Mortality In Chronic Hemodialysis Patients Research Articles

Left Ventricular Geometry and Inferior Vena Cava Diameter Co-Modify the Risk of Cardiovascular Outcomes in Chronic Hemodialysis Patients.

Background and Objectives: Left ventricular hypertrophy (LVH) represents a significant cardiovascular risk in patients undergoing chronic hemodialysis (CHD). A large inferior vena cava diameter (IVCD), potentially indicative of fluid overload and a contributing factor to elevated cardiovascular risk, has not been sufficiently explored. Therefore, our study aims to gain further insights into this aspect. Materials and Methods: A retrospective cohort study enrolled patients receiving CHD in a single medical center with available echocardiography from October to December 2018. They were categorized into four groups based on LVH geometry and IVCD. Cox proportional hazard models assessed the risk of major adverse cardiovascular effects (MACEs) and cardiovascular and overall mortality after multivariate adjustments. Kaplan-Meier analysis depicted MACE-free events and survival during the follow-up time. Results: Of the 175 CHD patients, 38, 42, 45, and 50 exhibited small IVCD with eccentric and concentric LVH and large IVCD with eccentric and concentric LVH, respectively. Compared to small IVCD and eccentric LVH, large IVCD and eccentric LVH had the highest risk of MACEs, followed by large IVCD and concentric LVH (aHR: 4.40, 3.60; 95% CI: 1.58-12.23, 1.28-10.12, respectively). As for cardiovascular mortality, large IVCD and concentric LVH had the highest risk, followed by large IVCD and eccentric LVH, and small IVCD and concentric LVH. (aHR: 14.34, 10.23, 8.87; 95% CI: 1.99-103.35, 1.41-74.33; 1.01-77.87). The trend in overall mortality risk among the groups was similar to that of cardiovascular mortality. Conclusions: LVH geometry and IVCD co-modify the risk of MACEs and cardiovascular and overall mortality in CHD patients. The highest risk of MACEs is associated with large IVCD and eccentric LVH, while the highest risk of cardiovascular and overall mortality is linked with large IVCD and concentric LVH.

#1298 Combination of clinical frailty score and biomarkers as mortality predictor in hemodialysis patients

Abstract Background and Aims Frailty is common among hemodialysis (HD) patients. Its assessment is usually based on clinical criteria. In the present work, we evaluated the interest of combining clinical frailty score and biomarkers to predict mortality of chronic HD patients. Three biomarkers were assessed: myostatin, insulin-like growth factor-1 (IGF-1) and dehydroepiandrosterone sulfate (DHEA-S) Method Prevalent HD patients were enrolled from September 2016 to October 2017 in two centers in Liège, Belgium in this observational prospective study and followed up for 5 years. Myostatin, IGF-1 and DHEA-S levels were measured at baseline. Frailty was assessed using Fried's five points frailty score (≥3 indicates frailty). The ability to predict mortality was assessed by calculating areas under the curve (AUC). AUCs were compared by Hanley & McNeil test. Results We included 125 HD patients with the following characteristics: median age was 67 [53; 78] years; 60% of men; 41% of diabetic and median dialysis vintage of 30 [16; 54] months. Among them, 46% were classified as “Frail” according to Fried. The median follow up was 49 [19; 60] months (Table 1). The ability (AUC) of Fried score, myostatin, IGF-1 and DHEA-S to predict mortality was significant and comparable: 0.72 (95% CI: 0.63 to 0.80), 0.72 (95% CI: 0.64 to 0.80), 0.68 (95% CI: 0.59 to 0.76) and 0.73 (95% CI: 0.64 to 0.80), respectively (Fig. 1). Combining (by logistic regression) one biomarker with Fried score improved significantly the AUC with myostatin (AUC = 0.79, 95% CI: 0.71 to 0.86, p = 0.0049), IGF-1 (AUC = 0.78, 95% CI: 0.70 to 0.85, p = 0.0099) and DHEA-S (AUC = 0.79, 95% CI: 0.71 to 0.86, p = 0.0018) compared to Fried score alone. Compared to biomarker alone, the combination also improved significantly AUC for myostatin and IGF-1 (p = 0.035 and p = 0.011 respectively) but not for DHEA-S. The combination of several biomarkers with Fried score did not significantly improve mortality prediction compared to the combination of a single biomarker with Fried score. Conclusion The study suggests that combining Fried frailty score with either myostatin, IGF-1 or DHEA-S concentration improves the prediction of five-year mortality in chronic HD patients.

