Outpatient Dialysis Centers Research Articles

#927 Assessment of kidney function recovery post discharge in patients with acute kidney injury requiring dialysis during hospitalization

Abstract Background and Aims Acute kidney injury requiring dialysis (AKI-D) is a serious medical condition that becomes increasingly common and associated with high rate of mortality. Identifying modifiable predictors of AKI-D patients’ outcomes will lead to better care and improve kidney and patient survival. This study aimed to assess long-term outcomes (ESRD, HD-independence, or death) of AKI-D patients after hospital discharge as well as to identify the clinical predictors of their outcomes. Method We followed 64 AKI-D patients who survived till hospital discharge and continued receiving dialysis treatment in outpatient dialysis center. Follow up continued for 6 months between January 2016 and December 2022 for patients discharged from Hamad General Hospital to receive dialysis in Fahd Ben Jassim Kidney center. All demographic data, patients’ comorbidities, hospital course, laboratory values and outpatient dialysis details were collected and analysed. Follow up of recovered patient was continued for 2 years either in nephrology or low clearance clinic. Results During follow up, 20 patients (31.3%) recovered enough kidney function to stop dialysis while 44 patients (68.7%) were declared as ESRD. The average time to recovery was 106 ± 81 days. No significant difference was noticed between both groups regard to patients’ age, gender or comorbidities. Recovered patients had more ICU admission rate compared to non-recovered patients (60% and 29.5% of patients respectively, p 0.028) and more use of vasopressors (p 0.002). Moreover, the recovered patients received significantly more dialysis sessions during hospital stay than non-recovered patients (p 0.009). Conclusion Close monitoring of AKI-D patients during ICU admission, use of vasopressors, and frequent dialysis sessions may facilitate recovery of kidney function. More research is needed to identify the modifiable predictors of AKI-D patients’ outcomes.

Human Factors Contributing to Infection Prevention in Outpatient Hemodialysis Centers: A Mixed Methods Study

Infection prevention efforts in dialysis centers can avert patient morbidity and mortality but are challenging to implement. The objective of this study was to better understand how the design of the work system might contribute to infection prevention in outpatient dialysis centers. Mixed methods, observational study. Six dialysis facilities across the United States visited by a multidisciplinary team over 8 months. At each facility, structured macroergonomic observations were undertaken by a multidisciplinary team using the SEIPS 1.0 model. Ethnographic observations were collected about staff encounters with dialysis patients including the content of staff conversations. Selective and axial coding were used for qualitative analysis and quantitative data were reported using descriptive statistics. Organizational and sociotechnical barriers and facilitators to infection prevention in the outpatient dialysis setting were identified. Features related to human performance, (eg, alarms, interruptions, and task stacking), work system design (eg, physical space, scheduling, leadership, and culture), and extrinsic factors (eg, patient-related characteristics) were identified. This was an exploratory evaluation with a small sample size. This study used a systematic macroergonomic approach in multiple outpatient dialysis facilities to identify infection prevention barriers and facilitators related to human performance. Several features common across facilities were identified that may influence infection prevention in outpatient care and warrant further exploration.

Structured handoff to improve communication from inpatient to outpatient dialysis units: A quality improvement project.

Patients with end-stage kidney disease requiring dialysis encounter high hospital readmission rates. One contributor is poor communication between hospitals and outpatient dialysis facilities. We hypothesized that improved communication may reduce 30-day hospital readmissions for patients on dialysis at an urban, safety net hospital. We created a standardized discharge handoff tool that is easy to use and provides concise data for dialysis centers. The handoff tool is a novel, electronic MACRO template (called a "dot-phrase") to be included in discharge documentation. Instructions for the dot-phrase and electronic facsimile (e-faxing) were sent to Internal Medicine residents immediately prior to their rotation on an inpatient Renal service. We then measured the intervention implementation rate and its impact on hospital readmission metrics. We compared 3 months of preintervention and 6months of postintervention data, identifying 82 and 135 index discharges in each respective study period. Patients were predominantly male (56.2%) and receiving hemodialysis (89.8%); a minority (9.2%) were undomiciled at the time of discharge. Mean age was 60.5 years (SD 14.0). Renal discharges followed by 30-day Renal readmission were not statistically lower in the postintervention group for the index discharge alone (26.8% vs. 20.0%, p=0.12), but were for overall discharges (51.2% vs. 25.7%, p < 0.0001). The dot-phrase was used in 95.4% of discharge summaries, and 74.7% of discharge summaries were e-faxed within 24 h of discharge. There was high uptake of a standardized discharge handoff tool among Internal Medicine residents on a Renal inpatient service. Using a handoff tool and e-faxing may improve communication with outpatient dialysis centers and may reduce readmissions among some patients but is likely insufficient to fully address high readmission rates. Subsequent intervention iterations would benefit from further collaboration with outpatient dialysis units for customization of the handoff tool to meet local communication needs.

