Kidney Disease Outcomes Quality Initiative Research Articles

#672 Intradialytic hypotension and adverse symptoms are not related

Abstract Background and Aims Intradialytic hypotension (IDH) is the most common side-effect of intermittent hemodialysis (HD). Yet, its definition lacks consensus about the magnitude of blood pressure (BP) drops, occurrence of adverse symptoms (AS) and/or interventions. Generally, BP is measured twice/hour, while additional readings are carried out when AS arise. Consequently, AS became a prerequisite for the diagnosis of IDH, both in the National Kidney Disease Outcomes Quality Initiative (KDOQI) and in the European Best Practice Guideline (EBPG). Yet, a large study on the associations between 8 IDH definitions and mortality, showed that an absolute nadir systolic blood pressure (SBP) <90 mmHg or <100 mmHg (with a pre-dialysis SBP < 160 mmHg or SBP ≥160 mmHg resp.) is most strongly associated with mortality. Neither AS nor interventions were related to outcome. Due to the absence of reliable studies, however, it is still unclear whether IDH and AS are related. Therefore, 1) the occurrence of (a)symptomatic IDH was evaluated according to the nadir-based definition; 2) relations between real-time AS and IDH were explored; 3) associations between IDH-susceptibility and physical intradialytic patient-reported outcome measures (PID-PROMS) were analysed. Methods Forty HD patients were cross-over randomized to standard HD (S-HD), cool HD (C-HD), low-(LV) and high-volume (HV) hemodiafiltration (HDF), each for two weeks. Every second week, BP was measured every 15 minutes during treatment. While AS were monitored real-time, PID-PROMS were documented after each modality with a modified dialysis symptom index [mDSI] questionnaire. The occurrence of symptomatic and asymptomatic IDH, defined as a SBP < 90 or 100 mmHg (depending on the pre-dialysis SBP), was evaluated. For each presentation of AS, we assessed its association with blood pressure by examining concurrent IDH using both the KDOQI/EBPG definitions and the nadir-based definition (Fig. 2). Patients were stratified into tertiles of IDH (IDH-prone, IDH-intermediate and IDH-resistant). The frequency and severity of discrete symptoms, recovery time and total symptom-burden were compared using logistic regression models and Kruskal-Willis tests. Results In 458 sessions, 222 IDH-episodes occurred of which 98% were asymptomatic. While nursing records revealed 24 real-time AS, 54% was BP-related and 17% fulfilled the nadir-based criteria, leaving 46% of AS unrelated to IDH (Fig. 2). IDH-prone patients experienced headaches more frequently (p = 0.01), and perceived dizziness (p = 0.05) and shivering (p < 0.01) more severely. No associations were found between IDH-susceptibility and symptom-burden, recovery time, or other discrete side-effects. Conclusions 1) Most IDH-episodes are asymptomatic; 2) Conversely, 46% of AS occur without IDH and (3) PID-PROMS are completely independent of IDH-susceptibility. 4) Symptom-based definitions severely underestimate IDH, when compared to a nadir-based IDH definition.

Epidemiological Characteristics of Chronic Renal Failure Patients of Hodeidah, Yemen in 2023

Chronic renal failure (CRF) is an emergent worldwide public health problem. The increasing incidence of CRF warrants a need for an epidemiological approach to better understand the disease and its prevention. Therefore, the study aims to describe the epidemiological characteristics of chronic renal failure patients in Hodeidah, Yemen. The study included 560 patients with CRF in retrospective study (a case series based on medical files) in Center of Dialysis and Renal Diseases of Hodeidah, Yemen from 1st January 2023 to 31st December 2023. The patients were diagnosed based on evidence – based clinical practice guideline of all stages of CRF that was extracted from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKFKDOQI). Epidemiological data were reported with ethical approval consideration, data obtained were analyzed. 560 cases were diagnosed with renal failure, 555 patients (99.107 %) of them were diagnosed with CRF and 5 patients (0.89 %) were diagnosed with acute renal failure (ARF). CRF patients was founded 61.81 % in the males while 38.11 % in the females. However, this difference was statistically significant (X2= 30.921; p < 0.00001). The age range of patients was from 5 to 95 years, where 54.64% of cases occurred more than 50 years then 39.28 % between 18 to 49 years and the lower frequency was in children less than 18 years (5.22%) with different significant ( X2= 226.314 ; p < 0.00001). In addition, 81.98 % of patients in rural and 18.02 % in urban. The maximum cases were reported in summer session namely 13.21 % in July and 11.25 % in August. On the other hand , the major causes were chronic diseases 406 case (73.14 %) that diagnosed and recorded , 161 case (29 %) of hypertension ,132 case (23.78 %) of diabetes , 113 (20.36 %) of inflammation nephrolithiasis obstructive uropathy , 8 cases (1.44 %) of genetic polycystic renal disease , and 4 cases ( 0.72 % ) of sedative narcotic addiction and 137 case (24.68%) of unknown causes with different significant ( X2= 119.00 ; p < 0.00001). The chronic diseases namely diabetes and hypertension were the major causes reported to develop the CRF, therefore, to prevent the development of CRF based on center for control diseases and control (CDC), managing risk factors.