#2973 COVID-19 increased hemodialysis patients’ mortality, relation with inflammation and telomere attrition

Abstract Background and Aims An increased risk of mortality and hospitalization has been consistently demonstrated in patients with CKD who are additionally affected by corona virus disease 19 (COVID-19). In this study, we tried to identify predictive factors of mortality and hospitalizations, especially the ratio of neutrophils to lymphocytes (NLR), lactate dehydrogenase (LDH), c-reactive protein (CRP), disease status of COVID-19, telomere length in peripheral blood cells (TL) and 2-year risk score. Method A total of 130 chronic hemodialysis patients, were enrolled in the present study and followed up for 18 months. Routine laboratory parameters including LDH, were determined by standard automated methods, redox status parameters SOD and O2. - Using spectrophotometric methods.TL was determined using the modified Cawthon method and was calculated as the T/S ratio. Kaplan-Meier analysis was used to test survival predictors. Results Patients in deceased group (30%) were significantly older (p <0.001), with higher body mass index (BMI), (p < 0.01) than survived patients. Also, patients in the deceased group had higher levels of LDH, NLR index, CRP compared to survivors. Lower lymphocytes and shortened TL were characteristic of these patient groups, but the deceased group had the lowest lymphocytes (p < 0.005) and telomeres (p<0.002), and had the highest NLR (0.004). The difference in 2-years risk score also was significant (p < 0.001), with higher scores in the deceased group. Kaplan-Meier survival analysis showed six parameters were significant predictors in the following order of significance: COVID-19 status, 2-years risk score, NLR, TL, CRP, LDH. Using binary logistic regression analysis Summary risk score, a combination of these six parameters revealed as the best predictor of patients’ survival in this group of parameters (Log rank=25.4, P < 0.001). Conclusion Independent predictors of mortality in chronic haemodialysis patients are higher NLR, CRP, LDH, Lower lymphocytes and shortened TL, and COVID -19 made the situation even worse by significantly arising these patients’ mortality rate.

#704 Albumin, inflammation and nutrition in hemodialisis patients in Colombia: a cohort study

Abstract Background and Aims Hypoalbuminemia is a well-identified risk factor for mortality in chronic hemodialysis patients. As a negative acute phase reactant, albumin levels could be associated with several factors that affect the patient on hemodialysis (HD), such as alterations in the rate of hepatic synthesis, an increase in the rate of catabolism, or an increase in losses due to the dialysis process. The objective of the present study is to analyze serum albumin values in repeated measurements over time in two cohorts, one with expanded HD (HDx) enabled by the medium cut-off membrane (MCO) Theranova and the other with high flux (HF) HD and estimate the relationship with other relevant variables. Method Cohort study, one with HDx enabled by Theranova® and the other with HF HD, adult prevalent HD patients (> 90 days) at Baxter Renal Care Services Colombia starting between September 1, 2017, and November 30, 2017, with follow-up for up to 48 months. Sociodemographic and clinical characteristics were summarized descriptively, and a mixed linear model with repeated measures was performed to evaluate the association between dialysis membrane and albumin levels, controlling for confounding variables. Results We evaluated 1092 patients (62% male): 533 in HF-HD vs. 559 in HDx (Table 1); the median age was 61 years, 42% had a history of diabetes, and 19% had cardiovascular disease. We found no differences in albumin levels over time when comparing Theranova versus HF HD patients, p-value = 0.789 (see Fig. 1). No association between serum albumin levels and the Theranova dialyzer was found with the linear mixed model with repeated measures when controlling for confounding variables, p-value= 0.198. On the other hand, we found that serum albumin was associated with inflammatory and nutritional variables such as C reactive protein, Ratio platelets/lymphocytes, and Protein Energy Wasting (PEW) (Table 2). Conclusion Variables including nutritional status and inflammation, age, and hospitalization events are associated with serum albumin levels varying over time. Variation in serum albumin levels over time are not associated with type of dialyzer (Theranova® vs HF).

