Outcomes In Hemodialysis Research Articles

Safety and efficacy of hemodialysis and peritoneal dialysis in treating end-stage diabetic nephropathy: a meta-analysis of randomized controlled trials.

Present investigation aims to elucidate safety and efficacy of hemodialysis as well as peritoneal dialysis in treating end-stage diabetic nephropathy. We searched various databases for articles from the database starting date to October 2019. The analysis involved studies that contained outcomes of hemodialysis and peritoneal dialysis in the treatment of end-stage diabetic nephropathy. A total of 12 randomized controlled trials (RCTs) with 932 participants were collected. Meta-analysis results suggested that comparing with peritoneal dialysis group, hemodialysis group had a higher incidence of cardiovascular and cerebrovascular events and bleeding complications. There was no statistically significant difference regarding the infection (P = 0.71) or malnutrition (P = 0.53) incidence between the two forms of dialysis. Hemodialysis could better improve the levels of albumin [mean difference (MD) = 6.80, 95% CI = (4.17-9.44)] and hemoglobin [MD = 3.40, 95% CI = (0.94-5.86)] than peritoneal dialysis after 3months or more. In treating end-stage diabetic nephropathy patients, peritoneal dialysis had a lower incidence of cardiovascular and cerebrovascular events, as well as bleeding complication than hemodialysis. However, hemodialysis could better improve albumin and hemoglobin levels than peritoneal dialysis after 3months.

β-Blocker Use and Cardiovascular Outcomes in Hemodialysis: A Systematic Review

Rationale & ObjectiveThere is conflicting evidence regarding the type of β-blockers to use in dialysis patients. This systematic review seeks to determine whether highly dialyzable β-blockers are associated with higher rates of cardiovascular events and mortality in hemodialysis patients than poorly dialyzable β-blockers.Study DesignA systematic review of the existing literature was conducted. A meta-analysis was performed using data from the selected studies.Setting & Study PopulationsParticipants were from the United States, Canada, and Taiwan. The mean ages of participants ranged from 55.9-75.7 years.Selection Criteria for StudiesWe searched the Ovid MEDLINE database from 1990 to September 2020. Studies without adult hemodialysis participants and without comparisons of at least 2 β-blockers of different dialyzability were excluded.Data ExtractionBaseline and adjusted outcome data were extracted from each study.Analytical ApproachRandom-effects models were used to calculate pooled risk ratios using fully adjusted models from individual studies.ResultsFour cohort studies were included. Pooling fully adjusted models, highly dialyzable β-blockers did not influence mortality (HR, 0.94; 95% CI, 0.81-1.08; I2 = 0.84) compared with poorly dialyzable β-blockers but were associated with a reduction in cardiovascular events (HR, 0.88; 95% CI, 0.83-0.93). There was significant heterogeneity between studies (I2 = 0.35). Only 1 study reported on adverse events. Intradialytic hypotension was more common in those on carvedilol (a poorly dialyzable β-blocker) compared with those on metoprolol (a highly dialyzable β-blocker; adjusted incidence rate ratio, 1.10; 95% CI, 1.09-1.11).LimitationsNo randomized controlled trials were identified. Each study used different analytic methods and different definitions for outcomes. Classifications of β-blockers varied. Only 1 study reported on adverse events.ConclusionsPooled data suggest highly dialyzable β-blockers are associated with similar mortality events and fewer cardiovascular events compared with poorly dialyzable β-blockers.

Short-term Outcomes Of Intermittent Hemodialysis In Patients With Ventricular Assist Devices

