Initiation Of Maintenance Dialysis Research Articles

Access to Kidney Transplantation after a Failed First Kidney Transplant and Associations with Patient and Allograft Survival: An Analysis of National Data to Inform Allocation Policy.

Patients who have failed a transplant are at increased risk of repeat transplant failure. We determined access to transplantation and transplant outcomes in patients with and without a history of transplant failure. In this observational study of national data, the proportion of waitlisted patients and deceased donor transplant recipients with transplant failure was determined before and after the new kidney allocation system. Among patients initiating maintenance dialysis between May 1995 and December 2014, the likelihood of deceased donor transplantation was determined in patients with (n=27,459) and without (n=1,426,677) a history of transplant failure. Among transplant recipients, allograft survival, the duration of additional kidney replacement therapy required within 10 years of transplantation, and the association of transplantation versus dialysis with mortality was determined in patients with and without a history of transplant failure. The proportion of waitlist candidates (mean 14%) and transplant recipients (mean 12%) with transplant failure did not increase after the new kidney allocation system. Among patients initiating maintenance dialysis, transplant-failure patients had a higher likelihood of transplantation (hazard ratio [HR], 1.16; 95% confidence interval [95% CI], 1.12 to 1.20; P<0.001). Among transplant recipients, transplant-failure patients had a higher likelihood of death-censored transplant failure (HR, 1.44; 95% CI, 1.34 to 1.54; P<0.001) and a greater need for additional kidney replacement therapy required within 10 years after transplantation (mean, 9.0; 95% CI, 5.4 to 12.6 versus mean, 2.1; 95% CI, 1.5 to 2.7 months). The association of transplantation versus dialysis with mortality was clinically similar in waitlisted patients with (HR, 0.32; 95% CI, 0.29 to 0.35; P<0.001) and without transplant failure (HR, 0.40; 95% CI, 0.39 to 0.41; P<0.001). Transplant-failure patients initiating maintenance dialysis have a higher likelihood of transplantation than transplant-naïve patients. Despite inferior death-censored transplant survival, transplantation was associated with a similar reduction in the risk of death compared with treatment with dialysis in patients with and without a prior history of transplant failure.

Association of Initiation of Maintenance Dialysis with Functional Status and Caregiver Burden.

Little is known about the functional course after initiating dialysis in elderly patients with ESKD. The aim of this study was to assess the association of the initiation of dialysis in an elderly population with functional status and caregiver burden. This study included participants aged ≥65 years with ESKD who were enrolled in the Geriatric Assessment in Older Patients Starting Dialysis study. All underwent a geriatric assessment and a frailty screening (Fried Frailty Index and Groningen Frailty Indicator) at dialysis initiation. Functional status (activities of daily life and instrumental activities of daily life) and caregiver burden were assessed at baseline and after 6 months. Decline was defined as loss of one or more domains in functional status, stable as no difference between baseline and follow-up, and improvement as gain of one or more domains in functional status. Logistic regression was performed to assess the association between the combined outcome functional decline/death and potential risk factors. Of the 196 included participants functional data were available for 187 participants. Mean age was 75±7 years and 33% were women. At the start of dialysis, 79% were care dependent in functional status. After 6 months, 40% experienced a decline in functional status, 34% remained stable, 18% improved, and 8% died. The prevalence of high caregiver burden increased from 23%-38% (P=0.004). In the multivariable analysis age (odds ratio, 1.05; 95% confidence interval, 1.00 to 1.10 per year older at baseline) and a high Groningen Frailty Indicator compared with low score (odds ratio, 1.97; 95% confidence interval, 1.05 to 3.68) were associated with functional decline/death. In patients aged ≥65 years, functional decline within the first 6 months after initiating dialysis is highly prevalent. The risk is higher in older and frail patients. Loss in functional status was mainly driven by decline in instrumental activities of daily life. Moreover, initiation of dialysis is accompanied by an increase in caregiver burden.

Effects of Early Frequent Nephrology Care on Emergency Department Visits among Patients with End-stage Renal Disease.

