Individuals Receiving Maintenance Hemodialysis Research Articles

Ondansetron and the Risk of Sudden Cardiac Death among Individuals Receiving Maintenance Hemodialysis.

Individuals receiving hemodialysis have high incidence of sudden cardiac death and are susceptible to QT interval prolonging medication-related cardiac complications. Ondansetron, an antiemetic with known QT prolonging potential, is associated with fatal arrythmias in the general population when administered intravenously. The cardiac safety of ondansetron in the hemodialysis population is unknown. We conducted a new-user, active-comparator, cohort study using US Renal Data System data (2012-2019) to examine the association between the initiation of oral ondansetron vs. antiemetics with lesser QT prolonging potential (promethazine, metoclopramide or prochlorperazine) and the 10-day risk of sudden cardiac death among individuals receiving hemodialysis. We used inverse probability of treatment weighted survival models to estimate adjusted hazard ratios (aHRs), risk differences (aRDs), and 95% confidence intervals (CIs). We used an intention-to-treat approach in which non-sudden cardiac death was considered a competing event. We examined additional cardiac outcomes in secondary analyses. Of the 119,254 study patients, 64,978 (54.5%) initiated ondansetron, and 54,276 (45.5%) initiated a comparator antiemetic. Initiation of ondansetron versus a comparator antiemetic was associated with higher relative and absolute 10-day risks of sudden cardiac death, aHR (95% CI) = 1.44 (1.08, 1.93); aRD (95% CI) = 0.06% (0.01%, 0.11%). The number needed to harm was 1,688. Analyses of additional cardiac outcomes yielded similar findings. Compared with initiation of antiemetics with lesser QT prolonging potential, initiation of ondansetron was associated with higher short-term cardiac risks among people receiving hemodialysis.

Randomized Controlled Trial of the Effect of an Exercise Rehabilitation Program on Symptom Burden in Maintenance Hemodialysis: A Clinical Research Protocol.

People receiving hemodialysis experience high symptom burden that contributes to low functional status and poor health-related quality of life. Management of symptoms is a priority for individuals receiving hemodialysis but limited effective treatments exist. There is emerging evidence that exercise programming can improve several common dialysis-related symptoms. The primary aim of this study is to evaluate the effect of an exercise rehabilitation program on symptom burden in individuals receiving maintenance hemodialysis. Multicenter, randomized controlled, 1:1 parallel, open label, prospective blinded end point trial. Three facility-based hemodialysis units in Winnipeg, Manitoba, Canada. Adults aged 18 years or older with end-stage kidney disease receiving facility-based maintenance hemodialysis for more than 3 months, with at least 1 dialysis-related symptom as indicated by the Dialysis Symptom Index (DSI) severity score >0 (n = 150). Supervised 26-week exercise rehabilitation program and 60 minutes of cycling during hemodialysis thrice weekly. Exercise intensity and duration were supervised and individualized by the kinesiologist as per participant baseline physical function with gradual progression over the course of the intervention. Usual hemodialysis care (no exercise program). Our primary outcome is change in symptom burden at 12 weeks as measured by the DSI severity score. Secondary outcomes include change in modified DSI severity score (includes 10 symptoms most plausible to improve with exercise), change in DSI severity score at 26 and 52 weeks; time to recover post-hemodialysis; health-related quality of life measured using EuroQol (EQ)-5D-5L; physical activity behavior measured by self-report (Godin-Shepherd questionnaire) and triaxial accelerometry; exercise capacity (shuttle walk test); frailty (Fried); self-efficacy for exercise; and 1-year hospitalization and mortality. Change in primary outcome will be compared between groups by independent 2-tailed t test or Mann-Whitney U test depending on data distribution and using generalized linear mixed models, with study time point as a random effect and adjusted for baseline DSI score. Similarly, change in secondary outcomes will be compared between groups over time using appropriate parametric and nonparametric statistical tests depending on data type and distribution. The COVID-19 pandemic restrictions on clinical research at our institution delayed completion of target recruitment and prevented collection of accelerometry and physical function outcome data for 15 months until restrictions were lifted. The application of an exercise rehabilitation program to improve symptom burden in individuals on hemodialysis may ameliorate common symptoms observed in individuals on hemodialysis and result in improved quality of life and reduced disability and morbidity over the long term. Importantly, this pragmatic study, with a standardized exercise intervention that is adaptable to baseline physical function, addresses an important gap in both clinical care of hemodialysis patients and our current knowledge.