Lower product of magnesium × potassium is associated with higher mortality in chronic hemodialysis patients: a cohort study

This study aimed to investigate the Mg × K product on the mortality risk of hemodialysis patients with concomitant hypokalemia and lower magnesium levels. This was a prospective observational study of patients in a HD center in southern Taiwan. A total of 444 HD patients were divided into 5 groups by the Mg × K product: group 1, bottom quintile, median Mg × K: 7.87, IQR: 7.03–8.12 (n = 89, age: 64 ± 13 years old); group 2, median Mg × K: 9.37, IQR: 8.97–9.86 (n = 89, age:62 ± 13 years old); group 3, median Mg × K: 10.95, IQR: 10.50–11.26 (n = 89, age:64 ± 13 years old); group 4, median Mg × K: 12.30, IQR: 11.87–12.82 (n = 89, 61 ± 12 years old); and group 5, top quintile, median Mg × K: 14.92, IQR:14.07–16.23 (n = 88, 62 ± 11 years old). The patients were followed up for 2 years to determine the risk of all-cause mortality. Patients with a lower Mg × K product had more comorbidities, malnutrition-inflammation status, and a higher mortality risk. Using multivariable Cox regression analysis, a higher Mg × K [HR, 0.89; 95%CI (0.81–0.98)] was found to be an independent predictor of better survival. HD patients with a lower Mg × K product had more comorbidities, a marked malnutrition-inflammation status, and were associated with long-term mortality. A higher Mg × K value is a favorable survival factor.

Serum chloride as a marker of cardiovascular and all-cause mortality in chronic hemodialysis patients: 5-Year follow-up study

BackgroundHypochloremia has been associated with increased mortality in patients with hypertension, heart failure, sepsis, and chronic kidney disease (CKD). The pathophysiological mechanisms of this finding are not clear. There are no studies describing an association between serum chloride levels (Cl−) and mortality in incident chronic hemodialysis (HD) patients. MethodRetrospective cohort study of the incident population in our chronic outpatient hemodialysis program between January 1, 2016, and January 1, 2021 (N=374). Survival time was collected in all patients and analyzed using the Kaplan–Meyer method. A multivariate Cox regression model was performed to predict the probability of survival, applying a stepwise procedure. ResultsDuring the median follow-up period of 20 months, 83 patients died. The 5-year overall survival rate for our patients was 45%. Both natremia and chloremia had no significant differences when compared by sex, vascular access, or etiology. There was an inverse correlation between Cl− and interdialytic weight gain (r=−0.15) (p=0.0038). Patients belonging to the quartile with lower Cl− levels had less probability of survival than patients in the quartile with higher Cl− levels (27% and 68%, respectively, p=0.019). On the other hand, in the multivariate Cox regression model, variables significantly associated with higher mortality were being older, having higher baseline comorbidity by modified Charlson index, not taking diuretics and having lower albumin and chloride levels. Particularly, higher Cl− levels was independently associated with both lower all-cause mortality (adjusted hazard ratio [HR]=0.84; 95% confidence interval [CI], 0.77–0.92; p=0.0001) and cardiovascular mortality (HR 0.9; 95% CI, 0.83–0.97; p<0.0057). ConclusionsLower Cl− levels were associated with higher all-cause and cardiovascular mortality in incident patients on chronic hemodialysis in our health area.

Physical Activity, Body Composition, Serum Myokines and the Risk of Death in Hemodialysis Patients.

Background and Objectives: The aim of this study was to assess the relationship between habitual physical activity, body composition, serum myokine concentration, and all-cause mortality in chronic hemodialysis patients. Materials and Methods: A prospective cohort study with a 7-year follow-up was conducted in a group of 38 patients (24 men, 14 women, mean age 65.6 ± 13.9 years, dialysis vintage 1.17 ± 1.25 years). Baseline serum concentrations of myokines-follistatin and myostatin-were assessed along with a measurement of physical activity with multidimensional accelerometery, body composition, and the force of forearm muscle contraction. Survival analysis was performed using the Kaplan-Meier method for tertiles of follistatin, serum myostatin, body composition, and physical activity expressed in metabolic equivalents (MET). Results: The mean physical activity among patients was 81 min/24 h (median 38.5 min), and the mean weekly 3MET activity was 493 min (median 218 min). The probability of survival of patients was significantly lower in the subgroup with 3MET/24 h less than 26 min/24 h and 3METt less than 148 min per week compared to the other subgroup (p = 0.006 and p = 0.006, respectively). During the 70-month follow-up, the subgroup with the lowest baseline follistatin concentration showed a significantly lower risk of death (p = 0.02). Baseline myostatin levels were not significant risk factors for mortality, nor were BMI or lean and fat tissue index categories. Conclusions: Physical activity and low plasma follistatin, but not body composition indexes or plasma myostatin, could serve as predictors of all-cause mortality in hemodialysis patients.

