Outcomes In Maintenance Hemodialysis Patients Research Articles

P0948ASSOCIATION OF PHASE ANGLE WITH NUTRITION, MORTALITY, MAJOR ADVERSE CARDIOVASCULAR EVENTS AND SARCOPENIA IN MAINTENANCE HEMODIALYSIS PATIENTS

Abstract Background and Aims Nutrition has been consistently important in end stage renal disease patients. However, it is difficult to obtain adequate nutritional status while avoiding fluid overload, hyperphosphatemia and hyperkalemia in hemodialysis patients. In addition, there is no golden standard for diagnosing protein energy wasting (PEW) in maintenance hemodialysis patients. We studied the clinical significance of phase angle using bioelectrical impedance analysis (BIA), one of the PEW diagnostic tools, to predict various clinical outcomes in maintenance hemodialysis patients. Method We retrospectively enrolled patients who received hemodialysis for more than 3 months from 2016 to March 2019, excluding patients had active cancer, or died within 30 days, had no BIA data. We evaluated the factors related phase angle and the role of phase angle as predictors of all-cause mortality and major adverse cardiovascular events (MACE), sarcopenia. Results Of 191 patients, 63.4% were men, mean age was 64.2 ± 12.4 years, mean body mass index (BMI) was 23.8 ± 6.9 kg/m2, and the most common underlying disease were hypertension and diabetes mellitus. Lower phase angle group (phase angle ≤4°) patients had older age, higher portion of women, malnourished, and history of coronary artery disease (CAD) than higher phase angle group (phase angle >4°) patients. Phase was significantly related with nutritional parameters. During a median follow up of 16.7 months, 14.1% (n=27) patients experienced a MACE, 11.0% (n=21) patients died. In multivariate Cox analyses, lower phase angle, higher CRP level and history of CAD were significantly related with all-cause mortality even after adjustment for covariates. However, phase angle was not significantly associated with MACE and sarcopenia. Conclusion In maintenance hemodialysis patients, phase angle was significantly related to mortality as well as nutritional status, but MACE and sarcopenia were not. Clinicians should be careful to find and treat correctable factors with low phase angle and high CRP level in maintenance hemodialysis patients.

P1484PROGRESSION OF AORTIC ARCH CALCIFICATION IS ASSOCIATED WITH OVERALL AND CARDIOVASCULAR MORTALITY IN HEMODIALYSIS

Abstract Background and Aims Vascular calcification is common and associated with unfavorable outcomes among patients with end-stage renal disease (ESRD). However, little is known whether the progression of vascular calcification outweights the baseline calcification in association with overall and cardiovascular (CV) mortality in hemodialysis (HD) patients. Method This study included 140 maintenance HD patients. Vascular calcification was assessed using aortic arch calcification (AoAC) score measured from chest radiographs at the baseline and the second year of follow-up. Progression of vascular calcification (△AoAC) was defined as the difference between the two measurements of AoAC. The association of △AoAC with overall and CV mortality was evaluated using multivariable Cox regression analysis. Results During the mean follow-up period of 7.8 years, there were 49 (35%) overall mortality and 27 (19.3%) CV mortality. High brachial-ankle pulse wave velocity was positively correlated with △AoAC, whereas old age and high hemoglobin were negatively correlated with △AoAC. In multivariate adjusted Cox analysis, increased △AoAC (per 1 unit), but not baseline AoAC, was significantly associated with overall mortality (HR, 1.183; 95% CI, 1.056–1.327; p = 0.004) and CV mortality (HR, 1.194; 95% CI, 1.019–1.398; p = 0.028). Conclusion Progression of AoAC outperformed the baseline AoAC in association with increased risk of overall and CV mortality in HD patients. Regular follow-up of chest radiograph and AoAC score assessments are simple and cost-effective to identify the high-risk individuals of unfavorable outcomes in maintenance HD patients.