The influence of near-infrared therapy on arteriovenous fistula patency in haemodialysis patients: A multicentre, randomised, controlled clinical trial.

Arteriovenous fistula (AVF) is the preferred vascular access for patients undergoing haemodialysis (HD). AVF malfunction remains a major clinical problem and is a significant independent risk factor for death. Although far-infrared (FIR) therapy has been shown to reduce complications and improve the patency rate of AVFs in various studies, it has been cautiously recommended by the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines for AVF care due to insufficient evidence. Therefore, it is necessary to identify more effective methods for preventing AVF dysfunction. Many in vitro studies and few clinical studies have examined the effects of near-infrared (NIR) therapy on the vasculature. This study will examine the effects of NIR therapy on AVF. A randomised, controlled, open-label, multicentre trial will compare the effect of NIR on AVF patency after 1 year of therapy with that of a control group of patients with existing AVF. One group of patients received NIR treatment above their AVFs, whereas the control group received regular care. The primary outcome is the primary fistula patency rate within 12 months. In addition, acute changes in inflammatory, vasodilatory and haemodynamic parameters after a single treatment in the first 40 participants will be examined. This study was registered in the Clinical Trials Registry (ChiCTR2300071305) at https://register.clinicaltrials.gov/. This study will explore the long-term and acute effects of NIR on AVFs. The study findings will provide information that can be used to develop new technical support for the prevention of AVF dysfunction in patients undergoing haemodialysis.

Biomedical Evaluation of Early Chronic Kidney Disease in the Air Force: Building a Predictive Model from the Taiwan Military Health Service.

Chronic kidney disease (CKD) is one of the most common diseases worldwide. The increasing prevalence and incidence of CKD have contributed to the critical problem of high medical costs. Due to stressful environments, aircrew members may have a high risk of renal dysfunction. A better strategy to prevent CKD progression in Air Force personnel would be to diagnosis CKD at an early stage. Since few studies have been conducted in Taiwan to examine the long-term trends in early CKD in Air Force aircrew members, this study is highly important. We investigated the prevalence of CKD and established a predictive model of disease variation among aircrew members. In this retrospective study, we included all subjects who had received physical examinations at a military hospital from 2004 to 2010 and who could be tracked for four years. The Abbreviated Modification of Diet in Renal Disease Formula (aMDRD) was used to estimate the glomerular filtration rate (GFR) and was combined with the National Kidney Foundation/ Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) to identify CKD patients. A total of 212 aircrew members were assessed. The results showed that the prevalence of CKD was 3.8%, 9.4%, 9.0%, and 9.4% in each of the four years. According to the logistic regression analysis, abnormal urobilinogen levels, ketones, and white blood cell (WBC) counts in urine and a positive urine occult blood test increased the risk of CKD. A positive urine occult blood test can be used to predict the future risk of CKD. Moreover, the generalized estimating equation (GEE) model showed that a greater risk of CKD with increased examination time, age and seniority had a negative effect. In conclusion, abnormal urobilinogen levels, ketones, and urine WBC counts in urine as well as a positive urine occult blood test might serve as independent predictors for CKD. In the future, we can focus not only on annual physical examinations but also on simple and accurate examinations, such as urine occult blood testing, to determine the risk of CKD and prevent its progression in our aircrew members.

Prevalence and risk factors of erythropoiesis stimulating agents hyporesponsiveness in chronic hemodialysis patients attending nephrology center of Benghazi

Background: Anemia is quite prevalent in end stage renal disease patients. Despite availability of different forms of erythropoiesis stimulating agents, many end stage renal disease patients are anemic according to National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative guidelines. Patient and methods: we conduct a cross sectional study between May 2022 and July 2022, targeting adult chronic hemodialysis patients, to investigate the prevalence of erythropoiesis stimulating agents hyporesponsiveness, to assess if patients are receiving the appropriate weight-based dosing of these agents, and to identify additional risk factors behind inadequate response to therapy.390 end stage renal disease patients are receiving chronic hemodialysis at nephrology center of Benghazi. Incident hemodialysis patients, patients with other hematological disease or with malignancy are excluded. Finally, 150 patients met the inclusion criteria and enrolled in the study. Results: 100 (66.7%) are male, and 50 (33.3%) are females. Age is 50.6 ±13.2 years. Erythropoiesis stimulating agents hyporesponsiveness is prevalent in chronic hemodialysis patients, 130 (86.7%) patients are anemic as their Hb levels were <11 g/dl, while only 20 (13.3%) patients have Hb levels of >/=11g/dl. There is a significant relationship between gender and ESA response, as hyporesponsiveness is more observed in male patients (P < .005). We find that 105 (70%) patients are receiving an appropriate weight-based dose, while only 45 (30%) patients were giving an inappropriate dose. When the relationship between ESA dosing and patients' response to ESA is examined, we find, that despite receiving the appropriate dose, 90 (60%) patients are ESA hyporesponsive, while only 15 (10%) are responsive to the appropriate weight-based dose. However, no statistical association is found between ESA hyporesponsiveness and age or weekly hours of dialysis. Conclusion: despite receiving an appropriate dosage of ESA, our study population shows high prevalence of ESA hyporesponsive anemic state. New strategies should be applied to detect risk factors and adopt therapeutic measures to reduce its high prevalence in hemodialysis population.

