Initial Renal Replacement Therapy Research Articles

Initial renal replacement therapy (RRT) modality associates with 90-day postdischarge RRT dependence in critically ill AKI survivors

PurposeReal-world comparison of RRT modality on RRT dependence at 90 days postdischarge among ICU patients discharged alive after RRT for acute kidney injury (AKI). MethodsUsing claims-linked to US hospital discharge data (Premier PINC AI Healthcare Database [PHD]), we compared continuous renal replacement therapy (CRRT) vs. intermittent hemodialysis (IHD) for AKI in adult ICU patients discharged alive from January 1, 2018 to June 30, 2021. RRT dependence at 90 days postdischarge was defined as ≥2 RRT treatments in the last 8 days. Between-group differences were balanced using inverse probability treatment weighting (IPTW). ResultsOf 34,804 patients, 3804 patients (from 382 hospitals) had claims coverage for days 83–90 postdischarge. Compared to IHD-treated patients (n = 2740), CRRT-treated patients (n = 1064) were younger; had more admission to large teaching hospitals, surgery, sepsis, shock, mechanical ventilation, but lower prevalence of comorbidities (p < 0.05 for all). Compared to IHD-treated patients, CRRT-treated patients had lower RRT dependence at hospital discharge (26.5% vs. 29.8%, p = 0.04) and lower RRT dependence at 90 days postdischarge (4.9% vs. 7.4% p = 0.006) with weighted adjusted OR (95% CI): 0.68 (0.47–0.97), p = 0.03. Results persisted in sensitivity analyses including patients who died during days 1–90 postdischarge (n = 112) or excluding patients from hospitals with IHD patients only (n = 335), or when excluding patients who switched RRT modalities (n = 451). ConclusionsAdjusted for potential confounders, the odds of RRT dependence at 90 days postdischarge among survivors of RRT for AKI was 30% lower for those treated first with CRRT vs. IHD, overall and in several sensitivity analyses. SummaryCritically ill patients in intensive care units (ICU) may develop acute kidney injury (AKI) that requires renal replacement therapy (RRT) to temporarily replace the injured kidney function of cleaning the blood. Two main types of RRT in the ICU are called continuous renal replacement therapy (CRRT), which is performed almost continuously, i.e., for >18 h per day, and intermittent hemodialysis (IHD), which is a more rapid RRT that is usually completed in a little bit over 6 h, several times per week. The slower CRRT may be gentler on the kidneys and is more likely to be used in the sickest patients, who may not be able to tolerate IHD. We conducted a data-analysis study to evaluate whether long-term effects on kidney function (assessed by ongoing need for RRT, i.e., RRT dependence) differ depending on use of CRRT vs. IHD. In a very large US linked hospital-discharge/claims database we found that among ICU patients discharge alive after RRT for AKI, fewer CRRT-treated patients had RRT dependence at hospital discharge (26.5% vs. 29.8%, p = 0.04) and at 90 days after discharge (4.9% vs. 7.4% p = 0.006). In adjusted models, RRT dependence at 90 days postdischarge was >30% lower for CRRT than IHD-treated patients. These results from a non-randomized study suggest that among survivors of RRT for AKI, CRRT may result in less RRT dependence 90 days after hospital discharge.

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis.

Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). One hundred-fifty-three ICUs in 13 countries. Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). None. Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007). Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.