Randomized controlled trial of medium cut-off versus high-flux dialyzers on quality of life outcomes in maintenance hemodialysis patients

Medium cut-off (MCO) dialyzers help remove larger middle molecules associated with symptoms related to the accumulation of uremic retention solutes. We investigated the effect of an MCO dialyzer on the improvement of quality of life (QOL) in maintenance hemodialysis (HD) patients. Forty-nine HD patients with high-flux dialysis were randomly assigned to either an MCO (Theranova 400, Baxter) or a high-flux (FX CorDiax 80 or 60, Fresenius Medical Care) dialyzer and completed the study. QOL was assessed at baseline and after 12 weeks of treatment using the Kidney Disease Quality of Life Short Form-36, and pruritus was assessed using a questionnaire and visual analog scale. The reduction ratios of middle molecules were also evaluated. Laboratory markers, including serum albumin, did not differ between the two groups after 12 weeks. Removals of kappa and lambda free light chains were greater for MCO dialyzer than high-flux dialyzer. The MCO group had higher scores than the high-flux group in the domains of physical functioning and physical role (75.2 ± 20.8 vs. 59.8 ± 30.1, P = 0.042; 61.5 ± 37.6 vs. 39.0 ± 39.6, P = 0.047, respectively), and the MCO group had lower mean scores for morning pruritus distribution and the frequency of scratching during sleep (1.29 ± 0.46 vs. 1.64 ± 0.64, P = 0.034; 0.25 ± 0.53 vs. 1.00 ± 1.47, P = 0.023, respectively). MCO dialyzers may improve patient-reported outcomes, particularly the physical components of QOL and uremic pruritus, in patients with high-flux dialyzers.

Clinicodemographic Profile and Outcome of Maintenance Hemodialysis Patients in a Tertiary Hospital of Central Nepal, Chitwan

Background Maintenance hemodialysis is a popular treatment modality of renal replacement therapy for end stage renal disease patients; however their mortality seemed to be rising in our centre. There were no previous studies regarding the clinicodemographic profile and outcome of maintenance hemodialysis patients from this region. Objective This study was carried out with an objective to know the clinicodemographic profile and outcome of maintenance hemodialysis patients in our centre. Method This study was a hospital based prospective observational study carried out over a period of three year, from May 2016 to April 2019, in the hemodialysis unit of the department of nephrology. All the consecutive end stage renal disease patients on maintenance hemodialysis were included in the study. The patient's demographic profile and outcome were studied and analysed using appropriate statistical tools. Result A total of 156 patients were enrolled in the study. Males were 96(61.5%) and females were 60(38.5%). The mean age of the patient was 52.2±15.6 years. The commonest causes of end stage renal disease and reasons for admission were Type 2 diabetes mellitus 68(43.6%) and volume overload with heart failure 101(64.7%) respectively. At the end of three years, 39(25%) were expired, 14(8.9%) were transferred to other centre and four (2.6%) underwent kidney transplantation. The average duration of hemodialysis was 20.3± 17.5 months. Majority of the patients 154(98.7%) had repeat admission ranging from 1 time 21(13.5%) to 10 times two (1.3%). There was a significant association between age ≥ 40 years and diabetes with mortality (p value < 0.003 and < 0.028 respectively). Conclusion The commonest cause of end stage renal disease and the reason of admission were Type 2 diabetes mellitus 68 (43.6%) and volume overload with heart failure 101 (64.7%) respectively. The overall mortality was 39 (25%) and the commonest cause of mortality was sepsis/health care associated pneumonia 30 (76.9%). There was significant association between age ≥ 40 years and diabetes with mortality (p value < 0.003 and < 0.028 respectively).

Superior prognostic value of soluble suppression of tumorigenicity 2 for the short-term mortality of maintenance hemodialysis patients compared with NT-proBNP: a prospective cohort study

