Initiation Of Dialysis Therapy Research Articles

Epidemiology and Mortality of New-Onset Diabetes After Dialysis

OBJECTIVEWe examined the predictors and risks associated with pre-existing versus new-onset diabetes mellitus (DM) after initiation of chronic dialysis therapy in end-stage renal disease (ESRD) patients.RESEARCH DESIGN AND METHODSIn the Taiwan National Health Insurance Research Database, we examined records of ESRD patients who initiated dialysis between 1999 and 2005. Patients were followed until death, transplant, dialysis withdrawal, or 31 December 2008. Predictors of new-onset DM and mortality were calculated using Cox models.RESULTSA total of 51,487 incident dialysis patients were examined in this study, including 25,321 patients with pre-existing DM, 3,346 with new-onset DM, and 22,820 without DM at any time. Patients’ age (mean ± SD) was 61.8 ± 11.5, 61.6 ± 13.7, and 56.5 ± 16.6 years in pre-existing, new-onset DM, and without DM groups, respectively. The cumulative incidence rate of new-onset DM was 4% at 1 year and 21% at 9 years. Dialysis modality was not a risk factor for new-onset DM (peritoneal dialysis to hemodialysis hazard ratio [HR] of new-onset DM, 0.94 [95% CI 0.83–1.06]). Pre-existing DM was associated with 80% higher death risk (HR 1.81 [95% CI 1.75–1.87]), whereas the new-onset DM was associated with 10% increased death risk (HR 1.10 [95% CI 1.03–1.17]).CONCLUSIONSWhereas dialysis modality does not appear to associate with new-onset DM, both pre-existing and new-onset DM are related to higher long-term mortality in maintenance dialysis patients.

Timing of Return to Dialysis in Patients with Failing Kidney Transplants

In the last decade, the number of patients starting dialysis after a failed kidney transplant has increased substantially. These patients appear to be different from their transplant-naïve counterparts, and so may be the timing of dialysis therapy initiation. An increasing number of studies suggest that in transplant-naïve patients, later dialysis initiation is associated with better outcomes. Very few data are available on timing of dialysis reinitiation in failed transplant recipients, and they suggest that an earlier return to dialysis therapy tended to be associated with worse survival, especially among healthier and younger patients and women. Failed transplant patients may also have unique issues such as continuation of immunosuppression versus withdrawal or the need for remnant allograft nephrectomy with regard to dialysis reinitiation. These patients may have a different predialysis preparation work-up, worse blood pressure control, higher or lower serum phosphorus levels, lower serum bicarbonate concentration, and worse anemia management. The choice of dialysis modality may also represent an important question for these patients, even though there appears to be no difference in mortality between patients starting peritoneal versus hemodialysis. Finally, failed transplant patients returning to dialysis appear to have a higher mortality rate compared with transplant-naïve incident dialysis patients, especially in the first several months of dialysis therapy. In this review, we will summarize the available data related to the timing of dialysis initiation and outcomes in failed kidney transplant patients after returning to dialysis.

Timing of Arteriovenous Fistula Creation in Patients With CKD: A Decision Analysis

The optimal time for arteriovenous fistula (AVF) referral is uncertain. Improving the timeliness of referral may reduce central venous catheter (CVC) use. Monte Carlo simulation model. Patients with chronic kidney disease (CKD) followed up in a multidisciplinary clinic, overall and stratified by age. Decision analysis, patient, patient's lifetime. AVF referral, using 1 of 2 strategies: refer when hemodialysis is anticipated to begin within a certain time frame or refer when estimated glomerular filtration rate (eGFR) drops below a certain threshold. A range of values for each strategy are compared to each other with respect to incident vascular access type (AVF or CVC), percentage of patients with an unnecessary AVF creation, and life expectancy after dialysis therapy initiation. A 15-month referral time frame gave 34% with incident CVCs, 14% with unnecessary AVFs, and a life expectancy of 1,751 days. Time frames of 12-18 months performed similarly. Referral at eGFR of 20 mL/min/1.73 m(2) gave 38% with incident CVCs, 20% with unnecessary AVFs, and life expectancy of 1,742 days. Using an eGFR threshold of 15 mL/min/1.73 m(2), 10% had an unnecessary AVF. Policy performance was affected by CKD progression rate and age. For fast progressors (ΔeGFR = -7mL/min/1.73 m(2) per year), referral at eGFR of 25 mL/min/1.73 m(2) achieved a similar incident CVC percentage (~40%) as referral at 15 mL/min/1.73 m(2) in slower progressors (ΔeGFR = -2.78 mL/min/1.73 m(2) per year). For patients aged 70-80 and 80-90 years, time frames of 15-18 months yielded 16%-22% with unnecessary AVFs (vs 9%-11% in 50- to 60-year-olds); an eGFR threshold strategy of 20 mL/min/1.73 m(2) yielded 24% unnecessary AVFs in 80- to 90-year-olds versus 16% in 50- to 60-year-olds. Our model does not consider patients with nonlinear CKD progression or acute kidney injury. We did not include arteriovenous grafts or consider cost or quality of life. In general, AVF referral within about 12 months of the estimated time to dialysis performed best among time frame strategies, and referral at eGFR < 15-20 mL/min/1.73 m(2) performed best among threshold strategies. The timing of referral should also be guided by the individual rate of CKD progression. Elderly patients with CKD could be referred later to reduce the risk of creating an AVF that is never used.