In this retrospective cohort study, we examined the association between predialysis nephrology care status and emergency department (ED) events among patients with end-stage renal disease. Data pertaining to 76,702 patients who began dialysis treatment between 1999 and 2010 were obtained from the National Health Insurance Research Database of Taiwan (NHIRD). The patients were divided into three groups based on the timing of the first nephrology care visit prior to the initiation of maintenance dialysis, and the frequency of nephrologist visits (i.e., early referral/frequent consultation, early referral/infrequent consultation, late referral). At 1-year post-dialysis initiation, a large number of the patients had experienced at least one all-cause ED visit (58%), infection-related ED visit (17%), or potentially avoidable ED visit (7%). Cox proportional hazard models revealed that patients who received early frequent care faced an 8% lower risk of all-cause ED visit (HR: 0.92; 95% CI: 0.90–0.94), a 24% lower risk of infection-related ED visit (HR: 0.76; 95% CI: 0.73–0.79), and a 24% lower risk of avoidable ED visit (HR: 0.76; 95% CI: 0.71–0.81), compared with patients in the late referral group. With regard to the patients undergoing early infrequent consultations, the only marginally significant association was for infection-related ED visits. Recurrent event analysis revealed generally consistent results. Overall, these findings indicate that continuous nephrology care from early in the predialysis period could reduce the risk of ED utilization in the first year of dialysis treatment.

Treatment of Anemia With Darbepoetin Prior to Dialysis Initiation and Clinical Outcomes: Analyses From the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT)

Evidence from clinical trials to guide patient preparation for maintenance dialysis therapy is limited. Although anemia is associated with mortality and cardiovascular (CV) disease in individuals initiating maintenance dialysis therapy, it is not known if treatment of anemia before dialysis therapy initiation with erythropoiesis-stimulating agents alters outcomes. Post hoc analysis of a randomized controlled trial. Participants with type 2 diabetes and chronic kidney disease who progressed to dialysis therapy (n=590) in the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT). Randomized treatment assignment (darbepoetin vs placebo). All-cause mortality, CV mortality, nonfatal myocardial infarction, heart failure, and stroke within the first 180 days of dialysis therapy initiation. Proportional hazards regression. Overall, 590 of 4,038 (14.6%) participants initiated dialysis therapy during the trial (n=298 and 292 in the darbepoetin and placebo groups, respectively). Corresponding hemoglobin levels were 11.3±1.6 and 9.5±1.5g/dL (P<0.001). Death from any cause occurred in 31 (10.4%) participants assigned to darbepoetin and 28 (9.6%) assigned to placebo (HR, 1.16; 95% CI, 0.69-1.93), while death from CV causes occurred in 15 (5.0%) and 13 (4.5%) participants, respectively (HR, 1.21; 95% CI, 0.58-1.93). There were no differences in risk for nonfatal myocardial infarction or heart failure. Stroke occurred in 8 (2.8%) participants assigned to darbepoetin and 1 (0.3%) assigned to placebo (HR, 8.6; 95% CI, 1.1-68.7). Post hoc analyses of a subgroup of study participants. Despite initiating dialysis therapy with a higher hemoglobin level, prior treatment with darbepoetin was not associated with a reduction in mortality, myocardial infarction, or heart failure in the first 180 days, but a higher frequency of stroke was observed. In the absence of more definitive data, this may inform decisions regarding the use of erythropoiesis-stimulating agents to treat mild to moderate anemia in patients with type 2 diabetes and chronic kidney disease nearing dialysis therapy initiation.

Clinical presentation at initiation of maintenance dialysis and subsequent survival: A retrospective cohort study.