Medium Cut-Off versus Low-Flux Dialyzers in Hemodialysis Patients with COVID-19: Clinical Outcomes and Reduction in Interleukin-6

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has caused extensive morbidity and mortality worldwide. Hemodialysis (HD) patients are both vulnerable to COVID-19 infection and tend to suffer greater disease severity and mortality. This retrospective study aimed to compare medium cut-off (MCO) and low-flux (LF) membrane dialyzers in terms of interleukin-6 (IL-6) reduction, change in inflammatory state, intradialytic complications, and mortality in chronic HD patients with COVID-19. Method: HD patients with a confirmed COVID-19 infection were admitted to the hospital for 10–14 days and underwent HD at the COVID-HD unit. Choice of dialyzer membrane used (MCO vs. LF) depended on the primary nephrologist(s). We collected data on demographics, baseline characteristics, laboratory results, diagnosis, treatments, HD prescription, hemodynamic status during HD, and mortality at 14 and 28 days after. Results: IL-6 reduction ratio (RR) in the MCO group was 9.7 (interquartile range, 71.1) percent, which was significantly higher than that of the LF group (RR, −45.7 [interquartile range, 70.2] percent). The incidence rate of intradialytic hypotension in the MCO group was 3.846 events per 100 dialysis hours (95% confidence interval [CI], 1.954–6.856), which was significantly lower than that of the LF group (9.057; 95% CI, 5.592–13.170). Overall, mortality was not significantly different between the two groups. Conclusion: The MCO membrane was more effective in removing IL-6 and was better tolerated than the LF membrane. Large, randomized controlled trials are required to confirm the relative benefits of the MCO membrane, especially mortality. However, due to the COVID-19 pandemic, our results suggest that the MCO membrane may be beneficial in chronic HD patients with COVID-19.

Antihypertensive Medications Use among Chronic Hemodialysis Patients Visiting the Outpatient Department of Nephrology of a Tertiary Care Centre: A Descriptive Cross-sectional Study

Anti-hypertensive medications are prescribed for the management of high blood pressure which is the leading cause of mortality in chronic hemodialysis patients. The objective of our study was to find out the prevalence of anti-hypertensive medication use among chronic hemodialysis patients visiting the outpatient Department of Nephrology of a tertiary care centre. This was a descriptive cross-sectional study conducted among chronic hemodialysis patients visiting the Department of Nephrology of a tertiary care centre from 2 April 2022 to 30 September 2022. Ethical approval was taken from the Institutional Review Committee (Reference number: 062-078/079). A convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. The prevalence of anti-hypertensive medications use was present in 102 (97.14%) (93.95-100, 95% Confidence Interval) patient undergoing hemodialysis. The three common drugs prescribed for hypertensive patients were amlodipine 79 (77.45%), torsemide 59 (57.84%), and prazosin 48 (47.05%). The prevalence of antihypertensive medication use among patients undergoing hemodialysis was higher than other similar studies done in similar settings. anti-hypertensive drugs; hemodialysis; prevalence.

Serum chloride as a marker of cardiovascular and all-cause mortality in chronic hemodialysis patients: 5-Year follow-up study

BackgroundHypochloremia has been associated with increased mortality in patients with hypertension, heart failure, sepsis, and chronic kidney disease (CKD). The pathophysiological mechanisms of this finding are not clear. There are no studies describing an association between serum chloride levels (Cl−) and mortality in incident chronic hemodialysis (HD) patients. MethodRetrospective cohort study of the incident population in our chronic outpatient hemodialysis program between January 1, 2016, and January 1, 2021 (N=374). Survival time was collected in all patients and analyzed using the Kaplan–Meyer method. A multivariate Cox regression model was performed to predict the probability of survival, applying a stepwise procedure. ResultsDuring the median follow-up period of 20 months, 83 patients died. The 5-year overall survival rate for our patients was 45%. Both natremia and chloremia had no significant differences when compared by sex, vascular access, or etiology. There was an inverse correlation between Cl− and interdialytic weight gain (r=−0.15) (p=0.0038). Patients belonging to the quartile with lower Cl− levels had less probability of survival than patients in the quartile with higher Cl− levels (27% and 68%, respectively, p=0.019). On the other hand, in the multivariate Cox regression model, variables significantly associated with higher mortality were being older, having higher baseline comorbidity by modified Charlson index, not taking diuretics and having lower albumin and chloride levels. Particularly, higher Cl− levels was independently associated with both lower all-cause mortality (adjusted hazard ratio [HR]=0.84; 95% confidence interval [CI], 0.77–0.92; p=0.0001) and cardiovascular mortality (HR 0.9; 95% CI, 0.83–0.97; p<0.0057). ConclusionsLower Cl− levels were associated with higher all-cause and cardiovascular mortality in incident patients on chronic hemodialysis in our health area.