<h3>Introduction</h3> There is little evidence about the short-term outcomes of patients undergoing implantation of ventricular assist devices (VADs) who require initiation of chronic intermittent hemodialysis (IHD). Filling this knowledge gap may help anticipate potential complications and improve outcomes. <h3>Methods</h3> This is a chart review, retrospective study that included all patients who underwent VAD implantation followed by initiation of IHD at our center. Intermittent hemodialysis was defined as ≤6-hour sessions, 3-4 times weekly. Continuous renal replacement therapy (CRRT) did not meet this inclusion criteria. Continuous and categorical variables were expressed in means (standard deviation) and numbers (%), respectively. <h3>Results</h3> Among the 11 patients that met inclusion criteria, 6 (54.6%) were female, 6 (54.6%) were African American, 6 (54.6%) had non-ischemic cardiomyopathy, 6 were being bridged to HT, and 9 (81.8%) had chronic kidney disease. Home regimen was available for 10 patients, all of whom were taking loop diuretics, but only 7 (70%) and 3 (30%) of them had medical regimens with ACEIs or ARBs, and spironolactone, respectively. All patients received tunneled catheters, and in 2 of them AV fistulas were performed afterwards. At least 3 patients experienced asymptomatic hypotension (<60 mm Hg) during the first 10 IHD sessions, leading to finishing the session early in one of the cases. Another patient had catheter thrombosis leading to catheter exchange. No other major event was documented during the 10 initial IHD sessions. One patient started IHD outpatient without complications. Among the 10 (90.9%) patients who started IHD during index hospitalization, the length of hospital stay was 81.5 (±40.7) days, and their most relevant complications were death (1), stroke (1), infections (5), gastrointestinal bleeding (4), right ventricular failure (2), and tracheostomy (1). For those who started IHD during index hospitalization, time to first readmission was 44.6 (±36.3) days, with 4 (44.4%) patients being readmitted within 30 days, and 1 of them dying during the first readmission. Additional information is found in Table 1. <h3>Conclusions</h3> This study confirms feasibility of IHD initiation after VAD implantation, even as outpatient, but also proves a high burden of morbidity during index hospitalization and short-term follow up. Larger studies prospective studies with the newest VADs could provide valuable insight into this strategy for left ventricular and renal replacement therapies.

Outcomes Of Intermittent Hemodialysis During Support With Ventricular Assist Devices: A Potential Bridge To Heart/kidney Transplantation?

Introduction Severe renal dysfunction is a contraindication for receiving ventricular assist devices (VADs). Hence, patients with end-stage heart failure (ESHF) and severe renal dysfunction who are not candidates for heart/kidney transplantation (HT/KT) may only be considered for either intermittent hemodialysis (IHD) or hospice. However, there is little evidence about the outcomes of patients with ESHF who are initiated on IHD after VAD implantation. Methods We reviewed the medical charts of all patients in our center who received IHD after VAD implantation. We considered IHD <6-hour sessions 3-4 times weekly, excluding continuous renal replacement therapy (CRRT). Continuous variables were expressed in means and standard deviations, or medians and p25-p75, according to their distribution. Categorical variables were represented in absolute numbers and percentages. Results Eleven patients (54.1 [±9.9] years of age, 6 [54.6%] women, and 6 [54.6%] African American) underwent VAD implantation as destination therapy (40%) or bridge to transplant (60%) and received IHD. Seven (63.6%) of them received HeartMate II, whereas the other patients were supported with HVAD HeartWare, and HeartMate 3 systems. By the time of VAD implantation, nine (81.8%) patients had history of chronic kidney disease with a median GFR was 60 (45-60) mL/min/1.73 m2 and a mean creatinine was 1.2 (±0.4) mg/dL. The mean outpatient furosemide-dose equivalent prior VAD implantation was 106 (±59.7) mg/day. Ten patients started IHD prior to discharge after VAD placement with a median time from VAD implantation to initiation of IHD was 26 (17-50) days. Another patient was initiated on IHD as outpatient within a year after receiving a VAD. Eight (72.7%) patients died during a follow-up of 886.7 (±762.1) days after initiation of IHD with a median survival time of 838 days. Three patients were bridged to transplantation: 2 HT/KT, and 1 HT (recovered renal function). Details about the timeline of events can be found in Fig 1. Conclusions Intermittent hemodialysis helped to bridge 2 VAD patients to HT/KT, and another to HT and recovery of renal function. Larger studies could provide valuable insight into this potential strategy to widen the options of advanced heart failure therapies for patients with ESHF. Severe renal dysfunction is a contraindication for receiving ventricular assist devices (VADs). Hence, patients with end-stage heart failure (ESHF) and severe renal dysfunction who are not candidates for heart/kidney transplantation (HT/KT) may only be considered for either intermittent hemodialysis (IHD) or hospice. However, there is little evidence about the outcomes of patients with ESHF who are initiated on IHD after VAD implantation. We reviewed the medical charts of all patients in our center who received IHD after VAD implantation. We considered IHD <6-hour sessions 3-4 times weekly, excluding continuous renal replacement therapy (CRRT). Continuous variables were expressed in means and standard deviations, or medians and p25-p75, according to their distribution. Categorical variables were represented in absolute numbers and percentages. Eleven patients (54.1 [±9.9] years of age, 6 [54.6%] women, and 6 [54.6%] African American) underwent VAD implantation as destination therapy (40%) or bridge to transplant (60%) and received IHD. Seven (63.6%) of them received HeartMate II, whereas the other patients were supported with HVAD HeartWare, and HeartMate 3 systems. By the time of VAD implantation, nine (81.8%) patients had history of chronic kidney disease with a median GFR was 60 (45-60) mL/min/1.73 m2 and a mean creatinine was 1.2 (±0.4) mg/dL. The mean outpatient furosemide-dose equivalent prior VAD implantation was 106 (±59.7) mg/day. Ten patients started IHD prior to discharge after VAD placement with a median time from VAD implantation to initiation of IHD was 26 (17-50) days. Another patient was initiated on IHD as outpatient within a year after receiving a VAD. Eight (72.7%) patients died during a follow-up of 886.7 (±762.1) days after initiation of IHD with a median survival time of 838 days. Three patients were bridged to transplantation: 2 HT/KT, and 1 HT (recovered renal function). Details about the timeline of events can be found in Fig 1. Intermittent hemodialysis helped to bridge 2 VAD patients to HT/KT, and another to HT and recovery of renal function. Larger studies could provide valuable insight into this potential strategy to widen the options of advanced heart failure therapies for patients with ESHF.

