Initiation Of Hemodialysis In Patients Research Articles

The Natural Course of Total Kidney Volume in Patients with Autosomal Dominant Polycystic Kidney Disease undergoing Hemodialysis

Objectives The natural course of native kidneys after hemodialysis initiation in patients with autosomal dominant polycystic kidney disease (ADPKD) remains poorly understood. Methods We measured the total volumes of native kidneys in 12 patients who had at least one enhanced computed tomography (CT) image both before and after initiation of hemodialysis (group 1) and in 18 patients who had no image before dialysis but more than two images after dialysis (group 2). In patients with images, the last image was used for analysis only after dialysis. Results The mean total kidney volume (TKV) (± SD) before hemodialysis initiation was 3132 ± 1413 mL and the mean TKV of the last image was 3047 ± 1323 mL in group 1. The mean TKV change rate (%) was −5.2 ± 27.4% ( P > 0.05) during follow-up of 3.9 ± 1.9 years in group 1. The mean TKV change rate was 2.8 ± 34.4% ( P > 0.05) in group 2. The follow-up period after dialysis initiation ranged from 4.2 ± 4.7 to 8.0 ± 5.2 years. Conclusions The results suggest that the TKV of native polycystic kidneys decreases substantially after hemodialysis initiation. This reduction occurs mainly during the early post-hemodialysis period and followed by a slow enlargement of TKV.

Is an Increase in Anion Gap a Predictor of Hemodialysis Initiation in Patients with Advanced CKD?

Is an Increase in Anion Gap a Predictor of Hemodialysis Initiation in Patients with Advanced CKD?

Does Static Intra Access Pressure Monitoring of Arteriovenous Fistulas Predicts Intra Access Stenosis?

The initiation of hemodialysis in patients with chronic kidney disease (CKD) requires vascular access formation. The choice of vascular access for individual patient depends on various factors however arteriovenous fistula (AVF) is conventionally considered to be the vascular access of choice. Once hemodialysis is initiated through a mature AVF, there is an ongoing need for surveillance of the AVF to ensure adequate function and prevent vascular access issues among which flow obstruction (both inflow and outflow) remains the most important. AVF stenosis can potentially lead to inadequate dialysis delivery and thrombosis thus leading to access loss. Physical examination and AVF Doppler ultrasonography (DUS) are useful for evaluation of stenosis in the arteriovenous connection and the outflow tract. Periodic assessment of the AVF with Static Intra access Pressure (SIAPR) determination may be a reliable means of predicting vascular access stenosis.
 Material & Methods A cross sectional study carried out at Department of Nephrology, Fatima Memorial Hospital, Lahore from July 2018 to December 2018. In total 113 patients were included, and all patients underwent SIAPR assessment and Doppler Ultrasound of AVF.
 Results Mean age of the patients was 56.81±9.38 years, male to female ratio of the patients was 1.8:1. In this study the SIAPR was suggestive of stenosis in 87(76.99%) patients. The sensitivity, specificity and diagnostic accuracy of SIAPR against Doppler US of the AVF for detection of stenosis was 75.86%, 22.62% & 36.28% respectively
 Conclusion SIAPR has low specificity and diagnostic accuracy compared to Doppler US for detection of AVF stenosis.

Temporary central venous catheter at hemodialysis initiation and reasons for use: a cross-sectional study

