Predialysis Care Research Articles

Transfusion Management of Incident Dialysis Patients in Canada: A Prospective Observational Study.

Background:Several studies have demonstrated harm associated with using erythropoiesis-stimulating agents (ESA) to achieve higher hemoglobin (Hb) levels. Subsequently, more conservative use of ESAs has changed anemia therapy in patients with chronic renal failure.Objective:The objectives were to identify transfusion rates in hemodialysis (HD) patients during the first year of therapy, to identify factors associated with the probability of transfusion, describe reasons for the transfusions, and identify the Hb values associated with each transfusion. An exploratory objective was to describe the age of red blood cell transfusions.Design:This was a multicenter prospective observational cohort study.Setting:There were 12 study sites in 5 Canadian provinces. The study was performed from 2012 to 2014.Methods:The study patients were adult incident chronic HD patients in these centers. Patients with acute kidney injury, peritoneal dialysis, and planned transfer to satellite units were excluded. Patients had to receive at least 1 month of chronic HD to be eligible. Data for 3 months prior to HD were obtained by retrospective chart review. Prospectively, charts were reviewed monthly for 12 months for data abstraction.Results:There were 314 patients enrolled and 79.9% completed 12 month follow-up. Ninety-four (29.9%) patients received at least 1 unit of blood. During the first 90 days, the transfusion episode rate was 148.4 per 100 patient-years compared with 62.6 per 100 patient-years post 90 days. The most frequent indication was a low Hb value (92%) with gastrointestinal bleeding, surgical blood loss, and fatigue accounting for 9.9%, 8.6%, and 4.5%, respectively. Some patients had >1 indication. The mean Hb values prior to transfusion episodes ranged from 75.3 to 78.6 g/L. Cox regression analysis on time to first transfusion and time to first hospitalization/death both showed an association with inpatient initiation of HD. Some 37.5% initiated HD as an inpatient and differed from those starting as an outpatient. They had less predialysis care and laboratory data suggested more inflammation. The mean and median ages of the blood units transfused were 24.9 (SD = 10.0) and 23 days (interquartile range = 17-33).Conclusions:This work reported the blood transfusion rate in incident HD patients in Canada during a period associated with conservative ESA prescription. The major indication for transfusion was a low Hb rather than clinical symptoms. Initiation of HD as an inpatient was independently associated with the probability of receiving a blood transfusion. These findings require further investigation.

Health-related quality of life trajectories during predialysis care and associated illness perceptions.

To identify health-related quality of life (HRQOL) trajectories during 18 months of predialysis care and associated patient characteristics and illness perceptions. 396 incident predialysis patients participating in the prospective PREdialysis PAtient REcord-2 study completed every 6 months the 36-item Short Form Health Survey (i.e., mental and physical HRQOL) and Revised Illness Perception Questionnaire. HRQOL trajectories were examined using latent class growth models, and associated baseline factors were identified using logistic regression. Analyses for illness perceptions were adjusted for demographic and clinical characteristics. Three physical HRQOL trajectories (low-stable [34.1% of the sample], medium-declining [32.5%], and high-increasing [33.4%]) and two mental HRQOL trajectories (low-stable [38.7%] and high-stable [61.3%]) were identified. Increased odds for a low-stable physical HRQOL trajectory were detected in older patients (Odds ratio [OR] = 1.04), patients with cardiovascular disease (OR = 2.1) and patients who believed to a lesser extent they can personally control their disease (ORadj = 0.88). Increased odds for both a low-stable physical and mental HRQOL trajectory were detected in patients who believed to a higher extent that their disease is cyclical, has negative consequences, causes negative feelings, and in patients who believed to a lesser extent they understand their disease (ORadj ranged between 0.84 and 1.36). Additionally, patients who attributed more symptoms to their disease had increased odds for a medium-declining (ORadj = 1.21) and low-stable physical HRQOL trajectory (ORadj = 1.50). Older age and cardiovascular disease are markers for unfavorable physical HRQOL trajectories, and stronger negative illness perceptions are markers for unfavorable physical and mental HRQOL trajectories. Targeting negative illness perceptions could possibly optimize HRQOL during predialysis care. (PsycINFO Database Record

Obesity and risk of death or dialysis in younger and older patients on specialized pre-dialysis care.