Survival outcome of haemodialysis and peritoneal dialysis

End-stage renal disease (ESRD) is a challenging and growing health issue, with number of patients increasing globally. The use of dialysis has greatly improved the survival and life expectancy of ESRD patients. Haemodialysis (HD) and peritoneal dialysis (PD) are 2 broad dialysis modalities used for ESRD. Despite the advancement and proliferation of both modalities over

Identifying the Association of Time-Averaged Serum Albumin Levels with Clinical Factors among Patients on Hemodialysis Using Whale Optimization Algorithm

Time-averaged serum albumin (TSA) is commonly associated with clinical outcomes in hemodialysis (HD) patients and considered as a surrogate indicator of nutritional status. The whale optimization algorithm-based feature selection (WOFS) model could address the complex association between the clinical factors, and could further combine with regression models for application. The present study aimed to demonstrate an optimal multifactor TSA-associated model, in order to interpret the complex association between TSA and clinical factors among HD patients. A total of 829 HD patients who met the inclusion criteria were selected for analysis. Monthly serum albumin data tracked from January 2009 to December 2013 were converted into TSA categories based on a critical value of 3.5 g/dL. Multivariate logistic regression was used to analyze the association between TSA categories and multiple clinical factors using three types of feature selection models, namely the fully adjusted, stepwise, and WOFS models. Five features, albumin, age, creatinine, potassium, and HD adequacy index (Kt/V level), were selected from fifteen clinical factors by the WOFS model, which is the minimum number of selected features required in multivariate regression models for optimal multifactor model construction. The WOFS model yielded the lowest Akaike information criterion (AIC) value, which indicated that the WOFS model could achieve superior performance in the multifactor analysis of TSA for HD patients. In conclusion, the application of the optimal multifactor TSA-associated model could facilitate nutritional status monitoring in HD patients.

Feasibility and safety of coronary catheterization with the distal radial approach for hemodialysis patients