Rate of Arteriovenous Fistula Stenosis and Access Recirculation among Individuals Receiving Maintenance Hemodialysis

Background: Arteriovenous fistula stenosis and access recirculation in hemodialysis represent critical challenges, influencing the efficiency of vascular access and dialysis treatment outcomes. Objective: The objective is to assess the prevalence of arteriovenous fistula (the AVF) stenosis as well as access recirculation (AR) in patients of hemodialysis. Study Design: Cross sectional study. Settings: Department of Nephrology, Bolan Medical Complex Hospital, Quetta. Duration: From 1st April 2022 to 1st September, 2022. Methods: Adult patients having age 18 years to 80 years receiving maintenance hemodialysis 3 times in a week were included in this study. Patients who were willing to provide informed consent participated in the study. Patients with active infections or sepsis, with a history of vascular access interventions within the last three months, pregnant or lactating women as well as patients with cognitive impairment were excluded from study. Outcome variables will be incidence of AVF Stenosis which was determined by regular ultrasound assessments and monitoring of clinical symptoms. Statistical analyses were performed using SPS version 22. Results: The study comprised 150 maintenance hemodialysis patients with a mean age of 55±10. Age distribution showed that 20% were between 18-40 years, 53.3% between 41-60 years, 23.3% between 61-80 years, and 3.3% were older than 80 years. Sixty percent (60%) of the participants were male, while 40% were female. The mean duration of AV fistula use was 3.21± 2.65 years, with 14.66% having duration of 6-12 months, 41.33% between 1-3 years, and 44% using AV fistulas for more than 3 years. Seventy-five point three percent (75.3%) of patients had hypertension, 40.0% had diabetes mellitus, and 28.0% had cardiovascular disease. Additionally, 16.7% of patients presented with other comorbidities. Out of total 25 (16.7%) patients were affected by arteriovenous fistula (AVF) stenosis, while access recirculation was observed in 20 patients (13.3%). Conclusion: In conclusion, our study reveals a notable incidence of arteriovenous fistula (AVF) stenosis and access recirculation among maintenance hemodialysis patients. The observed associations with age and AVF duration underscore the complexity of vascular access complications.

Atypical antipsychotics and the risk of sudden cardiac death among individuals receiving maintenance hemodialysis

ObjectiveIndividuals receiving hemodialysis have high rates of sudden cardiac death (SCD). This study characterized oral atypical antipsychotic use and compared the cardiac safety of atypical antipsychotics with QT prolongation FDA warnings to that of atypical antipsychotics without such warnings among outpatients receiving hemodialysis. MethodsData for this active-comparator, new-user cohort study were obtained from the U.S. Renal Data System (2007–2019). The primary outcome was 1-year SCD risk. Fine and Gray proportional subdistribution hazard models with inverse probability of treatment weighting were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). ResultsThe quetiapine vs. atypical antipsychotics without QT prolongation warnings cohort included 18,943 quetiapine new-users and 19,571 non-warning atypical antipsychotic new-users. When compared to new-use of atypical antipsychotics without QT prolongation warnings, quetiapine new-use was not associated with the risk of SCD (aHR (95% CI) = 1.00 (0.93, 1.07)) or broader cardiac outcomes. Comparisons of all atypical antipsychotics with QT prolongation warnings vs. atypical antipsychotics without warnings generated similar results. ConclusionsQuetiapine, which carries an FDA warning for QT prolongation, did not associate with cardiac risk compared to atypical antipsychotics without warnings among hemodialysis outpatients. Findings may inform prescriber selection of atypical antipsychotics in this population.

