Incident HD Patients Research Articles

#586 Effects of nursing facility residency on mortality in incident HD patients

Abstract Background and Aims As the elderly population increases and nuclear families are formed, the number of elderly people who are managed in nursing facility is increasing. We investigated whether dialysis performed while residing in a nursing facility before dialysis affects the mortality rate of dialysis patients. Method We enrolled 2,597 patients who visited the hemodialysis clinics of 17 teaching hospitals and surveyed the characteristics of underlying diseases, laboratory findings, and medication between patients who started dialysis while admitted to a nursing facility and those who did not. Then, multivariate survival analysis was performed to see if starting dialysis after entering a nursing facility increased mortality. Results 9.1% (n=237) of the subjects underwent dialysis while admitted to a nursing facility. This group was predominantly female and older. Also the prevalence of diabetes, dementia, heart failure and atrial fibrillation was higher. There were many users of anti-platelet agents, warfarin, dementia drugs, and antidepressants. Additionally this group showed lower weight, lymphocyte, iPTH, albumin, phosphorus, and total cholesterol and higher duration of diabetes, and alkaline phosphatase. In multivariate analysis controlling for age, sex, access type, dementia, malignancy, ischemic heart disease, cerebrovascular accident, heart failure, atrial fibrillation, liver cirrhosis, fracture, coronary artery disease, ejection fraction, lymphocyte, platelet, BUN, Cr, albumin, phosphorus, total cholesterol, RAS blockade, B-blocker, calcium channel blocker, warfarin, hyperlipidemia drugs, Calcium-based phosphate binder, sevelamer, anti-depressant, and dementia medication, the HR of group receiving dialysis after being admitted to a nursing facility was 1.658 [1.309, 2.100]. Conclusion In summary, the current study suggests a correlation between starting dialysis in a nursing facility and a higher mortality rate among dialysis patients.

#3472 PRELIMINARY DATA FROM MOTHER HDX STUDY: A MULTICENTRE OPEN-LABEL RCT STUDY TO EXPLORE THE MORBIMORTALITY WITH THE THERANOVA HDX VS OL-HDF

Abstract Background and Aims Dialysis patients have a high rate of cardiovascular morbidity and mortality. For this reason, new technical advances are necessary to be introduced in clinical practice. Medium cut-off (MCO) membranes are a new generation of membranes that allow the removal of a greater number of medium-sized molecules compared to high-flux hemodialysis (HF-HD) but retaining albumin. Theranova, a MCO membrane has an increased permeability and also produces high convective volume in the form of internal filtration. For these special properties, MCO generated a new concept of therapy called expanded HD (HDx). Until now, online hemodiafiltration (OL-HDF) has demonstrated its superiority, in terms of survival, compared to HF-HD. But the comparison between OL-HDF and HDx is a question not solved. Method The MOTheR HDx study trial (NCT03714386) is an open-label, multicentric, prospective, 1:1 randomized, parallel-group trial designed to evaluate the efficacy and safety of HDx compared to OL-HDF in incident HD patients in Spain for up to 36 months. The main endpoint is to determinate if HDx is non inferior to OL-HDF at reducing the combined outcome of all-cause dead and stroke (ischemic or hemorrhagic), acute coronary syndrome (angina and myocardial infarction), peripheral arterial disease (amputation or revascularization) and ischemic colitis (mesenteric thrombosis). Results Now we have enrolled 513 patients, 44 excluded and 469 were randomized. 229 were allocated to HDx and 240 to OL-HDF. No differences were found in neither baseline characteristics, hemodialysis or pharmacological treatment, nor laboratory parameters. Follow up time was similar in both groups: 15.06 (12.8) vs 13.73 (11.51) months [HR 0.84 (0.50-1.40)] without differences in mortality: 29 (12.7%) vs 31 (12.9%) [HR 0.89 (0.54-1.48)] in HDx and HDF respectively (Figure 1). Conclusion These preliminary results from Mother study support that HDx is not inferior to OL-HDF in reducing the all-cause mortality outcome.