#4939 EFFECTS OF PREVIOUS HEMODIALYSIS TREATMENT ON PERITONEAL DIALYSIS OUTCOMES

Abstract Background and Aims Patients with end-stage renal disease (ESRD) frequently need to change dialysis modality. While the transition from peritoneal dialysis (PD) to hemodialysis (HD) is not an uncommon occurrence, the opposite is less frequent and much less studied. The aim of this study was to compare the outcomes of patients who started renal replacement therapy (RRT) with PD and patients who transitioned from HD to PD. Method Retrospective single-center cohort study with patients who started PD between 1st January 2010 and 31st December 2017, with a median follow-up of 60 months. Patients were separated in two groups, one where the initial RRT was PD (“PD first”) and another who transitioned from HD to PD (“Previous HD”). Clinical outcomes (complications during PD, technique failure, hospitalizations) and dialysis adequacy were compared between the two groups. Results Among the 137 patients included in this study, 22 transitioned directly from HD and 115 were PD first. The population included 63,7% of male gender, with a mean age of 52,9 ± 14,6 years and a mean Charleston score of 4,4 ± 2,2. Sixty percent had diabetes and 65,2% had hypertension. Median time on PD was 112,7 months (IQR 44,2). Patients who transitioned from HD had lower residual diuresis both at start of PD (1153 ± 920 vs. 1880 ± 924; p &amp;lt; 0,007) and at the end of follow-up (750 ± 1074 vs. 1252 ± 836; p &amp;lt; 0,037). A higher rate of UF failure was observed in patients who transitioned from HD (30,1% vs. 10,9%; p = 0,036). Annual rate of peritonitis and hospitalization was the same between groups. Technique failure (death or hemodialysis transfer) was not different between groups (52,1% vs. 53,6%, p = 0,903; logrank 0,301). Conclusion Residual diuresis was lower in the group that was previously in HD, which might be explained by the negative impact of HD in the preservation of renal residual function. Despite comparable DM prevalence and similar rates of PD-related infections a greater proportion of previous HD patients developed UF failure. Previous HD can predict a more complex volemic control in PD because of a lower residual renal function. Despite that, technique failure, hospitalizations, infections and outcomes at end of follow-up were similar in both groups. PD can be considered a viable dialysis technique in terms of outcomes in patients transferred from HD. Table 1:Analysis of HD first versus PD first groups.VariableTotal (n = 135)Previous HD (n = 22)PD first (n = 113)P-valueGender (male), n (%)86 (63.7)14 (60.9)72 (64.3)0.756Age at start of PD (years) (a)52.9 ± 14.652.0 ± 15.553.0 ± 14.60.772Time in PD (months) (a)112.7 ± 44.297.7 ± 56.2115.2 ± 41.60.107Hypertension, n (%)88 (65.2)11 (47.8)77 (68.8)0.055Diabetes, n (%)54 (60)10 (43.5)44 (39.3)0.709Charleston Score (a)4.4 ± 2.24.6 ± 2.34.3 ± 2.20.519PD adequacyKtV at PD start (a)2.7 ± 0.82.5 ± 0.72.7 ± 0.90.201KtV at end of follow-up (a)2.1 ± 0.61.9 ± 0.72.1 ± 0.60.250Residual diuresis at PD start (mL/24h) (a)1769 ± 9551153 ± 9201880 ± 9240.007Residual diuresis at end of follow-up (mL/24h) (a)1175 ± 889750 ± 10741252 ± 8360.037UF failure, n (%)17 (14)6 (30.1)11 (10.9)0.036ComplicationsAnnual peritonitis rate (a)0.1 ± 0.20.1 ± 0.30.1 ± 0.20.855Annual exit tunnel infections rate (a)0.0 ± 0.10.0 ± 0.10.0 ± 0.10.845Annual tunnel infections rate (a)0.0 ± 0.00.0 ± 0.00.0 ± 0.00.890Annual hospitalizations rate (a)0.2 ± 0.50.2 ± 0.50.2 ± 0.50.955Outcomes at end of follow-up, n (%)0.071 PD maintenance31 (23)4 (17.4)27 (24.1) HD transfer52 (38.5)5 (21.7)47 (42) Kidney transplantation29 (21.5)7 (30.4)22 (19.6) Death20 (14.8)7 (30.4)13 (11.6) Loss of follow-up3 (2.2)0 (0)3 (2.7)

Antiepileptic therapy in a patient with star fruit intoxication: A case report.

It is rare for uremia patients to have epileptic seizures after eating star fruit, only a dozen cases are reported worldwide. Such patients usually have poor prognoses. Few patients had good prognoses, all of them were treated with expensive renal replacement therapy. At present, there is no report on the addition of drug therapy to these patients based on the initial renal replacement therapy. A 67-year-old male patient with star fruit intoxication who had a history of diabetic nephropathy, hypertension, polycystic kidney, and chronic kidney disease in the uremic phase, and regular hemodialysis 3 times a week for 2 years. Initial clinical manifestations include hiccups, vomiting, speech disturbances, delayed reactions, and dizziness, which gradually progress to hearing and visual impairment, seizures, confusion, and coma. This patient was diagnosed with seizures caused by star fruit intoxication. The experience of eating star fruit and the electroencephalograms can prove our diagnosis. We performed intensive renal replacement therapy according to the recommendations in the literature. However, his symptoms did not improve significantly until he received an extra dose of levetiracetam and resumed his previous dialysis schedule. The patient was discharged after 21 days without neurologic sequelae. Five months after discharge, he was readmitted due to poor seizure control. To improve the prognosis of these patients and to reduce their financial burden, the use of antiepileptic drugs should be emphasized.