Comparison of Dietary Inflammatory Index Scores with Inflammatory and Anthropometric Metrics in Individuals Receiving Maintenance Hemodialysis

ObjectivesThe modified dietary inflammatory index (DII) is a scoring tool that reflects inflammatory influence of diet components and has been studied as a predictor of inflammatory markers. This study explored correlations between modified DII scores, C-reactive protein (CRP), and conicity index (Ci) in patients receiving maintenance hemodialysis (MHD). MethodsThis study was a secondary analysis of 142 participants in the Rutgers Nutrition and Kidney Disease database. Food intake data were collected using the NHANES multi-pass method and were reflective of a dialysis treatment day. The modified DII scores were divided into tertiles; tertile 1 had the least inflammatory (negative) and tertile 3 had the most inflammatory (positive) scores. Correlations between DII scores, CRP, and Ci were measured using Spearman’s and Pearson’s Coefficients. Between tertile differences were compared using Kruskal-Wallis and ANOVA. ResultsThe median age was 55.3 years and 59.2% were male. The majority were African American (83.8%) and non-Hispanic (77.5%). The range of modified DII scores was –9.7 to 536.0, and the median score was 203.2, indicating a pro-inflammatory diet. The median scores for tertille 3 (338.1) were significantly higher than tertiles 1 or 2 (114.6 and 201.5, p-value < 0.001). Tertile 3 consumed more omega-3 fats, fiber, calories, total fat, and saturated fat. The median CRP and Ci were 5.6 mg/L and 1.33 ± 0.1, and did not differ significantly by tertile. A non-significant, small, positive correlation was observed between DII scores and CRP (r = 0.161, p = 0.071), but not for Ci (r = 0.046, p = 0.586). ConclusionsThis sample consumed a mostly pro-inflammatory diet. Food selections may be the result of consuming convenience foods on dialysis days, which are generally pro-inflammatory. Regardless, in our sample the pro-inflammatory dietary intakes did not correlate with markers of inflammation, likely due to homogeneity across the tertiles. While exploratory, this tool may assist clinicians in assessing patients on MHD who may benefit from individualized nutrition therapy to reduce their risks for chronic inflammation. Funding SourcesResearch reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (awards 1R15DK090593-01A1,6R15DK090593-02, and 3R15DK090593-02S1).

Effects of Sodium-Specific Medical Nutrition Therapy from a Registered Dietitian Nutritionist in Individuals with Chronic Kidney Disease: An Evidence Analysis Center Systematic Review and Meta-Analysis

Dietary sodium intake can increase risk of hypertension, a leading cause of kidney failure in individuals with chronic kidney disease. The objective of this systematic review was to examine the effect of sodium-specific medical nutrition therapy provided by a registered dietitian nutritionist or international equivalent on blood pressure and urinary sodium excretion in individuals with chronic kidney disease, stages 2 through 5, receiving maintenance dialysis and posttransplant. Medline, the Cumulative Index to Nursing and Allied Health Literature, Cochrane Cochrane Central Register of Controlled Trials, and other databases were searched to identify eligible controlled trials published in the English language from January 2000 until June 2020 that addressed the research question. Risk of bias was assessed using the RoB 2.0 tool and quality of evidence was examined by outcome using the Grading of Recommendations Assessment, Development, and Evaluation method. Of the 5,642 articles identified, eight studies were included in the final analyses. Six studies targeted clients who were not dialyzed, including one with clients who were posttransplantation, and two studies with clients receiving maintenance hemodialysis. Sodium-specific medical nutrition therapy from a registered dietitian nutritionist significantly reduced clinic systolic blood pressure (mean difference –6.7, 95% CI –11.0 to –2.4 mm Hg; I2 = 51%) and diastolic blood pressure (mean difference –4.8, 95% CI, –7.1 to –2.4 mm Hg; I2 = 23%) as well as urinary sodium excretion (mean difference –67.6, 95% CI –91.6 to –43.6 mmol/day; I2 = 84.1%). Efficacy was limited to individuals who were not dialyzed, including posttransplantation, but the intervention did not significantly improve blood pressure in individuals receiving maintenance hemodialysis. Adults with chronic kidney disease should begin to work with registered dietitian nutritionist early in the course of disease to receive individualized, effective counseling to improve risk factors and, ultimately, health outcomes.