Mortality in elderly hemodialysis patients, influence of frailty and comorbidity

Background: Mortality in end-stage kidney disease (ESKD) remains high, especially among the elderly with a higher burden of comorbidity and frailty. In this group, dialysis may not offer better survival compared to conservative management. Frailty defined by clinical frailty scale (CFS) and comorbidity by Charlson Comorbidity Index (CCI) are known independent predictors of mortality. Our aim was to compare which one had higher impact on early mortality in urgent-start hemodialysis patients. Methods: We conducted a retrospective cohort study of patients aged 65 years and over, who started hemodialysis as their first renal replacement therapy (RRT) between January 2014 and December 2020. CFS and mCCI, at time of HD start, were used to evaluate, respectively, frailty and comorbid disease burden. The primary outcome was death in the first 6 months of RRT. Results: During the study period 166 patients were included. The median age, at time of hemodialysis start, was 75 years ± 6.3 years. The mortality at 6 months was 19% (n=31). For both scales, the analysis of ROC curve, stablished the optimal cut-off to predict the event death at first 6 months as ≥ 5points. The performance of CFS was superior to the mCCI, in fact, the area under the curve was significantly higher in CFS (0.739) versus the mCCI (0.620). A CFS≥5 had a sensitivity/specificity of 94%/44% in prediction the primary outcome. On the other hand, a mCCI≥5 predicts the same outcome with a sensitivity/specificity of 26%/88%. The diagnostic odds ratio for CFS≥5 was 11.6, compared to only 2.7 for mCCI≥5. Lastly, we constructed a model in which both scores interacted (as categorical variables), which after multivariable adjustment showed that mCCI/CFS <5/≥5 and ≥5/≥5 were independent predictors of mortality (HR=7.06; P=0.017; HR=10.708; P=0.002; respectively). Interestingly, no events were observed in the mCCI≥5/CFS<5 group. Conclusions: In this cohort of urgent-start incident HD patients, frailty defined by CFS was a stronger predictor of mortality than comorbidity defined by CCI.

Prognostic value of the combination of neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio and platelet-to-lymphocyte ratio on mortality in patients on maintenance hemodialysis.

Hemodialysis (HD) is the most important renal replacement therapy for patients with end-stage kidney disease (ESKD). Systemic inflammation is a risk factor of mortality in HD patients. Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) are new inflammatory markers. However, previous studies have inconsistent conclusions about the predictive value of NLR, MLR and PLR on mortality of HD patients. The aim of this study was to establish an inflammation scoring system by including NLR, MLR and PLR, and evaluate the association between the inflammation score and all-cause and cardiovascular mortality in HD patients. In this single center retrospective cohort study, 213 incident HD patients from January 1, 2015 to December 31, 2020 were included. Baseline demographic and clinical data and laboratory measurements were collected. According to the optimal cut-off values, NLR, MLR and PLR were assigned 0 or 1 point, respectively. Then, the inflammation score was obtained by adding the NLR, MLR and PLR scores. All patients were followed until July 31, 2021. The associations of the inflammation score with all-cause and cardiovascular mortality were assessed by multivariable-adjusted Cox models. Of 213 patients, the mean (± SD) age was 56.8 ± 14.4 years, 66.2% were men, and 32.9% with diabetes. The primary cause of ESKD was mainly chronic glomerulonephritis (46.5%) and diabetic nephropathy (28.6%). The median inflammation score was 2 (interquartile range = 1-3). During a median 30 months (interquartile range = 17-50 months) follow-up period, 53 patients had died, of which 33 deaths were caused by cardiovascular disease. After adjusting for demographics, primary diseases and other confounders in multivariable model, the inflammation score = 3 was associated with a hazard ratio for all-cause mortality of 4.562 (95% confidence interval, 1.342-15.504, P = 0.015) and a hazard ratio for cardiovascular mortality of 4.027 (95% confidence interval, 0.882-18.384, P = 0.072). In conclusion, an inflammation scoring system was established by including NLR, MLR and PLR, and the higher inflammation score was independently associated with all-cause mortality in HD patients.

Transitions in an integrated model of renal replacement therapy in a regional health system

Introduction and objectivesThe choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques. Material and methodsThe study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008–2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition. ResultsA total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KT). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p < 0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs KTX group 8.3%, p < 0.001) and less access to a transplant (HD group 30.4% vs PD group 51.6%; p < 0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD → PD: 0.7 years (SD 1.1) vs PD → HD: 1.5 years (SD 1.4) p < 0.001), are younger (HD → PD: 53.5 years (SD 16.7) vs PD → HD: 61.6 years (SD 14.6); p < 0.001), presented less mortality (HD → PD: 24.5% vs PD → HD: 32.0%; p < 0.001) and higher access to a transplant (HD → PD: 49.4% vs PD → HD: 31.7%; p < 0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one. ConclusionOur data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.

