HD patients from a nationwide cohort study of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) to develop a prognostic risk score. Candidate risk factors for early death within 1 year was evaluated using multivariate logistic regression analysis. The risk score was developed by summing up points derived from parameter estimate values of independent risk factors. The association between risk score and early death was tested using Cox proportional hazards models. This risk score was validated twice by using an internal validation cohort derived from the JRDR and an external validation cohort collected for this study. Using the development cohort (n = 2,000), nine risk factors were retained in the risk score: older age (>85), yes = 2, no = 0; sex, male = 2, female = 0; lower body mass index (<20), yes = 2, no = 0; cancer, yes = 1, no = 0; dementia, yes = 3, no = 0; lower creatinine (<6.5 mg/dL), yes = 1, no = 0; lower albumin (<3.0 g/dL), yes = 3, no = 0; normal or high calcium (≥8.5 mg/dL), yes = 1, no = 0; and higher C reactive protein (>2.0 mg/dL), yes = 2, no = 0. In the internal and external validation cohorts (n = 739, 140, respectively), the medium- and high-risk groups (total score, 6 to 10 and 11 or more, respectively) showed significantly higher risk of early death than the low-risk group (total score, 0 to 5) (p<0.001). We developed a prognostic risk score predicting early death within 1 year in incident elderly Japanese HD patients, which may help detect elderly patients with a high-risk of early death after HD introduction.

Incidence of Chronic Kidney Disease Stage 5 Hemodialysis Patients in the Month of December 2023 – A Snapshot survey

Introduction: Chronic kidney disease progressing to hemodialysis is a significant health care burden. Since no formal registry including all incident hemodialysis patients is nonexistent. This snapshot survey was conducted to document new enrolling patients in the hemodialysis units across Pakistan.&#x0D; Methods: a simple survey was devised to enquire about the new enrollments for maintenance dialysis in each unit. Age and gender and geographical location of the patients was asked.&#x0D; Results: A total of 995 patients were enrolled in different dialysis units during the month of December 2023. Majority were males and in the age range less than 40 years.&#x0D; Conclusion: A significant number of patients are being enrolled for maintenance dialysis each month, highlighting the increasing burden of CKD patients progressing to ESKD. Larger studies and national hemodialysis registry may help in understanding the actual burden on health budget.

Geriatric Nutritional Risk Index and First-Year Mortality in Incident Hemodialysis Patients.

The Geriatric Nutritional Risk Index is a simple nutritional screening method, and this study aimed to investigate the association between the initial Geriatric Nutritional Risk Index and all-cause mortality in incident patients in the first year after the initiation of hemodialysis. This study is a retrospective cohort study and used the Korean Renal Data System database. Patients who were eligible for Geriatric Nutritional Risk Index assessment and underwent hemodialysis from January 2016 to December 2019 were included. The primary outcome was all-cause mortality, and outcome evaluation was performed in December 2020. A Cox proportional hazard model was used to analyze the association between the Geriatric Nutritional Risk Index and mortality. A total of 10,545 patients were included, and the mean age was 63.9 ± 3.7 years. The patients were divided into four groups by the quartile of the Geriatric Nutritional Risk Index with a mean value of 96.2 ± 8.2. During the study period, 545 (5.2%) deaths occurred. The surviving patients had higher Geriatric Nutritional Risk Index values than ones who died in the first year of hemodialysis initiation (96.6 ± 7.5 vs. 88.2 ± 9.3, p < 0.001). Quartile 1 (Geriatric Nutritional Risk Index < 91.8) showed a significantly increased risk of all-cause (Hazard Ratio: 2.56; 95% Confidence Interval: 2.13-3.09; p < 0.001) and cardiovascular mortality (Hazard Ratio: 22.29; 95% Confidence Interval: 1.71- 3.08; p < 0.001) at the first year in comparison with Quartile 4 (Geriatric Nutritional Risk Index ≥ 101.3). In areas under the receiver-operating characteristic curves of all-cause mortality, the Geriatric Nutritional Risk Index model improved predictive values, compared to the baseline model. The area with the Geriatric Nutritional Risk Index model was significantly higher than the one with a model including albumin or body mass index (p < 0.001). These findings suggest that a low Geriatric Nutritional Risk Index (<91.8) is associated with first-year all-cause and cardiovascular mortality in patients who start hemodialysis and may be a useful and reproducible tool for assessing prognoses in this population.