BackgroundObesity is associated with increased mortality and accelerated decline in kidney function in the general population. Little is known about the effect of obesity in younger and older pre-dialysis patients. The aim of this study was to assess the extent to which obesity is a risk factor for death or progression to dialysis in younger and older patients on specialized pre-dialysis care.MethodIn a multicenter Dutch cohort study, 492 incident pre-dialysis patients (>18y) were included between 2004–2011 and followed until start of dialysis, death or October 2016. We grouped patients into four categories of baseline body mass index (BMI): <20, 20–24 (reference), 25–29, and ≥30 (obesity) kg/m2 and stratified patients into two age categories (<65y or ≥65y).ResultsThe study population comprised 212 patients younger than 65 years and 280 patients 65 years and older; crude cumulative risk of dialysis and mortality at the end of follow-up were 66% and 4% for patients <65y and 64% and 14%, respectively, for patients ≥65y. Among the <65y patients, the age-sex standardized combined outcome rate was 2.3 times higher in obese than those with normal BMI, corresponding to an excess rate of 35 events/100 patient-years. After multivariable adjustment the hazard ratios (HR) (95% CI) for the combined endpoint by category of increasing BMI were, for patients <65y, 0.92 (0.41–2.09), 1 (reference), 1.76 (1.16–2.68), and 1.81 (1.17–2.81). For patients ≥65y the BMI-specific HRs were 1.73 (0.97–3.08), 1 (reference), 1.25 (0.91–1.71) and 1.30 (0.79–1.90). In the competing risk analysis, taking dialysis as the event of interest and death as a competing event, the BMI-specific multivariable adjusted subdistribution HRs (95% CI) were, for patients <65y, 0.90 (0.38–2.12), 1 (reference), 1.47 (0.96–2.24) and 1.72 (1.15–2.59). For patients ≥65y the BMI-specific SHRs (95% CI) were 1.68 (0.93–3.02), 1 (reference), 1.50 (1.05–2.14) and 1.80 (1.23–2.65).ConclusionWe found that obesity in younger pre-dialysis patients and being underweight in older pre-dialysis patients are risk factors for starting dialysis and for death, compared with those with a normal BMI.

PP.07.18] CHRONIC KIDNEY DISEASE, END STAGE RENAL DISEASE, AND KIDNEY TRANSPLANTATION IN SURINAME

Objective: The high hypertension and diabetes burden in low and middle income countries is expected to lead to an increase in chronic kidney disease (CKD) and the need of renal replacement therapy. We aimed to estimate the prevalence of CKD and end stage renal disease (ESRD), and assess the availability of kidney transplantation in Suriname, a middle income country with a current population size of nearly 574.000 persons of mainly South Asian and African descent. Our previous studies showed that around 80% of the adult population is prehypertensive or hypertensive, and around 26% has prediabetes or diabetes. Design and method: We analysed data of the Healthy Life in Suriname (HELISUR) study, a random population sample, to estimate the number of patients with CKD (eGFR <60 ml/min/1.73 m2) and ESRD (eGFR <15 ml/min/1.73 m2); and analysed data of dialysis centers to assess the number of patients on renal replacement therapy. Results: We found that around 2% of the adult population had CKD (est. n = 11.500). Of these, 63% had an eGFR of 30–59; 28% of 15–29, and 9% of <15 mL/min/1.73 m2 (est. n = 1035). The number of patients on hemodialysis has starkly increased in the past years. In 2014, 516 patients were on maintenance dialysis. The majority of these patients (76%) had a history of hypertension, 47% had a history of diabetes, and 30% had both conditions. There was no health care facility to provide renal transplants or predialysis care. Although all patients had health insurance, patients experienced difficulties in accessing dialysis. In particular transportation to the clinic and out-of-pocket expenses for drugs were unaffordable for low-income patients. Conclusions: The high cardiovascular risk burden in Suriname creates a challenge for the health-care system to provide and sustain renal replacement therapy. Kidney transplantation is not available in Suriname. A previous study showed this to be mainly due to the lack of technical means to perform the procedure and the lack of eligible donors. Thus, our results highlight the need for effective population-based strategies to reduce the cardiovascular disease burden of hypertension and diabetes, and prevent kidney failure.