Ultrafiltration rate and incident atrial fibrillation among older individuals initiating hemodialysis.

Higher ultrafiltration (UF) rates are associated with numerous adverse cardiovascular outcomes among individuals receiving maintenance hemodialysis. We undertook this study to investigate the association of UF rate and incident atrial fibrillation in a large, nationally representative US cohort of incident, older hemodialysis patients. We used the US Renal Data System linked to the records of a large dialysis provider to identify individuals ≥67 years of age initiating hemodialysis between January 2006 and December 2011. We applied an extended Cox model as a function of a time-varying exposure to compute adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of delivered UF rate and incident atrial fibrillation. Among the 15414 individuals included in the study, 3177 developed atrial fibrillation. In fully adjusted models, a UF rate >13 mL/h/kg (versus ≤13 mL/h/kg) was associated with a higher hazard of incident atrial fibrillation [adjusted HR 1.19 (95% CI 1.07-1.30)]. Analyses using lower UF rate thresholds (≤10 versus >10 mL/h/kg and ≤8 versus >8 mL/h/kg, separately) yielded similar results. Analyses specifying the UF rate as a cubic spline (per 1 mL/h/kg) confirmed an approximately linear dose-response relationship between the UF rate and the risk of incident atrial fibrillation: risk began at UF rates of ~6 mL/h/kg and the magnitude of this risk flattened, but remained elevated, at rates ≥9 mL/h/kg. In this observational study of older individuals initiating hemodialysis, higher UF rates were associated with higher incidences of atrial fibrillation.

Screening for Depression in People with Kidney Failure.

A large proportion of patients with CKD before and after initiation of maintenance dialysis suffer from major depressive disorder, such that about 20% of those with non-dialysis CKD and 25% of those with kidney failure are affected ([1][1]). More daunting is the actuality, validated in multiple

Plasma Endothelin-1 and Risk of Death and Hospitalization in Patients Undergoing Maintenance Hemodialysis.

Endothelin-1 is a potent endothelium-derived vasoconstrictor peptide implicated in the pathogenesis of hypertension, congestive heart failure, and inflammation, all of which are critical pathophysiologic features of CKD. To test the hypothesis that plasma endothelin-1 levels are associated with increased risks of mortality and hospitalization in patients with chronic kidney failure, we measured plasma endothelin-1 levels in a prospective cohort of 794 individuals receiving maintenance hemodialysis. The primary outcomes were time to death and time to hospitalization. The median plasma endothelin-1 level was 2.02 (interquartile range, 1.57-2.71) pg/ml. During a median follow-up period of 28 (interquartile range, 21-29) months, 253 individuals (32%) died and 643 individuals (81%) were hospitalized at least once. In multivariable models adjusted for demographic, clinical, and laboratory variables, individuals in the highest quartile of plasma endothelin-1 had a 2.44-fold higher risk of death (hazard ratio, 2.44; 95% confidence interval, 1.61 to 3.70) and a 1.54-fold higher risk of hospitalization (hazard ratio, 1.54; 95% confidence interval, 1.19 to 1.99) compared with individuals in the lowest quartile. The Harrell C-statistic of the fully adjusted model increased from 0.73 to 0.74 after addition of natural log-transformed plasma endothelin-1 (P<0.001) for all-cause mortality, and increased from 0.608 to 0.614 after addition of natural log-transformed plasma endothelin-1 (P=0.002) for hospitalization. Higher plasma endothelin-1 is associated with adverse clinical events in patients receiving hemodialysis independent of previously described risk factors. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_05_15_CJN11130919.mp3.