Earlier-Start Versus Usual-Start Dialysis in Patients With Community-Acquired Acute Kidney Injury: A Randomized Controlled Trial

Optimum timing of the initiation of dialysis therapy in acute kidney injury is not clear. Prospective, open label, 2-arm, randomized, controlled trial. 208 adults with acute kidney injury with progressively worsening azotemia at the artificial kidney dialysis unit of a tertiary-care referral center in western India. Earlier-start dialysis was initiated when serum urea nitrogen and/or creatinine levels increased to 70 and 7 mg/dL, respectively, whereas the usual-start dialysis patients (control group) received dialysis when clinically indicated as judged by treating nephrologists. Primary outcome was in-hospital mortality and dialysis dependence at 3 months. Secondary outcome in patients receiving dialysis was time to recovery of kidney function, computed from time of enrollment to the last dialysis session. Of 585 screened patients, 102 were assigned to earlier-start dialysis, and 106 to usual-start dialysis. Baseline characteristics were similar between randomized groups. 93 (91.1%) and 88 (83.1%) participants received dialysis in the intervention and control groups, respectively. Mean serum urea nitrogen and serum creatinine levels at dialysis therapy initiation were 71.7 ± 21.7 (SD) and 7.4 ± 5.3 mg/dL, respectively, in the intervention group versus 100.9 ± 32.6 and 10.41 ± 3.3 mg/dL in the control group. Data on primary outcome were available for all patients. In-hospital mortality was 20.5% and 12.2% in the intervention and control groups, respectively (relative risk, 1.67; 95% CI, 0.88-3.17; P = 0.2). 4.9% and 4.7% of patients in the intervention and control groups, respectively, were dialysis dependent at 3 months (relative risk, 1.04; 95% CI, 0.29-3.7; P = 0.9). Study was not double blind, event rate (ie, mortality) was less than predicted, wide CIs preclude definitive findings. Our data do not support the earlier initiation of dialysis therapy in community-acquired acute kidney injury.

Screening for coronary heart disease at the starting of dialysis could lead End-Stage Kidney Disease (ESKD) patients to be better prognosis

Background: International guidelines have recommended making a screening for coronary heart disease (CHD) at the initiation of dialysis therapy. However it remains unclear whether the screening has an advantage for the prognosis of dialysis patients. Aim: The aim of this study is to explore the influence of screening for CHD at the starting of dialysis on the survival for new dialysis patients. Methods: Between January 1993 and December 2010, 358 ESKD patients without cardiac disease started chronic dialysis at our hospital and were enrolled into a preliminary database. Among 358 patients, 222 ESKD patients (62%) were underwent a screening regardless of a suspicion of CHD within 3 months of starting dialysis by SPECT or CAG. Then to minimize the selection bias for performing the screening, a propensity-matched analysis was performed. Finally 204 ESKD patients (102 screening group vs. 102 non-screening group) were selected. The survivals for all cause of death and cardiac death were compared between two groups in propensity matched patients. Results: During the follow-up period, 75 all cause of deaths and 26 cardiac deaths were observed. Figure shows the Kaplan-Meier survival curves for all cause of death and cardiac death. The screening had a beneficial effect for all cause of death (HR: 0.50, p=0.004) in univariate analysis. After adjusting for age, sex, diabetes, serum creatinin level, the beneficial effect remained significant and independent (HR: 0.50, p=0.007). For cardiac death, the screening also had an advantage in univariate analysis (HR: 0.24, p=0.025) and multivariate analysis (HR: 0.50, p=0.007) after adjusting for age, sex, diabetes, serum creatinin level. ![Figure][1] The Kaplan-Meier survival curves Conclusions: Screening for CHD at the stating dialysis could play a role for improving of prognosis in ESKD patients. [1]: pending:yes