Clinical practice guidelines increasingly favor a more symptom-driven approach to maintenance dialysis initiation. But, little is known about the clinical presentation at dialysis initiation, such as the different kinds of signs and symptoms present at dialysis initiation, illness acuity at dialysis initiation, and how these aspects of the clinical presentation relate to subsequent survival. This is a retrospective cohort study of a random sample of veterans who initiated dialysis between 2000 and 2009 at Veterans Affairs (VA) medical centers across the country (N = 1,691). We looked at associations between the clinical presentation (types of signs and/or symptoms and illness acuity) at the time of dialysis initiation and 1-year mortality. The most common types of signs and/or symptoms at initiation were gastrointestinal (50.9%) and cardiopulmonary (48.7%). The crude mortality rate was 174.2 deaths per 1000 patients per year (95% CI 154.7, 196.1). Among different categories of signs and/or symptoms, only cardiopulmonary signs and/or symptoms were associated with a higher 1-year risk of mortality after initiation (risk ratio (RR) 1.32, 95% CI 1.05, 1.69) in adjusted analyses. Patients who were acutely ill at initiation were more likely to die during the following year as compared with those who initiated dialysis in the outpatient setting (RR 1.57, 95% CI 1.15, 2.21). With the exception of cardiopulmonary signs and/or symptoms, most signs and/or symptoms documented around the time of dialysis initiation were not associated with an increased risk of death during the year after initiation. In contrast, whether patients were acutely ill at the time of initiation was strongly associated with an increased risk of death after initiation regardless of the specific signs and/or symptoms present. Limitations of this study include retrospective study design, residual confounding, and lack of generalizability to non-VA settings.

Prospective associations between environmental heavy metal exposure and renal outcomes in adults with chronic kidney disease.

In Taiwan, Changhua County residents were exposed to high heavy metal pollution and exhibited high heavy metal levels in blood and urine. We examined associations between heavy metals in residential soil and renal outcomes of residents with chronic kidney disease (CKD). From 1 January 2003 to 30 June 2015, we retrospectively identified CKD patients with an estimated glomerular filtration rate of <60mL/min per 1.73m2 at one tertiary care centre. We linked data displaying heavy metal concentrations from farm soil adjacent to the patients' residences to clinical outcomes. We included 2343 CKD patients (533 with progression to end-stage renal disease [ESRD] and 1810 without]. We followed these patients for 3.49±2.27years, until death or initiation of maintenance dialysis. There were high correlations among the concentrations of the eight metals: arsenic, cadmium, chromium, mercury, copper, lead, nickel, and zinc. After factor analysis, chromium, copper, nickel, and zinc were grouped and labelled Factor 1. High Factor 1 concentration near the patients' residences was associated with diagnoses of hypertension, diabetes mellitus, and cerebral vascular accident. Patients living in areas with high Factor 1 concentrations were at higher risk of ESRD. After multivariate adjustment [adjusted hazard ratio: 1.08, 95% Confidence interval: 1.01-1.14, P=0.02], only zinc and nickel were risk factors for progression to ESRD. Patients with CKD, with long-term exposure to soil-based heavy metals, had rapid progression to ESRD. Groups of minerals from the same source of contamination may accumulate and lead to additional harm.

Association of Circulatory Iron Deficiency With an Enlarged Heart in Patients With End-Stage Kidney Disease

High prevalence of iron deficiency (ID) and cardiomyopathy have been observed in patients with end-stage kidney disease (ESKD). Our objective was to clarify associations between ID and cardiac remodeling in patients with ESKD. A cross-sectional study was conducted using 1974 Japanese patients with ESKD at the initiation of maintenance dialysis. Levels of hemoglobin (Hb), iron status, and cardiac enlargement as assessed by the cardiothoracic ratio (CTR) were determined immediately before the first hemodialysis session. Circulatory ID was defined as transferrin saturation (TSAT)<20%, and stored ID was defined as ferritin level <100ng/dL. The mean age was 67years. Median CTR was 54.0%. The prevalence of circulatory and stored ID was found to be 38% and 34%, respectively. CTR was higher in patients with circulatory ID than in those without. Even in ESKD patients without overhydration, significant negative association was observed between TSAT and CTR. Higher odds ratios in parallel with higher CTR categories compared with the reference category of CTR <45% were found in patients with TSAT <20% on multinomial analysis, but ferritin did not show any significant associations. The odds ratio for CTR >54% showed an upward trend in patients with TSAT <20% (odds ratio: 1.3) and <10% (odds ratio: 1.6) compared with the reference, even after adjusting for confounding variables such as Hb and ferritin. However, that phenomenon was eliminated by adding usage of an iron agent. Circulatory ID is closely associated with an enlarged heart independent of ferritin and Hb. Iron supplementation in the predialysis phase of chronic kidney disease may prevent cardiac remodeling independent of Hb level in patients chronic kidney disease.

