Percentage Of Dialysis Patients Research Articles

MO731: Predictors of Early and 1-Year Mortality After an Acute Coronary Event in Haemodialysis Patients

Abstract BACKGROUND AND AIMS Cardiovascular disease (CVD) is the leading cause of mortality in haemodialysis (HD) patients (40%), mainly secondary to a coronary event (17%). According to the European Society of Cardiology (ESC), beta-blockers (BBs), anti-platelets, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs) and statins are the cornerstones of CVD prevention. However, a great percentage of dialysis patients remain undermedicated. Our aim is to identify the predictors of mortality in HD patients after an acute myocardial infarction (AMI) during hospitalization and 1 year after the cardiac event. Methods We performed an observational retrospective study of all HD patients admitted to the coronary intensive care unit between January 2017 and December 2020 due to a myocardial infarction. Our variables of interest were collected before and after hospital discharge and 1 year after. We assessed patients’ frailty using the clinical frailty scale (CFS) and baseline cardiovascular (CV) risk using ESC’s classification; as we focused in HD patients (very-high risk of CVD), we classified CV risk regardless of the kidney disease. IBM SPSS 23.0 was used to perform statistical analysis; the confidence interval (CI) was set at 95%. RESULTS We collected 70 patients (males: n = 51, 73.2%), with a mean age of 70.9 ± 12.2 years and a median time in HD of 73.2 ± 60 months. Identifiable CV risk factors were: dyslipidaemia (98.6%), arterial hypertension (95.7%), heart failure (74.3%), diabetes (57.1%) and obesity (55.7%); mean total cholesterol and low-density lipoprotein cholesterol (LDL) levels were 151 ± 39.6 and 97.5 ± 34.1 mg/dL, respectively. As a result, 81.4% of our sample was classified as having a very high baseline CV risk. Before admission, most patients were on statin therapy (87.1%), but only 34.2% were taking the proper statin class/dosage adjusted to their CV risk. In fact, only 7.1% were previously medicated with all prognosis-modifying drugs (ACEis/ARBs, statins, anti-platelets and BBs). The mean hospitalization stay was 10.3 ± 9 days, and the early mortality rate (30 days post-admission) was 18.6%. Mortality was higher in older patients (72.5 ± 10.3 versus 69.1 ± 10.9 years; P = .3), males (21.6 versus 10.5%), with longer HD vintage (82.8 ± 46.8 versus 70.8 ± 48 months; P = 0.41) and higher CV risk (very-high CV risk, 84.6 versus 80%; P = .7); hypoalbuminemia (serum albumin < 3.0 g/dL) (OR 5.4, 95% CI 1.2–25.1; P = .028) and higher frailty score (CFS ≥ 4) (OR 6.1, 95% CI 1.2–30.0; P = .002) prompt a worse short-term prognosis. The mortality rate after 1 year was 30%, with a median time of 5.6 ± 2.4 months since the cardiac event. Mortality was also higher in older patients (71.5 ± 10 versus 69 ± 10 years; P = .34), males (31.3 versus 26.3%; P = 0.70), with longer dialysis vintage (85.2 ± 45.6 versus 67.2 ± 48; P = .14) and longer hospitalizations (12.8 ± 9.9 versus 9.3 ± 8.3; P = .12). After discharge, patients prescribed with at least three prognosis-modifying drugs had a lower 1-year mortality rate (3.2 versus 26.9%; OR 11, 95% CI 1.2–97.0; P = .003). Hypoalbuminemia (OR 9.4, 95% CI 2.3–4.3’; P = .002) and higher frailty scores (CFS ≥ 4) (OR 4.1, 95% CI 1.2–14.0; P = .025) were associated with worse outcomes. CONCLUSION We concluded that most HD patients were undermedicated prior to a coronary event given their baseline CV risk. Despite most studies in HD patients did not find a beneficial long-term effect of starting statin therapy after HD initiation, one must always individualize therapy according to the patient's CV risk. In our series, better-nourished patients with at least three prognosis-modifying drugs had a lower mortality rate, which highlights the importance of these drugs on survival together with optimal nutritional care.