Predicting End-Stage Renal Disease After Liver Transplant

Few equations have been developed to predict end-stage renal disease (ESRD) after deceased donor liver transplant. This retrospective observational cohort study analyzed all adult deceased donor liver transplant recipients in the Scientific Registry of Transplant Recipients (SRTR) database, 1995–2010. The prediction equation for ESRD was developed using candidate predictor variables available in SRTR after implementation of the allocation policy based on the model for end-stage liver disease. ESRD was defined as initiation of maintenance dialysis therapy, kidney transplant or registration on the kidney transplant waiting list. We used Cox proportional hazard models to develop separate equations for assessing risk of ESRD by 6 months posttransplant and between 6 months and 5 years posttransplant. Variables in the 6-month equation included recipient age, history of diabetes, history of dialysis before liver transplant, history of malignancy, body mass index, serum creatinine and liver donor risk index. Variables in the 6-month to 5-year equation included recipient race, history of diabetes, hepatitis C status, serum albumin, serum bilirubin and serum creatinine. The prediction equations have good calibration and discrimination (C statistics 0.74–0.78). We have produced risk prediction equations that can be used to aid in understanding the risk of ESRD after liver transplant.

Trends in Relative Mortality Between Hispanic and Non-Hispanic Whites Initiating Dialysis: A Retrospective Study of the US Renal Data System

Hispanic patients undergoing long-term dialysis experience better survival compared with non-Hispanic whites. It is unknown whether this association differs by age, has changed over time, or is due to differential access to kidney transplantation. National retrospective cohort study. Using the US Renal Data System, we identified 615,618 white patients 18 years or older who initiated dialysis therapy between January 1, 1995, and December 31, 2007. Hispanic ethnicity (vs non-Hispanic whites), year of end-stage renal disease incidence, age (as potential effect modifier). All-cause and cause-specific mortality. We found that Hispanics initiating dialysis therapy experienced lower mortality, but age modified this association (P < 0.001). Compared with non-Hispanic whites, mortality in Hispanics was 33% lower at ages 18-39 years (adjusted cause-specific HR [HRcs], 0.67; 95% CI, 0.64-0.71) and 40-59 years (HRcs, 0.67; 95% CI, 0.66-0.68), 19% lower at ages 60-79 years (HRcs, 0.81; 95% CI, 0.80-0.82), and 6% lower at 80 years or older (HRcs, 0.94; 95% CI, 0.91-0.97). Accounting for the differential rates of kidney transplantation, the associations were attenuated markedly in the younger age strata; the survival benefit for Hispanics was reduced from 33% to 10% at ages 18-39 years (adjusted subdistribution-specific HR [HRsd], 0.90; 95% CI, 0.85-0.94) and from 33% to 19% among those aged 40-59 years (HRsd, 0.81; 95% CI, 0.80-0.83). Inability to analyze Hispanic subgroups that may experience heterogeneous mortality outcomes. Overall, Hispanics experienced lower mortality, but differential access to kidney transplantation was responsible for much of the apparent survival benefit noted in younger Hispanics.

Hyponatremia, Mineral Metabolism, and Mortality in Incident Maintenance Hemodialysis Patients: A Cohort Study