Implementing a Health Utility Assessment Platform to Acquire Health Utilities in a Hemodialysis Outpatient Setting: Feasibility Study.

BackgroundPatients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transplant. A potential way to reduce wait times is using hepatitis C virus (HCV)–viremic kidneys.ObjectiveAs preparation for developing a shared decision-making tool to assist patients with ESKD with the decision to accept an HCV-viremic kidney transplant, our initial goal was to assess the feasibility of using The Gambler II, a health utility assessment tool, in an ambulatory dialysis clinic setting. Our secondary goals were to collect health utilities for patients with ESKD and to explore whether the use of race-matched versus race-mismatched exemplars impacted the knowledge gained during the assessment process.MethodsWe used The Gambler II to elicit utilities for the following ESKD-related health states: hemodialysis, kidney transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney. We created race exemplar video clips describing these health states and randomly assigned patients into the race-matched or race-mismatched video arms. We obtained utilities for these 3 health states from each patient, and we evaluated knowledge about ESKD and HCV-associated health conditions with pre- and postintervention knowledge assessments.ResultsA total of 63 patients with hemodialysis from 4 outpatient Dialysis Center Inc sites completed the study. Mean adjusted standard gamble utilities for hemodialysis, transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney were 82.5, 89, and 75.5, respectively. General group knowledge assessment scores improved by 10 points (P<.05) following utility assessment process. The use of race-matched exemplars had little effect on the results of the knowledge assessment of patients.ConclusionsUsing The Gambler II to collect utilities for patients with ESKD in an ambulatory dialysis clinic setting proved feasible. In addition, educational information about health states provided as part of the utility assessment process tool improved patients’ knowledge and understanding about ESKD-related health states and implications of organ transplantation with HCV-viremic kidneys. A wide variation in patient health state utilities reinforces the importance of incorporating patients’ preferences into decisions regarding use of HCV-viremic kidneys for transplantation.

A Readmission Risk Model for Hospitalized Patients Receiving Dialysis: Evaluation of Predictive Performance

Reducing unnecessary hospital readmissions for patients with kidney failure requiring dialysis is an important priority for hospitals, nephrologists, and outpatient dialysis centers. Dialysis receiving patients have overall higher 30-day hospital readmission rates compared to others. The US Renal Data System 2020 Annual Data Report shows 30-day readmission rates for Medicare beneficiaries aged greater than or equal to 66 years were 16.6% for individuals without chronic kidney disease, 23.2% with chronic kidney disease, and 31.1% with patients receiving dialysis.

MO914: Development of Antibody Response to SARS-COV-2 Vaccines in Haemodialysis Patients

Abstract BACKGROUND AND AIMS Previous data has shown a reduced immune response shortly after SARS-CoV-2 vaccinations in haemodialysis patients. We therefore investigated the long-term antibody response in patients from different outpatient dialysis centres at 4 weeks and 6 months after a complete vaccination against COVID-19. The results were compared with the humoral responses of non-dialysis subjects. METHODS We designed a retrospective multicentric cohort study, enrolling 106 haemodialysis patients and 50 non-dialysis patients after the SARS-CoV-2 vaccination. SARS-CoV-2 antibody testing was performed as part of routine clinical practice 4 weeks as well as 6 months after the immunization with chemiluminescence immunoassays designed to detect antibodies against the SARS-CoV-2 spike protein (Elecsys Anti-SARS-CoV-2 S, Roche Diagnostics, Mannheim, Germany). Testing was performed in the Institute of Laboratory Medicine of the University Hospital Munich. According to the manufacturer's specifications, anti-SARS-CoV-2 S titres &amp;gt;0.8 U/mL are considered reactive (sensitivity 98.8% and specificity 99.9%). Anti-SARS-CoV-2 S titres &amp;lt; 100 U/mL were defined as a low antibody response. RESULTS A total of 106 haemodialysis patients with a median age of 73 years received a SARS-CoV-2 vaccination (n = 105 mRNA, n = 1 AstraZeneca). Of these, 50 non-dialysis patients with a median age of 56 years received a SARS-CoV-2 vaccination (n = 45 mRNA, n = 5 mRNA/AstraZeneca). During the observational period, 8 haemodialysis patients and 2 non-dialysis patients additionally contracted a SARS-CoV-2 infection. Between the two testings, an overall decrease in anti-SARS-CoV-2 S antibody titres was observed (haemodialysis patients from a median of 252 to 95 U/mL, non-dialysis patients from a median of 1621 to 441 U/mL). At 6 months after the complete vaccination, 99 (93%) haemodialysis patients still presented with a detectable anti-SARS-CoV-2 spike antibody response (&amp;gt;0.8 U/mL), comparable to 100% of the non-dialysis subjects. However, 60 (57%) haemodialysis patients showed low antibody response (&amp;lt;100 U/mL), whereas only 5 (10%) non-dialysis patients presented with low antibody response. Patients with an additional infection showed an increased titre of antibodies during follow-up. CONCLUSIONS Our data suggest regular antibody testing as well as a need for booster vaccination in the vulnerable population of haemodialysis patients.