Post-dialysis heart rate variability predicted mortality in chronic hemodialysis patients

Abstract Background Autonomic disturbance is common in end stage renal disease (ESRD) and may be responsible for mortality in these patients. Heart rate variability (HRV) is the useful tool to assess for autonomic function. The predictive value of HRV on overall-mortality and proper timing of HRV measurement in chronic hemodialysis patients remain to be determined. Propose To evaluate the predictive value of HRV on all-cause mortality and explore the proper timing of HRV assessment by performing repeated HRV measurements at different time points including before, during and after hemodialysis. Methods We enrolled ESRD on hemodialysis patients between April 2018 to December 2018. HRV measurements were recorded 10 minutes before hemodialysis, 4 hours during hemodialysis and 10 minutes after hemodialysis. Baseline characteristics, clinical parameters and all-cause mortality were recorded. Cox-proportional hazard regression was used for the analysis of the association between HRV parameters with all-cause mortality. Results There were 163 patients enrolled to the study. After a median follow up of 40.4 months, 37 (22.7%) patients were expired. From multivariable Cox proportional hazard regression, the post-dialysis HRV parameters including lower very low frequency (VLF) (hazard ratio [HR], 0.900; 95% confidence interval [CI], 0.850–0.953; p&amp;lt;0.001), lower normalized low frequency (nLF) (HR, 0.954; 95% CI, 0.922–0.987; p=0.007), lower LF/HF ratio (HR, 0.268; 95% CI, 0.103–0.699; p=0.007) and higher normalized high frequency (nHF) (HR, 1.047; 95% CI, 1.012–1.083; p=0.007) were the independent predictors for all-cause mortality. HRV parameters at pre-dialysis and during dialysis were not associated with all-cause mortality. Patients with post-dialysis LF/HF ratio lower than the median value (&amp;lt;1.1) had a significantly higher all-cause mortality (log rank p=0.006) (Figure 1). Conclusion Post-dialysis period could be the most appropriate timing for HRV measurement. The HRV parameters at post-dialysis including lower VLF, lower nLF, higher nHF and lower LF/HF ratio were the independent predictors for all-cause mortality in chronic hemodialysis patients. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Faculty of Medicine endowment fund for medical research, Chiang Mai University, Thailand

Hemodialysis facility star rating affects mortality in chronic hemodialysis patients: a longitudinal observational cohort study.

Many countries have their own hemodialysis (HD) quality assurance programs and star rating systems for HD facilities. However, the effects of HD quality assurance programs on patient mortality are not well understood. Therefore, in the present study, the effects of the Korean HD facility star rating on patient mortality in maintenance HD patients were evaluated. This longitudinal, observational cohort study included 35,271 patients receiving HD treatment from 741 facilities. The fivestar ratings of HD facilities were determined based on HD quality assessment data from 2015, which includes 12 quality measures in structural, procedural, and outcome domains. The patients were grouped into high (three to five stars) and low (one or two stars) groups based on HD facility star rating. Cox proportional hazards model was used to evaluate the effects of star rating on patient mortality during the mean follow-up duration of 3 years. The patient ratio between high and low HD facility star rating groups was 82.0% vs. 18.0%. The patients in the low star rating group showed lower single-pool Kt/V and higher calcium and phosphorus levels compared with subjects in the high star rating group. After adjusting for sociodemographic and clinical parameters, the HD facility star rating independently increased the mortality risk (hazard ratio, 1.11; 95% confidence interval, 1.04-1.18; p = 0.002). The HD facilities with low star rating showed higher patient mortality.