Hyponatremia is associated with increased mortality in chronic diseases. Recent animal studies also implicate hyponatremia in bone abnormalities. However, associations between hyponatremia, mineral bone abnormalities, and mortality in incident hemodialysis patients are unknown. Nonconcurrent prospective cohort study. Incident hemodialysis patients from the Accelerated Mortality on Renal Replacement (ArMORR) cohort with available serum sodium measurements from the time of dialysis therapy initiation (n = 6,127) were classified as hyponatremic (sodium, <135 mEq/L) or normonatremic (sodium, 135-145 mEq/L) based on glucose-corrected sodium level at the time of dialysis therapy initiation. Patients with sodium levels >145 mEq/L were excluded (n = 74). Hyponatremia (sodium, <135 mEq/L). Mineral bone abnormalities; rates of falls, fractures, and mortality. Hyponatremia and mineral bone abnormalities were assessed at the time of hemodialysis therapy initiation. Data for other outcomes were collected during a 1-year follow-up. Univariate and multivariable logistic and Cox proportion hazard analyses were conducted to compute ORs and HRs, respectively, with 95% CIs. 775 patients were hyponatremic and 5,278 were normonatremic at baseline. In univariate analyses, hyponatremia was associated with hypercalcemia (OR, 1.92; 95% CI, 1.11-3.30), elevated alkaline phosphatase level (OR, 1.36; 95% CI, 1.12-1.66), and hypoparathyroidism (OR, 1.40; 95% CI, 1.18-1.65). Similar relationships were observed in multivariable models. No statistically significant relationships were observed with phosphorus abnormalities, hypovitaminosis D, falls, or fractures. 965 (15.8%) patients had died at the 1-year follow up. Compared with normonatremic patients, hyponatremic patients had higher 1-year mortality in univariate (HR, 1.59; 95% CI, 1.34-1.87) and multivariable analyses (HR, 1.42; 95% CI, 1.19-1.69). Low rate of falls and fractures, lack of data for bone density and fibroblast growth factor 23. In incident hemodialysis patients, hyponatremia is associated with hypercalcemia, elevated alkaline phosphatase levels, hypoparathyroidism, and increased 1-year mortality. Future studies are needed to examine whether treatments to alter hyponatremia have effects on mineral bone abnormalities and mortality.

Risk Factors for ESRD in Individuals With Preserved Estimated GFR With and Without Albuminuria: Results From the Kidney Early Evaluation Program (KEEP)

Given the increasing costs and poor outcomes of end-stage renal disease (ESRD), we sought to identify risk factors for ESRD in people with preserved estimated glomerular filtration rate (eGFR), with or without albuminuria, who were at high risk of ESRD. This cohort study included participants in the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) with eGFR ≥ 60 mL/min/1.73 m(2) at baseline stratified by the presence or absence of albuminuria. The Chronic Kidney Disease Epidemiology Collaboration equation was used to calculate eGFR. Urine was tested for albuminuria by semiquantitative dipstick. The outcome was the development of treated chronic kidney failure, defined as initiation of maintenance dialysis therapy or kidney transplantation, determined by linkage to the US Renal Data System. We used a Cox model with the Fine-Gray method to assess risk factors for treated chronic kidney failure while accounting for the competing risk of death. During a median follow-up of 4.8 years, 126 of 13,923 participants with albuminuria (16/10,000 patient-years) and 56 of 109,135 participants without albuminuria (1.1/10,000 patient-years) developed treated chronic kidney failure. Diabetes was a strong risk factor for developing treated chronic kidney failure in participants with and without albuminuria (adjusted HRs of 9.3 [95% CI, 5.7-15.3] and 7.8 [95% CI, 4.1-14.8], respectively). Black race, lower eGFR, and higher systolic blood pressure also were associated with higher adjusted risks of developing treated chronic kidney failure. In a diverse high-risk cohort of KEEP participants with preserved eGFR, we showed that diabetes, higher systolic blood pressure, lower eGFR, and black race were risk factors for developing treated chronic kidney failure irrespective of albuminuria status, although the absolute risk of kidney failure in participants without albuminuria was very low. Our findings support testing for kidney disease in high-risk populations, which often have otherwise unrecognized kidney disease.

Association of Serum Bicarbonate With Risk of Renal and Cardiovascular Outcomes in CKD: A Report From the Chronic Renal Insufficiency Cohort (CRIC) Study