Intravenous Iron Dosing and Infection Risk in Patients on Hemodialysis: A Prespecified Secondary Analysis of the PIVOTAL Trial

Experimental and observational studies have raised concerns that giving intravenous (IV) iron to patients, such as individuals receiving maintenance hemodialysis, might increase the risk of infections. The Proactive IV Iron Therapy in Haemodialysis Patients (PIVOTAL) trial randomized 2141 patients undergoing maintenance hemodialysis for ESKD to a high-dose or a low-dose IV iron regimen, with a primary composite outcome of all-cause death, heart attack, stroke, or hospitalization for heart failure. Comparison of infection rates between the two groups was a prespecified secondary analysis. Secondary end points included any infection, hospitalization for infection, and death from infection; we calculated cumulative event rates for these end points. We also interrogated the interaction between iron dose and vascular access (fistula versus catheter). We found no significant difference between the high-dose IV iron group compared with the lose-dose group in event rates for all infections (46.5% versus 45.5%, respectively, which represented incidences of 63.3 versus 69.4 per 100 patient years, respectively); rates of hospitalization for infection (29.6% versus 29.3%, respectively) also did not differ. We did find a significant association between risk of a first cardiovascular event and any infection in the previous 30 days. Compared with patients undergoing dialysis with an arteriovenous fistula, those doing so via a catheter had a higher incidence of having any infection, hospitalization for infection, or fatal infection, but IV iron dosing had no effect on these outcomes. The high-dose and low-dose IV iron groups exhibited identical infection rates. Risk of a first cardiovascular event strongly associated with a recent infection.

The relationship of volume overload and its control to hypertension in hemodialysis patients.

Hypertension is highly prevalent and associated with poor clinical outcomes among individuals receiving maintenance hemodialysis (HD). Volume overload is a key modifiable contributor to hypertension and cardiovascular disease in the HD population. Despite their importance, assessment and treatment of volume overload and hypertension remain major clinical challenges and have substantial implications for both clinical outcomes and patient experiences of care. This review will summarize current data on the diagnosis, epidemiology, pathophysiology, and clinical consequences of hypertension and volume overload in HD patients. We will also identify priorities for future research studies.

Ultrafiltration-profiled hemodialysis to reduce dialysis-related cardiovascular stress: Study protocol for a randomized controlled trial

Rapid fluid removal (ultrafiltration, UF) is associated with higher cardiovascular morbidity and mortality among individuals receiving maintenance hemodialysis (HD). Fluid removal rates that exceed vascular refill rates can result in hemodynamic instability, end-organ damage to the heart, kidneys, gut and brain, among other organs, and patient symptoms. There are no known evidence-based HD treatment strategies to reduce harm from higher UF rates. Ultrafiltration profiling, the practice of varying UF rates to maximize fluid removal during periods of greatest hydration and plasma oncotic pressure, has been proposed as an HD treatment intervention that may reduce UF rate-related complications. This study is a randomized 4-phase cross-over trial in which participants are successively alternated between study arms with intervening washout periods, and treatment order is randomized. After 4-week screening and 6-week baseline periods, participants are randomized to HD with conventional UF or HD with UF profiling for a period of 3 weeks followed by a 1-week washout period before crossing over. Participants cross into conventional UF and UF profiling phases twice (2 phases per arm). The primary outcomes of interest are intradialytic hypotension (nadir intradialytic systolic blood pressure <90 mmHg), pre-to post-HD change in troponin T (expressed as a percentage), change in left ventricular global longitudinal strain (an echocardiographic measure of left ventricular systolic function), and development of intradialytic left ventricular stunning (worsening of contractile function in ≥2 segments). This study will determine the impact of UF profiling on UF rate-related cardiovascular complications in prevalent, maintenance HD patients.

Cumulative Exposure to Frequent Intradialytic Hypotension Associates With New-Onset Dementia Among Elderly Hemodialysis Patients

Cumulative Exposure to Frequent Intradialytic Hypotension Associates With New-Onset Dementia Among Elderly Hemodialysis Patients

Failed Target Weight Achievement Associates with Short-Term Hospital Encounters among Individuals Receiving Maintenance Hemodialysis.