Association of serum fibroblast growth factor 21 levels with skeletal muscle mass and mortality in chronic hemodialysis patients

Fibroblast growth factor 21 (FGF21) is a hormone that modulates metabolic pathways, which acts as a myokine under metabolic stress. We aimed to explore the association of serum FGF21 levels with skeletal muscle mass and mortality in patients on hemodialysis (HD). Baseline serum FGF21 levels were measured, and a portable whole-body bioelectrical impedance device was used to assess skeletal muscle mass. One hundred twenty-four patients undergoing chronic HD were categorized into high- and low-FGF21 groups according to the median FGF21 value. Patients with low FGF21 values had lower body weight, body mass index, skeletal muscle mass index (SMI=skeletal muscle mass/height2), and serum triglyceride levels. Log serum FGF21 levels revealed a modest but positive correlation with SMI (r=0.30, p=0.001) and independently predicted SMI after multiple adjustment (β=1.59, p=0.027). During a median follow-up period of 66 months, all-cause mortality and cardiovascular death rates did not differ significantly between the high- and low-FGF21 groups. We also failed to demonstrate FGF21 as an independent predictor of all-cause mortality. Serum FGF21 levels exhibited a positive association with skeletal muscle mass but were not predictive of mortality in patients undergoing chronic HD.

Pentraxin 3 Predicts Arteriovenous Fistula Functional Patency Loss and Mortality in Chronic Hemodialysis Patients

Introduction: Viable vascular access is the lifeline for hemodialysis patients. In the nondialysis population, emerging evidence suggests that circulating pentraxin 3 (PTX3), neutrophil gelatinase-associated lipocalin (NGAL), and chitinase-3-like protein 1 (CHI3L1) are associated with cardiovascular inflammation and endothelial injury. However, predictive values of these three biomarkers on arteriovenous fistula (AVF) outcomes are unknown. Methods: This prospective observational cohort study enrolled 135 hemodialysis patients using AVF and then followed them for 3 years. Plasma levels of PTX3, NGAL, and CHI3L1 were measured. Patients were followed up prospectively for two clinical outcomes, including AVF functional patency loss and death. Cox proportional hazards regression models were used to analyze hazard ratios for the commencement of AVF functional patency loss and mortality. Results: Among 135 patients, the mean age was 66.0 ± 15.7 years old and 48.1% were male. The plasma level of PTX3, NGAL, and CHI3L1 was 2.8 ± 2.3 ng/mL, 349.2 ± 111.4 ng/mL, and 185.5 ± 66.8 ng/mL, respectively. During a 3-year follow-up period, the plasma level of PTX3 was an independent predictor for AVF functional patency loss (per 1 ng/mL increase, HR 1.112 [95% CI: 1.001–1.235], p = 0.048). Besides, patients with higher plasma levels of PTX3 were more likely to suffer from cardiovascular mortality (per 1 ng/mL increase, HR 1.320 [95% CI: 1.023–1.703], p = 0.033), infectious mortality (per 1 ng/mL increase, HR 1.394 [95% CI: 1.099–1.769], p = 0.006), and all-cause mortality (per 1 ng/mL increase, HR 1.233 [95% CI: 1.031–1.476], p = 0.022). Conclusions: The plasma level of PTX3, not NGAL or CHI3L1, was associated with higher risks of AVF functional patency loss in chronic hemodialysis patients, showing its value in reflecting AVF endothelial dysfunction. Furthermore, PTX3 also predicts mortality in chronic hemodialysis patients.

Relationship of Vascular Access Flow with Impaired Right Ventricular Function in Chronic Hemodialysis Patients

Background: Cardiovascular events are the leading cause of morbidity and mortality in chronic hemodialysis patients. Impaired right ventricular function is often associated with poor survival in hemodialysis patients. Objective: To determine the effect of vascular access flow (AVFs) of right ventricular function. Methods: This cross-sectional study was done in Department of Nephrology, DMCH during the period January 2020 to July 2021. End stage renal disease patient underwent hemodialysis for ≥3 months were recruited in the study. Patients with chronic respiratory disease, severe valvar heart disease, AVFs flow&lt;200ml/min were excluded. Right ventricular function was assessed by Tricuspid Annular Plane Systolic Excursion (TAPSE) through echocardiography and AVFs blood flow by color duplex study. History for diabetes mellitus, glomerulonephritis and hypertension were retrieved from medical records in addition to variable age and gender. Results of the biochemical variable also retrieved. TAPSE ≤16mm was taken as cut off to characterize subjects as Group I, impaired right ventricular function. Those with &gt;16mm termed as Group II, normal right ventricular function. Data were expressed as mean±SD and number (present) as appropriate. Unpaired student t test, invariable and multivariable analysis were performed as applicable using statistical package for social science (SPSS). p&lt;0.05% was taken as level of significant. Results: of the total 80 subject 26 constituted Group I and 54 in Group II. Distribution of male and female did not show any statistical association. Distribution of gender in two groups did not show any statistical association. Distribution of the subjects in age cluster was similar in the two groups. History of DM, GN, and HTN distribution in the two groups was also similar. Duration of hemodialysis (mean±SD) in Group I was 28.04 months and 26.39 months in Group II; two group did not show statistical difference (p=0.529). Systolic blood pressure was 163 mmHg and 160mmHg in Group I and Group II respectively and diastolic blood pressure (mean±SD, mmHg) was 92mmHg and 92mmHg in Group I and Group II respectively; did not statistical difference (p=0.283 and 0.960 respectively). AVFs blood flow 1603±382ml/min (mean±SD,ml/min) in group I was significantly higher compared to the counterpart group II 791±189ml/min. The trend was supported by the significant (p=0.001) inverse relationship between TAPSE and AVFs blood flow. In Group I radio cephalic and brachiocephalic AV fistula distribution was 12 vs 24 (46.2 vs 53.8%) which in the Group II was 51 vs 3(94.4 vs 5.6%). Conclusion: Data concluded that brachiocephalic AVFs lead to significantly higher blood flow than the radio cephalic fistula resulting impaired right ventricular function, which reconfirmed the usefulness of distal AVF as a vascular access in patient for hemodialysis.