FC 103: Matched Control Study on Applied Long-Term Anti-Thrombotic Therapies and Clinical Outcome of Atrial Fibrillation in HD-Patients Based on German Network Data

Abstract BACKGROUND AND AIMS Hemodialysis (HD) patients (pts) with atrial fibrillation (AF) are at high risk for cardiovascular events, severe bleeding and rapid vascular/valvular calcification. Thus, antivitamin-K based oral anticoagulation (VK-OAC) for HD patients is debated, since prospective trials are missing and US register studies are often limited to 3–6 months OAC use. We studied AF risk-factors, long-term antithrombotic therapies and clinical outcomes in a large German HD cohort. METHOD We analysed pseudonymized benchmarking data in a German out-patient dialysis center network (Verband Deutsche Nierenzentren, DN) based on quarterly electronically transmitted data. Diagnoses coded by ‘International Classification of Diseases (ICD)’ and ‘Anatomical Therapeutical Chemical (ATC)’ drug codes of adult HD patients 2013–2018. RESULTS In 2013, 2753 (18%) of 15 682 HD-pts had AF as coded diagnosis. Baseline CHA2DS2-VASc (4.0/1.5 mean/SD) and HAS-BLED (3.2/0.9) risk-scores indicated high risk for embolism and bleeding. Charlson Comorbidity Index (CCI) was high (6.4/2.8) and median observation was 2.1 years (range 0.01–6 years). Beside HD-related heparin, four main OAC approaches were applied: no active therapy, VK-OAC+/-aspirin/clopidogrel (VK-OAC+/-Asp/Clop), heparin-based therapy (heparin+/-Asp/Clop) or 1–2 antithrombocyte drugs (Asp/Clop). A total of 959 pts (35%) changed therapy, but 1794 pts (65%) had no change in OAC regime during the 6 year study period and were used for final therapy-related outcome analysis (Table 1). Both AF risk-scores overestimated de-novo events. Total 6-year event rate was low (7.5%; &amp;lt;1.3% per year) and comparable for all anticoagulant therapies, especially for cerebral ischemic events (2.8%; range 1.2–3.7; NS). All three antithrombotic therapies had similar overall events as without active therapy (7.6 versus 7.3%), including cerebral adverse events (ischemic: 3.0 versus 2.6%; bleeding: 0.7 versus 0.6%; NS). Survival (Kaplan–Meier) was analysed for matched controls by propensity-score based on mortality risk factors in multivariate Cox regression: age (HR 1.05), sex (female HR 0.78), CCI (HR 1.07) and albumin (HR 0.93). Six-year mortality rates were high (63%) and matched analysis showed significant lower survival (P &amp;lt; 0.001) without anticoagulant (median 1.8 years) or on heparin-based therapy (1.7 years) than on Asp/Clop (2.9 years) or VK-OAC based therapy (2.8 years). This relation was similar for subgroups on age, CCI or changed therapy. CONCLUSION Our large study showed that baseline CHA2DS2-VASc and HAS-BLED scores had no predictive value for clinical events in HD pts with AF. Cerebral ischemic event rates over 6 years were low (&amp;lt;0.7%/year) and similar for all three antithrombotic therapies and even no active therapy, suggesting major benefit of regular dialysis-related heparin supply. Since median survival on Asp/Clop is similar to VK-OAC therapy and even 1 year better than on no active or heparin-based therapy, we conclude that antithrombotic therapy in HD patients with AF can effectively be done with Asp/Clop and VK-OAC should be avoided. For future prospective trials, we recommend to apply Asp/Clop as first-line control therapy evaluating new direct-acting oral anticoagulants (DOAK) and/or interventional approaches (i.e. left atrial appendage closure) in HD patients with AF.

Diminished Short- and Long-Term Antibody Response after SARS-CoV-2 Vaccination in Hemodialysis Patients.