The purpose of this study is to evaluate serum bicarbonate level as a risk factor for renal outcomes, cardiovascular events, and mortality in patients with chronic kidney disease (CKD). Observational cohort study. 3,939 participants with CKD stages 2-4 who enrolled in the Chronic Renal Insufficiency Cohort (CRIC) between June 2003 and December 2008. Serum bicarbonate level. Renal outcomes, defined as end-stage renal disease (either initiation of dialysis therapy or kidney transplantation) or 50% reduction in estimated glomerular filtration rate (eGFR); atherosclerotic events (myocardial infarction, stroke, or peripheral arterial disease); congestive heart failure events; and death. Time to event. Mean eGFR was 44.8 ± 16.8 (SD) mL/min/1.73 m(2), and median serum bicarbonate level was 24 (IQR, 22-26) mEq/L. During a median follow-up of 3.9 years, 374 participants died, 767 had a renal outcome, 332 experienced an atherosclerotic event, and 391 had a congestive heart failure event. In adjusted analyses, the risk of developing a renal end point was 3% lower per 1-mEq/L increase in serum bicarbonate level (HR, 0.97; 95% CI, 0.94-0.99; P = 0.01). The association was stronger for participants with eGFR >45 mL/min/1.73 m(2) (HR, 0.91; 95% CI, 0.85-0.97; P = 0.004). The risk of heart failure increased by 14% (HR, 1.14; 95% CI, 1.03-1.26; P = 0.02) per 1-mEq/L increase in serum bicarbonate level over 24 mEq/L. Serum bicarbonate level was not associated independently with atherosclerotic events (HR, 0.99; 95% CI, 0.95-1.03; P = 0.6) and all-cause mortality (HR, 0.98; 95% CI, 0.95-1.02; P = 0.3). Single measurement of sodium bicarbonate. In a cohort of participants with CKD, low serum bicarbonate level was an independent risk factor for kidney disease progression, particularly for participants with preserved kidney function. The risk of heart failure was higher at the upper extreme of serum bicarbonate levels. There was no association between serum bicarbonate level and all-cause mortality or atherosclerotic events.

Nephrology for the people: Presidential Address at the 42nd Regional Meeting of the Japanese Society of Nephrology in Okinawa 2012.

The social and economic burdens of dialysis are growing worldwide as the number of patients increases. Dialysis is becoming a heavy burden even in developed countries. Thus, preventing end-stage kidney disease is of the utmost importance. Early detection and treatment is recommended because late referral is common, with most chronic kidney disease (CKD) patients remaining asymptomatic until a late stage. Three-quarters of dialysis patients initiated dialysis therapy within 1 year after referral to the facility. Since its introduction in 2002, the definition of CKD has been widely accepted not only by nephrologists but also by other medical specialties, such as cardiologists and general practitioners. Japan has a long history of general screening for school children, university students, and employees of companies and government offices, with everybody asked to participate. The urine test for proteinuria and hematuria is popular among Japanese people; however, the outcomes have not been well studied. We examined the effects of clinical and laboratory data from several sources on survival of dialysis patients and also predictors of developing dialysis from community-based screening (Okinawa Dialysis Study, OKIDS). At an early CKD stage, patients are usually asymptomatic; therefore, regular health checks using a urine dipstick and serum creatinine are recommended. The intervals for follow-up, however, are debatable due to the cost. CKD is a strong risk factor for developing cardiovascular disease and death and also plays an important role in infection and malignancies, particularly in elderly people. People can live longer with healthy kidneys.

Hemodialysis Access Usage Patterns in the Incident Dialysis Year and Associated Catheter-Related Complications

Hemodialysis (HD) access is considered a critical and actionable determinant of morbidity, with a growing literature suggesting that initial HD access type is an important marker of long-term outcomes. Accordingly, we examined HD access during the incident dialysis period, focusing on infection risk and successful fistula creation during the first dialysis year. Longitudinal cohort. All US adults admitted to Fresenius Medical Care North America facilities within 15 days of first maintenance dialysis session between January 1 and December 31, 2007. Vascular access type at HD therapy initiation. Vascular access type at 90 days and at the end of the first year on HD therapy, bloodstream infection within the first year by access type, and catheter complication rate. Of 25,003 incident dialysis patients studied, 19,622 (78.5%) initiated dialysis with a catheter; 4,151 (16.6%), with a fistula; and 1,230 (4.9%), with a graft. At 90 days, 14,105 (69.7%) had a catheter, 4,432 (21.9%) had a fistula, and 1,705 (8.4%) had a graft. Functioning fistulas and grafts at dialysis therapy initiation had first-year failure rates of 10% and 15%, respectively. Grafts were seldom replaced by fistulas (3%), whereas 7,064 (47.6%) of all patients who initiated with a catheter alone still had only a catheter at 1 year. Overall, 3,327 (13.3%) patients had at least one positive blood culture during follow-up, with the risk being similar between the fistula and graft groups, but approximately 3-fold higher in patients with a catheter (P<0.001 for either comparison). Nearly 1 in 3 catheters (32.5%) will require tissue plasminogen activator use by a median of 41 days, with 59% requiring more than one tissue plasminogen activator administration. Potential underestimation of bacteremia because follow-up blood culture results did not include samples sent to local laboratories. In a large and representative population of incident US dialysis patients, catheter use remains very high during the first year of HD care and is associated with high mechanical complication and bloodstream infection rates.