Background Both soluble suppression of tumorigenicity 2 (sST2) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are promising biomarkers associated with the adverse clinical outcomes of dialysis patients. Our research aims at exploring and comparing the roles of sST2 and NT-proBNP in predicting the short-term and long-term mortality of maintenance hemodialysis (MHD) patients. Methods A prospective cohort study was performed. Patients undergoing hemodialysis in July 2014 were enrolled from the Blood Purification Center of Ruijin Hospital. MHD patients were followed up for 3 years. The primary outcome was all-cause mortality at the 1-year and 3-year follow-up, while the secondary outcome was cardiovascular mortality. Serum sST2 level was detected by quantified ELISA kits. Clinical data were analyzed by SPSS 23.0 version. Results 205 patients were recruited. The median sST2 level was 15.99 (11.60, 20.49) ng/ml. After 3 years of follow-up, both all-cause and cardiovascular mortality in 1 year and all-cause and cardiovascular mortality in 3 years increased significantly with serum sST2. For short-term mortality, no significant difference was observed in patients with increasing NT-proBNP levels. Cox regression analysis indicated that only sST2 was independent in predicting the risk of short-term outcomes. For long-term mortality, both sST2 and NT-proBNP were independent risk factors, while a higher hazard ratio was observed for NT-proBNP. Conclusions Serum sST2 is a novel biomarker associated with adverse clinical outcomes in MHD patients. It was significant for both all-cause and cardiovascular mortality in MHD patients and may provide better prognostic value in short-term prognosis than the classic biomarker NT-proBNP.

Impact of serum fibroblast growth factor(FGF)23 and carotid intima-media thickness on long-term outcome in maintenance hemodialysis patients

Objective To assess the predictive value of serum fibroblast growth factor(FGF)23 level and carotid intima-media thickness(CIMT)for the long-term outcome in maintenance hemodialysis(MHD)patients. Methods A total of 88 MHD patients were enrolled, with a median follow-up of 73.2 months(a range from 11.5 to 75.7 months). CIMT and atherosclerotic plaques were measured by B-mode Doppler ultrasound at baseline by an experienced sonographer.Blood samples were collected and stored in the -80℃ refrigerator for measuring serum FGF23 levels. Results The 88 patients were aged(64.2±11.5)years, with 52 males and 36 females, and the mean CIMT was(1.34±0.38)mm.Carotid artery atherosclerotic plaque was detected in 72(81.8%)subjects.Carotid artery atherosclerotic plaques(CASP)were found in 58(65.9%)patients aged 60 years and over.Compared with non-elderly patients, elderly patients had the characteristics of high incidence of cardiovascular disease and poor nutritional status.During the follow-up period, 34 patients died and 23(67.6%)patients died of cardiovascular disease.Kaplan-Meier curves showed that cardiovascular disease-free survival rate was higher in the normal CIMT group than in thickening CIMT group(Log Rank P=0.003). And subjects with low level of FGF23 had a better survival rate than those with moderate to high level of FGF23(Log Rank P=0.043). Multivariate COX regression analysis showed that FGF23(HR=1.056, 95%CI: 1.007-1.108, P=0.026)and CIMT(HR=1.165, 95%CI: 1.032-1.315, P=0.013)were independent predictors for cardiovascular mortality.Multivariate COX regression analysis showed that serum calcium(HR=0.022, 95%CI: 0.001-0.489, P=0.016), hemoglobin(HR=0.966, 95%CI: 0.937-0.997, P=0.033), FGF23(HR=1.071, 95%CI: 1.017-1.128, P=0.010)and CIMT(HR=1.202, 95%CI: 1.049-1.377, P=0.008)were independent predictors for cardiovascular mortality in elderly MHD patients. Conclusions Serum level of FGF23 and CIMT are the important predictors for cardiovascular mortality in MHD patients.The proportion of elderly patients with cardiovascular disease is higher, in which the factors affecting prognosis are more complex. Key words: Maintenance hemodialysis; Tunia media; Fibroblast growth fator 23; Prognosis

Association between serum ferritin levels and clinical outcomes in maintenance hemodialysis patients: a retrospective single-center cohort study