A clinical model to predict successful renal replacement therapy (RRT) discontinuation in patients with Acute Kidney Injury (AKI)

IntroductionIdeal timing of Renal Replacement Therapy (RRT) discontinuation in Acute Kidney Injury (AKI) is still unknown. We aimed to study the role of creatinine-related variables in predicting RRT successful discontinuation and to propose a clinical predictive score. MethodsIn this single-centre retrospective study, we evaluated all AKI patients in whom RRT was interrupted for at least 48 hours. Patients who were still RRT-independent 7 days after initial RRT cessation were included in the “Success” group and opposed to the “Failure” group. We evaluated baseline characteristics and variables collected at the time of RRT interruption, as well as the Kinetic estimated Glomerular Filtration Rate (KeGFR), the simple variation in serum Creatinine (ΔsCr), and the incremental creatinine ratio on the first three days after RRT interruption. Multivariable analysis was performed to evaluate prediction of success. Internal validation using a simple binomial generalized regression model with Lasso estimation and 5-fold cross validation method was performed. ResultsWe included 124 patients, 49 in the “Failure” group and 75 in the “Success” group. All creatinine-related variables predicted success in simple and multiple logistic regression models. The best model generated a clinical score based on the odds ratio obtained for each variable and included urine output, non-renal SOFA score, fluid balance, serum urea, serum potassium, blood pH, and the variation in sCr values after RRT discontinuation. The score presented an area under the ROC of 0.86 (95% CI 0.76‒1.00). ConclusionCreatinine variation between the first 2 consecutive days after RRT discontinuation might predict success in RRT discontinuation. The developed clinical score based on these variables might be a useful clinical decision tool to guide hemodialysis catheter safe removal.

Overview of peritoneal dialysis outcomes in Northern Cyprus: a nation based study

Aim: Peritoneal dialysis (PD) is the more preferred renal replacement therapy (RRT) option for most patients with end-stage renal disease (ESRD) who can not achieve a kidney transplantation. By an enhanced national PD program, more patients may have a chance to take the advantage of this treatment option. In this study, we aim to investigate whether PD is preferred as the first dialysis treatment modality in Northern Cyprus and reveal the outcomes in order to improve the further PD program. &#x0D; Material and Method: Peritoneal dialysis patients aged above 18 years who were followed between 2003-2021 in Northern Cyprus were investigated retrospectively. Demographic data, primary kidney diseases, comorbidities and previous RRT modalities were analysed. Episode(s) of peritonitis, total duration on PD therapy, switch to kidney transplantation or HD, and mortality rate were evaluated. Outcomes of elderly (≥ 65 years) and diabetic patients who were dropped out from PD were found out.&#x0D; Results: A total of 123 patients aged 18-83 years were included in the study. Forty percent of 123 PD patients initiated RRT with PD. The median time was found 1 month in the rest of the patients to transfer PD from other modalities. Renal transplantation was performed in 16.8% of patients during follow-up whereas 34.7% were transferred to HD after 41 months. Inadequate dialysis (40.7%), PD-related infections (29.6%), ultrafiltration insufficiency (18.5%), mechanical complications (11.1%) were the most common causes of switching from PD to HD. The duration of being under PD therapy was 36.5 months for 46 patients who died under PD therapy. Cardiovascular events (50%) and various infections (%35) were the leading causes of mortality. A total of 48 (43.2%) PD patients had at least one episode of peritonitis. Total duration on PD treatment, PD rate as initial RRT modality, the prevalence of hypertension and diabetes mellitus (DM), peritonitis rate, and use of automated PD were not significantly different between elderly (n=34) and adult individuals (18-65 years). The duration of being under PD therapy was longer for males than females (p=0.044) and the duration of PD therapy was similar in the dropped out patients with or without DM (p=0.205).&#x0D; Conclusion: A significant amount of patients received HD before initiation of PD (60%). Age is not be considered as a challenging barrier for PD initiation in Northern Cyprus. Precautions to prevent the development of peritonitis may contribute to extend the total duration of PD treatment.