MO895: Comorbidity or Frailty, Which One Has a Greater Impact on Early Mortality in Incident Elderly Dialysis Patients?

Abstract BACKGROUND AND AIMS Mortality in end-stage renal disease remains high, especially among the elderly with a higher burden of comorbidity and frailty. In this group, dialysis (HD) may not offer better survival compared with conservative management. Frailty defined by clinical frailty scale (CFS) and comorbidity by modified Charlson Comorbidity Index (mCCI) are known independent predictors of mortality. Our aim is to compare that has higher impact on early mortality in incident elderly HD patients. METHOD We conducted a retrospective cohort study of patients aged 65 years and over, who started HD as their first renal replacement therapy (RRT) between January 2014 and December 2019. CFS and mCCI, at time of HD start, were used to evaluate, respectively, frailty and comorbid disease burden. The primary outcome was death in the first 6 months of RRT. The optimal cut-off for our outcome was defined through the analysis of a receiver operating characteristic (ROC) curve. Survival curves were constructed using Kaplan–Meier method, with comparison between patients' groups being done by log-rank test. Multivariable Cox analysis was applied to assess independent predictors of early mortality. All p values are two-tailed, p value &amp;lt; 0.05 is considered to indicate statistical significance. RESULTS 166 patients were included, 107 (64%) started HD by central venous catheter. The median age, at time of haemodialysis start, was 75 years ± 6.3 years. The mortality at 6 months was 19% (n = 31). For both scales, the analysis of ROC curve, stablished the optimal cut-off to predict the event death at first 6 months of HD as ≥ 5points. The performance of CFS was superior to the mCCI (P = 0.031; Figure 1 top). In fact, the area under the curve is higher in CFS (0.739) versus the mCCI (0.620). A CFS ≥ 5 had a sensitivity/specificity of 94%/44% in prediction the primary outcome. On the other and, a mCCI ≥ 5 predicts the same outcome with a sensitivity/specificity of 26%/88%. The diagnostic odds ratio for CFS ≥ 5 was 11.6, compared with only 2.7 for mCCI ≥ 5. When confronted using the Kaplan–Meier method, both CSF &amp;lt; 5 versus CSF ≥ 5 and mCCI &amp;lt; 5 versus mCCI ≥ 5 presented different survival rates that proved to be statistically significant by log rank test (P &amp;lt; 0.001 and P = 0.020, respectively; Figure 1 medium and bottom). CFS was an independent predictor of 6 month mortality both as a categorical (CSF ≥ 5) (HR = 3.64; P = 0.004) and continuous variable (HR = 1.95; P &amp;lt; 0.01). mCCI didn't prove to be an independent predictor. Lastly, we constructed a model in which both scores interacted (as categorical variables), in this multivariable adjusted model mCCI/CFS &amp;lt; 5/≥5 and ≥ 5/≥5 were intendent predictors of mortality (HR = 6.141; P = 0.022) (HR = 10.58; P = 0.002). Interestingly, no events were observed in the mCCI ≥ 5/CFS &amp;lt; 5 group. CONCLUSION In this cohort of incident elderly HD patients, frailty defined by CFS was a stronger predictor of mortality than comorbidity defined by CCI. The group of mCCI/CFS (≥5/≥5) has a 10-time higher chance of dying than the reference group. Our data also suggest that simple scores can predict the risk of early mortality in incident HD patients and should be used to guide the decision-making process for elderly patients and to improve the quality of the information given to patients and families.

Incremental and Personalized Hemodialysis Start: A New Standard of Care

IntroductionIncremental hemodialysis (iHD) may attenuate “dialysis shock” and reduce costs, preserving quality of life. It is considered difficult to reconcile with HD wards’ routine; fear of underdialysis and increasing mortality are additional concerns. The aim of this study was to evaluate mortality, morbidity, and costs in a large HD ward where iHD is the standard of HD start.MethodsThis observational study included all incident HD patients in 2017 to 2021, stratified according to HD start: iHD (1–2 sessions/wk), decremental HD (dHD, 3 sessions/wk at start, later reduced), or standard (3 sessions/wk). Results were compared with data recorded in the same unit before the incremental program (2015–2017) and with a propensity score-matched cohort from the French Renal Epidemiology and Information Network (REIN) registry.ResultsA total of 158 patients started HD in 2017 to 2021, 57.6% on iHD, 8.9% dHD, and 33.5% standard HD schedule. Patients on the standard schedule had lower initial estimated glomerular filtration rate (eGFR) (5 vs. 7 ml/min per 1.72 m2, P = 0.003). We found no survival differences according to period of start (same center) and propensity score matching (REIN). Patients intensively followed in the pre-HD period were more likely to start on iHD-dHD. Persistence on iHD-dHD was about 50% at 1 year and 35% at 2 years. Hospitalization rates and time to first hospitalization or death did not differ between the schedules. The iHD-dHD policy allowed a 16% cost saving, even accounting for supplemental biochemical tests.ConclusionOur study reveals that iHD can be a new standard of care, as it is safe and feasible in up to two-thirds of patients on incident HD.