BackgroundFerritin is a well-known marker of iron deficiency anemia, but the target in maintenance hemodialysis (MHD) patients remains controversial. This study examined the association between baseline ferritin levels and clinical outcomes.MethodsWe retrospectively collected the data of outpatients on MHD for 5 years at St. Luke’s International Hospital from July 2009. Patients with baseline ferritin levels of > 100 ng/mL in June 2009 were defined as the high-ferritin (HF) group and the remaining patients as the low-ferritin (LF) group. The primary endpoint was all-cause mortality. The secondary endpoints included cardiovascular events and infection-related hospitalizations. Log-rank test and Cox proportional hazard analysis were performed.ResultsOf 116 patients (age, 65.4 ± 13.4 years, 70% males), 29 (25%) and 87 (75%) belonged to the HF and LF groups, respectively. During the follow-up period of 1825 (interquartile range 819–1825) days, 38 patients (23 in the HF and 15 in the LF groups) died. According to the Kaplan–Meier survival curves, the HF group had significantly poor survival compared with the LF group (p = 0.0089). After adjusting for age, sex, vintage of hemodialysis, C-reactive protein levels, and history of cardiovascular events, the hazard ratio (HR) for the HF group was 2.49 (95% confidence interval (CI), 1.21–5.12). The multivariate analysis of cardiovascular events revealed a similar result with statistical significance (HR 2.69; 95% CI 1.12–6.46). Infection-related hospitalizations did not exhibit any statistically significant difference.ConclusionsIn MHD patients, ferritin levels > 100 ng/mL is associated with increased rates of all-cause mortality and cardiovascular events.

Effect of intradialytic exercise on daily physical activity and sleep quality in maintenance hemodialysis patients.

Physical inactivity and sleep disturbance are frequently observed and relate to poor clinical outcomes in maintenance hemodialysis patients. We aimed to investigate the effect of intradialytic exercise on daily physical activity and sleep quality, measured by an accelerometer, in maintenance hemodialysis patients. This study randomly assigned ambulatory maintenance hemodialysis patients aged≥20years on dialysis≥6months, without a hospitalization history for the previous 3months to 4 groups: aerobic exercise (AE), resistance exercise (RE), combination exercise (CE), and control. A stationary bike was used for AE and a TheraBand®/theraball for RE. A 12-week intradialytic exercise program (3 times/week) was completed in the AE (n=11), RE (n=10), and CE (n=12) groups. The control group (n=13) received only warm-up stretching. At baseline and 12-week follow-up, daily physical activity and sleep quality were measured with a triaxial accelerometer (wActiSleep-BT; ActiGraph, Pensacola, FL) during a continuous 7-day wear period. We observed a significant increase in metabolic equivalent (MET; kcal/h/kg) in the AE (1.02±0.03 vs 1.04±0.04, P=0.04) and CE (1.06±0.05 vs 1.09±0.08, P=0.01) groups at 12weeks compared with baseline. When comparing between-group changes in MET, there was a significant increase in METs in the CE group (0.03±0.03 vs - 0.01±0.04, P=0.02) compared with the control group. The total number of sedentary bouts (per week) decreased significantly in the AE (200±37 vs 174±36, P=0.01), RE (180±31 vs 130±49, P=0.03), and CE groups (180±45 vs 152±46, P=0.04) at 12weeks compared with baseline. The average sleep fragmentation index, indicating poor sleep quality, decreased significantly at 12weeks compared with baseline in the AE (51.4±8.0 vs 44.5±9.6, P=0.03) and RE groups (52.3±7.3 vs 40.0±15.4, P=0.01). Intradialytic exercise appears to be clinically beneficial in improving daily physical activity and sleep quality in maintenance hemodialysis patients.

Independent Association of Overhydration with All-Cause and Cardiovascular Mortality Adjusted for Global Left Ventricular Longitudinal Systolic Strain and E/E’ Ratio in Maintenance Hemodialysis Patients