Short-term studies have shown an attenuated immune response in hemodialysis patients after COVID-19-vaccination. The present study examines how antibody response is maintained after vaccination against SARS-CoV-2 in a large population of hemodialysis patients from six outpatient dialysis centers. We retrospectively assessed serum antibody levels against SARS-CoV-2 spike protein and nucleocapsid protein (electrochemiluminescence immunoassays, Roche Diagnostics) after COVID-19-vaccination in 298 hemodialysis and 103 non-dialysis patients (controls), comparing early and late antibody response. Compared to a non-dialysis cohort hemodialysis patients showed a favorable but profoundly lower early antibody response, which decreased substantially during follow-up measurement (median 6 months after vaccination). Significantly more hemodialysis patients had anti-SARS-CoV-2-S antibody titers below 100 U/mL (p < 0.001), which increased during follow-up from 23% to 45% but remained low in the control group (3% vs. 7%). In multivariate analysis, previous COVID-19 infections (p < 0.001) and female gender (p < 0.05) were significantly associated with higher early as well as late antibody vaccine response in hemodialysis patients, while there was a significant inverse correlation between patient age and systemic immunosuppression (p < 0.001). The early and late antibody responses were significantly higher in patients receiving vaccination after a SARS-CoV-2 infection compared to uninfected patients in both groups (p < 0.05). We also note that a higher titer after complete immunization positively affected late antibody response. The observation, that hemodialysis patients showed a significantly stronger decline of SARS-CoV-2 vaccination antibody titers within 6 months, compared to controls, supports the need for booster vaccinations to foster a stronger and more persistent antibody response.

Dietary protein intake and the risk of all-cause and cardiovascular mortality in maintenance hemodialysis patients: A multicenter, prospective cohort study

ObjectivesThe association between dietary protein intake (DPI) and mortality in people receiving maintenance hemodialysis (MHD) remains uncertain. We aimed to explore the relationship of DPI with all-cause and cardiovascular (CV) mortality, and to examine the possible modifiers for the associations, in Chinese MHD patients. MethodsThis multicenter prospective cohort study was conducted in eight outpatient dialysis centers in South China. We enrolled 1044 MHD patients in 2014 and 2015. The DPI was assessed using a 3-d 24-h dietary recall. Using Cox proportional hazard models, we estimated the hazard ratios (HRs) with their corresponding 95% confidence intervals (CIs) for all analyzed end points. ResultsDuring a median follow-up of 45 mo, there were 354 (33.9%) deaths, 210 of which were CV related. Compared with patients with a DPI of 1.0 to < 1.4 g/kg ideal body weight (IBW)/d, a significantly higher risk of all-cause mortality was found in those with a DPI < 1.0 g/kg IBW/d (adjusted HR, 1.84; 95% CI, 1.42–2.38) or ≥ 1.4 g/kg IBW/d (adjusted HR, 1.49; 95% CI, 1.00–2.22). Similar trends were found for CV mortality. Moreover, we found a significantly stronger positive association between DPI (≥ 1.4 versus 1.0 to < 1.4 g/kg IBW/d) and all-cause mortality in women (adjusted HR, 2.05; 95% CI, 1.00–4.22) than in men (adjusted HR, 0.89; 95% CI, 0.49–1.63; P for interaction = 0.0487). ConclusionIn Chinese MHD patients, a DPI of 1.0 to < 1.4 g/kg IBW/d was associated with lower risks of all-cause and CV mortality.

Appetite as a predictor of malnutrition in end-stage renal disease patients in Saudi Arabia.

Patients with chronic kidney disease (CKD) undergoing hemodialysis (HD) are at high risk for malnutrition. This study aimed to 1) Investigate the prevalence of malnutrition among CKD patients undergoing maintenance HD; 2) Assess level of knowledge and appetite among patients; 3) Identify potential predictors of malnutrition. This cross-sectional study included 71 CKD patients on HD who were recruited from two principal outpatient dialysis centers located in Jeddah, Saudi Arabia. Data were collected using an interviewer-administered questionnaire which included sociodemographic and health characteristics, nutritional status (assessed using the Patient-Generated Subjective Global Assessment [PG-SGA]), biochemical data, nutritional knowledge, and appetite status (assessed using Council of Nutrition Appetite Questionnaire [CNAQ]). Forty-four percent of patients included in this study were malnourished, and over half of the patients had limited nutritional knowledge and appetite. Hemoglobin level and the CNAQ score were found to be independently negatively associated with the PG-SGA score (B: -1.03 [95% confidence interval (CI): -1.99, - 0.08] and B: -0.37 [95% CI: -0.64, -0.11], respectively). Renal healthcare professionals should assess the nutritional status of HD patients and identify barriers to adequate nutrition. Patients with poor appetite should specifically be targeted for nutrition-focused evaluation and management.