Análisis de las transiciones en el modelo integrado de tratamiento sustitutivo renal en un sistema regional de salud

Introduction and objectivesThe choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques. Material and methodsThe study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008–2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition. ResultsA total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p<0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p<0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p<0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD→PD: 0.7 years (SD 1.1) vs PD→HD: 1.5 years (SD 1.4) p<0.001), are younger (HD→PD: 53.5 years (SD 16.7) vs PD→HD: 61.6 years (SD 14.6); p<0.001), presented less mortality (HD→PD: 24.5% vs PD→HD: 32.0%; p<0.001) and higher access to a transplant (HD→PD: 49.4% vs PD→HD: 31.7%; p<0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one. ConclusionOur data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.

MO813ANALYSING TRANSITIONS IN THE INTEGRATED MODEL OF RENAL REPLACEMENT THERAPY IN A REGIONAL HEALTH SYSTEM

Abstract Background and Aims Every year 83,000 Europeans and 6,500 Spanish CKD patients require dialysis or transplantation. The choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. A single therapy option might not be adequate across a patient’s entire lifespan and a majority of patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. Transitions should be considered as an expected progression in the patient’s treatment options. In these circumstances, there are new questions about the best sequence of techniques. Method This observational study examined a cohort of all incident patients from the Madrid Registry of Renal Patients (REMER), who initiated RRT between January 2008 and December of 2018. This study used the proportional hazards models and competitive risk models to examine the impact of transitions between RRT modalities on survival. We performed an intention-to-treat (ITT) analysis, according to the initial RRT chosen and an as treated (AT) analysis, by RRT received (Only HD, Only PD, PD then HD or HD then PD). Results A total of 8,971 patients started RRT during this period in Madrid (6.6 Million population): 7,207 on hemodialysis (HD), 1,401 on peritoneal dialysis (PD) and 363 received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p &amp;lt;0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p &amp;lt;0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (66% in less than 6 months), are younger and behave like those treated only with PD. Those who change from PD to HD do so later (1.5 years on average), are older (61.6 vs 53.5 years) and present higher mortality and less access to kidney transplantation than the group who initiates in HD and transfer to PD. Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 58.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). This analysis reflects how patients who change dialysis modality share more characteristics with the second technique than the original one. Conclusion Our data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and should be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and repports of renal registries.

FC 080VARIABILITY IN SERUM PHOSPHATE ASSESSED BY DIRECTIONAL CHANGE IS ASSOCIATED WITH INCREASED MORTALITY

Abstract Background and Aims Prior studies showed that there is a wide variability between serial pre-dialysis measurements of serum phosphate (P). Serum P vary can be due to changes in nutritional intake, underlying bone disorders, medication use or inflammation. Various variability markers have been investigated to study the association between P variability and its association with outcomes, however, the directional trends have not been studied in depth. We aimed to study directional changes and investigated its association with outcomes. Method All adult incident HD patients treated in Fresenius Medical Care North America (FMCNA) clinics between 01/2010 and 10/2018 were included in this retrospective cohort study. Serum P levels were averaged from month 1 to 6 after the initiation of dialysis (baseline). Baseline absolute and directional range (DR) of serum P were calculated. DR of P was calculated as: P min/max (t2) – P max/min (t1), with P (t1) and P (t2) represents the timepoint when either the min P value or max P value was measured, whichever comes first, and with t2 happened after t1. It is positive when the minimum antedates the maximum, otherwise negative. All-cause mortality was recorded between months 7 and 18. Cox proportional hazards models with spline terms were applied to explore the association between absolute and DR of P and all-cause mortality. Additionally, tensor product smoothing splines were computed to study the interactions of P with absolute P and DR of P and their joint associations with outcomes, respectably. Results We studied 353,142 patients. The average age was 62.7 years, 58% were male, 64% were diabetic. Baseline P was 4.98 mg/dL, median absolute range was 2.40 mg/dL, median DR was 1.1 mg/dL. Across different levels of P, both higher levels of absolute range and DR of P were associated with higher risk of mortality (Figure 1, Figure 2). The associations even seemed stronger in patients with lower levels of serum P and with negative DR (Figure 1). Conclusion Lower levels of serum P are independently associated with an increased risk of all-cause mortality. Whereas both a positive and negative DR of P are in general associated with increased mortality, the effects of an increase are most predominant in patients with higher levels of serum P, whereas a negative directional range are most predominant in patients with low serum P. This could be explained by the fact that patients with lower levels of P are generally malnourished or inflamed, where a further reduction indicates nutritional deterioration.