‘Kidney Health for All’ - Implications for India

‘Kidney Health for All’ - Implications for India

Efficacy of Three Renal Replacement Therapy Modalities for the Treatment of Acute Kidney Injury Caused by Wasp Sting

Background/Aim: This study mainly aimed to explore the therapeutic effects of 3 renal replacement therapy (RRT) modalities on acute kidney injury (AKI) caused by wasp stings. Methods: A retrospective study from September 2016 to December 2019 was conducted. Thirty-one patients with AKIs caused by wasp sting were selected and divided into 3 groups according to the initial RRT modality received, namely, (1) the intermittent hemodialysis combined with hemoperfusion (IHD + HP) group, (2) the continuous veno-venous hemodiafiltration (CVVHDF) group, and (3) the CVVHDF combined with HP (CVVHDF + HP) group. The laboratory results were measured and analyzed before treatment on the 3rd, 7th, and 14th days of treatment. The renal function outcomes and survival of the patients were investigated at 3 months follow-up. Results: The laboratory results of enzyme measures and inflammatory indicators in wasp sting patients increased significantly in the early stage and 3 RRT modalities were effective in reducing these indicators. In addition, continuous RRT modality (CVVHDF and CVVHDF + HP) showed better clearance of myoglobin than IHD + HP. The serum creatinine levels of patients in the 3 groups did not recover to baseline within 14 days after beginning treatment. Nevertheless, the CVVHDF + HP group was better than the CVVHDF group, and CVVHDF was better than the IHD + HP group on the 3rd day. The interleukin (IL)-6 and IL-10 levels in CVVHDF + HP and IHD + HP groups were obviously lower than those in the CVVHDF group on the 3rd day. In the follow-up study, the recovery rate of renal function in CVVHDF and CVVHDF + HP groups was significantly better than that in the IHD + HP group. Conclusion: Early RRT was effective in the treatment of patients with A KI caused by wasp sting. CVVHDF + HP and CVVHDF modalities were better than the IHD + HP group in venom clearance and renal function recovery.

Mortality outcomes and clinical background of children on maintenance dialysis without receiving kidney transplantation.

Some pediatric patients on maintenance dialysis may need end-of-life care in the future because of being excluded from the indication of kidney transplantation and experiencing difficulty in continuation of their dialysis. This study aimed to thoroughly elucidate mortality outcomes of children on maintenance dialysis including the cause of death and clinical background of exclusion from indication of transplantation. This single-center retrospective study enrolled 53 children who received kidney transplantation (5) or maintenance peritoneal dialysis (PD, 48) as initial renal replacement therapy (RRT). We examined the selected RRT modalities, mortality outcomes, clinical backgrounds of cause of death, and risk factors of excluding from future the indication of transplantation. Nine (17%) of all 53 patients, all receiving PD (9/48, 19%), were finally excluded from next RRT indication-7 were excluded due to severe extrarenal complications that indicated high risk for transplantation and 2 were excluded due to severe psychomotor retardation and at the guardians' discretion. Patients who were excluded from the indication had a younger age at PD induction and higher proportion of cerebral and cardiac complications or psychomotor retardation than patients who were included in the indication. Of the nine patients, seven died; of which, one patient died due to fatal progression of extrarenal complications and six died due to infectious or noninfectious dialysis-related complications. Patients with severe extrarenal complications or psychomotor retardation tend to be excluded from the indication of transplantation. Their condition becomes fatal because of the complications of long-term dialysis and progression in extrarenal complications.

Renal and overall outcomes of double-positive (ANCA and anti-GBM antibodies) patients compared to ANCA-associated vasculitis patients with severe renal involvement: A multicenter retrospective study with systematic renal pathology analysis