Quantifying carotid stiffness in chronic kidney disease using ultrafast ultrasound imaging.

The mortality and disability of chronic kidney disease (CKD) are highly linked to the incidence of atherosclerotic cardiovascular events. Numerous clinical biochemical indicators of renal function often only increase in advanced stages of CKD, driving an urgent need for reliable indicators of atherosclerosis in early CKD. Ultrafast pulse wave velocity (ufPWV) can evaluate the stiffness of the straight carotid in vivo and quantitatively reflect the degree of early atherosclerosis. However, the use of ufPWV in CKD has not yet been reported. In this study, we aimed to explore the association between carotid stiffness, quantified using ufPWV, and renal function in CKD patients. This cross-sectional study enrolled a total of 582 participants between March 2017 and May 2022 in the Affiliated Hospital of Nanjing University of Traditional Chinese Medicine. Among those, 205 individuals without a history of CKD and estimated glomerular filtration rate (eGFR) ≥90 mL/min/1.73 m2 were included as controls. According to the Kidney Disease Outcomes Quality Initiative (K/DOQI) expert group of the American Kidney Foundation staging for CKD, 44 stages 1 and 2 CKD patients were included in the early CKD group, whereas 49 stages 3, 4, and 5 CKD patients were included in the advanced CKD group. Clinical and serum parameters, ultrasonic characteristics including carotid intima-media thickness (cIMT), and pulse wave velocity at the beginning of systole (PWV-BS) and pulse wave velocity at the end of systole (PWV-ES) of systole were analyzed. One-way analysis of variance (ANOVA) and least significant difference (LSD) tests were performed to compare cIMT, PWV-BS, and PWV-ES among subgroups in pairs. Pearson's correlation analysis, scatter plots, and subgroups correlation analysis were used to determine the relationships among ultrasound characteristics (cIMT, PWV-BS, PWV-ES), and major cardiovascular risk factors. PWV-BS and PWV-ES for the early and advanced CKD groups were significantly higher than those for controls (all P<0.05). PWV-ES had the greatest correlation with age (r=0.474, P<0.001). PWV-ES had the greatest increase with age in the early CKD group (r=0.698, P<0.001). ufPWV can be used for the quantitative evaluation of carotid stiffness in CKD patients. PWV-ES may be more advantageous in the assessment of carotid atherosclerosis in early CKD patients.

Extent of Achieving KDOQI Targets For hemodialysis Adequacy in Libyan dialysis patients: A Multicentre Cross-Sectional Study

Dialysis is a therapy to maintain the lives of end stage renal disease patients (ESRD), and the adequacy of hemodialysis is essential as it can improve patient’s survival, quality of life and biochemical profiles. This study aimed to evaluate the extent of achieving Kidney Disease Outcomes Quality Initiative (KDOQI) targets for dialysis adequacy, haemoglobin level, mineral bone disorders and nutritional status among hemodialysis patients. patients and method: This study was carried out on 286 regular haemodialysis adult patients from eleven hemodialysis centers in Libya. Patients subjected to BMI calculations. Blood samples collected for complete blood count, serum albumin, blood urea pre and post dialysis session, serum creatinine, total serum calcium, serum phosphate, serum alkaline phosphatase, C reactive protein, and serum iPTH levels. Targets measures based on the KDOQI Clinical Practice Guidelines. Result: Mean Kt/V was 1.31±0.40.only 174 (60.84%) patients had adequate dialysis dose (Kt/V&gt;1.2). Mean iPTH was 490.08±694.7. According to the KDOQI, guideline 19.2% of the patients was within the target range for parathormone level. 26.92 % of studied patients had a haemoglobin level of 11gm/dl or more. Mean serum albumin is 3.81±0.64, hypoalbuminemia (albumin &lt;3.5g/dl) was in 27.98% of studied patients. Conclusion: According to KDOQI guidelines 39.16% of the studied patients did not achieve the target dose for adequate clearance, 73.08% did not achieve the target haemoglobin level; and, only 19.2% of the studied patients were within the target range for parathyroid hormone level. According to BMI as nutritional markers, 14.0% of studied patients were underweight and 27.98% were with serum albumin below (3.5 g/dl).

Predicting recurrent interventions after radiocephalic arteriovenous fistula creation with machine learning and the PREDICT-AVF web app.

Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines discourage ongoing access salvage attempts after two interventions prior to successful use or more than three interventions per year overall. The goal was to develop a tool for prediction of radiocephalic arteriovenous fistula (AVF) intervention requirements to help guide shared decision-making about access appropriateness. Prospective cohort study of 914 adult patients in the United States and Canada undergoing radiocephalic AVF creation at one of the 39 centers participating in the PATENCY-1 or -2 trials. Clinical data, including demographics, comorbidities, access history, anatomic features, and post-operative ultrasound measurements at 4-6 and 12 weeks were used to predict recurrent interventions required at 1 year postoperatively. Cox proportional hazards, random survival forest, pooled logistic, and elastic net recurrent event survival prediction models were built using a combination of baseline characteristics and post-operative ultrasound measurements. A web application was created, which generates patient-specific predictions contextualized with the KDOQI guidelines. Patients underwent an estimated 1.04 (95% CI 0.94-1.13) interventions in the first year. Mean (SD) age was 57 (13) years; 22% were female. Radiocephalic AVFs were created at the snuffbox (2%), wrist (74%), or proximal forearm (24%). Using baseline characteristics, the random survival forest model performed best, with an area under the receiver operating characteristic curve (AUROC) of 0.75 (95% CI 0.67-0.82) at 1 year. The addition of ultrasound information to baseline characteristics did not substantially improve performance; however, Cox models using either 4-6- or 12-week post-operative ultrasound information alone had the best discrimination performance, with AUROCs of 0.77 (0.70-0.85) and 0.76 (0.70-0.83) at 1 year. The interactive web application is deployed at https://predict-avf.com. The PREDICT-AVF web application can guide patient counseling and guideline-concordant shared decision-making as part of a patient-centered end-stage kidney disease life plan.

KDOQI Commentary on the KDIGO 2022 Update to the Clinical Practice Guideline for Diabetes Management in CKD

The Kidney Disease: Improving Global Outcomes (KDIGO) guideline for diabetes management in chronic kidney disease (CKD) was updated in 2022, just 2 years after the previous update. The need for this rapid update is reflective of the recent and unprecedented positive results of numerous clinical trials aimed at reducing kidney and cardiovascular morbidity and mortality in people with diabetes. The Kidney Disease Outcomes Quality Initiative (KDOQI) work group for diabetes in CKD, convened by the National Kidney Foundation, provides herein a commentary on these changes, particularly the implications for health care in the United States. Changes to the KDIGO guideline mirror the evolution of sodium/glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists from purely antihyperglycemic agents to cardiorenal-metabolic therapeutics, and the lower estimated glomerular filtration rate of≥20mL/min/1.73m2 for SGLT2 inhibitor initiation. New data have also brought the addition of the first-in-class, Federal Drug Administration-approved nonsteroidal mineralocorticoid receptor antagonist finerenone as an agent to reduce cardiorenal end points. While there has been significant progress in innovation, there remain serious challenges to implementation, particularly in the United States where inequities in insurance coverage and high costs limit their use, particularly in vulnerable populations, ultimately widening health care disparities.

Multicenter Randomized Controlled Trial of APERTO-Paclitaxel Drug-Eluting Balloon Angioplasty Versus Standard Percutaneous Transluminal Angioplasty in Dysfunctional Hemodialysis Grafts and Native Fistulae.

to assess the safety and efficacy of APERTO-Paclitaxel-coated balloon angioplasty versus standard angioplasty for the treatment of dysfunctional hemodialysis shunts and native arteriovenous fistulae. consecutive patients with dysfunctional dialysis related to underlying efferent vein stenosis were included and randomized 1:1 to either APERTO-paclitaxel drug-coated balloon (study arm) or standard percutaneous transluminal angioplasty (control arm). Primary endpoint is time from treatment until dialysis access dysfunction according to standardized Kidney Disease Outcomes Quality Initiative (KDOQI)-guidelines and assessed by Kaplan-Meier survival curves and tested for significance with log-rank analysis. Secondary endpoints include device, technical, and clinical success of the index angioplasty procedure. The study included 103 patients (n=51 study-group) with a de novo (n=33) dysfunctional native arteriovenous fistula (n=79) in the forearm (n=60). The majority of included patients were male with a mean age of 69.8 years, presenting with a dysfunctioning autologous arteriovenous fistula in the forearm. Device-related complications did not occur in any of the included patients. Functional hemodialysis access without need for re-intervention at 1 year after index procedure was found in n=10 (19.6%) and n=5 (9.6%) of patients treated with, respectively, paclitaxel drug-coated balloon and percutaneous transluminal angioplasty (p=0.612). A nonsignificant benefit of paclitaxel drug-coated balloon (n=5; 25%) over percutaneous transluminal angioplasty (n=1; 11%) was found (p=0.953) in de novo lesions in autologous fistulas. APERTO-paclitaxel drug-coated balloon is a safe balloon catheter to manage dysfunctional hemodialysis access; however, longer period of adequate hemodialysis circuit functioning after endovascular index stenosis treatment, using APERTO-paclitaxel drug-coated balloon versus percutaneous transluminal angioplasty could not be demonstrated. APERTO-paclitaxel drug-coated balloon catheter is a safe device to manage dysfunctional hemodialysis access. Compared to conventional angioplasty balloon, the APERTO drug-coated balloon will not result in longer period of adequate hemodialysis circuit functioning. A non-significant benefit of APERTO drug-coated balloon was found in de novo lesions in autologous fistulas.