Skin Colonizers and Catheter Associated Blood Stream Infections in Incident Indian Dialysis Patients.

Introduction:Skin colonization is a risk factor for multi-drug resistant (MDR) catheter-associated bloodstream infections (CABSI). This study aimed to determine the prevalence and spectrum of skin colonizing MDR organisms in incident HD patients and their correlation with CABSI.Methods:This single-center prospective cohort study included consecutive adult incident HD patients who underwent tunneled or non-tunneled internal jugular vein HD catheter insertion between June 1, 2017 and October 31, 2017. Nasal, axillary, and exit site swabs were obtained prior to catheter insertion, at 14–21 days, and 28–35 days after catheter insertion.Results:Forty-three patients (69.7% male, 32.5% diabetic) were included and provided baseline swabs, while 29 and 10 patients respectively were available for follow-up swabs. MDR bacterial colonization, MRSA colonization, and MDR gram-negative colonization on the baseline set of swabs were seen in 76.7%, 69.7%, and 9.3% patients respectively. Of the 29 patients with at least two consecutive sets of swabs, 79.3% showed persistent colonization by MDR gram-positive organisms, most commonly by MRSA. Six patients developed a CABSI during the follow-up period (incidence rate 3.7 per 1000 patient days), 83.4% were gram negative, and in only one instance (16.6%) was the bacterial strain identical to that which had previously colonized the skin.Conclusions:Three-fourths of HD patients were colonized by MDR bacteria prior to HD initiation. Despite the majority being persistently colonized by MDR gram-positive organisms, CABSIs were predominantly gram negative.

Endothelial dysfunction and low-grade inflammation in the transition to renal replacement therapy.

End-stage renal disease (ESRD) strongly associates with cardiovascular disease (CVD) risk. This risk is not completely mitigated by renal replacement therapy. Endothelial dysfunction (ED) and low-grade inflammation (LGI) may contribute to the increased CVD risk. However, data on serum biomarkers of ED and LGI during the transition to renal replacement therapy (dialysis and kidney transplantation) are scarce. We compared serum biomarkers of ED and LGI between 36 controls, 43 participants with chronic kidney disease (CKD) stage 5 non-dialysis (CKD5-ND), 20 participants with CKD stage 5 hemodialysis (CKD5-HD) and 14 participants with CKD stage 5 peritoneal dialysis (CKD5-PD). Further, in 34 and 15 participants repeated measurements were available during the first six months following dialysis initiation and kidney transplantation, respectively. Serum biomarkers of ED (sVCAM-1, E-selectin, P-selectin, thrombomodulin, sICAM-1, sICAM-3) and LGI (hs-CRP, SAA, IL-6, IL-8, TNF-α) were measured with a single- or multiplex array detection system based on electro-chemiluminescence technology. In linear regression analyses adjusted for potential confounders, participants with ESRD had higher levels of most serum biomarkers of ED and LGI than controls. In addition, in CKD5-HD levels of serum biomarkers of ED and LGI were largely similar to those in CKD5-ND. In contrast, in CKD5-PD levels of biomarkers of ED were higher than in CKD5-ND and CKD5-HD. Similarly, in linear mixed model analyses sVCAM-1, thrombomodulin, sICAM-1 and sICAM-3 increased after PD initiation. In contrast, incident HD patients showed an increase in sVCAM-1, P-selectin and TNF-α, but a decline of hs-CRP, SAA and IL-6. Further, following kidney transplantation sVCAM-1, thrombomodulin, sICAM-3 and TNF-α were lower at three months post-transplantation and remained stable in the three months thereafter. Levels of serum biomarkers of ED and LGI were higher in ESRD as compared with controls. In addition, PD initiation and, less convincingly, HD initiation may increase levels of selected serum biomarkers of ED and LGI on top of uremia per se. In contrast to dialysis, several serum biomarkers of ED and LGI markedly declined following kidney transplantation.