Variation in Access to Kidney Transplantation Across Renal Programs in Ontario, Canada.

In the United States, kidney transplant rates vary significantly across end-stage renal disease (ESRD) networks. We conducted a population-based cohort study to determine whether there was variability in kidney transplant rates across renal programs in a health care system distinct from the United States. We included incident chronic dialysis patients in Ontario, Canada, from 2003 to 2013 and determined the 1-, 5-, and 10-year cumulative incidence of kidney transplantation in 27 regional renal programs (similar to U.S. ESRD networks). We also assessed the cumulative incidence of kidney transplant for "healthy" dialysis patients (aged 18-50 years without diabetes, coronary disease, or malignancy). We calculated standardized transplant ratios (STRs) using a Cox proportional hazards model, adjusting for patient characteristics (maximum possible follow-up of 11 years). Among 23 022 chronic dialysis patients, the 10-year cumulative incidence of kidney transplantation ranged from 7.4% (95% confidence interval [CI] 4.8-10.7%) to 31.4% (95% CI 16.5-47.5%) across renal programs. Similar variability was observed in our healthy cohort. STRs ranged from 0.3 (95% CI 0.2-0.5) to 1.5 (95% CI 1.4-1.7) across renal programs. There was significant variation in kidney transplant rates across Ontario renal programs despite patients having access to the same publicly funded health care system.

GUIDE, a structured pre-dialysis programme that increases the use of home dialysis.

BackgroundDespite the many advantages it offers, the percentage of dialysis patients that receive home dialysis [peritoneal dialysis (PD) or home haemodialysis (HHD)] in the Netherlands has declined over the last decade. Pre-dialysis education could stimulate the use of home dialysis. This article presents the results of the pre-dialysis programme GUIDE, with regard to the following question: Does the implementation of a structured pre-dialysis programme with a home-focused approach increase the number of pre-dialysis patients that choose and receive home dialysis?MethodsThe GUIDE process starts when a patient has an eGFR of 15 mL/min/1.73 m2. The process begins with a home visit from a case manager and the completion of questionnaires by the patient, the case manager and the nephrologist. A multidisciplinary meeting (MDM) is held to determine a specific patient profile (or treatment recommendation). This is followed by patient education, a second MDM and finally the selection of the treatment by the patient and the nephrologist. This retrospective observational study describes the selection process of all patients that received a treatment recommendation between 12 September 2013 and 18 December 2014 at Meander Medical Centre. Data were collected by file research and analysis of questionnaires.ResultsOne hundred and two patients were included. They started the process at a mean eGFR of 12.3 mL/min/1.73 m2. Home dialysis was recommended for 62.8% of the patients who were advised to have dialysis treatment. Of the patients that opted for dialysis, 34.2% chose PD and 8.2% chose HHD; 22.9% started home dialysis as their first therapy, compared with 17.6% in the months before implementation of GUIDE. Finally, 32.1% of the patients that received dialysis therapy received home dialysis. In the months before GUIDE, an average of just 19.5% of the patients that received dialysis received home dialysis.ConclusionsIn comparison to historical data, the pre-dialysis programme GUIDE increases the number of patients that choose and receive home dialysis.

An Overview of Regular Dialysis Treatment in Japan (As of 31 December 2013).