BackgroundThe distal radial approach (DRA) has been proposed as an alternative approach for coronary angiography (CAG) and percutaneous coronary intervention (PCI). However, its outcomes in hemodialysis (HD) patients have not been well studied in detail. We aimed to determine the feasibility and safety of coronary intervention with the DRA for HD patients. MethodsWe performed CAG or PCI with the DRA in 2500 consecutive patients between October 2018 and February 2020. The patients included 98 HD patients (HD group) and 2402 non-HD patients (non-HD group). The primary endpoints were the rates of procedural success and puncture site-related complications. The secondary endpoints were puncture site-related complications one year after the procedure. As a subanalysis, we also compared the outcomes on the basis of CAG and PCI. ResultsThe procedural success rates were similar in the HD and non-HD groups (80.6% vs. 82.6%, p = 0.61 for the entire cohort; 78.3% vs. 80.9%, p = 0.58 for CAG; and 86.2% vs. 88.0%, p = 0.78 for PCI). The bleeding complications rates were low and there was no difference between groups (6.1% vs. 4.1%, p = 0.33 for the entire cohort; 0% vs. 2.2%, p = 0.21 for CAG; and 20.7% vs. 10.3%, p = 0.079 for PCI). Radial artery occlusion occurred in only one patient in the HD group after the procedure. ConclusionsAlthough modified hemostasis methods could be necessary for HD patients undergoing PCI, coronary intervention with the DRA is feasible and safe for both HD and non-HD patients.

Associations, microbiology and outcomes of pre-training peritoneal dialysis-related peritonitis.

Pre-training peritonitis (PTP), defined as peritonitis that occurred after catheter insertion and before peritoneal dialysis (PD) training, is increasingly recognized as a risk factor for adverse patient outcomes, yet poorly understood with limited studies conducted to date. This study was conducted to identify the associations, microbiologic profiles and outcomes of PTP compared to post-training peritonitis. This single-centre, case-control study involved patients with kidney failure who had PD as their first kidney replacement therapy and had experienced an episode of PD peritonitis between 1 January 2005 and 31 December 2015. Individuals experiencing their first episode of peritonitis were included in the study and categorized according to whether it occurred pre- or post-training. The primary outcome was peritonitis cure rates and composite outcome of hemodialysis (HD) transfer for ≥30 days or death. The secondary outcomes included catheter removal and refractory peritonitis rates. Among 683 patients who received PD for the first time, 121 (17.7%) had PTP while 265 (38.8%) had post-training peritonitis. PTP patients were more likely to have had exit-site infection (ESI) prior to peritonitis (24.8% compared to 17% in the post-training peritonitis group, p = 0.2). Culture-negative peritonitis was significantly more common in the PTP patients (53.7%) than in the post-training group (27.3%, p < 0.001). The cure was achieved in 68.9% of cases and was not significantly different between the PTP and post-training peritonitis groups (66.1% vs. 70.2%; OR 0.83, 95% CI 0.51-1.35). Lower odds of cure were associated with peritonitis caused by moderate and high severity organisms (OR 0.49, 95% CI 0.29-0.85; OR 0.18, 95% CI 0.08-0.43, respectively). Composite outcome of HD transfer or death was more commonly observed among patients with PTP (87.5% vs. 75.8%; OR 2.2, 95% CI 1.20-4.48) in whom significantly shorter median time to HD transfer was observed (PTP 10.7 months vs. post-training peritonitis 21.9 months, p < 0.0001). PTP is a common condition that is highly associated with preceding ESI, is frequently culture-negative and is associated with worse composite outcome of HD transfer or death. PTP rates should be routinely monitored and reported by PD units for continuous quality improvement.

Epidemiology of haemodialysis outcomes.

Haemodialysis (HD) is the commonest form of kidney replacement therapy in the world, accounting for approximately 69% of all kidney replacement therapy and 89% of all dialysis. Over the last six decades since the inception of HD, dialysis technology and patient access to the therapy have advanced considerably, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes vary widely across the world and, overall, the rates of impaired quality of life, morbidity and mortality are high. Cardiovascular disease affects more than two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality. In addition, patients on HD have high symptom loads and are often under considerable financial strain. Despite the many advances in HD technology and delivery systems that have been achieved since the treatment was first developed, poor outcomes among patients receiving HD remain a major public health concern. Understanding the epidemiology of HD outcomes, why they might vary across different populations and how they might be improved is therefore crucial, although this goal is hampered by the considerable heterogeneity in the monitoring and reporting of these outcomes across settings.

Neutrophil:lymphocyte ratio correlates with the uremic toxin indoxyl sulfate and predicts the risk of death in patients on hemodialysis.