International Study of Comparative Health Effectiveness with Medical and Invasive Approaches–Chronic Kidney Disease (ISCHEMIA-CKD): Rationale and design

Patients with chronic kidney disease (CKD) and stable ischemic heart disease are at markedly increased risk of cardiovascular events. Prior trials comparing a strategy of optimal medical therapy (OMT) with or without revascularization have largely excluded patients with advanced CKD. Whether a routine invasive approach when compared with a conservative strategy is beneficial in such patients is unknown. ISCHEMIA-CKD is a National Heart, Lung, and Blood Institute-funded randomized trial designed to determine the comparative effectiveness of an initial invasive strategy (cardiac catheterization and optimal revascularization [percutaneous coronary intervention or coronary artery bypass graft surgery, if suitable] plus OMT) versus a conservative strategy (OMT alone, with cardiac catheterization and revascularization [percutaneous coronary intervention or coronary artery bypass graft surgery, if suitable] reserved for failure of OMT) on long-term clinical outcomes in 777 patients with advanced CKD (defined as those with estimated glomerular filtration rate <30 mL/min/1.73m2 or on dialysis) and moderate or severe ischemia on stress testing. Participants were randomized in a 1:1 fashion to the invasive or a conservative strategy. The primary end point is a composite of death or nonfatal myocardial infarction. Major secondary endpoints are a composite of death, nonfatal myocardial infarction, hospitalization for unstable angina, hospitalization for heart failure, or resuscitated cardiac arrest; angina control; and disease-specific quality of life. Safety outcomes such as initiation of maintenance dialysis and a composite of initiation of maintenance dialysis or death will be reported. The trial is projected to have 80% power to detect a 22% to 24% reduction in the primary composite end point with the invasive strategy when compared with the conservative strategy. ISCHEMIA-CKD will determine whether an initial invasive management strategy improves clinical outcomes when added to OMT in patients with advanced CKD and stable ischemic heart disease.

Aquaporin 11 rs2276415 variant and progression of chronic kidney disease.

The Aquaporin 11 (AQP11) rs2276415 variant has been implicated in kidney disease in Type 2 diabetes. Association of the AQP11 variant with chronic kidney disease (CKD) beyond diabetic nephropathy is unknown, with no studies reported in the Chinese population. We explored the risk of CKD progression associated with the AQP11 rs2276415 variant in a population-based study in China. We conducted a prospective cohort study of 620 participants with CKD (Stages 2-5 and who were not receiving dialysis) at the Nephrology Center of First Affiliated Hospital of Jiaxing University between July 2011 and December 2014 and followed up for 3 years. Incident CKD progression, defined as an increase in creatinine levels of at least 0.4 mg/dL (35 µmol/L) above baseline or maintenance dialysis initiation or transplantation, was examined by AQP11 genotypes. During the follow-up period, CKD progression developed in 170 individuals. Cumulative events-free survival was significantly dependent on AQP11 genotypes with an apparent gene-dose effect (log-rank P < 0.001). Adjusting for sex, age and major CKD risk factors, the A allele of AQP11 gene (GA + AA) increased the risk of CKD progression by 1.92 (95% confidence interval 1.31- 2.84). The AQP11 rs2276415 variant predicts CKD progression in the Chinese population, independent of traditional risk factors. Exploring the pathways mediating the association may shed light on novel therapeutic targets in the pathophysiology of CKD.

Echocardiographic parameters and renal outcomes in patients with preserved renal function, and mild- moderate CKD

BackgroundEchocardiographic characteristics across the spectrum of chronic kidney disease (CKD) have not been well described. We assessed the echocardiographic characteristics of patients with preserved renal function and mild or moderate CKD referred for echocardiography and determined whether echocardiographic parameters of left ventricular (LV) and right ventricular (RV) structure and function were associated with changes in renal function and mortality.MethodsThis retrospective cohort study enrolled all adult patients who had at least one trans-thoracic echocardiography between 2004 and 2014 in our institution. The composite outcome of doubling of serum creatinine or initiation of maintenance dialysis or kidney transplantation was the primary outcome. Mortality was the secondary outcome.Results29,219 patients were included. Patients with worse renal function had higher prevalence of structural and functional LV and RV abnormalities. Higher estimated glomerular filtration rate (eGFR) was independently associated with preserved LV ejection fraction, preserved RV systolic function, and lower LV mass, left atrial diameter, pulmonary artery pressure, and right atrial pressure, as well as normal RV structure. 1041 composite renal events were observed. 8780 patients died during the follow-up. Pulmonary artery pressure and the RV, but not the LV, echocardiographic parameters were independently associated with the composite renal outcome. In contrast, RV systolic function, RV dilation or hypertrophy, LV ejection fraction group, LV diameter quartile, and pulmonary artery pressure quartile were independently associated with all-cause mortality.ConclusionsEchocardiographic abnormalities are frequent even in early CKD. Echocardiographic assessment particularly of the RV may provide useful information for the care of patients with CKD.