Background/Aims: Fluid overload is common and associated with morbidity and mortality in patients with end-stage renal disease. The relationship between fluid overload and cardiac function is complex, and whether fluid overload is associated with adverse outcomes in patients undergoing hemodialysis (HD) independently of systolic and diastolic function of the left ventricle (LV) remains unclear. Methods: The present study aimed to investigate the relationship between overhydration and all-cause and cardiovascular (CV) mortality after adjusting for LV function in 178 maintenance HD patients. The relative hydration status (overhydration/ extracellular water, ∆HS) was measured using a body composition monitor, and then used to assess the fluid status. A ∆HS ≥7% was defined as fluid overload. Global left ventricular longitudinal systolic strain (GLS), and the early filling and early diastolic mitral annular velocity (E/E’) ratio were assessed using speckle-tracking and tissue Doppler echocardiography. Results: During a mean follow-up period of 2.7 years, 24 patients died, including 11 CV deaths. An increased ∆HS was significantly associated with all-cause and CV mortality in the univariate analysis. This prognostic significance remains after multivariate adjusting for GLS and E/E’ ratio for all-cause (HR, 1.123; 95% CI, 1.063–1.186; p-value < 0.001) and CV (HR, 1.088; 95% CI, 1.005–1.178; p-value =0.037) mortality. Moreover, ∆HS significantly improved the prognostic value beyond conventional clinical and echocardiographic parameters. Conclusion: A higher ∆HS was independently associated with increased all-cause and CV mortality after adjusting for systolic and diastolic function of the LV. This suggests that ∆HS may be a relevant target for improving outcomes in maintenance HD patients.

Associations of physical activity energy expenditure with nutritional-inflammatory markers in hemodialysis patients.

Sedentariness, high inflammation status and malnutrition are highly prevalent in end-stage kidney disease patients on maintenance hemodialysis (MHD). This study investigated associations of weekly physical activity energy expenditure (PAEE) with clinical and anthropometric markers of nutrition and inflammation. The analysis was performed using baseline cross-sectional data of 640 patients enrolled in the prospective cohort "The Prospective Study of the Prognosis of Patients Treated Chronically by Hemodialysis" (PROHEMO) developed in Salvador, BA, Brazil. The long version of the International Physical Activity Questionnaire was used to determine a summary measure of PAEE, the metabolic equivalent of task (MET), taking into account physical activities related to occupation, recreation, travel, sports, and housework. PAEE was the predictor variable. To assess associations of PAEE with outcomes, the sex-age-specific median MET was used. The malnutrition-inflammation score (MIS) with range of 0 to 30 (higher is worse), conicity index as indicator of abdominal adiposity and C-reactive protein (CRP) were the nutritional-inflammatory outcomes. The mean age of the patients was 48.9 ± 13.8 y, 60.3% were males, 16.7% diabetic, 88.1% nonwhite. In multivariable logistic regression models with adjustments for sociodemographic variables and comorbidities, PAEE ≤median was associated with MIS ≥6 (odds ratio [OR] = 1.57; 95% confidence interval [CI] = 1.08, 2.29), conicity index ≥1.3 (OR = 1.52, 95% CI = 1.03, 2.23) and CRP >1.30 mg/dL (OR = 1.69, 95% CI = 1.08, 2.84). Greater physical activity assessed by PAEE was associated with indicators of better nutritional and inflammation status. These results indicate opportunities for improving outcomes in MHD patients by counseling and treatment intervention.

Biochemical Markers and Cardiovascular Outcome in Maintenance Hemodialysis Patients

Biochemical Markers and Cardiovascular Outcome in Maintenance Hemodialysis Patients

Serum uric acid as a clinically useful nutritional marker and predictor of outcome in maintenance hemodialysis patients

ObjectiveThe importance of serum uric acid (SUA) for the maintenance of a hemodialysis (MHD) population has not been well established. The aim of this study was to determine if SUA levels are associated with nutritional risk and consequently with adverse clinical outcomes in MHD patients. MethodsThis was a 2-y prospective observational study, performed on 261 MHD outpatients (38.7% women) with a mean age of 68.6 ± 13.6 y. We measured prospective all-cause and cardiovascular (CV) hospitalization and mortality, nutritional scores (malnutrition-inflammation score [MIS) and geriatric nutritional risk index (GNRI), handgrip strength (HGS), and short-form 36 (SF36) quality-of-life (QoL) scores. ResultsSUA positively correlated with laboratory nutritional markers (albumin, creatinine), body composition parameters, HGS (r = 0.26; P < 0.001) and GNRI (r = 0.34; P < 0.001). SUA negatively correlated with MIS (r = −0.33; P < 0.001) and interleukin-6 (r = −0.13; P = 0.04). Patients in the highest SUA tertile had higher total SF-36 scores (P = 0.04), higher physical functioning (P = 0.003), and role-physical (P = 0.006) SF-36 scales. For each 1 mg/dL increase in baseline SUA levels, the first hospitalization hazard ratio (HR) was 0.79 (95% confidence interval [CI], 0.68–0.91) and first CV event HR was 0.60 (95% CI, 0.44–0.82); all-cause death HR was 0.55 (95% CI, 0.43–0.72) and CV death HR was 0.55 (95% CI, 0.35–0.80). Associations between SUA and mortality risk continued to be significant after adjustments for various confounders including MIS and interleukin-6. Cubic spline survival models confirmed the linear trends. ConclusionsIn MHD patients, SUA is a good nutritional marker and associates with body composition, muscle function, inflammation, and health-related QoL, upcoming hospitalizations, as well as independently predicting all-cause and CV death risk.