Mediating effect of vascular calcification in galectin-3-related mortality in hemodialysis patients

Galectin-3 levels have been studied as a potential biomarker for predicting cardiovascular (CV) risk and mortality in hemodialysis (HD) patients. Recently, a close relationship between galectin-3 and vascular calcification (VC) has been reported. Here, we investigated the role of VC as a mediating factor in the association between galectin-3 and mortality. Serum galectin-3 and baseline aortic arch calcification (AoAC) score were measured in 477 incident HD patients. Mortality data were obtained at a median follow-up of 40 months. Causal mediation analysis was performed to examine the effect of vascular risk factors on galectin-3-related mortality. The prevalence of AoAC in HD patients was 57% (n = 272), and elevated galectin-3 levels were associated with a significantly increased risk of AoAC. When the galectin-3 level was divided by the median level of 37 ng/mL, a higher galectin group increased the risk of all-cause mortality by 1.71-fold (95% CI 1.02–2.92, p = 0.048), even after adjustment for multiple CV risk factors. Mediation analysis showed that both the direct effect of the galectin-3 on mortality (β = 0.0368, bootstrapped 95% CI [0.0113–0.0622]) and the indirect effects were significant. AoAC score and high-sensitivity CRP levels significantly mediated the association between galectin-3 and mortality (total indirect effects: β = 0.0188, bootstrapped 95% CI [0.0066–0.0352]). This study suggests that the association between high galectin-3 and mortality may be partially mediated by higher VC and inflammatory state in HD patients.

Prevalence and risk factors of erythropoiesis stimulating agents hyporesponsiveness in chronic hemodialysis patients attending nephrology center of Benghazi

Background: Anemia is quite prevalent in end stage renal disease patients. Despite availability of different forms of erythropoiesis stimulating agents, many end stage renal disease patients are anemic according to National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative guidelines. Patient and methods: we conduct a cross sectional study between May 2022 and July 2022, targeting adult chronic hemodialysis patients, to investigate the prevalence of erythropoiesis stimulating agents hyporesponsiveness, to assess if patients are receiving the appropriate weight-based dosing of these agents, and to identify additional risk factors behind inadequate response to therapy.390 end stage renal disease patients are receiving chronic hemodialysis at nephrology center of Benghazi. Incident hemodialysis patients, patients with other hematological disease or with malignancy are excluded. Finally, 150 patients met the inclusion criteria and enrolled in the study. Results: 100 (66.7%) are male, and 50 (33.3%) are females. Age is 50.6 ±13.2 years. Erythropoiesis stimulating agents hyporesponsiveness is prevalent in chronic hemodialysis patients, 130 (86.7%) patients are anemic as their Hb levels were &lt;11 g/dl, while only 20 (13.3%) patients have Hb levels of &gt;/=11g/dl. There is a significant relationship between gender and ESA response, as hyporesponsiveness is more observed in male patients (P &lt; .005). We find that 105 (70%) patients are receiving an appropriate weight-based dose, while only 45 (30%) patients were giving an inappropriate dose. When the relationship between ESA dosing and patients' response to ESA is examined, we find, that despite receiving the appropriate dose, 90 (60%) patients are ESA hyporesponsive, while only 15 (10%) are responsive to the appropriate weight-based dose. However, no statistical association is found between ESA hyporesponsiveness and age or weekly hours of dialysis. Conclusion: despite receiving an appropriate dosage of ESA, our study population shows high prevalence of ESA hyporesponsive anemic state. New strategies should be applied to detect risk factors and adopt therapeutic measures to reduce its high prevalence in hemodialysis population.