Early mortality risk in incident Chinese hemodialysis patients: a retrospective cohort study

Background: Early mortality risk of maintenance hemodialysis (MHD) patients varies by country and ethnicity. Here, early mortality in incident Chinese HD patients were studied.Methods: Data from 1 January 2007 to 31 December 2013 were pulled from Beijing dialysis registry system. All included patients were followed to the end of 2013. This time period of dialysis was divided into six intervals (≤120, 121–365 days; 1–2, 2–3, 3–4, ≥5 years). Patients’ demographics, primary cause of end-stage renal disease (ESRD), date of first HD, date of death, cause for death, date and cause of censoring were extracted from the registry database. All-cause mortality (per 100 patient-years) was calculated for each period stratified by sex, age and cause of ESRD. Monthly mortality rates were also calculated.Results: A total of 11,955 patients were included, 6738 were males and 5217 were females. The mean age at dialysis initiation was 57.7 ± 16.1 years. The median follow-up time was 19.8 months. There were total 2555 deaths. The overall mortality rate was 8.2 per 100 patient-years. Mortality rates were 18.7, 7.5, 6.9, 6.9, 6.5 and 6.2 in each period. The first 2 months mortality rates were 41.9 and 16.6 per 100 patient-years. Higher mortality was observed in patients who were older, female, diabetic and hypertensive.Conclusions: The most critical period was the first 2 months of dialysis initiation. Patients who were older, female, diabetic and hypertensive had higher risk of early mortality. Our analysis highlighted that the transitional period from sever CKD stages to dialysis initiation, when optimal supportive care should be adopted, was crucial for patients’ survival.

Increased risks of mortality and atherosclerotic complications in incident hemodialysis patients subsequently with bone fractures: a nationwide case-matched cohort study.

BackgroundHemodialysis (HD) patients with bone fractures have an increased risk for death. However, the risks for mortality and atherosclerotic complications in incident HD patients subsequently with bone fractures are unknown.MethodsData derived from the Taiwan National Health Institute Research Database between January 1997 and December 2008 was analyzed. The enrolled patients included 3,008 incident HD patients subsequently with a single long bone fracture (LB Fx) and 2,070 incident HD patients subsequently with a single non-long bone fracture (NLB Fx). These patients were matched (1:5 ratio) for age, sex, and same duration of HD with incident HD patients who had no fractures and outcomes were measured over a 3-year follow-up.ResultsAfter demographic and co-morbidity adjustment, LB Fx increased the risk for overall mortality (HR = 1.59, p < 0.001) and stroke (HR = 1.09, p = 0.028) in incident HD patients. NLB Fx increased the risk for overall mortality (HR = 1.52, p < 0.001), stroke (HR = 1.19, p < 0.001), coronary artery disease (CAD), (HR = 1.13, p = 0.003), and peripheral arterial occlusive disease (PAOD), (HR = 1.41, p < 0.001) in incident HD patients. Moreover, incident patients subsequently with NLB Fx had significantly higher risks of CAD and PAOD than those subsequently with LB Fx.ConclusionsThe rates of mortality and stroke were significantly higher in incident HD patients subsequently with bone fractures than in matched patients without bone fractures. Incident HD patients subsequently with NLB Fx had significantly higher risks of CAD and PAOD than those subsequently with LB Fx and without bone fractures. Thus, incident HD patients subsequently with bone fractures should be closely followed for a higher mortality and possible development of atherosclerotic complications.

Effect of Age and Dialysis Vintage on Obesity Paradox in Long-term Hemodialysis Patients