Initiating Maintenance Dialysis Before Living Kidney Donor Transplantation When a Donor Candidate Evaluation Is Well Underway.

Preemptive kidney transplants result in better outcomes and patient experiences than transplantation after dialysis onset. It is unknown how often a person initiates maintenance dialysis before living kidney donor transplantation when their donor candidate evaluation is well underway. Using healthcare databases, we retrospectively studied 478 living donor kidney transplants from 2004 to 2014 across 5 transplant centers in Ontario, Canada, where the recipients were not receiving dialysis when their donor's evaluation was well underway. We also explored some factors associated with a higher likelihood of dialysis initiation before transplant. A total of 167 (35%) of 478 persons with kidney failure initiated dialysis in a median of 9.7 months (25th-75th percentile, 5.4-18.7 months) after their donor candidate began their evaluation and received dialysis for a median of 8.8 months (3.6-16.9 months) before kidney transplantation. The total cohort's dialysis cost was CAD $8.1 million, and 44 (26%) of 167 recipients initiated their dialysis urgently in hospital. The median total donor evaluation time (time from evaluation start to donation) was 10.6 months (6.4-21.6 months) for preemptive transplants and 22.4 months (13.1-38.7 months) for donors whose recipients started dialysis before transplant. Recipients were more likely to start dialysis if their donor was female, nonwhite, lived in a lower-income neighborhood, and if the transplant center received the recipient referral later. One third of persons initiated dialysis before receiving their living kidney donor transplant, despite their donor's evaluation being well underway. Future studies should consider whether some of these events can be prevented by addressing inappropriate delays to improve patient outcomes and reduce healthcare costs.

Cognitive Impairment in Non–Dialysis-Dependent CKD and the Transition to Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

Advanced chronic kidney disease is associated with elevated risk for cognitive impairment. However, it is not known whether and how cognitive impairment is associated with planning and preparation for end-stage renal disease. Retrospective observational study. 630 adults participating in the CRIC (Chronic Renal Insufficiency Cohort) Study who had cognitive assessments in late-stage CKD, defined as estimated glome-rular filtration rate≤ 20mL/min/1.73m2, and subsequently initiated maintenance dialysis therapy. Predialysis cognitive impairment, defined as a score on the Modified Mini-Mental State Examination lower than previously derived age-based threshold scores. Covariates included age, race/ethnicity, educational attainment, comorbid conditions, and health literacy. Peritoneal dialysis (PD) as first dialysis modality, preemptive permanent access placement, venous catheter avoidance at dialysis therapy initiation, and preemptive wait-listing for a kidney transplant. Multivariable-adjusted logistic regression. Predialysis cognitive impairment was present in 117 (19%) participants. PD was thefirst dialysis modality among 16% of participants (n=100), 75% had preemptive access placed (n=473), 45% avoided using a venous catheter at dialysis therapy initiation (n=279), and 20%were preemptively wait-listed (n=126).Predialysis cognitive impairment wasindependently associated with 78% lower odds of PD as the first dialysis modality (adjusted OR [aOR], 0.22; 95% CI, 0.06-0.74; P=0.02) and 42% lower odds of venous catheter avoidance at dialysis therapy initiation (aOR, 0.58; 95% CI, 0.34-0.98; P=0.04). Predialysis cognitive impairment was not independently associated with preemptive permanent access placement or wait-listing. Potential unmeasured confounders; single measure of cognitive function. Predialysis cognitive impairment is associated with a lower likelihood of PD as a first dialysis modality and of venous catheter avoidance at dialysis therapy initiation. Future studies may consider addressing cognitive function when testing strategies to improve patient transitions to dialysis therapy.

Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality

Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown. Observational study. 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years. Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to≥160mmHg in 10-mmHg increments) and 5 (<60 to≥90mmHg in 10-mmHg increments) categories, respectively, and as continuous measures. Postdialysis all-cause mortality, assessed over different follow-up periods (ie,<3, 3-<6, 6-<12, and≥12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access. Mean predialysis SBP and DBP were 141.2±16.1 (SD) and 73.7±10.6mmHg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP<140mmHg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95% CI, 1.96-2.93), 1.99 (95% CI, 1.66-2.40), 1.35 (95% CI, 1.13-1.62), 0.98 (95% CI, 0.78-1.22), and 0.76 (95% CI, 0.57-1.00) for SBP<120, 120 to<130, 130 to<140, 150 to<160, and≥160 (vs 140-<150) mmHg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality. Results cannot be inferred to show causality and may not be generalizable to women or the general US population. Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality.

Frequency of Early Predialysis Nephrology Care and Postdialysis Cardiovascular Events

Patients with kidney failure are at a high risk for cardiovascular events. Predialysis nephrology care has been reported to improve postdialysis survival, but its effects on postdialysis major adverse cardiovascular events (MACEs) have not been comprehensively studied. Observational cohort study. We used data from the National Health Insurance Research Database in Taiwan. Adult patients who initiated maintenance dialysis therapy in 1999 to 2010 were enrolled. We created 3 subtypes of predialysis nephrology care based on the time between the first nephrology visit and the initiation of dialysis therapy: early frequent (duration≥ 6 months; at least 1 nephrology visit every 3 months), early infrequent (duration≥ 6 months,<1 nephrology visit every 3 months), and late (duration< 6 months). MACE was defined using the primary diagnosis in hospitalization records of acute myocardial infarction, acute heart failure, acute stroke, or sudden death. We investigated the associations of different subtypes of nephrology care with postdialysis 1-year MACEs. Among the 60,329 eligible patients, 24,477 (40.6%) had early frequent, 12,763 (21.2%) had early infrequent, and 23,089 (38.3%) had late nephrology care. Compared to the late-nephrology-care group, the early-frequent group was associated with an ∼10% lower risk for 1-year MACEs (HR of 0.89 [95% CI, 0.82-0.96] for first MACE and relative risk of 0.91 [95% CI, 0.84-0.98] for recurrent MACEs). However, the early-infrequent-care group had similar risks for MACEs as the late group (HR of 0.95 [95% CI, 0.86-1.05] for first MACE and relative risk of 0.94 [95% CI, 0.86-1.02] for recurrent MACEs). Lack of physical and biochemical information because of inherent limitations from administrative claims data. Early frequent nephrology care for 6 or more months before the initiation of long-term dialysis therapy may improve 1-year postdialysis major cardiovascular outcomes.

A Clinical Risk Prediction Tool for 6-Month Mortality After Dialysis Initiation Among Older Adults

Information on an individual's risk for death following dialysis therapy initiation may inform the decision to initiate maintenance dialysis for older adults. We derived and validated a clinical risk prediction tool for all-cause mortality among older adults during the first 6 months of maintenance dialysis treatment. Prediction model using retrospective administrative and clinical data. We linked administrative and clinical data to define a cohort of 2,199 older adults (age≥ 65 years) in Alberta, Canada, who initiated maintenance dialysis therapy (excluding acute kidney injury) in May 2003 to March2012. Demographics, laboratory data, comorbid conditions, and measures of health system use. All-cause mortality within 6 months of dialysis therapy initiation. Predicted mortality by logistic regression with 10-fold cross-validation. 375 (17.1%) older adults died within 6 months. We developed a 19-point risk score for 6-month mortality that included age 80 years or older (2 points), glomerular filtration rate of 10 to 14.9mL/min/1.73m2 (1 point) or≥15mL/min/1.73m2 (3 points), atrial fibrillation (2 points), lymphoma (5 points), congestive heart failure (2 points), hospitalization in the prior 6 months (2 points), and metastatic cancer (3 points). Model discrimination (C statistic= 0.72) and calibration (Hosmer-Lemeshow χ2=10.36; P=0.2) were reasonable. As examples, a score< 5 equated to<25% of individuals dying in 6 months, whereas a score > 12 predicted that more than half the individuals would die in the first 6 months. The tool has not been externally validated; thus, generalizability cannot be assessed. We used readily available clinical information to derive and internally validate a 7-variable tool to predict early mortality among older adults after dialysis therapy initiation. Following successful external validation, the tool may be useful as a clinical decision tool to aid decision making for older adults with kidney failure.