HDL cholesterol, apolipoproteins, and cardiovascular risk in hemodialysis patients.

High concentrations of HDL cholesterol are considered to indicate efficient reverse cholesterol transport and to protect from atherosclerosis. However, HDL has been suggested to be dysfunctional in ESRD. Hence, our main objective was to investigate the effect of HDL cholesterol on outcomes in maintenance hemodialysis patients with diabetes. Moreover, we investigated the associations between the major protein components of HDL (apoA1, apoA2, and apoC3) and end points. We performed an exploratory, post hoc analysis with 1255 participants (677 men and 578 women) of the German Diabetes Dialysis study. The mean age was 66.3 years and the mean body mass index was 28.0 kg/m(2). The primary end point was a composite of cardiac death, myocardial infarction, and stroke. The secondary end point included all-cause mortality. The mean duration of follow-up was 3.9 years. A total of 31.3% of the study participants reached the primary end point and 49.1% died from any cause. HDL cholesterol and apoA1 and apoC3 quartiles were not related to end points. However, there was a trend toward an inverse association between apoA2 and all-cause mortality. The hazard ratio for death from any cause in the fourth quartile compared with the first quartile of apoA2 was 0.63 (95% confidence interval, 0.40 to 0.89). The lack of an association between HDL cholesterol and cardiovascular risk may support the concept of dysfunctional HDL in hemodialysis. The possible beneficial effect of apoA2 on survival requires confirmation in future studies.

Daily physical activity and physical function in adult maintenance hemodialysis patients.

BackgroundMaintenance hemodialysis (MHD) patients reportedly display reduced daily physical activity (DPA) and physical performance. Low daily physical activity and decreased physical performance are each associated with worse outcomes in chronic kidney disease patients. Although daily physical activity and physical performance might be expected to be related, few studies have examined such relationships in MHD patients, and methods for examining daily physical activity often utilized questionnaires rather than activity monitors. We hypothesized that daily physical activity and physical performance are reduced and correlated with each other even in relatively healthier MHD patients.MethodsDaily physical activity, 6-min walk distance (6-MWT), sit-to-stand, and stair-climbing tests were measured in 72 MHD patients (32 % diabetics) with limited comorbidities and 39 normal adults of similar age and gender mix. Daily physical activity was examined by a physical activity monitor. The human activity profile was also employed.ResultsDaily physical activity with the activity monitor, time-averaged over 7 days, and all three physical performance tests were impaired in MHD patients, to about 60–70 % of normal values (p < 0.0001 for each measurement). Human activity profile scores were also impaired (p < 0.0001). MHD patients spent more time sleeping or in marked physical inactivity (p < 0.0001) and less time in ≥ moderate activity (p < 0.0001). These findings persisted when comparisons to normals were restricted to men or women separately. After adjustment, daily physical activity correlated with 6-MWT but not the two other physical performance tests. Human activity profile scores correlated more closely with all three performance tests than did DPA.ConclusionsEven in relatively healthy MHD patients, daily physical activity and physical performance are substantially impaired and correlated. Whether training that increases daily physical activity or physical performance will improve clinical outcome in MHD patients needs to be examined.

Survival and other clinical outcomes of maintenance hemodialysis patients in Taiwan: a 5-year multicenter follow-up study.