Background Hospitalizations and 30-day readmissions are common in the hemodialysis population. Actionable clinical markers for near-term hospital encounters are needed to identify individuals who require swift intervention to avoid hospitalization. Aspects of volume management, such as failed target weight (i.e, estimated dry weight) achievement, are plausible modifiable indicators of impending adverse events. The short-term consequences of failed target weight achievement are not well established.Methods Statistically deidentified data were taken from a cohort of Medicare-enrolled, prevalent hemodialysis patients treated at a large dialysis organization from 2010 to 2012. We used a retrospective cohort design with repeated intervals, each consisting of 180-day baseline, 30-day exposure assessment, and 30-day follow-up period, to estimate the associations between failed target weight achievement and the risk of 30-day emergency department visits and hospitalizations. We estimated adjusted risk differences using inverse probability of exposure weighted Kaplan-Meier methods.Results A total of 113,561 patients on hemodialysis contributed 788,722 study intervals to analyses. Patients who had a postdialysis weight >1.0 kg above the prescribed target weight in ≥30% (versus <30%) of exposure period treatments had a higher absolute risk (risk difference) of 30-day: emergency department visits (2.13%; 95% confidence interval, 2.00% to 2.32%); and all-cause (1.47%; 95% confidence interval, 1.34% to 1.62%), cardiovascular (0.31%; 95% confidence interval, 0.24% to 0.40%), and volume-related (0.15%; 95% confidence interval, 0.11% to 0.21%) hospitalizations.Conclusions In the absence of objective measures of volume status, recurrent failure to achieve target weight is an easily identifiable clinical risk marker for impending hospital encounters among patients on hemodialysis.

A Comparative Study of Carvedilol Versus Metoprolol Initiation and 1-Year Mortality Among Individuals Receiving Maintenance Hemodialysis

Carvedilol and metoprolol are the β-blockers most commonly prescribed to US hemodialysis patients, accounting for ∼80% of β-blocker prescriptions. Despite well-established pharmacologic and pharmacokinetic differences between the 2 medications, little is known about their relative safety and efficacy in the hemodialysis population. A retrospective cohort study usinga new-user design. Medicare-enrolled hemodialysis patients treated at a large US dialysis organization who initiated carvedilol or metoprolol therapy from January 1, 2007, through December 30, 2012. Carvedilol versus metoprolol initiation. All-cause mortality, cardiovascular mortality, and intradialytic hypotension (systolic blood pressure decrease≥ 20mmHg during hemodialysis plus intradialytic saline solution administration) during a 1-year follow-up period. Survival models were used to estimate HRs and 95% CIs in mortality analyses. Poisson regression was used to estimate incidencerate ratios (IRRs) and 95% CIs in intradialytic hypotension analyses. Inverse probability of treatment weighting was used to adjust for several demographic, clinical, laboratory, and dialysis treatment covariates in all analyses. 27,064 individuals receiving maintenance hemodialysis were included: 9,558 (35.3%) carvedilol initiators and 17,506 (64.7%) metoprolol initiators. Carvedilol (vs metoprolol) initiation was associated with greater all-cause (adjusted HR, 1.08; 95% CI, 1.02-1.16) and cardiovascular mortality (adjusted HR, 1.18; 95% CI, 1.08-1.29). In subgroup analyses, similar associations were observed among patients with hypertension, atrial fibrillation, heart failure, and a recent myocardial infarction, the main cardiovascular indications for β-blocker therapy. During follow-up, carvedilol (vs metoprolol) initiators had a higher rate of intradialytic hypotension (adjusted IRR, 1.10; 95% CI, 1.09-1.11). Residual confounding may exist. Relative to metoprolol initiation, carvedilol initiation was associatedwith higher 1-year all-cause and cardiovascular mortality. One potential mechanism for these findings may be the increased occurrence of intradialytic hypotension after carvedilol (vs metoprolol) initiation.

Intradialytic Hypertension Frequency and Short-Term Clinical Outcomes Among Individuals Receiving Maintenance Hemodialysis.