Chronic kidney disease (CKD) is a major public health issue associated with increased cardiovascular, infectious and all-cause mortality. The neutrophil:lymphocyte ratio (NLR) is a predictive marker of the risk of death and cardiovascular events. Uremic toxins, notably indoxyl sulfate (IS), are involved in immune deficiency and cardiovascular complications associated with CKD. The aim of this study was to assess whether the NLR was related to uremic toxins and could predict clinical outcome in hemodialysis (HD) patients. We conducted a prospective cohort study of 183 patients on chronic HD. The main objective was to study the correlation between the NLR and uremic toxin serum levels. The secondary objective was to test if the NLR can predict the incidence of mortality, cardiovascular events and infectious events. Patients were separated into two groups according to the NLR median value (3.49). The NLR at inclusion was correlated with the NLR at the 6-month (r=0.55, P<0.0001) and 12-month (r=0.62, P<0.0001) follow-up. Among uremic toxins, IS levels were higher in the group with high NLR (104µmol/L versus 81µmol/L; P=0.004). In multivariate analysis, the NLR remained correlated with IS (P=0.03). The incidence of death, cardiovascular events and severe infectious events was higher in the group with high NLR [respectively, 38%versus 18% (P=0.004), 45%versus 26% (P=0.01) and 33%versus 21% (P=0.02)] than in the low NLR group. Multivariate analysis showed an independent association of the NLR with mortality (P=0.02) and cardiovascular events (P=0.03) but not with severe infectious events. In HD patients, the NLR predicted mortality and cardiovascular events but not severe infections and correlated positively with the level of the uremic toxin IS. The NLR could be an interesting marker for monitoring the risk of clinical events in CKD patients.

POS-557 COVID-19 IN HEMODIALYSIS PATIENTS: CLINICAL PARTICULARITIES AND OUTCOMES

The pandemic coronavirus infection (COVID-19), like the general population, has affected the care and outcomes of hemodialysis (HD) patients. Their high vulnerability is due to their comorbidities and circumstances limiting physical distancing during dialysis and therefore increases the risk of being exposed to COVID-19 infection. This study aims to report clinical particularities of covid-19 infection in our HD patients.

Relative validity and reproducibility of food frequency questionnaire for individuals on hemodialysis (NUGE-HD study).

Adequate assessment of food intake is essential to establish the magnitude and direction of the relationship of food, nutrients, and bioactive compounds with clinical outcomes of individuals in hemodialysis. We evaluated the relative validity and reproducibility of a specific food frequency questionnaire for individuals on hemodialysis (FFQ-HD). Eighty-two participants (57.3% male, 57.5 ± 14.4 years) from the open cohort Nutrition and Genetics in Hemodialysis Outcomes participated in this study. The relative validity of the FFQ-HD was assessed using the mean of two 24-h food recall (24hR) adjusted for within-subject variability as a reference method. We also performed Pearson correlations, and agreement between tertile, kappa statistics, and Bland-Altman scatter plots were validated. Reproducibility was assessed after 1 year using intraclass correlation coefficient (ICC). Daily energy intake was not different between FFQ-HD and 24hR (mean difference of 50.1kcal). Intake of protein, linolenic acid, fiber, phosphorus, potassium, sodium, calcium, and sugar showed a moderate correlation (r between 0.4 and 0.5) among instruments, while mean correlation coefficient was r=0.38 to food group intake. Bland-Altman plots showed good agreement for micronutrients, phosphorus, sodium, and potassium and for the groups "flour, bread, and pasta" and "processed, canned meat, salts, and seasonings". The reproducibility of FFQ-HD for nutrients and food groups was satisfactory, reaching a maximum ICC of 0.72 and 0.59, respectively. The FFQ-HD showed moderate validity and reproducibility for calories, nutrients, and food groups of clinical and nutritional interest for HD subjects so that it can be a useful tool in epidemiological studies in this population.