In contrast to the general population, higher body mass index (BMI) is associated with greater survival in patients receiving hemodialysis (HD; "obesity paradox"). We hypothesized that this paradoxical association between BMI and death may be modified by age and dialysis vintage. Retrospective observational study using a large HD patient cohort. 123,383 maintenance HD patients treated in DaVita dialysis clinics between July 1, 2001, and June 30, 2006, with follow-up through September 30,2009. Age, dialysis vintage, and time-averaged BMI. Time-averaged BMI was divided into 6 subgroups;<18.5, 18.5-<23.0, 23.0-<25.0, 25.0-<30.0, 30.0-<35.0, and≥35.0kg/m(2). BMI category of 23-<25kg/m(2) was used as the reference category. All-cause, cardiovascular, and infection-related mortality. Mean BMI of study participants was 27±7kg/m(2). Time-averaged BMI was<18.5 and≥35kg/m(2) in 5% and 11% of patients, respectively. With progressively higher time-averaged BMI, there was progressively lower all-cause, cardiovascular, and infection-related mortality in patients younger than 65 years. In those 65 years or older, even though overweight/obese patients had lower mortality compared with underweight/normal-weight patients, sequential increases in time-averaged BMI > 25kg/m(2) added no additional benefit. Based on dialysis vintage, incident HD patients had greater all-cause and cardiovascular survival benefit with a higher time-averaged BMI compared with the longer term HD patients. Causality cannot be determined, and residual confounding cannot be excluded given the observational study design. Higher BMI is associated with lower death risk across all age and dialysis vintage groups. This benefit is more pronounced in incident HD patients and those younger than 65 years. Given the robustness of the survival advantage of higher BMI, examining interventions to maintain or even increase dry weight in HD patients irrespective of age and vintage are warranted.

Can dialysis modality influence cardiovascular outcome?

IntroductionChildren with chronic kidney disease (CKD), particularlythose on long-term dialysis, have a significant burden ofcardiovascular disease (CVD). The mortality of children ondialysis is 700-fold higher than that of their healthy peers [1],andCVDisthemostcommoncauseofdeath[2–4].AmongstchildrenwithCKD,bothcardiac[5]andvasculardamageandcalcification[6]arepresentfromthepre-dialysisCKDstages,and these increase in prevalence and severity on dialysis [6].Importantly, all paediatric and adult studies conducted to datehave shown that CVD progression with deteriorating cardiacfunction and progressive vascular calcification is associatedwithalongdialysisvintage[ 1,3,6–11]onbothhaemodialysis(HD) and peritoneal dialysis (PD).Cardiovascular mortality among patients on PD and HDAdult studies havereported variable cardiovascular outcomesamong patientsonPD and HD. Ina recent study among adultdialysisrecipients,mortalitywaslowerinincidentPDpatientsthan in a matched HD group, and PD was associated withimprovedlong-termsurvivalamongstpatientsaged<65yearsand those without CVD and diabetes [12]. In the only rando-mised controlled study conducted to date that compares dial-ysis modalities, incident PD patients had a significantlyimprovedsurvival(hazardratio3.6,95%confidenceintervals0.8–15.4) compared to incident HD patients [13]. However,therewasnodifferenceintheriskofdevelopingdenovoCVDin incident PD and HD patients, although patients with pre-existingcoronaryarterydiseaseorcongestiveheartfailurehadsignificantly worse survival on PD than on HD [14]. Theprevalence of cardiac valvular calcification ranges from 32to 47 % in PD patients compared to 19–84 % in HD patientsbased on the results of several cohort studies in adult dialysispatients; one reason for the wide variation in the differencesreported may be differences in the management of mineraldysregulationperseandnotinthechoiceofdialysismodality.Data from the Australia and New Zealand Dialysis andTransplant Registry have shown that amongst children onchronic dialysis the number of deaths is approximately two-fold higheramong those onHD comparedtoPD [1].Howev-er, these data are not adjusted for time on dialysis, and themanagement of CKD in many HD patients may in fact havefailedonPD,puttingthesepatientsatincreasedmortalityrisk.MorerecentreportsfromtheUnitedStatesRenalDataSystem(USRDS) describe similar mortality rates; 28 and 32 % of alldeathsthatoccuramongpatientsonPDandHD,respectively,are due to a cardiovascular cause [2]. As with all registryreports these data are retrospective, the selection of dialysismodality may have influenced outcome and, in reality, chil-dren often switch between dialysis modalities and return todialysisafterafailedtransplant.Arandomisedcontrolledtrialin the field is highly unlikely, and data on cardiovascularoutcomes in matched cohorts of children on PD and HD arescarce. Moreover, it is difficult to extrapolate outcomes fromadult studies. Children starting dialysis rarely have vascularcalcification or overt CVD [6, 9]. In fact, children are morelikely to develop arteriosclerosis with calcification of thetunica media and concentric thickening of the vessel wall,whereas adults with CKD have a combination of intimal andmedial calcification, probably compounded by coexisting di-abetes, dyslipidaemia and hypertension.