Effect of Early Initiation of Dialysis on Cardiac Structure and Function: Results From the Echo Substudy of the IDEAL Trial

Abnormalities of cardiac structure and function are common in patients undergoing dialysis, and cardiovascular disease is the major cause of mortality in this group. Heart failure is a common clinical manifestation of cardiovascular disease and is preceded by left ventricular hypertrophy (LVH). There are variable reports about the impact of dialysis on LVH, both deleterious and beneficial. Our study investigated whether the timing of the initiation of dialysis therapy had an impact on cardiac structure and function. Randomized controlled trial. This is a cardiac substudy involving 182 patients with stage 5 chronic kidney disease in the IDEAL (Initiating Dialysis Early and Late) trial. The IDEAL trial randomly assigned patients on the basis of estimated glomerular filtration rate (eGFR), calculated using the Cockcroft-Gault equation, to start dialysis therapy early (GFR, 10-14 mL/min/1.73 m(2)), with the others starting late (GFR, 5-7 mL/min/1.73 m(2)). Echocardiograms were obtained at baseline and 12 months after randomization. Primary outcomes were change in left ventricular mass indexed for height (LVMi) between baseline and 12 months, left ventricular ejection fraction, left ventricular systolic annular velocity, ratio of mitral inflow velocity (E) to mitral annular velocity (Ea) (E/Ea), and left atrial volume indexed for height (LAVi). LVMi at baseline was elevated, but similar in both groups, with no significant change within or between groups at 12 months. E/Ea and LAVi were increased at baseline, consistent with significant diastolic dysfunction; there were no differences between groups at 12 months and no changes were observed for left ventricular volumes, left ventricular ejection fraction, stroke volume, and other echocardiographic parameters. Small multicenter study using echocardiography. Advanced cardiac disease in these patients with stage 5 chronic kidney disease did not progress during the 12-month study period and planned early initiation of dialysis therapy did not result in differences in any echocardiographic variables of cardiac structure and function.

Incremental prognostic value of an abnormal baseline spatial QRS-T angle in chronic dialysis patients

In order to improve the abysmal outcome of dialysis patients, it is critical to identify patients with a high mortality risk. The spatial QRS-T angle, which can be easily calculated from the 12 lead electrocardiogram (ECG), might be useful in the prognostication in dialysis patients. The objective of this study was to establish the prognostic value of the spatial QRS-T angle. All patients who initiated dialysis therapy between 2002 and 2009 in the hospitals of Leiden (LUMC) and Amsterdam (AMC) at least 3 months on dialysis were included. The spatial QRS-T angle was calculated, from a routinely acquired ECG, and its relationship with mortality was assessed. An abnormal spatial QRS-T angle was defined as ≥ 130° in men and ≥ 116° in women. In total, 277 consecutive patients (172 male, mean age 56.3 ± 17.0) were included. An abnormal spatial QRS-T angle was associated with a higher risk of death from all causes [hazard ratio (HR) 2.33; 95% confidence interval (CI) 1.46-3.70] and especially a higher risk of sudden cardiac death (HR 2.99; 95% CI 1.04-8.60). Furthermore, an abnormal spatial QRS-T angle was of incremental prognostic value, when added to a risk model consisting of known risk factors. In chronic dialysis patients the spatial QRS-T angle is a significant and independent predictor of all-cause and especially sudden cardiac death. It implies that this parameter can be used to identify high risk patients.

Phosphate Binders in CKD

Hyperphosphatemia has long been considered an important contributor to the mineral and bone disorder associated with CKD (CKD-MBD).[1][1] Already 50 years ago, Slatopolsky et al. [2][2] showed that as GFR decreased, fractional phosphate excretion rose because of inhibition of tubular phosphate

Epidemiologic trends in chronic renal replacement therapy over forty years: a Swiss dialysis experience.