BackgroundCreating permanent vascular access (VA) is recommended before hemodialysis initiation in patients with end-stage renal disease (ESRD). Although many patients are still introduced to hemodialysis with temporary central venous catheters (CVCs), the reasons for their use remain unclear. We aimed to clarify the characteristics of Japanese patients introduced to hemodialysis using temporary CVCs, the reasons for their use, and whether this rate can be reduced in the future.MethodsWe conducted this cross-sectional study in an acute care general hospital in Japan. We enrolled 393 patients aged ≥ 18 years who received a permanent VA creation for initiating hemodialysis. We classified participants into the temporary CVC group or the permanent VA group according to the VA type at hemodialysis initiation and compared their backgrounds. We identified why permanent VA could not be used at hemodialysis initiation for patients in the temporary CVC group.ResultsOf the 393 patients, 137 (35%) initiated hemodialysis with a temporary CVC, and arteriovenous fistulas (AVFs) were created as the first VA in all patients during hospitalization following hemodialysis initiation. The remaining 256 patients (65%) initiated hemodialysis via AVF cannulation. The duration of predialysis nephrology care was significantly shorter in the temporary CVC group than that in the permanent VA group. The median time from AVF creation to the first successful cannulation was also shorter in the temporary CVC group (8 vs. 66 days, P < 0.001), but the estimated glomerular filtration rate values at hemodialysis initiation did not differ. Reasons for temporary CVC use were varied and complex. Problems on the part of healthcare providers, patient behavioral issues, and characteristics of causative kidney disease itself were underlying reasons. Delayed referral to a nephrologist was less frequent than expected (16%) and the most commonly reported reason (20%) was that a nephrologist was unable to predict the timing of hemodialysis initiation.ConclusionsPatients with ESRD should be referred to a nephrologist earlier for AVF creation. However, given the already relatively high rate of hemodialysis initiation with permanent VA in Japan, we considered it surprisingly difficult to further reduce the temporary CVC usage rate in Japan.

Effect of Predialysis Recombinant Human Erythropoietin on Early Survival After Hemodialysis Initiation in Patients With Chronic Kidney Disease: Co-JET Study.

Progression of anemia in patients with chronic kidney disease (CKD) is associated with an increased risk of death and hospitalization. It is not sufficiently clear whether treating renal anemia with recombinant human erythropoietin (rHuEPO) has a beneficial effect on early survival after hemodialysis (HD) initiation in patients with CKD. The study was an open-label multicenter retrospective cohort study to evaluate the relationship between rHuEPO treatment and early survival after HD initiation in patients with CKD. Predialysis patients with CKD were divided into two groups: an rHuEPO-treated group (rHuEPO group) and a non-treatment group. The primary endpoint was all-cause mortality in the year after HD initiation. A total of 3261 patients were enrolled (2275 in the rHuEPO group and 986 in the non-treatment group). One-year survival was 95.36% in the rHuEPO group and 90.36% in the non-treatment group. The survival rate was significantly higher in the rHuEPO group (P < 0.0001). The results of multivariate analysis confirmed that predialysis treatment with rHuEPO is a predictor for reduced mortality risk (hazard ratio = 0.61, 95% confidence interval: 0.42-0.87, P = 0.006). Risk for the composite event of death/hospitalization was also lower in the rHuEPO group (hazard ratio = 0.88, 95% confidence interval: 0.78-0.98, P = 0.026). The results of this study suggest that treatment with rHuEPO can decrease early mortality risk after initiation of HD in patients with CKD. A prospective study is needed to further investigate early survival after HD initiation.

Predictors of Initiation for Predialysis Arteriovenous Fistula.

The optimal timing of predialysis arteriovenous fistula surgery remains uncertain. We evaluated factors associated with hemodialysis initiation in patients undergoing predialysis arteriovenous fistula surgery and derived a model to predict future initiation of dialysis. Our study retrospectively identified 308 patients undergoing predialysis arteriovenous fistula creation at a large medical center in 2006-2012 to determine whether they initiated hemodialysis. Multiple variable logistic regression analyzed which demographic and clinical factors predicted initiation of dialysis within 2 years of arteriovenous fistula surgery. A receiver operating characteristic area under the curve was used to quantify the predictive value of preoperative factors on the likelihood of initiating hemodialysis within 2 years. Overall, hemodialysis was initiated within 6 months, 1 year, and 2 years in 119 (39%), 175 (57%), and 211 (68%) patients, respectively. Using multiple variable logistic regression, four factors were associated with hemodialysis initiation at 2 years: eGFR at access surgery (odds ratio, 0.45; 95% confidence interval, 0.31 to 0.64 per 5 ml/min per 1.73 m2; P<0.001), diabetes (odds ratio, 2.51; 95% confidence interval, 1.22 to 5.15; P=0.003), GFR trajectory (odds ratio, 1.54; 95% confidence interval, 1.09 to 2.17 per 3 ml/min per 1.73 m2 per year; P=0.01), and spot urine protein-to-creatinine ratio (odds ratio, 1.39; 95% confidence interval, 1.14 to 1.71 per 1 U; P<0.001). eGFR alone had a moderate predictive value for dialysis initiation (area under the curve =0.69; 95% confidence interval, 0.63 to 0.76; P<0.001), whereas the full model had a higher predictive value (area under the curve =0.83; 95% confidence interval, 0.77 to 0.88; P<0.001). The likelihood of initiating hemodialysis within 2 years of predialysis arteriovenous fistula surgery is associated with eGFR at access surgery, diabetes, GFR trajectory, and magnitude of proteinuria. The combined use of all four variables improves the ability to predict future hemodialysis compared with the use of eGFR alone.