Factors Affecting Postoperative Morbidity and Mortality in Chronic Hemodialysis Patients

Factors Affecting Postoperative Morbidity and Mortality in Chronic Hemodialysis Patients

Relationship between malnutrition and possible sarcopenia in the AWGS 2019 consensus affecting mortality in hemodialysis patients: a prospective cohort study

BackgroundThe first objective of this study was to determine the relationship between muscle strength or physical performance and mortality, and the second objective was to show the relationship of Geriatric Nutritional Risk Index (GNRI) to muscle strength and physical performance decline.MethodsWe examined handgrip, the 5-times chair stand test, and GNRI in 635 maintenance hemodialysis patients and followed up for 72 months. Predictors for all-cause death were examined using Kaplan-Meier analysis and Cox proportional analysis. The relationship between possible sarcopenia and nutritional disorder (GNRI) was constructed receiver operating characteristic (ROC) curve. We used the Youden index to determine the optimal cutoff points for GNRI.ResultsThe multivariate Cox proportional hazard analysis revealed that the GNRI did not show any significance, although handgrip (HR 3.61, 95% CI 1.70–7.68, p < 0.001) and the 5-times chair stand test (HR 1.71 95% CI 1.01–2.90, p = 0.045) were significant predictors for mortality. On the evaluation of possible sarcopenia by handgrip strength, the area under curve (AUC) on ROC curve analysis were 0.68 (95% CI 0.64–0.72), and 5-chair stand, the AUC on ROC were 0.55 (95% CI 0.51–0.60). The cut-off value for the GNRI discriminating those at possible sarcopenia by handgrip strength based on the Youden index was 91.5.ConclusionsOur study suggests that the handgrip strength test of the AWGS 2019 sarcopenia consensus was a simple and useful tool to predict mortality in chronic hemodialysis patients. Furthermore, GNRI assessment can be a useful tool for screening before assessing possible sarcopenia when it is difficult to perform SARC-F to all patients.

Association of soluble ST2 and right ventricular dysfunction with mortality in chronic hemodialysis patients