Comparison of a Kidney Replacement Therapy Risk Score Developed in Kaiser Permanente Northwest vs Estimated Glomerular Filtration Rate in Advanced Chronic Kidney Disease Using Decision Curve Analysis

Introduction:Use of kidney replacement therapy (KRT) prediction models for guiding arteriovenous fistula (AVF) referrals in advanced chronic kidney disease (CKD) is unknown. We aimed to compare a hypothetical approach using a KRT prediction model developed in Kaiser Permanente Northwest to estimated glomerular filtration rate (eGFR) for AVF referrals.Methods:Our retrospective cohort consisted of patients with stage G4 CKD in Kaiser Permanente Northwest followed by nephrology. Two-year KRT risk was calculated at each nephrology visit up to 2 years from entrance into cohort based on a previously published model. We calculated sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) based on several 2-year KRT risk and eGFR cutoffs for outcome of hemodialysis at 18 months. We compared an approach of AVF referral using 2-year KRT risk and eGFR cutoffs using decision curve analysis.Results:Two-year KRT risk better discriminated progression to hemodialysis compared to eGFR < 15 mL/min (AUC 0.60 vs 0.69 at 2-year KRT risk > 20% and 0.69 at 2-year KRT risk > 40%, p = 0.003 and 0.006, respectively) but not to eGFR of 20 mL/min (AUC 0.64, p = 0.16 and 0.19, respectively). Decision curve analysis showed that AVF referral guided by 2-year KRT risk score resulted in higher net benefit compared to eGFR at low thresholds for referral.Conclusion:In stage G4 CKD, a 2-year KRT risk model better predicted progression to KRT at 18 months compared to an eGFR of 15 mL/min but not to 20 mL/min and may improve timely referral for AVF placement in patients at lower thresholds for referral.

Clinical Profile and Outcome in Long-term Hemodialysis: A Comparative Study of Hospital-based Versus Standalone Units.

Introduction:Chronic hemodialysis (CHD) remains the most “resorted to“ renal-replacement option in India. Pursuit for accessible and affordable dialysis has resulted in setting up standalone centers (SACs). We need more Indian data on the profile of CHD population and outcome of SAC compared to hospital-based units (HBUs).Material and Methods:We analyzed the clinical profile of patients on CHD for >5 years, compared the outcome between HBU and SAC, and analyzed the factors associated with mortality. Patients initiated between January 1, 2006 and December 31, 2012 and who have survived 5 years on CHD at HBU or SAC were enrolled and followed up prospectively for 2 years. Their clinical and biochemical profile, comorbidities, long-term complications, and mortality were analyzed.Results:The study included 137 patients, 41 (30%) from HBU and 96 (70%) from SACs. In both groups, the patients were predominantly male, aged 51–70 yrs, diabetic, unplanned initiation through catheters, and had average-dialysis vintage between 83 and 85 months. SAC had more patients with hemoglobin (> 11 gm/dL) and hyperparathyroidism with elevated SAP levels (P < 0.05). Both groups had comparable iron stores, serum calcium, and phosphorus. Comparable between groups, infections, coronary artery disease, and access complications accounted for most hospitalizations and sudden cardiac death and sepsis accounted for most mortality. A trend of better survival was seen in SAC. Multivariate analysis showed anemia, DM and hospitalizations were associated with mortality.Conclusion:We conclude that the outcomes of long-term CHD at SACs are not inferior to HBUs. Anemia, diabetes, and hospitalizations were associated with overall mortality. Benefits of SACs in cost, QOL, and employment opportunities need to be studied in the Indian context.

Timing of Antihypertensive Medications on Key Outcomes in Hemodialysis: A Cluster Randomized Trial.

We conducted this study to examine the effect of taking versus holding BP medications before hemodialysis on intradialytic hypotension (IDH). In this cluster randomized trial, each dialysis unit was randomly designated as TAKE or HOLD units. Participants within a TAKE unit were instructed to take all BP medications as prescribed, whereas participants within a HOLD unit were instructed to hold medications dosed more than once daily before hemodialysis. The intervention lasted for 4 weeks. We hypothesized that TAKE would be noninferior to HOLD on the primary outcome of asymptomatic IDH, defined as ≥30% of sessions with nadir systolic BP <90 mm Hg and on the following secondary outcomes: uncontrolled hypertension (predialysis systolic BP >160 mm Hg), failure to achieve dry weight, and shortened dialysis sessions. We randomized 10 dialysis units in a 1:1 ratio to TAKE or HOLD, which included 65 participants in TAKE and 66 participants in HOLD. We did not show that TAKE was noninferior to HOLD for the primary IDH outcome (mean unadjusted difference of 8%; 95% CI, -3% to 19%). TAKE was superior to HOLD for the outcome of uncontrolled hypertension (mean unadjusted difference of -15%, 95% CI, -28% to -1%). TAKE was noninferior to HOLD for the outcomes of failure to achieve dry weight and shortened dialysis sessions. In this cluster randomized trial that randomized patients to either taking or holding BP medications before hemodialysis, a strategy of taking BP medications dosed more than once daily was not noninferior to holding BP medications for the primary outcome of IDH, but did reduce the occurrence of uncontrolled hypertension. Whether any potential benefit of holding BP medications on reducing IDH is offset by any potential harm related to higher predialysis BP remains to be seen.