Intradialytic hypertension occurs in 5-20% of hemodialysis treatments. Observational data support an association between intradialytic hypertension and long-term mortality. However, the short-term consequences of recurrent intradialytic hypertension are unknown. Data were taken from a cohort of prevalent hemodialysis patients receiving treatment at a large United States dialysis organization on 1 January 2010. A retrospective cohort design with a 180-day baseline, 30-day exposure assessment, and 30-day follow-up period was used to estimate the associations between intradialytic hypertension frequency and 30-day outcomes. Intradialytic hypertension frequency was defined as the proportion of exposure period hemodialysis treatments with a predialysis to postdialysis systolic blood pressure rise >0 mm Hg. Multivariable Cox proportional hazards regression, adjusted for baseline clinical, laboratory, and dialysis treatment covariates, was used to estimate hazard ratios and 95% confidence intervals. Of the 37,094 study patients, 5,242 (14.1%), 17,965 (48.4%), 10,821 (29.2%), 3,066 (8.3%) had intradialytic hypertension in 0%, 1-32%, 33-66%, and ≥67% of exposure period treatments, respectively. More frequent intradialytic hypertension was associated with incremental increases in 30-day mortality and hospitalizations. Patients with intradialytic hypertension in ≥67% (vs. 0%) of exposure period treatments had the highest risk of all-cause death, hazard ratio [95% confidence interval]: 2.57 [1.68, 3.94]; cardiovascular (CV) death, 3.68 [1.89, 7.15]; all-cause hospitalizations, 1.42 [1.26, 1.62]; CV hospitalizations, 1.71 [1.36, 2.15]; and volume-related hospitalizations, 2.25 [1.25, 4.04]. Among prevalent hemodialysis patients, more frequent intradialytic hypertension was incrementally associated with increased 30-day morbidity and mortality. Intradialytic hypertension may be an important short-term risk marker in the hemodialysis population.

Ultrafiltration Rate Clinical Performance Measures: Ready for Primetime?

Mounting evidence supports a strong association between fluid management and outcomes among individuals receiving maintenance hemodialysis. The speed of fluid removal during dialysis (ultrafiltration, UF) is a modifiable aspect of fluid management that has attracted recent attention as a potential performance measure for facility fluid management practices. Observational data support an association between higher UF rates and adverse outcomes. This association is supported by the plausible pathophysiologic rationale of hypoperfusion-induced ischemic injury to the heart and other end-organs. However, no published clinical trial has studied the impact of lowering UF rates on clinical and patient-centered outcomes. Lowering UF rates requires interdialytic weigh gain reduction and/or extension of dialysis time. Weight gain reduction has proven difficult despite nutritional programs focused on salt and fluid restrictions, and patients are generally averse to longer treatment times. Thus, imposition of UF rate limitations may lead to failed target weight achievement and volume expansion over time. Despite these potential unintended consequences, the National Quality Forum endorsed an UF rate clinical performance measure in 2015. Prior to implementation of quality measure-imposed UF rate limitations, prospective studies of UF rates and outcomes are needed.

Relation between distal airspace size, bronchiolar attachments, and lung function.

BACKGROUND--Smoking related fixed airway obstruction may be due to airway scarring and narrowing or decreased support due to loss of adjacent alveolar walls. In this study of resected specimens, preoperative pulmonary function was compared with results of a morphometric study of lung structure. METHODS--Morphometric measurements were made on 42 inflation fixed lung specimens as follows: airspace wall surface area per unit volume (AWUV) was measured on at least 25 l mm2 histological fields from each specimen, expressed as a mean, and the mean of the lowest five measurements for each case (LF5). Minimum diameter, maximum diameter, diameter ratio (ellipticality), lumen area, and lumen circumference were measured on at least 16 non-respiratory bronchioles from each lung. Peribronchiolar alveolar support was measured as mean interalveolar attachment distance (IAAD). Measurements of pulmonary function included forced expiratory volume in one second (FEV1) (absolute and % predicted values; n = 42), slope of phase III (single breath nitrogen test; n = 28), closing volume (expressed as a percentage of vital capacity (CV/VC%); n = 28). RESULTS--Bronchiolar size was not independently related to the tests of lung function used. Percentage predicted FEV1 was related to mean IAAD, ellipticality, and mean AWUV. CV/VC% showed significant relation with ellipticality, mean AWUV, and LF5 AWUV. Slope of phase III increased with increasing IAAD. Significant correlations were found between ellipticality and AWUV (mean and LF5), and between ellipticality and IAAD. Both IAAD and ellipticality were significantly increased in patients with abnormally low FEV1. CONCLUSION--Destruction of airspace walls, particularly those attached to the peripheral bronchioles, is more influential in determining airflow limitation than bronchiolar size.