Serum phosphate as an additional marker for initiating hemodialysis in patients with advanced chronic kidney disease

BackgroundReconsidering when to initiate renal replacement therapy (RRT) in patients with chronic kidney disease (CKD) has been emphasized recently. With evolving modern aged and diabetes-prone populations, conventional markers of uremia are not sufficient for determining the optimal timing for dialysis initiation. This retrospective cohort study examined the association between hyperphosphatemia and uremic patients who need RRT registration. MethodsAll patients from the department of nephrology in one tertiary medical center in northern Taiwan who had advanced CKD and estimated glomerular filtration rates <8 mL/min/1.73 m2 from July 2009 to May 2013 were enrolled. We reviewed the medical records and collected data on demographics, comorbidities, underlying diseases, duration of nephrology care, use of phosphate binders, and laboratory results. Univariable and multivariable logistic regression models were used to identify factors associated with hemodialysis initiation decision making. ResultsDuring the study period, 209 of 292 patients with advanced CKD were enrolled in hemodialysis program and 83 patients (controls) were not. Univariable analysis indicated that male sex, current smoking, diabetes mellitus, hypertension, coronary artery disease, high serum creatinine level, and high serum phosphate level were associated with initiation of hemodialysis. Multivariable analysis indicated that those with higher serum phosphate level (odds ratio [OR] = 2.4, 95% confidence interval [CI] = 1.6–3.5, p = 1.4 × 10−5) and being in nephrology care for <12 months (OR = 0.4, 95% CI = 0.2–0.8, p = 0.016) tended to be significant markers for hemodialysis initiation. ConclusionHyperphosphatemia, in addition to conventional laboratory markers and uremic symptoms, may be a useful marker to determine timing of hemodialysis initiation in patients with advanced CKD.

Echocardiographic changes following hemodialysis initiation in patients with advanced chronic kidney disease and symptomatic heart failure with reduced ejection fraction

In patients without overt cardiac disease, the degree of left ventricular hypertrophy (LVH) gets worse following hemodialysis (HD) initiation; however, in patients with both advanced chronic kidney disease (CKD) and symptomatic heart failure (HF) with reduced ejection fraction (EF), the short-term effect of HD on LVH and LV geometry has not been examined. We hypothesized that left ventricular mass index (LVMI) would decrease following HD initiation in CKD patients with symptomatic HF. We retrospectively evaluated changes in LVMI, LV geometry, and LV fractional shortening (LVFS), assessed by 2D transthoracic echocardiography (TTE), in 41 patients with HF initiating HD while hospitalized from 1995 to 2006. HF was defined by LVEF ≤ 45% or dyspnea plus two of the following: raised jugular venous pressure, bibasilar crackles, pulmonary venous hypertension, interstitial edema on chest X-ray, or both. TTE was performed within 3 months prior to first HD and repeated 8.6 ± 5.2 months after start of HD. TTE recordings were obtained from storage and analyzed by a cardiologist blinded to patient clinical characteristics. Before initiation of HD, LVMI in 39 patients was 167.9 ± 53.1 g/m2 and it decreased by -24.3 ± 35.4 g/m2 by follow-up, p < 0.001. 26% of patients with concentric LVH at baseline had concentric remodeling or eccentric LVH at follow-up. LVFS did not significantly change over time in all 41 patients with HF (25.7 ± 8.7% vs. 26.4 ± 8.7%, p = 0.66). However, in an expanded analysis of all 69 patients with serial TTEs, a 1% increase in LVFS after starting HD was associated with a 16% reduction in risk of cardiovascular hospitalization at follow-up (HR 0.84, 95% CI 0.73 - 0.96, p = 0.01). LVMI decreases following HD initiation in CKD patients with symptomatic HF and reduced LVEF, possibly due to relief of venous congestion. Increase in LVFS following HD initiation predicts improved cardiac outcome.