Objective Double-positive patients (DPPs), combining serum and/or histological findings for glomerular basement membrane (GBM) disease and anti-neutrophil cytoplasmic antibodies (ANCAs), are rare and poorly described. This study aimed to compare characteristics between DPPs and ANCA-associated vasculitis (AAV) patients with severe renal involvement. Method This retrospective multicentre study compared 33 DPPs and 45 AAV patients with severe renal involvement (serum creatinine > 300 μmol/L), all with biopsy-proven nephropathy. Results All DPPs (including 18% exhibiting negative serum anti-GBM antibodies) presented severe acute kidney failure with histological GBM involvement. Compared to AAV patients, they had higher serum creatinine (719 vs 501 μmol/L; p = 0.006) and a higher proportion of patients requiring initial renal replacement therapy (82% vs 36%; p < 0.001). Berden classification differed significantly (p = 0.003), with more crescentic glomerulonephritis and fewer sclerotic lesions in DPPs. One-year renal survival was significantly lower in DPPs than in AAV patients (27% vs 64%; p < 0.0002). With comparable proportions of ANCA subtypes (two-thirds with anti-myeloperoxidase autoantibodies), numbers of extrarenal manifestations (mostly pulmonary in two-thirds), remission-inducing immunosuppressants, and median follow-ups (3 years) between groups, relapse rates were similar: 9.1% of DPPs and 10% of AAV patients. Conclusion Although DPPs have features of both kinds of vasculitis, the anti-GBM component is the dominant phenotype, with more severe renal presentation and prognosis compared to AAV patients with severe renal failure. Simultaneous testing of both antibodies and systematically performed renal biopsy should be recommended in all rapidly progressing glomerulonephritis patients to recognize this difficult-to-treat, rare disease.

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.

Assisted Peritoneial Dialysis - Opportunity For Equal Access To Renal Replacement Therapy By Peritoneal Dialysis

Advances in science and dialysis technology have allowed patients with end-stage renal disease (ESRD) to continue living by starting renal replacement therapy (RRT) - peritoneal dialysis (PD), hemodialysis (HD) or renal transplantation – “a gifted life”. It is recommended that the initial RRT be PD, and later switch to HD if no renal transplantation has been performed yet. In recent years, there has been an increase of elderly patients with a physical or intellectual inability to perform PD alone - they either begin HD or (all too often) sign an informed disagreement on RRT. Assisted PD (aPD) is appropriate for these patients. Assisted PD is also indicated in patients on PD who have developed complications/illnesses that make them unable to cope on their own. Do all patients have an equal chance of starting assisted PD? In Bulgaria, assisted PD is not regulated as a medico-social activity, but there are patients who need assistance. Usually that is done by trained family members. There are patients, however, who cannot rely on the help of relatives, and those in hospices and nursing homes who do not have the chance to benefit from the assisted PD. In many European countries, there is a medico-social network providing assisted PD. The regulation of assisted PD in Bulgaria as a type of medico-social activity done by trained staff in patients' homes, hospices and nursing homes would allow every patient to have equal access to assisted PD and an equal chance for a better quality of life.

EXECUTIVE ORDER ON ADVANCING AMERICAN KIDNEY HEALTH: A MARKOV ANALYSIS OF LONG-TERM COSTS

Background: Hemodialysis (HD) remains the most common method for renal replacement therapy (RRT) in the United States. On July, 2019 an Executive Order released from the Trump administration recommended swift action to increase the rate of home dialysis/peritoneal dialysis (PD) utilization (1). It remains unclear to what extent such a measure would affect long-term costs for end-stage renal disease (ESRD) patients. Methods: A decision analytic Markov state transition model was created to simulate the life of ESRD patients as they transitioned through life (transplant, death, graft failure). Two patient groups were created whereby patients underwent either initial RRT with 1) PD or 2) HD. State transitions to end-stage renal disease requiring dialysis, transplantation, and death were modeled, as well as associated costs. Sensitivity analysis of the ratio of patient undergoing initial PD vs. HD was estimated. Base case patients were defined as being a 55 years old patient. Markov parameters were extracted from literature review (2-5). Results: Increased utilization of home dialysis therapy/PD was associated with reduced total lifetime costs. Compared to current-era PD utilization, 80% PD catheter use, as recommended by recent Executive Order was associated with a $39,029 reduction in costs per patient ($530,984 vs. $491,954). For the current kidney transplant waitlist population, an estimated $3.6 billion savings is estimated with successful implementation of Executive Order. Conclusion: Implementation of recent Executive Order on Advancing American Kidney Health is estimated to drastically reduce total healthcare spending for ESRD patients.