Extended-hours hemodialysis is associated with lower mortality risk in patients with end-stage renal disease

Extended-hours hemodialysis offers substantially longer treatment time compared to conventional hemodialysis schedules and is associated with improved fluid and electrolyte control and favorable cardiac remodeling. However, whether extended-hours hemodialysis improves survival remains unclear. Therefore, we determined the association between extended-hours compared to conventional hemodialysis and the risk of all-cause mortality in a nationally representative cohort of patients initiating maintenance dialysis in the United States from 2007 to 2011. Survival analyses using causal inference modeling with marginal structural models were performed to compare mortality risk among 1206 individuals undergoing thrice weekly extended-hours hemodialysis or 111,707 patients receiving conventional hemodialysis treatments. The average treatment time per session for extended-hours hemodialysis was 399 minutes compared to 211 minutes for conventional therapy. The crude mortality rate with extended-hours hemodialysis was 6.4 deaths per 100 patient-years compared with 14.7 deaths per 100 patient-years for conventional hemodialysis. In the primary analysis, patients treated with extended-hours hemodialysis had a 33% lower adjusted risk of death compared to those who were treated with a conventional regimen (95% confidence interval: 7% to 51%). Additional analyses accounting for analytical assumptions regarding exposure and outcome, facility-level confounders, and prior modality history were similar. Thus, in this large nationally representative cohort, treatment with extended-hours hemodialysis was associated with a lower risk for mortality compared to treatment with conventional in-center therapy. Adequately powered randomized clinical trials comparing extended-hours to conventional hemodialysis are required to confirm these findings.

Effect of long-acting erythropoiesis-stimulating agents on hemoglobin levels at the initiation of dialysis

The goal of the present study was to explore the differences in effects between erythropoiesis-stimulating agent (ESA) types on hemoglobin (Hb) level at the initiation of maintenance dialysis. This was a cross-sectional study. From January 2006 to October 2012, 2920 patients with end-stage kidney disease commenced hemodialysis (HD) at nine participating hospitals. The criteria for exclusion from the database were (1) presence of cancer or gastrointestinal bleeding and (2) serum C-reactive protein ≥0.3 mg/dL. A total of 1263 patients were entered into the final database. We explored the association of yearly trend of Hb level just before the first HD session with the different types of ESA in the predialysis period. During the 7-year study period, patients’ Hb levels at the initiation of dialysis dramatically increased from 8.6 to 9.1 g/dL. Parallel to this increase, the use of long-acting ESA also increased from 0 to 80 %. A higher level of Hb was confirmed in the long-acting ESA group compared with the short-acting group (9.5 vs. 8.7 g/dL, P < 0.01). Multivariate regression analysis showed a strong association of Hb level with the use of long-acting ESA (r = 0.155, P = 0.003), even after adjusting for confounding variables and estimated dose of epoetin. The change in the type of ESA used from short-acting to long-acting played a role in the increase of patients’ Hb levels at the initiation of dialysis. A long-acting ESA has the potential effect of maintaining an optimal Hb level even in the advanced stages of CKD.