Carotid artery calcification and atherosclerosis at the initiation of hemodialysis in patients with end-stage renal disease

Vascular calcification and atherosclerosis frequently develop in end-stage renal disease (ESRD). Although several reports have investigated both carotid artery calcification (CAAC) and carotid atherosclerosis in ESRD patients, the relationship between the two vascular conditions has remained unclear. The aim of this study was to assess the prevalence of CAAC and carotid artery plaque (CAP) in patients with ESRD and to investigate potential factors contributing to the development of CAAC and CAP. This cross-sectional study assessed CAAC and CAP using multidetector computed tomography and high-resolution B-mode ultrasonography, respectively, in 135 patients with ESRD at the start of hemodialysis. The prevalence of CAAC and CAP was examined. The risk factors associated with CAAC and CAP were also evaluated using a logistic regression model. CAAC and CAP were found in 71% and 65%, of the patients, respectively. A logistic regression analysis adjusted for age and gender showed that CAAC was significantly associated with age, hypertension, dyslipidemia, serum albumin, calcium-phosphorus product, proteinuria and CAP. In contrast, in the same analysis, CAP was significantly correlated with age, male gender, diabetes, intact parathyroid hormone, proteinuria and CAAC. In the multivariate analysis, CAAC was independently associated with age, hypertension, and calcium-phosphorus product. Male gender was identified as an independent determinant for CAP. Furthermore, CAP remained as an independent risk factor of CAAC (odds ratio (OR): 13.89; 95% confidence interval (CI): 4.08-47.29), and CAAC also showed a high OR for having CAP (OR: 11.74; 95% CI: 4.12-33.51). Both CAAC and CAP were associated with traditional and/or non-traditional risk factors. The risk factors of CAAC were different from those of CAP. CAAC or CAP was identified to be an independent risk factor for each other with a high OR, thus suggesting a strong relationship between carotid calcification and atherosclerosis.

Nutrition in hemodialysis patients previously on a supplemented very low protein diet

Nutritional safety of protein-restricted diets in patients with chronic renal failure is controversial. In the present study, we have assessed the evolution of nutritional status after initiation of hemodialysis in patients previously treated by a supplemented very low protein diet (SVLPD). Nutritional data were prospectively collected during the first year of hemodialysis from 15 consecutive patients treated with a SVLPD (0.3 g protein/kg/day supplemented with essential amino acids, calcium, iron, and vitamins) and compared to 15 age- and gender-matched end-stage renal disease (ESRD) patients previously on a less-restricted diet (0.90 +/- 0.21 g protein/kg/day) who started hemodialysis during the same period. Dual-energy x-ray absorptiometry (DEXA) was used to assess body composition at 0, 6, and 12 months. Hemodialysis prescriptions, biologic data and 3-day food records were collected every 3 months. Protein intake was higher than 1.2 g/kg/day in both groups as soon as 3 months after the start of hemodialysis. Albumin and prealbumin increased significantly during the first 6 months in all patients. Body mass index (BMI) increased in all patients (+0.97 +/- 1.31 kg/m2; P < 0.001) reflecting a gain in fat mass in the overall population (+2.36 +/- 2.94 kg/m2; P < 0.001) while lean body mass remained stable overall. Once on hemodialysis, SVLPD patients rapidly increased protein intake. Nutritional status improved in all patients, with a gain in fat mass in all, and a gain in lean body mass in SVLPD men only. These data indicate that treatment with a SVLPD prior to hemodialysis initiation is nutritionally safe.