Importance of non-medical reasons for dropout in patients on peritoneal dialysis

To describe the associated factors for non-medical reasons for dropout in peritoneal dialysis (PD) patients. A retrospective cohort study was performed using registry data of adult patients commencing PD as their initial renal replacement therapy in one hospital-facilitated PD center in Taiwan between 2014 and 2018. The collected data included socio-demographics and relevant medical and PD-related parameters. Kaplan-Meier analysis was used to determine the impact of non-medical reasons and medical reasons on PD dropout. The analysis included 224 PD patients, of whom 37 dropped out for non-medical reasons and 187 for medical reasons during the study period. There was significant difference between the two cohorts in age (62.3years vs. 56.1years, P = 0.010) and PD vintage (median 3.4years vs. 4.8years, P = 0.001). Diabetes was more predominant in the cohort for non-medical reasons than in the one for medical reasons (54.1% vs. 27.3% respectively, P = 0.001). In non-medical reason cohort, two leading reasons given for dropping out were lacking of caregivers (n = 12) and losing confidence (n = 10), whereas PD-related peritonitis (n = 101) was the main medical reason for PD dropout. Using Kaplan-Meier curve analysis, patients in the non-medical reason cohort demonstrated higher cumulative dropout rate compared to patients in the medical reason cohort during a 10-year period (P < 0.001). The main characteristics of PD dropout patients for non-medical reasons are age, diabetes, patients' perception and caregiver support.

Risk factors affecting renal function and survival of patients with myeloperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis

To determine the prognostic values of clinical and laboratory features at the time of presentation on renal function and survival of patients with myeloperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis. (MPO-ANCA GN). A total of 119 patients (52 males and 67 females) with MPO-ANCA GN and hospitalized at the First Affiliated Hospital of Nanjing Medical University from January 2010 to April 2018 were enrolled. The baseline clinical characteristics, renal biopsy pathological data, and risk factors predictive of renal and patient survival were retrospectively analyzed. Among these 119 patients, the median serum creatinine at diagnosis was 354.30 (range, 216.10 - 637.30) mmol/L and the median estimated glomerular filtration rate (eGFR) was 14.78(range, 7.23-29.21) mL/min. In total, 58(48.7%) patients received initial renal replacement therapy (RRT). During a median follow-up duration of 32 (range, 3 - 113) months, 57(47.9%) patients progressed to end-stage renal disease (ESRD). Initial renal function status (i.e., initial RRT, serum creatinine, and eGFR) (p < 0.001) and hemoglobin level (p = 0.027) were significant risk factors for renal survival. During the follow-up, 69 (57.6%) of 119 patients survived. Age (p = 0.009) and urine red blood cell count (p = 0.012) were predictive of patient survival. Among patients with MPO-ANCA GN, poor renal function and lower hemoglobin level were predictive of ESRD, while older age and higher urinary red blood cell count were associated with a higher risk for all-cause mortality.

Correction to: Mode of initial renal replacement therapy and transplant outcomes in the chronic kidney disease in children (CKiD) study.

The original version of this article unfortunately contained a mistake.

Risk factors for loss of residual renal function in children with end-stage renal disease undergoing automatic peritoneal dialysis.

This study analysed children with end-stage renal disease treated with automated peritoneal dialysis (APD) in our centre to explore the risk factors associated with residual renal function (RRF) loss. Children treated with APD as the initial renal replacement therapy regimen from January 2008 to December 2016 were included. All the children had a daily urine volume of ≥100 ml/m2 when APD was initiated and a dialysis follow-up time of ≥12 months. A daily urine volume of <100 ml/m2 after 12 months of APD treatment was defined as loss of RRF. Possible risk factors that may be associated with RRF loss were analysed. A total of 66 children were included in the study. After 12 months of APD treatment, the daily urine volume decreased by 377.45 ± 348.80 ml/m2, the residual glomerular filtration rate decreased by 6.39 ± 3.69 ml/min/1.73 m2 and 29 of the patients (43.9%) developed RRF loss. The higher risk of RRF loss after 1 year of APD treatment was most pronounced in patients with daily urine volume of ≤400 ml/m2 before treatment, higher glucose exposure and higher ultrafiltration volume, while the lower risk of RRF loss was in patients with administration of diuretics. Each increase of 1 g/m2/day glucose exposure was associated with a 5% increase in RRF loss (odds ratio (OR) 1.05, p = 0.023) and each increase of 1 ml/m2/day ultrafiltration volume was associated with a 1% increase in RRF loss (OR 1.01, p = 0.013). In children undergoing APD, the risk for loss of RRF is associated with low urine volume at the start of APD, high glucose loading and high peritoneal ultrafiltration volume, while preservation of RRF is associated with the usage of diuretics.

Mode of initial renal replacement therapy and transplant outcomes in the chronic kidney disease in children (CKiD) study.