Timing of Initiation of Maintenance Dialysis

There is often considerable uncertainty about the optimal time to initiate maintenance dialysis in individual patients and little medical evidence to guide this decision. To gain a better understanding of the factors influencing the timing of initiation of dialysis in clinical practice. A qualitative analysis was conducted using the electronic medical records from the Department of Veterans Affairs (VA) of a national random sample of 1691 patients for whom the decision to initiate maintenance dialysis occurred in the VA between January 1, 2000, and December 31, 2009. Data analysis took place from June 1 to November 30, 2014. Central themes related to the timing of initiation of dialysis as documented in patients' electronic medical records. Of the 1691 patients, 1264 (74.7%) initiated dialysis as inpatients and 1228 (72.6%) initiated dialysis with a hemodialysis catheter. Cohort members met with a nephrologist during an outpatient clinic visit a median of 3 times (interquartile range, 0-6) in the year prior to initiation of dialysis. The mean (SD) estimated glomerular filtration rate at the time of initiation for cohort members was 10.4 (5.7) mL/min/1.73 m(2). The timing of initiation of dialysis reflected the complex interplay of at least 3 interrelated and dynamic processes. The first was physician practices, which ranged from practices intended to prepare patients for dialysis to those intended to forestall the need for dialysis by managing the signs and symptoms of uremia with medical interventions. The second process was sources of momentum. Initiation of dialysis was often precipitated by clinical events involving acute illness or medical procedures. In these settings, the imperative to treat often seemed to override patient choice. The third process was patient-physician dynamics. Interactions between patients and physicians were sometimes adversarial, and physician recommendations to initiate dialysis sometimes seemed to conflict with patient priorities. The initiation of maintenance dialysis reflects the care practices of individual physicians, sources of momentum for initiation of dialysis, interactions between patients and physicians, and the complex interplay of these dynamic processes over time. Our findings suggest opportunities to improve communication between patients and physicians and to better align these processes with patients' values, goals, and preferences.

Comparative Effectiveness of Renin-Angiotensin System Antagonists in Maintenance Dialysis Patients

Background/Aims: Whether angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) are differentially associated with reductions in cardiovascular events and mortality in patients receiving maintenance dialysis is uncertain. We compared outcomes between ACE and ARB users among hypertensive, maintenance dialysis patients. Methods: National retrospective cohort study of hypertensive, Medicare-Medicaid eligible patients initiating chronic dialysis between 1/1/2000 to 12/31/2005. The exposure of interest was new use of either an ACEI or ARB. Outcomes were all-cause mortality (ACM) and combined cardiovascular hospitalization or death (CV-endpoint). Cox proportion hazards models were used to compare the effect of ACEI vs ARB use on ACM and, separately, CV-endpoint. Results: ACM models were based on 3,555 ACEI and 1,442 ARB new users, while CV-endpoint models included 3,289 ACEI and 1,346 ARB new users. After statistical adjustments, ACEI users had higher hazard ratios for ACM (AHR = 1.22, 99% CI 1.05-1.42) and CV-endpoint (AHR = 1.12, 99% CI 0.99-1.27). Conclusions: Patients initiating maintenance dialysis who received an ACEI faced an increased risk for mortality and a trend towards an increased risk for CV-endpoints when compared to patients who received an ARB. Validation of these results in a rigorous clinical trial is warranted.

Racial and Ethnic Disparities in Use of and Outcomes with Home Dialysis in the United States.

Home dialysis, which comprises peritoneal dialysis (PD) or home hemodialysis (home HD), offers patients with ESRD greater flexibility and independence. Although ESRD disproportionately affects racial/ethnic minorities, data on disparities in use and outcomes with home dialysis are sparse. We analyzed data of patients who initiated maintenance dialysis between 2007 and 2011 and were admitted to any of 2217 dialysis facilities in 43 states operated by a single large dialysis organization, with follow-up through December 31, 2011 (n =: 162,050, of which 17,791 underwent PD and 2536 underwent home HD for ≥91 days). Every racial/ethnic minority group was significantly less likely to be treated with home dialysis than whites. Among individuals treated with in-center HD or PD, racial/ethnic minorities had a lower risk for death than whites; among individuals undergoing home HD, only blacks had a significantly lower death risk than whites. Blacks undergoing PD or home HD had a higher risk for transfer to in-center HD than their white counterparts, whereas Asians or others undergoing PD had a lower risk than whites undergoing PD. Blacks irrespective of dialysis modality, Hispanics undergoing PD or in-center HD, and Asians and other racial groups undergoing in-center HD were significantly less likely than white counterparts to receive a kidney transplant. In conclusion, there are racial/ethnic disparities in use of and outcomes with home dialysis in the United States. Disparities in kidney transplantation evident for blacks and Hispanics undergoing home dialysis are similar to those with in-center HD. Future studies should identify modifiable causes for these disparities.