Kidney Recovery in Patients With Acute Kidney Injury Treated in Outpatient Hemodialysis or Rehabilitation Facilities

Rationale & ObjectiveSince January 2017, patients with acute kidney injury requiring dialysis (AKI-D) can be discharged to outpatient dialysis centers for continued hemodialysis (HD) support. We aimed to examine the rate of kidney recovery, time to recovery, and hospitalization-related clinical parameters associated with kidney recovery in patients with AKI-D.Study DesignSingle-center prospective cohort study.Setting & Participants111 adult patients who were admitted to the University of Kentucky Hospital, experienced AKI-D, and were discharged with need of outpatient HD.ExposureHospitalization-related clinical parameters were evaluated.OutcomeKidney recovery as a composite of being alive and no longer requiring HD or other form of kidney replacement therapy.Analytical ApproachDiscrete-time survival analysis and logistic regression were used to determine adjusted probabilities of kidney recovery at prespecified time points and to evaluate clinical parameters associated with recovery.Results45 (41%) patients recovered kidney function, 25 (55.5%) within the first 30 days following discharge, 16 (35.5%) within 30 to 60 days, and 4 (9%) within 60 to 90 days. Adjusted probabilities of recovery were 36.7%, 27.4%, and 6.3%, respectively. Of the remaining patients, 49 (44%) developed kidney failure requiring chronic kidney replacement therapy and 17 (15%) died or went to hospice. Patients who did not recover kidney function were older, had more comorbid conditions, had lower estimated glomerular filtration rates at baseline, and received more blood transfusions during hospitalization when compared with those who recovered kidney function.LimitationsSelection bias given that patients included in the study were all eligible for AKI management with outpatient HD as part of Medicare/Medicaid services.ConclusionsAt least one-third of AKI-D survivors discharged from an acute care hospital dependent on HD recovered kidney function within the first 90 days of discharge, more commonly in the first 30 days postdischarge. Future studies should elucidate clinical parameters that can inform risk classification and interventions to promote kidney recovery in this vulnerable and growing population.

Online Reviews of Hemodialysis Centers Correlate With Medicare and Medicaid Survey Measures of Patient Experience.

Patient experience in outpatient hemodialysis has been shown to be significantly correlated with health outcomes. The current gold standard for assessing patient experience in outpatient hemodialysis is the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS). Online reviews of outpatient hemodialysis centers could potentially serve as an additional source of information regarding patient experience, but they have not been well validated. This study aims to determine whether overall scores and subscores from patient-authored online reviews of outpatient dialysis centers are correlated with current gold standard survey-based measures of patient experience in outpatient hemodialysis. All reviews of hemodialysis centers posted to the online review site CiteHealth.com between March 2008 and October 2019 were collected (1081 reviews of 762 centers). Publicly-available ICH-CAHPS survey summary data and End Stage Renal Disease Quality Incentive Program (ESRD QIP) summary data from May 2016 to October 2019 were obtained from the Dialysis Facility Compare website. Spearman correlation coefficients were calculated between facilities' mean online review overall scores and subscores within a given year and their ICH-CAHPS ratings from the same year. Statistical significance was assessed with a 2-tailed permutation test. A Bonferroni correction for multiple hypothesis testing was applied. The mean "Overall" score from CiteHealth.com had a significant positive correlation with the "Center Care Quality," "Staff," and "Facility" scores from ICH-CAHPS surveys. No significant correlation could be found between the mean "Overall" CiteHealth.com score and any other ICH-CAHPS patient satisfaction metric. There was a significant positive correlation between the mean CiteHealth.com "Center" score and the ICH-CAHPS "Center Care Quality" score, the mean CiteHealth.com "Facility" score and the ICH-CAHPS "Facility" score, and the mean CiteHealth.com "Staff" score and the ICH-CAHPS "Staff" score. No significant correlation was found between the mean CiteHealth.com "Nephrologist" score and the ICH-CAHPS "Nephrologist" score. No significant correlation was found between online review scores and ESRD QIP health outcome measures. Certain components of online reviews are significantly correlated with ICH-CAHPS measures of patient experience. Additionally, online reviews come with narrative comments that can offer specific insights into positive and negative aspects of patient care that cannot always be elucidated by numeric survey questions. Online reviews may have utility as an adjunctive source of information to patient experience surveys such as the ICH-CAHPS.