Higher Prevalence of Chronic Kidney Disease in Myelodysplastic Syndromes Patients Compared to Age- Adjusted General Population - Results from the Polish Adult Leukemia Group (PALG) Registry

Introduction Chronic comorbidities that are common in the elderly population can have a significant impact on the clinical course, the choice of treatment, and survival of myelodysplastic syndromes (MDS) patients. No studies have focused on the coexistence of two diseases that are common in the elderly population, chronic kidney disease (CKD) and MDS, so the epidemiological data and clinical implications of both diseases occurring together are unknown. Aims Primary objective: to assess the prevalence of CKD in patients with MDS in comparison to the age-adjusted general population. Secondary objective: to evaluate the impact of CKD on clinical course in MDS patients. Methods This was a prospective analysis using clinical and laboratory data from MDS patients who were registered in the Polish Adult Leukemia Group (PALG) Registry from 2010 to 2023. Data have been provided by 28 hematologic centers. CKD was defined as an eGFR &amp;lt; 60 mL/min/1.73m², disregarding albuminuria since urinalysis results were not recorded in the database. The stages of CKD were classified based on eGFR according to the NKF KDOQI National Kidney Foundation Kidney Disease Outcome Quality Initiative guidelines, and eGFR was calculated using CKD-EPI equation. For comparison of the prevalence of CKD in MDS subjects aged ≥60 years to the general population, we used data from the PolSenior 2 study (covering the years 2018-2019). Data were age and sex standardized using demographic tables from Statistics Poland (https:// demografia.stat.gov.pl/bazademografia/Tables.aspx). Median survival time was calculated using Kaplan-Meier estimator. Multivariate analysis was performed using Cox regression. Results Overall, data (including eGFR) were available for 1813 MDS patients. Median age at diagnosis was 71 years [IQR 64 - 78]. and 55.3% patients were male. Sixty percent of the patients were diagnosed as IPPS lower risk. At the time of MDS diagnosis, CKD was detected in 479 patients (26.4%). Among patients aged ≥ 60, the crude rate of CKD was 30.3%. The standardized rate of CKD in the general population aged ≥ 60 years was significantly lower than in the similarly aged MDS group, with rates of 13.2% [CI 12.3-14.1] and 25.5% [CI 22.9-28.4]; p&amp;lt;0.001, respectively. (Figure 1) Patients with CKD were significantly older (median 78 yo) than those without CKD (median 68 yo; p&amp;lt;0.001), and more likely to have diabetes (33.2% vs 19.7%; p&amp;lt;0.001), and to have coincidence of another malignancy (21.6%) than those without CKD (14.9%; p=0.001). Median hemoglobin concentration was significantly lower in the CKD group (8.9 g/dL) than in the non-CKD group (9.4 g/dL; p &amp;lt; 0.05). Subjects with decreased eGFR were more likely to be dependent on RBC transfusion (56.5%) than subjects with eGFR ≥ 60 ml/min per 1.73m 2 (48.9%; p=0.0008). Median survival of patients with eGFR ≥ 60 ml/min per 1.73m 2 was 2.5 y [CI 1.0-6.1] vs 1.4 y [CI 0.6-4.2] for CKD. In multivariate analysis we found that CKD stage, age ≥ 65, higher IPSS score, high-risk IPSS cytogenetics and ECOG &amp;gt;1 were independent predictors of shorter survival. (Figure 2). Conclusions Myelodysplastic syndrome (MDS) subjects are more likely to have chronic kidney disease (CKD) than the general population. The presence of CKD in MDS patients is associated with worse overall survival and higher RBC transfusion requirement.

Examining the Relationship between Dietary Intake, Socioeconomic Status, and Systolic Blood Pressure of Adults on Hemodialysis in Quito, Ecuador

BackgroundIn Ecuador, the number of adults on hemodialysis (HD) continues to rise. Currently, the effect dietary habits and socioeconomic status (SES) have on blood pressure is not known for those on HD. ObjectivesThe objectives of this study focused on adults on HD in Quito, Ecuador to 1) assess the relationship between dietary intake and SES; 2) compare dietary intake to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines; and 3) explore the relationship between dietary intake and systolic blood pressure. MethodsThis cross-sectional study was conducted at the dialysis center within Eugenio Espejo Specialties Hospital in Quito, Ecuador between May and June 2022 among 50 adults on HD. Three 24-h recalls were used to determine average dietary intake and the 25-item Instituto Nacional de Estadística y Censos-Stratification of SES was used to determine SES. Electrolytes and 2 blood pressure readings were collected. Qualitative narrative data analysis was performed to identify themes using NVivo v12. T-tests of independence, simple, and multiple linear regressions using age and sex as confounders were conducted using R and a P < 0.05 was deemed as statistically significant. ResultsOn an average, 76% of participants consumed <25 kcal/kg body weight energy and 64% consumed <1 g protein/kg body weight. Participants consumed less energy and protein compared with the KDOQI guidelines (P < 0.05). Positive relationships were observed with potassium and blood pressure (β = 0.020, P < 0.05) and SES with energy, protein, and phosphorus (P < 0.05). Themes that were identified as contributing to dietary intake were limited knowledge, lack of consistency with dietary information, and limited appetite. ConclusionsFindings from this study indicate that the focus should be on improving energy and protein intake for this population.

Effect of preoperative arterial diameter on hospitalization and mortality in patients undergoing hemodialysis with forearm arteriovenous fistula access.