Abstract Background End stage kidney disease (ESKD), is a triggering and facilitating factor for cardiac remodelling (i.e., morphologic hypertrophy and/or dilatation associated with deterioration of systolic and/or diastolic function) that contribute to heart failure (HF). RV dysfunction (RVD) has been demonstrated to predict mortality in ESKD patients. Purpose The present study aimed to investigate the potential associations between RVD and circulating biomarkers of myocardial inflammation and fibrosis with all-cause mortality in HD patients. Method We performed a retrospective single-centre cohort study of prevalent patients admitted in a chronic HD program for more than 3 months. Clinical characteristics and echocardiographic parameters were assessed in all patients. Pre-dialysis blood samples for measurement of inflammatory (e.g., C reactive protein, interleukin-1, interleukin-18) and fibrotic (e.g., soluble suppression of tumorigenesis-2 [sST2], galectin-3, C-terminal pro-peptide of procollagen type I and N-terminal pro-peptide of procollagen type III) biomarkers were collected. RVD was defined using tricuspid annular plane systolic excursion (TAPSE) &amp;lt;1.7 cm or pulsed Doppler peak annular velocity (S') &amp;lt;9.5 cm/s. The ability of sST2 to discriminate between mortality was assessed using AuROC curve. Results We enrolled forty-eight patients, mean patients age was 74 (64 – 79)years, and 62.5% were males. 95.8% of the patients had high blood pressure, and at least 70.8% had HF criteria. About 52.1% of the patients were on OnLine HDF. Regarding the echocardiogram parameters, 56.3% had no functional heart disease, 10.4% had LVD (LVEF ≤45% and diastolic dysfunction ≥ grade 2), and 33.3% had RVD (TAPSE &amp;lt;17mm and/or S'&amp;lt;9.5cm/s), with or without LVD. Mortality was higher 45.5% (log-rank, p=0.003) in patients with RVD as diagnosed by S' than in patients without RVD. No difference in mortality was observed for RVD defined by TAPSE. There were no differences in the morphology and function parameters of the left ventricle between patients with and without RVD. From all biomarkers measured only sST2 was associated with RVD. Indeed, an age- and sex-adjusted analyses showed that doubling of sST2 was inversely associated with a decreased in S' (estimate = −2.03, 95% CI [−3.04 to −1.00] cm/s; P=0.002). Mortality was increased in patients with sST2 ≥40.45 ng/mL compared to patients with sST2 &amp;lt;40.45 ng/mL (66.7% vs. 18.9%, log-rank; p=0.004). Conclusion This preliminary data would suggest that patients on chronic HD, circulating levels of sST2 were independently associated with RVD. In addition, elevated sST2 levels and RVD were associated with increased all-cause mortality. The myocardial pro-remodelling effect of sST2 in HD patients with RVD warrants further investigation. Funding Acknowledgement Type of funding sources: None.

Impact of the vascular access on morbidity and mortality in chronic hemodialysis patients

Abstract Background Patients with endstage renal disease (ESRD) have high rates of mortality and morbidity. Adequate dialysis is essential to maintain a high quality of life and survival in these patients. Vascular access is also known as a ‘lifeline’ for patients receiving hemodialysis (HD). Complications associated with vascular access result in frequent hospitalizations and often require intervention. These complications have significant impacts on the morbidity and mortality of dialysis patients, while also leading to high medical costs. As a result, having a wellfunctioning point of vascular access is very important. We aimed to study the prevelance of different types of vascular access and practice patterns at Ain Shams university hospitals and to study the impact of vascular access related problems on morbidity and mortality. Patients and Methods This study is a prospective cohort study conducted in Ain shams university hospitals dialysis units in which all adults with end-stage kidney disease (ESRD) from the three units were included in the study. All patients were assessed as regard basic demographics, patient characteristics and vascular access characteristics. At the start of the study and then after one year data about vascular access related mortality and morbidity were collected. Statistical data analysis was done using SPSS (statistical package for the social sciences, version 2019, SPSS, Inc, Chicago, III, USA) Results In our HD population where the majority of catheters were temporary nontunneled catheters, dialysis catheter use was associated with higher mortality and increased hospitalization rates compared with AV access. These results emphasize the urgent need to minimize the use of dialysis catheters. Conclusion Using dialysis catheter carries a higher risk for life threatening complications compared to AV access.

Arterial calcifications and osteoprotegerin in chronic hemodialysis patients: impact on 6-year survival.

The association between end-stage renal disease and cardiovascular mortality may be influenced through vascular alterations, in particular atherosclerosis and vascular calcification. The study goal was to assess the impact of each type of arterial intimal calcifications (AIC) and arterial medial calcifications (AMC), of osteoprotegerin (OPG), mineral metabolism markers and other features on all-cause and cardiovascular mortality in chronic hemodialysis patients. Ultrasound was performed in 87 patients on the carotid and femoral arteries, and the severity of AIC and AMC was assessed calculating a score according to the extension of calcification. We analyzed the link between AIC, AMC, OPG, mineral markers and mortality after 6years of follow-up. The cutoff value for OPG determined using ROC was 4.9pmol/l for all-cause and cardiovascular mortality. Patients with higher serum OPG levels presented higher mortality rates. Our study revealed that AIC, high OPG, low ankle-arm index, presence of diabetes, smoking status, and lack of arteriovenous fistula are associated with all-cause and cardiovascular mortality in univariate regression analysis. Multivariate analysis identified AIC scoring based on the segmentation method as an independent predictor of all-cause and cardiovascular mortality, along with increased OPG levels. AMC scoring was not a predictor of mortality. Identifying and scoring AIC on ultrasound and measuring OPG levels, as a basis of the HD patient assessment may become valuable tools in clinical work, as these have an impact on death toll.