The increasing aging and diabetes mellitus (DM) patients in dialysis population make the quality maintenance of dialysis an imperative issue. Recently, an increasing number of dialysis centers were run by private dialysis providers, many of which apply quality assurance programs and performance management systems to dialysis care. We studied patients in dialysis facilities in Taiwan run by a private chain to see clinical outcomes of centers operating under these systemic strategies. Hemodialysis patients from January 1, 2008 to December 31, 2012 in 25 dialysis facilities in Taiwan, which received the management and consultation from a dialysis service provider, NephroCare (NC), were included. Data pivotal to quality of dialysis were analyzed. During a 5-year interval, 5161 hemodialysis patients were included. For volume control, the proportion of patients with weight gain ≥4.5% decreases from 41.7% to 30.2%. Mean Kt/V is 1.74 ± 0.28. Mean albumin level is 3.92 ± 0.38 g/dL. Patients with phosphate <5.5 mg/dL is up to 71.8%. The mean hemoglobin level is 10.70 ± 1.40 g/dL. More than 80% of patients have adequate iron status. Further, 73% of patients use native arteriovenous fistula. Hospitalization-free survival rate was 56% at the fifth year. Patient survival rate at the fifth year was 66.4%. Overall clinical performances were maintained very stable in NC facilities from this temporal data analysis. The hospitalization and survival rate also compare favorably with those reported internationally. These results warrant further studies to justify the application of this kind of quality assurance programs and performance management systems in dialysis care.

Bioimpedance phase angle predicts muscle function, quality of life and clinical outcome in maintenance hemodialysis patients

The association of bioimpedance phase angle (PA), as a measure of nutritional status, with muscle function, health-related quality of life (QoL) and subsequent clinical outcomes in maintenance hemodialysis (MHD) patients. A 2-year prospective observational study on 250 MHD outpatients (36.8% women) with a mean age of 68.7±13.6 years. Prospective all-cause and cardiovascular (CV) hospitalization and mortality, malnutrition-inflammation score (MIS), handgrip strength (HGS), bioimpedance and short form 36 (SF-36) QoL scores were the study's measurements. Across the three PA tertile groups, HGS was incrementally higher in the higher PA tertiles (P<0.001), maintaining this order in both male (r=0.38, P<0.001) and female patients (r=0.36, P<0.001). Better self-reported QoL was noted with higher PA values. This trend was prominent in total score (P<0.001), mental health (P=0.005) and physical health (P<0.001) dimensions, and in most of the SF-36 scales. For each 1° increase in baseline PA, the first hospitalization hazard ratio (HR) was 0.79 (95% confidence interval (CI), 0.68-0.91) and first CV event HR was 0.70 (95% CI, 0.52-0.95); all-cause death HR was 0.63 (95% CI, 0.48-0.81) and CV death HR was 0.64 (95% CI, 0.44-0.91). Associations between PA and morbidity risk continued to be significant after adjustments for various confounders, but the association between PA and mortality risk was abolished after adding MIS to the multivariable model. For the MHD population, PA emerged as a useful predictor for impaired muscle function, health-related Qol, upcoming hospitalizations and mortality.

Hyperphosphatemia - The Risk Factor for Adverse Outcome in Maintenance Hemodialysis Patients

Hyperphosphatemia - The Risk Factor for Adverse Outcome in Maintenance Hemodialysis PatientsHyperphosphatemia is a potent stimulator of vascular and valvular calcifications in hemodialysis patients. To determine the prevalence of hyperphosphatemia and assess its effect on the outcome of hemodialysis patients, a total of 115 chronic hemodialysis patients were studied. Laboratory parameters were determined at baseline, and after 12 and 24 months of follow-up. Valvular calcification was assessed with echocardiography. Laboratory parameters were statistically analyzed with ANOVA. Survival analysis was performed with the Kaplan-Meier test and Log-Rank test. Hyperphosphatemia was present in 31.30% of the patients, high calcium-phosphate (Ca × P) product in 36.52% and valvular calcifications in 48.70%. Patients with serum phosphate &gt;2.10 mmol/L and Ca × P product &gt;5.65 mmol2/L2at baseline were at high risk for all-cause and cardiovascular mortality. Hyperphosphatemia is a risk factor for adverse outcome in patients on regular hemodialysis.