As pointed out by the recent Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access, the current quality of evidence supporting preoperative vascular anatomy and patient outcomes is suboptimal and insufficient to make recommendations. This study assessed arteriovenous fistulas (AVFs) created with different preoperative arterial diameters on hospitalization and mortality rates in patients undergoing hemodialysis at the authors' center. Data from 261 patients who underwent HD between 2017 and 2019 were retrospectively examined. Differences in mortality and hospitalization rates between patients with different preoperative arterial diameters were compared, and risk factors for mortality and hospitalization were analyzed. Smaller preoperative artery diameter (<2 mm) was associated with all-cause mortality (risk ratio [RR] 1.61 [95% confidence interval (CI) 1.45-1.90]; p < 0.01), and access-related (RR 1.68 [95% CI 1.24-2.44]; p < 0.01), and congestive heart failure (CHF)-related (RR 0.67 [95% CI 0.38-1.01]; p = 0.04) hospitalization. Longer catheter-dependent duration (⩾60 days) was associated with access-related hospitalization (RR 1.48 [95% CI 1.07-2.11]; p = 0.03), and higher postoperative brachial artery blood flow (⩾1500 mL/min) was associated with CHF-related hospitalization (RR 1.58 [95% CI 1.02-2.29]; p < 0.01). Higher postoperative brachial artery blood flow (⩾1500 mL/min) was associated with all-cause mortality (hazard ratio [HR] 1.20 [95% CI 1.09-2.32]; p = 0.04), whereas preoperative artery diameter (HR 0.98 [95% CI 0.93-1.86]; p = 0.08) and catheter-dependent duration (HR 1.06 [95% CI 0.47-2.13]; p = 0.82) were not associated with all-cause mortality. In this cohort, smaller preoperative artery diameter was associated with all-cause and access-related hospitalizations, while a larger preoperative artery and higher postoperative brachial blood flow were associated with CHF-related hospitalization. However, only higher postoperative brachial blood flow was associated with all-cause mortality.

Patient-Centered Quality Measures for Dialysis Care: A Report of a Kidney Disease Outcomes Quality Initiative (KDOQI) Scientific Workshop Sponsored by the National Kidney Foundation

Providing high-quality patient-centered care is the central mission of dialysis facilities. Assessing quality and patient-centeredness of dialysis care is necessary for continuous dialysis facility improvement. Based predominantly on readily measured items, current quality measures in dialysis care emphasize biochemical and utilization outcomes, with very few patient-reported items. Additionally, current metrics often do not account for patient preferences and may compromise patient-centered care by limiting the ability of providers to individualize care targets, such as dialysis adequacy, based on patient priorities rather than a fixed numerical target. Developing, implementing, and maintaining a quality program using readily quantifiable data while also allowing for individualization of care targets that emphasize the goals of patients and their care partners provided the motivation for a September 2022 Kidney Disease Outcomes Quality Initiative (KDOQI) Workshop on Patient-Centered Quality Measures for Dialysis Care. Workshop participants focused on 4 questions: (1) What are the outcomes that are most important to patients and their care partners? (2) How can social determinants of health be accounted for in quality measures? (3) How can individualized care be effectively addressed in population-level quality programs? (4) What are the optimal means for collecting valid and robust patient-reported outcome data? Workshop participants identified numerous gaps within the current quality system and favored a conceptually broader, but not larger, quality system that stresses highly meaningful and adaptive measures that incorporate patient-centered principles, individual life goals, and social risk factors. Workshop participants also identified a need for new, low-burden tools to assess patient goals and priorities.

Effect of Anemia on Physical Function and Physical Activity in CKD: The National Health and Nutrition Examination Survey, 1999-2016.

Key Points In a large sample representative of the US adult noninstitutionalized population, among participants with CKD stages 3–5, anemia was associated with a significantly lower level of physical activity.The presence of CKD and anemia showed a positive interaction on physical functioning outcomes. Among participants with CKD, physical functioning was worse in patients with anemia compared with those without anemia. Background CKD is a major public health problem worldwide. Anemia, a frequent and treatable complication of CKD, is associated with decreased physical functioning and physical activity. The objective of this study was to evaluate the joint association of CKD and anemia with physical functioning and physical activity in a representative sample of the US population. Methods Cross-sectional study using the National Health and Nutrition Examination Survey (NHANES) 1999–2016 for physical functioning outcomes (N=33,300) and NHANES 2007–2016 for physical activity (N=22,933). The NHANES physical functioning questionnaire included 19 items. The NHANES physical activity questionnaire captured work-related, leisure-time, and sedentary activities. Higher physical functioning scores represent worse function. CKD was classified using Kidney Disease Outcomes Quality Initiative 2002 criteria, and anemia was defined using the World Health Organization criteria. Results The adjusted mean differences (95% confidence interval) in overall physical functioning score comparing participants with anemia with those without anemia among participants with no CKD, CKD stages 1–2, and stages 3–5 were 0.5 (−0.1 to 1.0), 1.5 (0.2 to 2.8), and 3.6 (2.0 to 5.2). Anemia and CKD showed a supra-additive interaction for all physical functioning outcomes among participants in CKD stages 3–5. The prevalence of high physical activity was also lower in participants with anemia compared with those without anemia among participants in CKD stages 3–5 (adjusted prevalence ratio, 0.74; 95% confidence interval, 0.54 to 1.01). Conclusions CKD and anemia were associated with impairments in physical functioning and reduced physical activity. For physical functioning outcomes, the combined presence of CKD and of anemia showed a stronger effect than what was expected from their independent effects.