Institutional Usage of Ferric Pyrophosphate Citrate (FPC) Delivered Via Dialysate in Reducing Erythropoiesis Stimulating Agents (ESAs) and IV Iron Cost.

Dialysis patients are often iron deficient due to a multiple factors. Ferric pyrophosphate citrate is a complex iron salt that can be given via dialysate allowing maintenance of hemoglobin (Hgb) concentration and iron balance while reducing the need for IV iron. The purpose of this study is to perform a cost evaluation of FPC and the effect it has on lowering the dose/use of ESAs and IV iron therapy. This study reviewed the same 100 hemodialysis patient's charts before and after the use of FPC. The data points that were collected and analyzed are as follows: hemoglobin, ferritin levels, average weekly ESA dosing, and IV iron replacement therapy dose. Out of 100 patients, there was no statistical difference in the average hemoglobin, ferritin, and iron saturation levels observed in the patients before and after FPC use. The average weekly dose of darbepoetin alfa per patient was 52.74 μg before the FPC group compared to 39.27 μg in the post FPC group (P < .0001). The total dose of ferric gluconate per patient was 3290.01 mg in the before FPC group and 585.60 mg in the post FPC group (P < .0001). The average total iron sucrose dose per patient in the before FPC group was 3097.92 mg versus 1216.67 mg in the post FPC group (P < .1563). When comparing FPC's cost and implementation into both of our outpatient dialysis centers, this yielded a net savings of $296 751.49.

Changes in Dialysis Center Quality Associated With the End-Stage Renal Disease Quality Incentive Program : An Observational Study With a Regression Discontinuity Design.

In 2012, the Centers for Medicare & Medicaid Services started levying performance-based financial penalties against outpatient dialysis centers under the mandatory End-Stage Renal Disease Quality Incentive Program. To determine whether penalization was associated with improvement in dialysis center quality. Leveraging the threshold for penalization (total performance score< 60), a regression discontinuity design was used to examine the effect of penalization on quality over 2 years. Publicly available Medicare data from 2015-2018 were used. The effect of penalization at dialysis centers with different characteristics (for example, size or chain affiliation) was also examined. United States. Outpatient dialysis centers (n= 5830). Dialysis center total performance scores (a composite metric ranging from 0 to 100 based on clinical quality and adherence to reporting requirements) and individual measures that contribute to the total performance score. There were 1109 (19.0%) outpatient dialysis centers that received penalties in 2017 on the basis of performance in 2015. Penalized centers were located in ZIP codes with a higher average proportion of non-White residents (36.4% vs. 31.2%; P< 0.001) and residents with lower median income ($49290 vs. $51686; P< 0.001). Penalization was not associated with improvement in total performance scores in 2017 (0.4 point [95% CI, -2.5 to 3.2 points]) or 2018 (0.3 point [CI, -2.8 to 3.4 points]). This was consistent across dialysis centers with different characteristics. There was also no association between penalization and improvement in specific measures. The study could not account for how centers respond to penalization. Penalization under the End-Stage Renal Disease Quality Incentive Program was not associated with improvement in the quality of outpatient dialysis centers. None.

MO1007RELATIONSHIP BETWEEN DIALYSIS ADEQUACY, ULTRAFILTRATION RATE AND SURVIVAL IN YOUNG HEMODIALYSIS (HD) PATIENTS HAVING INITIATED CHRONIC HD IN CHILDHOOD*

Abstract Background and Aims Hemodialysis (HD) adequacy is currently assessed based on weight-normalized small solute clearance (spKt/V), with same targets in both adult and pediatric patients on chronic thrice weekly hemodialysis, despite lack of pediatric studies to support this. It has been hypothesised that pediatric patients of small size may require higher spKt/V targets, due to higher ratio of body surface area (BSA) to body weight and/or greater post-dialysis urea rebound. Ultrafiltration rates (UFR) &amp;gt;10-13 mL/kg/h, associated with increased mortality in adults, are furthermore routinely exceeded in pediatric patients with uncertain consequences. We aimed to characterize how different delivered HD adequacy metrics and UFR are associated with survival in a large cohort of patients who started HD in childhood. Method Retrospective analysis on a cohort of patients &amp;lt;30y on chronic HD since childhood (&amp;lt;19y), having received thrice-weekly HD 2004-2016 in outpatient DaVita dialysis centers. Mean delivered dialysis dose (spKt/V) and alternative measures of HD adequacy and fluid balance, including eKt/V, body-surface normalized Kt (Kt/BSA) and ultrafiltration rate (UFR), were investigated as predictors of survival in a Weibull regression model. Results A total of 1780 patients were included (age at initiation of HD: 0-12y: n=321, &amp;gt;12-18y: n=1459), with median spKtV=1.55, eKt/V=1.31, Kt/BSA=31.2 L/m2 and UFR=10.6 mL/kg/h. Kt/BSA was a better predictor of survival than spKt/V or eKt/V (P&amp;lt;0.001 versus P=0.002, respectively). UFR was associated with survival (P&amp;lt;0.001), with increased mortality &amp;lt;10/&amp;gt;18 mL/kg/h. Associations remained significant after adjusting for age, ethnicity, and etiology of kidney disease. Conclusion We found that targeting Kt/BSA&amp;gt;30 L/m2 in children and young adults on maintenance HD is associated with improved long-term outcomes, corresponding to spKt/V&amp;gt;1.4 (&amp;gt;12 years) and &amp;gt;1.6 (&amp;lt;12 years), respectively. Relatively high UFR of 10-18 ml/kg/h appears to be risk-free in this HD population.