Kidney transplant is the renal replacement therapy (RRT) of choice for children with end stage kidney disease (ESKD). Only 21.3% of children who initiate RRT receive a preemptive kidney transplant (PKT). We characterized the transition to RRT in children in the CKiD cohort including the prevalence of dialysis as first RRT vs. PKT and graft survival. 258 children enrolled in CKiD have initiated RRT, and 202 had post-RRT initiation data collected through phone or in-person follow-up. Characteristics by first RRT modality were compared using Chi-square and Kruskal-Wallis tests. Parametric-accelerated failure time models were fit for transplantation. Graft failure was characterized using Kaplan-Meier methods and log rank tests. Sixty-one percent received dialysis as first RRT modality and 39% PKT. Those with PKT were less likely to have glomerular disease and to be African-American, and had higher household-income. African-American subjects were nearly twice as likely to undergo dialysis prior to transplant. Those with a living donor and a college-educated mother had 40%-decreased odds of being dialysis experienced. Children with PKT were more likely to receive a living donor transplant. Only 5% of PKT subjects had graft failure by 4years compared to 16% of those initially treated with dialysis (p = 0.092); however, after adjustment the effect of dialysis exposure was attenuated (p = 0.206). CKiD subjects undergo PKT more often compared to nationally-reported rates, and are more likely to receive a kidney transplant within 1year of starting dialysis. African-American race and lower household-income are associated with decreased access to PKT.

Fewer hospitalizations and prolonged technique survival with home hemodialysis\u2013 a matched cohort study from the Swedish Renal Registry

BackgroundPatients on home hemodialysis (HHD) exhibit superior survival compared with patients on institutional hemodialysis (IHD) and peritoneal dialysis (PD). There is a sparsity of reports comparing morbidity between HHD and IHD or PD and none in a European population. The aim of this study is to compare morbidity between modalities in a Swedish population.MethodsThe Swedish Renal Registry was used to retrieve patients starting on HHD, IHD or PD. Patients were matched according to sex, age, comorbidity and start date. The Swedish Inpatient Registry was used to determine comorbidity before starting renal replacement therapy (RRT) and hospital admissions during RRT. Dialysis technique survival was compared between HHD and PD.ResultsRRT was initiated with HHD for 152 patients; these were matched with 608 patients with IHD and 456 with PD. Patients with HHD had significantly lower annual admission rate and number of days in hospital. (median 1.7 admissions; 12 days) compared with IHD (2.2; 14) and PD (2.8; 20).The annual admission rate was significantly lower for patients with HHD compared with IHD for cardiovascular diagnoses and compared with PD for infectious disease diagnoses. Dialysis technique survival was significantly longer with HHD compared with PD.ConclusionsPatients choosing HHD as initial RRT spend less time in hospital compared with patients on IHD and PD and they were more likely than PD patients, to remain on their initial modality. These advantages, in combination with better survival and higher likelihood of renal transplantation, are important incentives for promoting the use of HHD.

Incidence of Initial Renal Replacement Therapy Over the Course of Kidney Disease in Children.

The Chronic Kidney Disease in Children Study, a prospective cohort study with data collected from 2003 to 2018, provided the first opportunity to characterize the incidence of renal replacement therapy (RRT) initiation over the life course of pediatric kidney diseases. In the current analysis, parametric generalized gamma models were fitted and extrapolated for RRT overall and by specific treatment modality (dialysis or preemptive kidney transplant). Children were stratified by type of diagnosis: nonglomerular (mostly congenital; n = 650), glomerular–hemolytic uremic syndrome (HUS; n = 49), or glomerular–non-HUS (heterogeneous childhood onset; n = 216). Estimated durations of time to RRT after disease onset for 99% of the nonglomerular and glomerular–non-HUS groups were 42.5 years (95% confidence interval (CI): 31.0, 54.1) and 25.4 years (95% CI: 14.9, 36.0), respectively. Since onset for the great majority of children in the nonglomerular group was congenital, disease duration equated with age. A simulation-based estimate of age at RRT for 99% of the glomerular population was 37.9 years (95% CI: 33.6, 63.2). These models performed well in cross-validation. Children with glomerular disease received dialysis earlier and were less likely to have a preemptive kidney transplant, while the timing and proportions of dialysis and transplantation were similar for the nonglomerular group. These diagnosis-specific estimates provide insight into patient-centered prognostic information and can assist in RRT planning efforts for children with moderate-to-severe kidney disease who are receiving regular specialty care.