A nationwide survey of 4325 dialysis facilities was conducted at the end of 2013, among which 4268 (98.7%) responded. The number of new dialysis patients was 38,095 in 2013. Since 2008, the number of new dialysis patients has remained almost the same without any marked increase or decrease. The number of dialysis patients who died in 2013 was 30,751. The dialysis patient population has been growing every year in Japan; it was 314,438 at the end of 2013. The number of dialysis patients per million at the end of 2013 was 2470. The crude death rate of dialysis patients in 2013 was 9.8%. The mean age of new dialysis patients was 68.7 years and the mean age of the entire dialysis patient population was 67.2 years. The most common primary cause of renal failure among new dialysis patients was diabetic nephropathy (43.8%). The actual number of new dialysis patients with diabetic nephropathy has almost been unchanged for the last few years. Diabetic nephropathy was also the most common primary disease among the entire dialysis patient population (37.6%), followed by chronic glomerulonephritis (32.4%). The percentage of dialysis patients with diabetic nephropathy has been increasing continuously, whereas the percentage of dialysis patients with chronic glomerulonephritis has been decreasing. The number of patients who underwent hemodiafiltration (HDF) at the end of 2013 was 31,371, a marked increase from that in 2012. This number is more than twice that at the end of 2011 and approximately 1.5 times the number at the end of 2012. In particular, the number of patients who underwent online HDF increased approximately fivefold over the last 2 years. Among 151,426 dialysis patients with primary causes of renal failure other than diabetic nephropathy, 10.8% had a history of diabetes. Among those with a history of diabetes, 26.8% used glycoalbumin as an indicator of blood glucose level; and 33.0 and 27.6% were administered insulin and dipeptidyl peptidase (DPP)-4 inhibitor, respectively, as a medication of diabetes. The facility survey showed that 9392 patients underwent peritoneal dialysis (PD). The patient survey revealed that 1920 of these PD patients also underwent another dialysis method using extracorporeal circulation, such as hemodialysis (HD) or HDF. The number of patients who underwent HD at home at the end of 2013 was 461, a marked increase from that at the end of 2012 (393).

An overview of regular dialysis treatment in Japan (as of 31 December 2012).

A nationwide statistical survey of 4279 dialysis facilities was conducted at the end of 2012, among which 4238 responded (99.0%). The number of new dialysis patients was 38055 in 2012. Since 2008, the number of new dialysis patients has remained almost the same without any marked increase or decrease. The number of dialysis patients who died in 2012 was 30710; a slight decrease from 2011 (30743). The dialysis patient population has been growing every year in Japan; it was 310007 at the end of 2012, which exceeded 310000 for the first time. The number of dialysis patients per million at the end of 2012 was 2431.2. The crude death rate of dialysis patients in 2012 was 10.0%, a slight decrease from that in 2011 (10.2%). The mean age of new dialysis patients was 68.5 years and the mean age of the entire dialysis patient population was 66.9 years. The most common primary cause of renal failure among new dialysis patients was diabetic nephropathy (44.2%). The actual number of new dialysis patients with diabetic nephropathy has been approximately 16000 for the last few years. Diabetic nephropathy was also the most common primary disease among the entire dialysis patient population (37.1%), followed by chronic glomerulonephritis (33.6%). The percentage of dialysis patients with diabetic nephropathy has been continuously increasing, whereas not only the percentage but also the actual number of dialysis patients with chronic glomerulonephritis has decreased. The number of patients who underwent hemodiafiltration (HDF) at the end of 2012 was 21725, a marked increase from that in 2011 (14115). In particular, the number of patients who underwent on-line HDF increased threefold from 4890 in 2011 to 14069 in 2012. From the results of the facility survey, the number of patients who underwent peritoneal dialysis (PD) was 9514 and that of patients who did not undergo PD despite having a PD catheter in the abdominal cavity was 347. From the results of the patient survey, among the PD patients, 1932 also underwent another dialysis method using extracorporeal circulation, such as hemodialysis (HD) and HDF. The number of patients who underwent HD at home in 2012 was 393, a marked increase from that in 2011 (327).