The body weight change during the first year of HEMODIALYSIS IS a strong predictor of patient survival

Hemodialysis patients are exposed to a high risk of death. We report the influence of the body weight (BW) change (Δ) on the survival in an incident HD patient cohort.Between January 2000 to 2009, 251 patients (age=65,8±14,8 y.o.; F/M=93/158; diabetes=36%) survived at least one year after HD onset and were followed for 44,9 months. The prescribed BW decreased by 6.5±5% at Week 8 (W8) and then increased again. From W8 to W52, the BW Δ was+1,9±7,4%. According to the median of W52-W8 BW Δ (+2.35%), the Kaplan Meier analysis (see figure below) displayed a significant better survival in patients with a BW Δ above the median. These two groups were not different according to age, diabetes or cardiovascular event history but had a significant higher interdialytic weight gain and protein intake. In the Cox model analysis the patient overall mortality was related to age (p<0.0001), to the W52W8 BW Δ (p=0.017), to the CRP level at W52 (p=0.035) and to serum albumin at W52 (p=0.036). Hence weight gain during the first year of HD treatment was found a strong predictor of survival in HD patients. It was associated with a better food intake whereas the patient case-mix was not different. These data highlight the need for understanding what drives food intake in dialysis patients and for careful nutritional follow-up and support in incident HD patients. Figure options Download full-size image Download as PowerPoint slide

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.

308 Kidney Transplant in Incident PD and HD Patients

308 Kidney Transplant in Incident PD and HD Patients

Charlson Comorbidity Index is a Predictor of Outcomes in Incident Hemodialysis Patients and Correlates with Phase Angle and Hospitalization

The adjustment of comorbidity is important in international hemodialysis comparisons. The aim of this study is to verify if it is possible to use the Charlson Comorbidity Index (CCI), in an Italian population of incident hemodialysis patients from the Campania region as outcome predictors. A similar proposal has already been made for an American population of incident patients in peritoneal dialysis. The data for this study come from the Uremic Registry of Campania taken in the year 2001. This is an observational study in which demographic, comorbid, laboratory, treatment and insurance data were collected in 111 dialysis units (70%) in Campania. We evaluated 515 hemodialysis incident patients who were hemodialyzed in Campania between January 1 and December 31, 2001. The study was restricted to patients who had already undergone 90 days of hemodialysis. The duration of this study was 15 months. Charlson Comorbidity Index was performed. In 128 patients (24.8%) BIA measurements were performed after dialysis. We used Student's t test for unpaired data and Cox proportional model to analyze predictors of mortality. The variables analyzed were age at start of hemodialysis, sex, CCI, hemoglobin, diabetes, hypertension, albumin, days of hospitalization. The statistically significant variables, analyzed initially by univariate analysis, were chosen for multivariate analysis. We considered p < 0.05 statistically significant. A total of 515 patients (M = 316, F = 199) (age: 63.62 +/- 15.35 years) presented with the following diseases: NO diagnosed in 93 patients (19%), GN in 64 (13%) IN in 42 (99%), Hereditary in 55 (11%), Vascular in 66 (14%), Diabetes in 135 (28%), others in 30 (6%). Hemoglobin levels were 10.71 +/- 1.51 g/dL and albumin was 3.79 +/- 0.54 g/dL. The days of hospitalization for the population studied were 3364/year. After the study, 75 patients died and the overall mortality rate was 11.65/100 patient/years. Univariate analysis shows that there are significant differences calculated for age (median value 73 and 65 years, respectively for non-survivers and survivers), BMI (median value and 22 and 24 kg/m2, respectively), Hb (median value 9.5 and 11 g/dL, respectively), Albumin (median value 3.5 and 3.8 g/dL, respectively), days of hospitalization (median value 8 and zero days, respectively), CCI (median value 6 and 4 score, respectively, phase angle (median value 3.3 and 4 degree, respectively). The mortality rates (100 dialysis years) by the CCI score: the mortality rate was zero for patients with a CCI of 3; and it increased to approximately 60% of patient years with a CCI score of 6 or greater. The linear correlation between CCI and phase angle in living (y = 18.90 x -3.83; R2 = 0.56) and in the dead (y = 13.01 x -1.87; R2 = 0.29). We found that CCI is a strong predictor of mortality in incident HD patients as has also been indicated in PD patients; CCI correlates with phase angle calculated from Bioelectrical Impedance Analysis and this last factor can be used in the following examinations; several days of hospitalization are a very important determinant in the survival in hemodialysis patients.