Bilateral Internal Thoracic Artery Grafting in Hemodialysis Patients.

We compared postoperative outcomes in hemodialysis (HD) patients who underwent isolated coronary artery bypass grafting (CABG) for multivessel disease using either bilateral or single skeletonized internal thoracic artery.Methods and Results:Among 1,486 patients who underwent isolated CABG between 2002 and 2020, 145 HD patients were retrospectively analyzed. After inverse probability of treatment weighting, there were no significant differences in the preoperative characteristics. No significant differences in 30-day mortality (P=0.551) or postoperative deep sternal wound infection (P=0.778) were observed. However, the bilateral internal thoracic artery grafting group had a lower postoperative stroke rate (0% vs. 4.0%, P=0.019). No significant differences in freedom from all-cause death (P=0.760) and cardiac death (P=0.863) were found. In the multivariate Cox proportional hazards models, bilateral internal thoracic artery grafting was not associated with all-cause death (P=0.246) or cardiac death (P=0.435). Bilateral internal thoracic artery grafting in HD patients did not improve mid-term outcomes, but it was also not associated with worse postoperative outcomes. Use of the bilateral internal thoracic artery may be an important option in patients with limited conduits to prevent postoperative complications.

Blood flow rate: An independent risk factor of mortality in Chinese hemodialysis patients.

Studies suggested the association between blood flow rate (BFR) and mortality might be beyond dialysis adequacy. This study aimed to explore if BFR is an independent predictor of clinical outcomes in Chinese hemodialysis (HD) patients. This study included data from patients in China Dialysis Outcomes and Practice Patterns Study (DOPPS) Phase 5. Patients with a record of BFR were included, and demographic data, comorbidities, hospitalization, and death records were collected. Associations between BFR and all-cause mortality and hospitalization were analyzed using Cox regression models. One thousand four hundred twelve (98.9%) patients were included. Most patients were with BFR < 300 ml/min. After full adjustment, each 10-ml/min increase of BFR was associated with a 6.4% decrease in all-cause mortality risk (HR: 0.936, 95% CI: 0.880-0.996) but not first hospitalization (HR: 0.987, 95% CI: 0.949-1.027). The impact of BFR on mortality may be more prominent in patients who were male gender, nondiabetic, albumin < 4.0 g/dl, and hemoglobin ≥ 9.0 g/dl. Increased BFR is independently associated with a lower risk of all-cause mortality within the range of BFR 200-300 ml/min. And this effect is more pronounced in patients who were male gender, nondiabetic, albumin < 4.0 g/dl, and hemoglobin ≥ 9.0 g/dl.

The Impact of Frailty on Prognosis in Elderly Hemodialysis Patients: A Prospective Cohort Study.

PurposeTo explore the impact of frailty on adverse outcomes in elderly hemodialysis (HD) patients.Patients and MethodsAn observational and prospective cohort study was conducted in elderly patients (≥60) with HD, with an average 12-month follow-up. Fried frailty phenotype (FFP) was used to define frailty. Negative binomial regression was used to estimate the impact of frailty on the incidence of emergency visits, hospitalizations, acute cardiovascular events, and falls within a year. Cox regression analysis was used to assess the influence of frailty on all-cause mortality in elderly HD patients.ResultsOur study enrolled 150 elderly HD patients, and the prevalence of frailty was 34.7%. After adjustment, frailty was independently associated with increased all-cause mortality [hazard ratio (HR)=4.10, 95% CI: 1.09–15.43, p=0.037] and emergency visits [incidence rate ratio (IRR)=2.78 95% CI: 1.70–4.60, p<0.001]. Gait speed was an independent risk factor for all-cause deaths (HR=5.56 95% CI: 1.41–22.00, p=0.014), emergency visits (IRR=2.52 95% CI: 1.48–4.33, p<0.001), and hospitalizations (IRR=2.24, 95% CI: 1.19–4.21, p=0.010) in elderly HD patients.ConclusionFrailty was an independent indicator of all-cause mortality and emergency visits in elderly patients with HD.