BackgroundLong term longitudinal data are scarce on epidemiological characteristics and patient outcomes in patients on maintenance dialysis, especially in Switzerland. We examined changes in epidemiology of patients undergoing renal replacement therapy by either hemodialysis or peritoneal dialysis over four decades.MethodsSingle center retrospective study including all patients which initiated dialysis treatment for ESRD between 1970 and 2008. Analyses were performed for subgroups according to dialysis vintage, based on stratification into quartiles of date of first treatment. A multivariate model predicting death and survival time, using time-dependent Cox regression, was developed.Results964 patients were investigated. Incident mean age progressively increased from 48 ± 14 to 64 ± 15 years from 1st to 4th quartile (p < 0.001), with a concomitant decrease in 3- and 5-year survival from 72.2 to 67.7%, and 64.1 to 54.8%, respectively. Nevertheless, live span continuously increased from 57 ± 13 to 74 ± 11 years (p < 0.001). Patients transplanted at least once were significantly younger at dialysis initiation, with significantly better survival, however, shortened live span vs. individuals remaining on dialysis. Among age at time of initiating dialysis therapy, sex, dialysis modality and transplant status, only transplant status is a significant independent covariate predicting death (HR: 0.10 for transplanted vs. non-transplanted patients, p = 0.001). Dialysis vintage was associated with better survival during the second vs. the first quartile (p = 0.026).DiscussionWe document an increase of a predominantly elderly incident and prevalent dialysis population, with progressively shortened survival after initiation of renal replacement over four decades, and, nevertheless, a prolonged lifespan. Analysis of the data is limited by lack of information on comorbidity in the study population.ConclusionsSurvival in patients on renal replacement therapy seems to be affected not only by medical and technical advances in dialysis therapy, but may mostly reflect progressively lower mortality of individuals with cardiovascular and metabolic complications, as well as a policy of accepting older and polymorbid patients for dialysis in more recent times. This is relevant to make demographic predictions in face of the ESRD epidemic nephrologists and policy makers are facing in industrialized countries.

Association Between Prior Peripherally Inserted Central Catheters and Lack of Functioning Arteriovenous Fistulas: A Case-Control Study in Hemodialysis Patients

Although an arteriovenous fistula (AVF) is the hemodialysis access of choice, its prevalence continues to be lower than recommended in the United States. We assessed the association between past peripherally inserted central catheters (PICCs) and lack of functioning AVFs. Case-control study. Prevalent hemodialysis population in 7 Mayo Clinic outpatient hemodialysis units. Cases were without functioning AVFs and controls were with functioning AVFs on January 31, 2011. History of PICCs. Lack of functioning AVFs. On January 31, 2011, a total of 425 patients were receiving maintenance hemodialysis, of whom 282 were included in this study. Of these, 120 (42.5%; cases) were dialyzing through a tunneled dialysis catheter or synthetic arteriovenous graft and 162 (57.5%; controls) had a functioning AVF. PICC use was evaluated in both groups and identified in 30% of hemodialysis patients, with 54% of these placed after dialysis therapy initiation. Cases were more likely to be women (52.5% vs 33.3% in the control group; P = 0.001), with smaller mean vein (4.9 vs 5.8 mm; P < 0.001) and artery diameters (4.6 vs 4.9 mm; P = 0.01) than controls. A PICC was identified in 53 (44.2%) cases, but only 32 (19.7%) controls (P < 0.001). We found a strong and independent association between PICC use and lack of a functioning AVF (OR, 3.2; 95% CI, 1.9-5.5; P < 0.001). This association persisted after adjustment for confounders, including upper-extremity vein and artery diameters, sex, and history of central venous catheter (OR, 2.8; 95% CI, 1.5-5.5; P = 0.002). Retrospective study, participants mostly white. PICCs are commonly placed in patients with end-stage renal disease and are a strong independent risk factor for lack of functioning AVFs.

Mortality of Dialysis Patients According to Influenza and Pneumococcal Vaccination Status

Data from an immunocompromised subpopulation in which both vaccine recipients and nonrecipients have frequent opportunities for vaccination can help determine the associations between vaccination against seasonal influenza and pneumococcal disease and all-cause mortality. We surveyed dialysis centers and performed a retrospective analysis of health status at dialysis therapy initiation, vaccination for influenza and pneumococcal disease, laboratory results, and mortality associated with the 2005-2006 influenza season for patients in 3 End-Stage Renal Disease Networks across the United States. Of 1,033 dialysis facilities considered, 903 centers with a total patient population of 54,734 reported vaccination data. Analysis was limited to 36,966 patients on dialysis treatment for at least 1 year as of December 31, 2005. Vaccination status. OR for all-cause mortality (vaccinated vs unvaccinated patients). The estimated adjusted OR for mortality was significantly less than 1.0 for patient who received either vaccination and was lower for patients who had received both vaccinations than for those who had received either. Survival analysis confirmed these findings. Possible misclassification due to self-report of vaccination for some patients. Lack of vaccination date. Vaccination against influenza and pneumococcal disease is associated with improved survival in dialysis patients. The 2 vaccinations have independent effects on mortality.