An Overview of Regular Dialysis Treatment in Japan (as of 31 December 2004)

A statistical survey of 3932 nationwide hemodialysis (hereafter, dialysis) facilities was carried out at the end of 2004, and 3882 facilities (98.73%) responded. The population undergoing dialysis at the end of 2004 was 248 166, an increase of 10 456 patients (4.4%) from that at the end of 2003. The number of dialysis patients per million people was 1943.5. The crude death rate of dialysis patients from the end of 2003 to the end of 2004 was 9.4%. The mean age of patients who underwent dialysis in 2004 was 65.8 years, and that of the total dialysis population was 63.3 years. The percentage distribution of patients who underwent dialysis according to a newly underlying disease showed that 41.3% of patients had diabetic nephropathy and 28.1% had chronic glomerulonephritis. The frequency of calcium carbonate use for dialysis patients was 75.1% and that of sevelamer hydrochloride use was 26.2%. The frequency of sevelamer hydrochloride use does not necessarily have a strong correlation with the dose of calcium carbonate. Patients who received high doses of sevelamer hydrochloride tended to have a low concentration of arterial blood HCO(3-). Approximately 15% of dialysis patients used an intravenous vitamin D preparation, generally maxacalcitol. The longer the patients had been on dialysis, the higher the frequency of use of an intravenous vitamin D preparation. When the concentration of serum intact parathyroid hormone (PTH) was more than 200 pg/mL, the frequency of use of an orally administered vitamin D preparation decreased; but that of intravenous vitamin D preparation increased. The percentage of dialysis patients who received percutaneous ethanol injection therapy (PEIT) was 1.4%. The percentage was more than 50% in the patients who had been on dialysis for more than 10 years. The percentage of patients who received PEIT again was 35.0%. The percentage of patients who had been on hemodialysis for more than 10 years and received PEIT again was more than 50%.

Special issues in the management of patients with ESRD and HIV infection

During 1985 to 1999, the percentage of hemodialysis centers providing care to patients with human immunodeficiency virus (HIV) in the United States increased from 11% to 39%, and the percentage of dialysis patients with HIV infection increased from 0.3% to 1.4%. Therefore, nephrologists are going to be confronted not only with providing dialysis care, but also with primary care issues of these patients. In this review, we discuss issues related to HIV infection and end-stage renal disease, such as choice of renal replacement therapy, vascular access, anemia, vaccination, prevention of opportunistic infections, and antiretroviral therapy, that will help nephrologists not only provide optimal care, but also improve outcomes in these patients. Am J Kidney Dis 41:279-291.

Hong Kong Renal Registry 1995–1999

This report was based on the data from the Renal Registry of the Hospital Authority of Hong Kong, accounted for 90% to 95% of all the patients on renal replacement therapy (RRT) in Hong Kong. Patients who received RRT under the private sectors were not included in this report. The data were as of 31 March 1999. There were 11 renal units, five satellite centers and four major renal transplant centers. The number of patients on RRT was 4268 [627 patients per million (pmp)], of which 58% (2490 patients, 360 pmp) were on peritoneal dialysis (PD), 13% (576 patients, 85 pmp) on hemodialysis (HD) and 28% (1202 patients, 177 pmp) with functioning kidney transplants (TX). The net increase of the number of patients on RRT from previous year was 10%. The incidence of end-stage renal failure was 762 (112 pmp). The median age of the existing patients on RRT was 52, of which 33% were above the age of 61 years. The median age of the new patients was 56 years, of which 50% were above the age of 61 years. The major causes of renal failure for existing patients were glomerulonephritis 32%, unknown 26% and diabetes 21%. For the new cases, 34% were due to diabetic nephropathy. Of all the patients on RRT, 10% were serologically positive for hepatitis B infection while 6% were positive for hepatitis C infection. Of all the patients on dialysis, 81% were on PD, of which 92% were on continuous ambulatory peritoneal dialysis (CAPD). Of the CAPD patients, 13% were still using “connect” systems, 75% were using “disconnect” systems and 12% using UV flash systems. Nineteen percent of all the patients on dialysis were on HD, of which 54% were on hospital based HD, 21% on satellite center based HD, 9% on charitable center based HD and 3% on home HD. Of the 1202 patients with kidney transplants, 629 (52%) were transplanted in Hong Kong. Of these, 325 (52%) were cadaveric kidney transplantation. For the year ending 31 March 1999, 113 patients (17 pmp) received a kidney transplantation, of which 58 transplants were performed in Hong Kong (30 cadaveric kidneys and 28 living related kidneys). Thirty-one percent of all the patients on RRT were receiving erythropoietin therapy. The annual crude mortality rate for all RRT was 7% (8% for PD, 14% for HD and 1.6% with TX). The major causes of death were cardiovascular (24%), infection (22%) and cerebral vascular accident (6%). The 1 and 5 year patient survivals for kidney transplants performed in Hong Kong between 1 April 1993 to 31 March 1998 were 98%, 96% for living related kidney and 94%, 89% for cadaveric kidney. The 1 and 5 year graft survivals were 92%, 88% (censored), 91%, 85% (not censored) for living related kidney and 89%, 83% (censored), 86%, 79% (not censored) for cadaveric kidney. The overall peritonitis rate for all CAPD systems for the 7 months ending 31 March 1999 was one episode per 21 months. The peritonitis rate of the new disconnect systems was one episode per 20 to 27 months. The point prevalence rate of RRT (1997 data) for Hong Kong was within 15% range of that for Australia, Canada and most European countries, but only 40% to 60% of that for Japan, USA and Taiwan. The percentage of dialysis patients being treated with PD was highest in the world.