Vitamin E-Related Inhibition of Monocyte 5-Lipoxygenase and Cardiovascular Outcome in Maintenance Hemodialysis Patients

A daily supplement of vitamin E is recommended for the secondary prevention of cardiovascular events in end-stage renal disease patients on maintenance hemodialysis. Vitamin E has been entrusted with therapeutic properties against cardiovascular disease for more than 60 years. Several epidemiological studies and intervention trials have been performed with vitamin E, and some of them showed that it prevents atherosclerosis. For a long time, vitamin E was assumed to act by decreasing the oxidation of low-density lipoproteins, a key step in atherosclerosis initiation. However, at the cellular level vitamin E interferes with smooth muscle cell proliferation, platelet aggregation, monocyte adhesion, and oxidized low-density lipoproteins uptake and cytokine production, all reactions implied in the progression of atherosclerosis. Recent research points out that these effects may be not only the result of the antioxidant activity of vitamin E but also of its distinct molecular actions. These biological properties of vitamin E may allow to design better strategies for primary and secondary prevention of cardiovascular disease, with a potential exploitation of vitamin E supplements in primary and secondary prevention of major adverse cardiovascular events in all uremic patients. In this review, we also outline relevant patents on vitamin E and lipoxygenase inhibitors.

Fetuin-A, coronary artery calcification and outcome in maintenance hemodialysis patients

Previous studies have suggested that serum fetuin-A, a calcification inhibitor, predicts mortality in dialysis patients. This study investigated the relationships between fetuin-A, vascular calcification, and outcome in such patients. 58 patients on maintenance hemodialysis underwent multirow spiral computed tomography to determine baseline coronary artery calcification (CAC) score. Serum fetuin-A was measured repeatedly over time. Time-averaged fetuin-A inversely correlated with age and baseline CAC score. After partial correlation analysis controlling for age, the association between fetuin-A and CAC became insignificant. During the study, 27 of 58 patients died and 26 experienced at least one cardiovascular event. Low fetuin-A was associated with a significant increase in all-cause mortality and the occurrence of a cardiovascular event. The association of fetuin-A with mortality and cardiovascular event remained significant even when adjusting for confounding factors, including age and CAC score. Time-averaged fetuin-A was associated with survival and cardiovascular outcome, independent of vascular calcification.

Resource settings have a major influence on the outcome of maintenance hemodialysis patients in South India

Chronic kidney disease is reaching epidemic proportions and the number of patients on renal replacement therapy (RRT) is increasing worldwide and also in developing countries. To meet the challenge of providing RRT, a few charity organizations provide hemodialysis units for underprivileged patients, as the private hospitals are unaffordable for the majority. There is a paucity of information on the outcome of dialysis in these patients. Here, we describe the outcome of hemodialysis patients comparing the middle- and upper-class income group with the lower class income group. A retrospective analysis was carried out in 558 CKD patients initiated on maintenance hemodialysis in two different dialysis facilities. Group A (n=247) included those who belonged to the lowermost socioeconomic status and were undergoing dialysis in two nonprofit, charity (TANKER)-run dialysis units, and Group B (n=311) was undergoing dialysis in a nonprofit hospital setting where no subsidy was given. Those patients of a low socioeconomic status, especially those who are diabetics, have a higher death rate (Group A-38.1%, Group B-4.2%) and loss to follow-up (Group A-25.9%, Group B-0.3%) compared with those who are in the middle- and high-income group. Higher EPO use and hence higher hemoglobin levels (Group A-6.4+/-1.2, Group B-8.9+/-1.5 P<0.001) were observed in those who were in the middle and the higher income group. Lower serum phosphorus level was observed in the low-socioeconomic group (Group A-4.7+/-1.5, Group B-5.5+/-1.9, P<0.001). Patients belonging to the middle and higher socioeconomic group undergo more transplantations compared with the lower socioeconomic group (Group A-2.4%, Group B-65.6%).