A new nutritional screenig tool; gnri in japanese incident dialysis patients.

Background: Inflammation and malnutrition are common in chronic kidney disease (CKD) patients and among strong predictor of cardiovascular disease (CVD). Geriatric nutritional risk index [GNRI=1.489×albumin (g/dl) +41.7(body weight (BW) / ideal BW)] has been reported to be a simple and accurate nutritional screening tool in CKD patients as well as old people. Previous studies demonstrated low lymphocyte count (LLC) predicts poor outcome in patients with CVD and heart failure. Methods: A total of 68 Japanese incident dialysis patients (44 males, mean age 61±11 years) were enrolled and followed in an ongoing prospective study. Nutritional status [albumin, body mass index (BMI), abdominal circumstances, subjective global assessment (SGA) and GNRI] was assessed. Inflammatory biomarkers including white blood cell count (WBC) and differential were determined. Results: The median of GNRI was 95.4. When divided into two groups by the median, there were no association in age, gender, diabetes, SGA, medications including ESA between two groups. GNRI showed significantly correlation to hemoglobin (ρ=0.31, p=0.014) and did negatively correlation to WBC count (ρ=−0.24, p=0.049) and ferritin (ρ=−0.27, p=0.021) in Spearman’s rank test. Although these associations disappeared 1 year after initiation of dialysis therapy, the patients with higher incremental GNRI significantly showed increased lymphocyte count. Conclusion; Our results suggest that GNRI is a simple nutritional tool for dialysis patients and that GNRI might detect inflammation and predict CVD.

Associations of Plasma 25-Hydroxyvitamin D and 1,25-Dihydroxyvitamin D Concentrations With Death and Progression to Maintenance Dialysis in Patients With Advanced Kidney Disease

Low vitamin D concentrations are prevalent in patients with chronic kidney disease (CKD). We investigated the relationship between plasma 25-hydroxyvitamin D (25[OH]D) or 1,25-dihydroxyvitamin D (1,25[OH](2)D) concentrations with death, cardiovascular events, and dialysis therapy initiation in patients with advanced CKD. The HOST (Homocysteinemia in Kidney and End Stage Renal Disease) Study was a randomized double-blind trial evaluating the effects of high doses of folic acid on death and long-term dialysis therapy initiation in patients with advanced CKD (stages 4 and 5 not yet on dialysis therapy). 25(OH)D and 1,25(OH)(2)D were measured in stored plasma samples obtained 3 months after trial initiation and evaluated at clinically defined cutoffs (<10, 10-30, and >30 ng/mL) and tertiles (<15, 15-22, and >22 pg/mL), respectively. Cox proportional hazard models were used to examine the association between vitamin D concentrations and clinical outcomes. 1,099 patients with advanced CKD from 36 Veteran Affairs Medical Centers. 25(OH)D and 1,25(OH)(2)D concentrations. Death, cardiovascular events, and time to initiation of long-term dialysis therapy. After a median follow-up of 2.9 years, 41% (n = 453) died, whereas 56% (n = 615) initiated dialysis therapy. Mean 25(OH)D and 1,25(OH)(2)D concentrations were 21 ± 10 ng/mL and 20 ± 11 pg/mL, respectively. After adjustment for potential confounders, the lowest tertile of 1,25(OH)(2)D was associated with death (HR, 1.33; 95% CI, 1.01-1.74) and initiation of long-term dialysis therapy (HR, 1.78; 95% CI, 1.40-2.26) compared with the highest tertile. The association with death and initiation of dialysis therapy was moderately attenuated after adjustment for plasma fibroblast growth factor 23 (FGF-23) concentrations (HRs of lower tertiles of 1.20 [95% CI, 0.91-1.58] and 1.56 [95% CI, 1.23-1.99], respectively, compared with highest tertile). There was no association between 25(OH)D concentrations and outcomes. Participants were mostly men. Low plasma 1,25(OH)(2)D concentrations are associated with death and initiation of long-term dialysis therapy in patients with advanced CKD. FGF-23 level may attentuate this relationship.