Clinical-epidemiological characterization of patients submitted to hemodialysis according to the national kidney foundation, the kidney disease outcomes quality initiative – KDOQI in a hemodialysis reference center in the metropolitan region of São Paulo, Brazil

Introduction: hemodialysis is a treatment that helps in the survival of patients with renal failure, through an established cardiopulmonary bypass to carry out blood filtration, as a result, there is a need for a feasible, lasting and effective vascular access. There are two types of vascular access, arteriovenous fistulas, using autogenous veins or prostheses, and venous catheters. The indications for choosing the type of vascular access are related to the characteristics and restriction of use of each patient. Objective: to analyze the epidemiological, demographic and clinical profile of patients undergoing hemodialysis in two reference services in the metropolitan region of São Paulo, Brazil, and compare the clinical-surgical processes with those defined by the Kidney Guidelines disease Outcomes Quality Initiative (KDOQI). Methods: data were collected in two public hospitals, with patients undergoing hemodialysis, through registration forms and medical records, from August to December 2016. The volunteers were informed about the procedures and objectives of the study and, after agreeing, they signed a consent form. The variables age, gender, weight, height, body mass index, hemodialysis time, types of accesses already used , complications related to the accesses and underlying disease were analyzed. Patients with chronic renal failure undergoing hemodialysis of both genders, with no age restriction, were included. Patients not able to perform one of the techniques, arteriovenous fistula or catheter, were excluded . The collected data were compared with the Kidney guidelines disease Outcomes Quality Initiative (KDOQI). Results: a total of 252 individuals were included, of which 182 are patients undergoing reference hospital treatment in the city of São Bernardo do Campo, SP and 70 patients at the State University Hospital Mário Covas, a State reference in the clinical management of patients undergoing hemodialysis care. Conclusion: chronic kidney disease is highly prevalent with progression to end-stage chronic kidney failure (dialysis). The definition of the epidemiological profile of the population undergoing treatment, as well as the journey of venous accesses for hemodialysis (catheters and fistulas), are fundamental for the multidisciplinary team’s learning curve about complications throughout the course of the disease/treatment. Furthermore, the clinical-surgical management of this population is in line with the guidelines of the National Kidney Foundation. The treatment performed in these hemodialysis centers is efficient and in line with what the KDOQI recommends.

Association between anemia-related biomarkers and the adequacy of peritoneal dialysis in Chinese patients with chronic kidney disease.

Objectives: The study aimed to examine the association of three anemia-related biomarkers with the adequacy of peritoneal dialysis (PD) in patients with chronic kidney disease (CKD). Methods: This study included 127 PD patients. The total Kt/V urea (Kt/V) was calculated according to the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines. All patients were classified into two groups based on Kt/V, viz., adequate (Kt/V ≥1.7) and inadequate (Kt/V <1.7) groups. Effect sizes are expressed as odds ratios (ORs) and 95% confidence interval (CI). Results: After adjusting for age, gender, hypertension, diabetes, and PD duration, 20g/L increment in hemoglobin (Hgb) was observed to significantly reduce the risk of inadequate PD by 19% (OR; 95% CI; P: 0.81; 0.70 to 0.95; 0.009), 5g/L increment in the mean corpuscular hemoglobin concentration (MCHC) by 7% (0.93; 0.88 to 0.98; 0.009), and 5% increment in transferrin saturation (TS) by 23% (0.77; 0.64 to 0.94; 0.012). The gender-specific nomogram model was constructed by incorporating three significant anemia-related biomarkers and convenient influencing factors, and the prediction accuracy was good (concordance index (C-index): 0.686 for men and 0.825 for women). Conclusion: Our findings indicate that the deterioration of three anemia-related biomarkers (Hgb, MCHC, and TS) can precipitate the development of inadequate PD in Chinese patients with CKD.

Screening of Renal Function among a Group of Physicians Working in a Hospital Who are Often Self Neglected