Alta sensibilidad a la mupirocina en aislados de Staphylococcs aureus que colonizan pacientes en hemodiálisis en una unidad renal de Medellín, Colombia

Objetivo: describir el porcentaje de resistencia a la mupirocina y a otros antibióticos en aislados de Staphylococcus aureus que colonizan pacientes en hemodiálisis.&#x0D; Métodos: estudio descriptivo en el que se incluyeron pacientes en hemodiálisis en una unidad renal de Medellín. La colonización por S. aureus fue evaluada en las fosas nasales y en la piel. La identificación bacteriana se realizó por PCR y la sensibilidad antibiótica se determinó por el sistema automatizado VITEK-2 y por el método E-test. Las características clínicas de los pacientes fueron evaluadas con la historia clínica.&#x0D; Resultados: se incluyeron 210 pacientes, de estos el 50,5 % (n = 106) fueron mujeres, con una mediana para la edad de 62 años (RIC 51,87-71,13). De las características clínicas se destacó el uso frecuente de antibióticos: 59 % (n = 124) y la historia de hospitalización: 69 % (n = 145). El porcentaje de colonización por S. aureus fue de 33,8 % (n = 71) y el sitio más frecuente de colonización fue las fosas nasales (19 %; n = 40). Todos los aislados fueron sensibles a la mupirocina por el método de VITEK-2. Sin embargo, un aislado presentó resistencia de bajo nivel a la mupirocina por E-test. La colonización por aislados resistentes a meticilina (SARM) fue de 4,8 % (n = 10) y estos presentaron, principalmente, resistencia solamente a la oxacilina (58,3 %; n = 7).&#x0D; Conclusión: la alta sensibilidad a la mupirocina en aislados de S. aureus colonizantes sugiere su uso como terapia profiláctica en pacientes en hemodiálisis con alto riesgo de infección. Es importante fortalecer los programas de uso racional de antibióticos para evitar la diseminación de mecanismos de resistencia a estos y a otros en las unidades renales.

Proactive Measures to Combat a SARS-CoV-2 Transmission Among High Risk Patients and Health Care Workers in an Outpatient Dialysis Facility.

Background: End-stage-renal-failure (ESRF) patients attending clustered out-patient dialysis are susceptible to SARS-CoV-2 infection. Comorbidities render them vulnerable to severe COVID-19. Although preventative and mitigation strategies are recommended, the effect of these are unknown. A period of “potential-high-infectivity” results if a health-care-worker (HCWs) or a patient becomes infected. Aim: We describe and analyze early, universal SARS-CoV-2 real time reverse transcription polymerase chain reaction (RT-PCR) tests, biomarker monitoring and SARS-CoV-2 preventative strategies, in a single dialysis center, after a positive patient was identified. Methodology: The setting was a single outpatient dialysis center in Johannesburg, South Africa which had already implemented preventative strategies. We describe the management of 57 patients and 11 HCWs, after one of the patients tested positive for SARS-CoV-2. All individuals were subjected to RT-PCR tests and biomarkers (Neutrophil-Lymphocyte Ratio, C-reactive protein, and D-Dimer) within 72 h (initial-tests). Individuals with initial negative RT-PCR and abnormal biomarkers (one or more) were subjected to repeat RT-PCR and biomarkers (retest subgroup) during the second week. Additional stringent measures (awareness of viral transmission, dialysis distancing and screening) were implemented during the period of “potential high infectivity.” The patient retest subgroup also underwent clustered dialysis until retest results became available. Results: A second positive-patient was identified as a result of early universal RT-PCR tests. In the two positive-patients, biomarker improvement coincided with RT-PCR negative tests. We identified 13 individuals for retesting. None of these retested individuals tested positive for SARS-CoV-2 and there was no deterioration in median biomarker values between initial and retests. Collectively, none of the negative individuals developed COVID-19 symptoms during the period “potential high infectivity.” Conclusion: A SARS-CoV-2 outbreak may necessitate additional proactive steps to counteract spread of infection. This includes early universal RT-PCR testing and creating further awareness of the risk of transmission and modifying preventative strategies. Abnormal biomarkers may be poorly predictive of SARS-CoV-2 infection in ESRF patients due to underlying illnesses. Observing dynamic changes in biomarkers in RT-PCR positive and negative-patients may provide insights into general state of health.