Home haemodialysis in the 1990s.

Home haemodialysis has been utilized successfully in mencing long-term dialysis, but the number of low risk the treatment of end-stage renal failure (ESRF ) since patients beginning dialysis, who would have been 1961. After an initial expansion in home haemodialysis assessed previously as suited to training for home during the 1970s and early 1980s, the number of haemodialysis, remains unchanged. Such low risk patients receiving this mode of dialysis has decreased patients must now be opting for either peritoneal progressively over the past decade despite a major dialysis or hospital-based haemodialysis. This trend expansion in the total number of patients on chronic may be due to an increase in the number of regional renal replacement therapy [1]. In the US, the percent- renal units resulting in the provision of hospital haemoage of dialysis patients on home haemodialysis was dialysis nearer patients’ homes, the expansion of con39.2% in 1972, 23.7% in 1976 and 1.3% in 1992 [1,2]. tinuous ambulatory peritoneal dialysis (CAPD) and This international trend was also apparent in Scotland, automated peritoneal dialysis (APD) in the 1980s and where the number of patients receiving home haemo- socio-demographic changes in the family unit and in dialysis decreased from 160 in 1987 to 75 in 1995 while the workplace which may have led to fewer unpaid the total number of dialysis patients increased from helpers being able to assist with home haemodialysis. 760 to 1180 over the same time period [3]. In During the past 10 years in the West of Scotland Lombardy, Italy, which, like Scotland, also has a (population ~2.8 million), the number of renal units complete registry of patients on renal replacement has risen from three to six, the median age and number therapy, the percentage of dialysis patients on home of patients receiving chronic dialysis have increased, haemodialysis decreased from 15.7 to 5.3% over the the proportion of single person households has decade from 1983 in spite of a major increase in the increased, and peritoneal dialysis patient numbers have acceptance rate for dialysis and only a minor increase remained stable while the number of home haemodiain renal transplantation rates [4]. In our centre, the lysis patients has halved. Other factors may also have number of home haemodialysis patients at the end of influenced the decline of home haemodialysis over the each consecutive year from 1990 to 1997 was 60, 56, past decade: the perceived complexity of the technique, 48, 44, 41, 43, 39 and 42, indicating that home haemo- the low risk of air embolism, the additional time before dialysis patient numbers have remained stable over the and after every treatment required for setting up and past 4 years. clearing the haemodialysis system, and doubts about the cost-eVectiveness of the technique when patient numbers in each unit are small. Why has home haemodialysis declined in recent years?