Background: Prevalence of Chronic Kidney Disease (CKD) has been increasing rapidly worldwide and early screening to detect kidney disease, particularly at its early stages is pivotal to stop its further deterioration. Population-based study on detection at early-stage of kidney disease and it’s prevalence are scanty in our country, especially among the medical professional personnel. Hence taking advantage of the observance of World Kidney Day’ 2020, we conducted a screening pro-gram for kidney disease organized at the Chattagram Maa-O-Shishu Hospital (CMOSH) premises among a group of physicians of the hospital.&#x0D; Materials and methods: This was a cross-sectional observational study among 67 physicians of different ranks (Medical Officer to Professor) working at CMOSH in different discipline. Age, body weight, height, Body Mass Index (BMI), blood pressure were documented, and urinary protein and serum creatinine were measured at a single sitting. Kidney function was estimated by calculating the Glomerular Filtration Rate (GFR) using the Modification of Diet in Renal Disease (MDRD) formula. Kidney function was classified according to estimated GFR (eGFR) and Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines.&#x0D; Results: A total of 67 working physicians of the hospital were studied. Majority subjects (30) were in the age group of 20-29 years. Among all 11.9% participants had proteinuria (Trace to 1 plus). The distribution of eGFR was symmetrical, with the majority (70.10%) of subjects in the 60–89 ml/min category, 11.90% had 30-59 ml/min category and only 17.90% of the study population had eGFR &gt; 90 ml/min. An inverse relation between eGFR and age, and a direct relation between eGFR and BMI were observed.&#x0D; Conclusion: Proteinuria low eGFR levels might be related with future decline in renal function among the studied subjects and so regular health check-up is important to abate the potential epidemic of kidney disease among the health professionals.&#x0D; Chatt Maa Shi Hosp Med Coll J; Vol.22 (1); January 2023; Page 14-18

Assessment of Dietary Acid Load in Children with Chronic Kidney Disease: An Observational Study.

Dietary acid load (DAL), which reflects the balance between acid- and alkaline-forming foods, is a modifiable risk factor for metabolic acidosis in CKD. Owing to the paucity of data in the Indian context, we undertook this cross-sectional study to estimate DAL and assess acid and alkaline food consumption in children with CKD2-5D (Chronic kidney disease stage 2 to 5 and 5D-those on hemodialysis). Clinical profile, dietary assessment of energy, protein intake/deficits, and macronutrients were noted and computed using software created by the division of nutrition, St John's research institute based on Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines in clinically stable children with CKD2-5D. DAL was estimated using potential renal acid load (PRAL in mEq/day) = (0.49 × protein intake in g/day) + (0.037 × phosphorus-intake in mg/day) - (0.02 × potassium intake in mg/day) - (0.013 × calcium intake in mg/day) - (0.027 × magnesium intake in mg/day). A positive dietary PRAL (>0) favors acidic content and negative (<0) favors alkaline content. PRAL was stratified into quartiles for analysis. The association of various clinical and dietary parameters were analysed across these quartiles. Eighty-one children [of mean age 122 ± 47 months; 56 (69%) boys, 29 (36%) on dialysis, 62 (77%) non-vegetarians] were studied. Twenty-eight (34%) were on bicarbonate supplements. A positive PRAL (9.97 ± 7.7 mEq/day) was observed in 74/81 (91%) children with comparable proportions in those with CKD2-5 and 5D [47/52 (90%) vs. 27/29 (93%) respectively, P > 0.05]. Protein intake was significantly higher in the highest quartile compared to the lowest quartile of PRAL in CKD2-5 (55 ± 16 g/day vs. 40 ± 14 g/day, P < 0.001) and 5D groups (47 ± 15 g/day vs. 25 ± 11 g/day, P = 0.002). A majority of the participants 60/81 (74%) consumed highly acidic and minimal alkali foods. In children with CKD2-5D, PRAL estimation revealed high DAL in the majority with a high consumption of acidic foods. These findings provide implications for appropriate dietary counseling in children with CKD.

Barriers to Implementing the Kidney Disease Outcomes Quality Initiative End-Stage Kidney Disease Life Plan Guideline

ObjectiveThe updated 2019 National Kidney Foundation Kidney Disease Outcomes Quality Initiative vascular access guidelines recommend patient-centered, multi-disciplinary construction and regular update of an individualized end-stage kidney disease (ESKD) Life-Plan (LP) for each patient, a dramatic shift from previous recommendations and policy. The objective of this study was to examine barriers and facilitators to implementing the LP among key stakeholders.MethodsSemi-structured individual interviews were analyzed using inductive and deductive coding. Codes were mapped to relevant domains in the Consolidated Framework for Implementation Research (CFIR).ResultsWe interviewed 34 participants: 11 patients with end-stage kidney disease, 2 care partners, and 21 clinicians who care for patients with end-stage kidney disease. In both the clinician and the patient/care partner categories, saturation (where no new themes were identified) was reached at 8 participants. We identified significant barriers and facilitators to implementation of the ESKD LP across three CFIR domains: Innovation, Outer setting, and Inner setting. Regarding the Innovation domain, patients and care partners valued the concept of shared decision-making with their care team (CFIR construct: innovation design). However, both clinicians and patients had significant concerns about the complexity of decision-making around kidney substitutes and the ability of patients to digest the overwhelming amount of information needed to effectively participate in creating the LP (innovation complexity). Clinicians expressed concerns regarding the lack of existing evidence base which limits their ability to effectively counsel patients (innovation evidence base) and the implementation costs (innovation cost). Within the Outer Setting, both clinicians and patients were concerned about performance measurement pressure under the existing “Fistula First” policies and had concerns about reimbursement (financing). In the Inner Setting, clinicians and patients stressed the lack of available resources and access to knowledge and information.ConclusionGiven the complexity of decision-making around kidney substitutes and vascular access, our findings point to the need for implementation strategies, infrastructure development, and policy change to facilitate ESKD LP development.