Serum chloride as a marker of cardiovascular and all-cause mortality in chronic hemodialysis patients: 5-Year follow-up study

BackgroundHypochloremia has been associated with increased mortality in patients with hypertension, heart failure, sepsis, and chronic kidney disease (CKD). The pathophysiological mechanisms of this finding are not clear. There are no studies describing an association between serum chloride levels (Cl−) and mortality in incident chronic hemodialysis (HD) patients. MethodRetrospective cohort study of the incident population in our chronic outpatient hemodialysis program between January 1, 2016, and January 1, 2021 (N=374). Survival time was collected in all patients and analyzed using the Kaplan–Meyer method. A multivariate Cox regression model was performed to predict the probability of survival, applying a stepwise procedure. ResultsDuring the median follow-up period of 20 months, 83 patients died. The 5-year overall survival rate for our patients was 45%. Both natremia and chloremia had no significant differences when compared by sex, vascular access, or etiology. There was an inverse correlation between Cl− and interdialytic weight gain (r=−0.15) (p=0.0038). Patients belonging to the quartile with lower Cl− levels had less probability of survival than patients in the quartile with higher Cl− levels (27% and 68%, respectively, p=0.019). On the other hand, in the multivariate Cox regression model, variables significantly associated with higher mortality were being older, having higher baseline comorbidity by modified Charlson index, not taking diuretics and having lower albumin and chloride levels. Particularly, higher Cl− levels was independently associated with both lower all-cause mortality (adjusted hazard ratio [HR]=0.84; 95% confidence interval [CI], 0.77–0.92; p=0.0001) and cardiovascular mortality (HR 0.9; 95% CI, 0.83–0.97; p<0.0057). ConclusionsLower Cl− levels were associated with higher all-cause and cardiovascular mortality in incident patients on chronic hemodialysis in our health area.

Associations between abrupt transition, dialysis-requiring AKI, and early mortality in ESKD among U.S. veterans

BackgroundMortality is high within the first few months of starting chronic dialysis. Pre-ESKD trajectory of kidney function has been shown to be predictive of early death after dialysis initiation. We aim to better understand how two key aspects of pre-dialysis kidney function—an abrupt transition pattern and an episode of dialysis-requiring AKI (AKI-D) leading directly to ESKD—are associated with early mortality after dialysis initiation.MethodsWe extracted national data from U.S. Veterans Health Administration cross-linked with the United States Renal Data System (USRDS) to identify patients who initiated hemodialysis during 2009–2013. We defined abrupt transition as having a mean outpatient eGFR ≥ 30 ml/min/1.73m2 within 1 year prior to ESKD. AKI-D was identified using inpatient serum creatinine measurements (serum Cr increase by at least 50% from baseline) along with billing codes for inpatient receipt of dialysis for AKI within 30 days prior to the ESKD start date. We used multivariable proportional hazards models to examine the association between patterns of kidney function prior to ESKD and all-cause mortality within 90 days after ESKD.ResultsTwenty-two thousand eight hundred fifteen patients were identified in the final analytic cohort of Veterans who initiated hemodialysis and entered the USRDS. We defined five patterns of kidney function decline. Most (68%) patients (N = 15,484) did not have abrupt transition and did not suffer an episode of AKI-D prior to ESKD (reference group). The remaining groups had abrupt transition, AKI-D, or both. Patients who had an abrupt transition with (N = 503) or without (N = 3611) AKI-D had the highest risk of early mortality after ESKD onset after adjustment for demographics and comorbidities (adjusted HR 2.10, 95% CI 1.66–2.65 for abrupt transition with AKI-D; adjusted HR 2.10, 95% CI 1.90–2.33 for abrupt transition without AKI-D). In contrast, patients who experienced AKI-D without an abrupt transition pattern (N = 2141 had only a modestly higher risk of early death (adjusted HR 1.19, 95% CI 1.01–1.40).ConclusionsAn abrupt decline in kidney function within 1 year prior to ESKD occurred in nearly 1 in 5 incident hemodialysis patients (18%) in this national cohort of Veterans and was strongly associated with higher early mortality after ESKD onset.

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.

The Impact of Depressive Symptoms on Outcomes in Incident Hemodialysis Patients

The Impact of Depressive Symptoms on Outcomes in Incident Hemodialysis Patients