Survey of Current Practices of Outpatient Hemodialysis for AKI Patients

“I developed acute kidney injury requiring dialysis as a complication of heart surgery and was transferred to an outpatient dialysis center. I was readmitted to the hospital multiple times for severe fluid overload and congestive heart failure and became terrified to go back to the outpatient dialysis clinic that I felt had nearly killed me twice. My labs were checked once a week, but I felt I was not comprehensively evaluated and was never able to establish good communication with my nephrologist.

Higher dietary fibre intake is associated with lower CVD mortality risk among maintenance haemodialysis patients: a multicentre prospective cohort study.

High fibre intake is associated with reduced mortality risk in both general and chronic kidney disease populations. However, in dialysis patients, such data are limited. Therefore, the association between dietary fibre intake (DFI) and the risk of all-cause and CVD mortality was examined in this study. A total of 1044 maintenance haemodialysis (MHD) patients from eight outpatient dialysis centres in China were included in this study. Data on DFI were collected using 24-h dietary recalls for 3 d in a week and were normalised to actual dry weight. The study outcomes included all-cause and CVD mortality. Over a median of 46 months of follow-up, 354 deaths were recorded, of which 210 (59 %) were due to CVD. On assessing DFI as tertiles, the CVD mortality risk was significantly lower in patients in tertiles 2-3 (≥0·13 g/kg per d; hazard ratio (HR) 0·71; 95 % CI 0·51, 0·97) compared with those in tertile 1 (<0·13 g/kg per d). A similar but non-significant trend was found for the association between DFI (tertiles 2-3 v. tertile 1; HR 0·83; 95 % CI 0·64, 1·07) and all-cause mortality. In summary, higher DFI was associated with lower CVD mortality risk among Chinese MHD patients. This study emphasises the significance of DFI in MHD patients and provides information that is critical for the improvement of dietary guidelines for dialysis patients.

Частота инфицирования SARS-CoV-2 среди больных, получающих лечение программным гемодиализом

Patients with end-stage chronic kidney disease treated with hemodialysis are at risk of infection and severe course of the new coronavirus infection. This opinion was based on the data obtained as a result of PCR testing during the active phase of the disease with detailed clinical symptoms. However, this diagnostic method does not allow one to fully assess the prevalence of infection in the population. The aim – studying of the frequency of SARS-CoV-2 infection in patients receiving hemodialysis treatment and the spectrum of antiviral antibodies, depending on the nature of the course of COVID-19. Material and methods. 100 patients with chronic kidney disease (stage 5D) treated at the outpatient Dialysis Center (MCVTP) were included in the study by a simple random sample. The assessment of SARS-CoV-2 infection was carried out by analyzing the material of smears obtained from the naso-oropharynx by PCR and blood serum samples by ELISA. The study excluded 14 patients with dubious results for the determination of serological markers SARS-CoV-2 and 1 patient with active infection, who was isolated from the RNA of the virus. Results. IgM and IgG antibodies were detected in 49 (57.6%) of the 85 examined patients. 24 of them (group 1) were diagnosed with COVID-19 infection with typical clinical symptoms 3–9 months ago, and 25 (group 2) had no clinical manifestations of the acute respiratory infection at the appropriate time suggesting an asymptomatic course of the disease. IgM class antibodies were detected with equal frequency in group 1 and in group 2 (33.3 vs 24.0%, respectively, p<0.6). IgG antibodies exclusively to the nucleocapsid N-protein (IgGn) were detected only in the latent form of the disease (32%), while antibodies against the S-protein (spike protein) of the virus (IgGs and IgGn+s) were detected more often in the manifest form compared to the asymptomatic one (100 vs 60%, respectively, p<0.05). Conclusion. In a random cohort of patient receiving hemodialysis treatment, more than half were asymptomatic.Despite a wide range of prevention measures, SARS-CoV-2 infection among patients treated with hemodialysis is more than 2 times higher than in the general population. © 2021 Geotar Media Publishing Group. All rights reserved.