5-Year Outcomes Comparing Surgical Versus Transcatheter Aortic Valve Replacement in Patients With Chronic Kidney Disease

The aim of this study was to compare 5-year cardiovascular, renal, and bioprosthetic valve durability outcomes in patients with severe aortic stenosis (AS) and chronic kidney disease (CKD) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).Patients with severe AS and CKD undergoing TAVR or SAVR are a challenging, understudied clinical subset.Intermediate-risk patients with moderate to severe CKD (estimated glomerular filtration rate <60 mL/min/m2) from the PARTNER (Placement of Aortic Transcatheter Valve) 2A trial (patients randomly assigned to SAPIEN XT TAVR or SAVR) and SAPIEN 3 Intermediate Risk Registry were pooled. The composite primary outcome of death, stroke, rehospitalization, and new hemodialysis was evaluated using Cox regression analysis. Patients with and without perioperative acute kidney injury (AKI) were followed through 5 years. A core laboratory-adjudicated analysis of structural valve deterioration and bioprosthetic valve failure was also performed.The study population included 1,045 TAVR patients (512 SAPIEN XT, 533 SAPIEN 3) and 479 SAVR patients. At 5 years, SAVR was better than SAPIEN XT TAVR (52.8% vs 68.0%; P = 0.04) but similar to SAPIEN 3 TAVR (52.8% vs 58.7%; P = 0.89). Perioperative AKI was more common after SAVR than TAVR (26.3% vs 10.3%; P < 0.001) and was independently associated with long-term outcomes. Compared with SAVR, bioprosthetic valve failure and stage 2 or 3 structural valve deterioration were significantly greater for SAPIEN XT TAVR (P < 0.05) but not for SAPIEN 3 TAVR.In intermediate-risk patients with AS and CKD, SAPIEN 3 TAVR and SAVR were associated with a similar risk for the primary endpoint at 5 years. AKI was more common after SAVR than TAVR, and SAPIEN 3 valve durability was comparable with that of surgical bioprostheses.

Clinical Profile and Outcome of Haemodialysis in Patients With COVID-19 - A Single Centre Experience.

IntroductionSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing COVID-19 disease is the third coronavirus to have emerged in the last 20 years. The COVID-19 infection causes more severe illness in patients with comorbid diseases, especially in patients with diabetes, hypertension and kidney failure.MethodsThis is a retrospective study using electronic records and laboratory data of adult patients hospitalised at All India Institute of Medical Sciences (AIIMS), Patna between May 1st, 2020 and March 31st, 2021, who were diagnosed with COVID-19 and needed haemodialysis. The demographic characteristics, co-morbidities, symptoms, clinical course, laboratory parameters, and treatments were recorded. The aim of this study is to evaluate the clinical profile and outcome of patients on hemodialysis with COVID-19 infection.ResultsThe study included 261 COVID-19 patients who needed haemodialysis. The most common symptoms on admission were fever (72.8%), cough (64.3%) and dyspnoea (46.6%). The mean age was 58.4 +/-15 years. A total of 195 patients (74.7%) were male. The most common co-morbid condition was hypertension (85.1%) followed by diabetes (71.9%). A total of 118 (45.2) patients had acute on chronic kidney disease (CKD), 40 (15.3) were on maintenance haemodialysis (MHD) and 103 (39.5) were having acute kidney injury (AKI). Eight patients were renal transplant recipients. At presentation, 183 (70.1%) patients were having mild to moderately severe infection and 78 (29.9%) patients were having severe disease. A total of 213 patients required ICU admissions, 186 (75.3%) of whom required invasive ventilation. Overall mortality was 66% (172/261) and the rest were discharged.ConclusionThe study suggests that COVID-19 disease has a significantly more severe course and poorer outcome in patients requiring haemodialysis.