Seasonal variation in hemodialysis initiation: A single-center retrospective analysis.

The number of new dialysis patients has been increasing worldwide, particularly among elderly individuals. However, information on seasonal variation in hemodialysis initiation in recent decades is lacking, and the seasonal distribution of patients’ conditions immediately prior to starting dialysis remains unclear. Having this information could help in developing a modifiable approach to improving pre-dialysis care. We retrospectively investigated the records of 297 patients who initiated hemodialysis at Hiroshima Prefectural Hospital from January 1st, 2009 to December 31st, 2013. Seasonal differences were assessed by χ2 or Kruskal-Wallis tests. Multiple comparison analysis was performed with the Steel test. The overall number of patients starting dialysis was greatest in winter (n = 85, 28.6%), followed by spring (n = 74, 24.9%), summer (n = 70, 23.6%), and autumn (n = 68, 22.9%), though the differences were not significant. However, there was a significant winter peak in dialysis initiation among patients aged ≥65 years, but not in those aged <65 years. Fluid overload assessed by clinicians was the most common uremic symptom among all patients, but a winter peak was only detected in patients aged ≥65 years. The body weight gain ratio showed a similar trend to fluid overload assessed by clinicians. Pulmonary edema was most pronounced in winter among patients aged ≥65 years compared with other seasons. The incidences of infection were modestly increased in summer and winter, but not statistically significant. Cardiac complications were similar in all seasons. This study demonstrated the existence of seasonal variation in dialysis initiation, with a winter peak among patients aged ≥65 years. The winter increment in dialysis initiation was mainly attributable to increased fluid overload. These findings suggest that elderly individuals should be monitored particularly closely during the winter.

Dialysis Access as an Area of Improvement in Elderly Incident Hemodialysis Patients: Results from a Cohort Study from the International Monitoring Dialysis Outcomes Initiative

Background: Commencing hemodialysis (HD) using a catheter is associated with a higher risk of adverse outcomes, and early conversion from central-venous catheter (CVC) to arteriovenous fistula/graft (non-CVC) improves outcomes. We investigated CVC prevalence and conversion, and their effects on outcomes during the first year of HD in a multinational cohort of elderly patients. Methods: Patients ≥70 years from the MONDO Initiative who commenced HD between 2000 and 2010 in Asia-Pacific, Europe, North-, and South-America and survived at least 6 months were included in this investigation. We stratified by age (70-79 years [younger] vs. ≥80 years [older]) and compared access types (at first and last available date) and their changes. We studied the association between access at initiation and conversion, respectively, and all-cause mortality using Kaplan-Meier curve and Cox regression, and predicted the absence of conversion from catheter to non-CVC using adjusted logistic regression. Results: In 14,966 elderly, incident HD patients, survival was significantly worse when using a CVC at all times. In Europe, the conversion frequency from CVC to non-CVC was higher in the younger fraction. Conversion from non-CVC to CVC was associated with worsened outcomes only in the older fraction. Conclusion: These results corroborate the need for early HD preparation in the elderly HD population. Treatment of elderly patients who commence HD with a CVC should be planned considering aspects of individual clinical risk assessment. Differences in treatment practices in predialysis care specific to the elderly as a population may influence access care and conversion rate.

Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease

Background: Mortality in the immediate post-hemodialysis transition period is extremely high. Many end-stage renal disease (ESRD) patients in the US start dialysis in an inpatient setting, but the characteristics of patients starting dialysis as inpatients, and the association of inpatient hemodialysis transition with mortality remain unclear. Methods: We examined 48,261 US veterans who transitioned to hemodialysis between October 2007 and September 2011. Associations of inpatient hemodialysis starting with all-cause mortality were examined in Cox proportional hazard models, with adjustments for demographics, comorbidities, vascular access type, pre-dialysis nephrology care and medication use, and last pre-ESRD estimated glomerular filtration rate and hemoglobin. Results: A total of 22,338 (46.3%) patients received the first hemodialysis treatment in an inpatient setting. Inpatient hemodialysis transition was associated with older age, presence of a tunneled catheter, higher comorbidity burden, and lack of pre-dialysis nephrology care. A total of 8,674 patients died (mortality rate 405/1,000 patient-years, 95% CI 397-413) during the first 6 months after transition to hemodialysis. The starting of inpatient vs. outpatient hemodialysis was associated with significantly higher crude all-cause mortality, but this association was attenuated after multivariable adjustments. Conclusions: Transition to hemodialysis in an inpatient setting is more common in older and sicker individuals, and in patients without pre-dialysis nephrology care and those who used a catheter for vascular access. Future studies are needed to determine if a higher proportion of patients could start hemodialysis treatment in outpatient clinics, through interventions targeting modifiable risk factors such as timely vascular access placement or earlier nephrology referrals.

To dialyse or delay: a qualitative study of older New Zealanders’ perceptions and experiences of decision-making, with stage 5 chronic kidney disease

BackgroundIssues related to renal replacement therapy in elderly people with end stage kidney disease (ESKD) are complex. There is inadequate empirical data related to: decision-making by older populations, treatment experiences,...

Integrating Supportive Care Principles Into Dialysis Decision Making: A Primer for Palliative Medicine Providers

Despite advances in predialysis care and dialysis technology, patients with advanced chronic kidney disease and end-stage renal disease continue to experience multiple comorbidities, a high symptom burden, a shortened life expectancy, and substantial physical, emotional, and spiritual suffering. Patients with acute kidney injury and end-stage renal disease, especially if they are older, often undergo prolonged hospitalizations, greater use of intensive medical treatment, and limited survival. Unfortunately, most nephrologists are not trained to conduct shared decision-making conversations to elicit patients' values, preferences, and goals for treatment and address their patients' multifactorial suffering. These patients would benefit from the integration of supportive care principles into their care. This article addresses how supportive care specialists can collaborate with nephrology clinicians to provide patient-centered supportive care and identifies resources to assist them in this endeavor.

Association of Proteinuria with Central Venous Catheter Use at Initial Hemodialysis.

Central venous catheter (CVC) use is associated with increased mortality and complications in hemodialysis recipients. Although prevalent CVC use has decreased, incident use remains high. To examine characteristics associated with CVC use at initial dialysis, specifically looking at proteinuria as a predictor of interest. Retrospective cohort of 918 hemodialysis recipients from Kaiser Permanente Northwest who started hemodialysis from January 1, 2004, to January 1, 2014. Multivariable logistic regression was used to examine an association of proteinuria with the primary outcome of CVC use. More than one-third (36%) of patients in our cohort started hemodialysis with an arteriovenous fistula, and 64% started with a CVC. Proteinuria was associated with starting hemodialysis with a CVC (likelihood ratio test, p < 0.001) after adjustment for age, peripheral vascular disease, congestive heart failure, diabetes, sex, race, and length of predialysis care. However, on pairwise comparison, only patients with midgrade proteinuria (0.5-3.5 g) had lower odds of starting hemodialysis with a CVC (odds ratio = 0.39, 95% confidence interval = 0.24-0.65). Proteinuria was associated with use of CVC at initial hemodialysis. However, a graded association did not exist, and only patients with midgrade proteinuria had significantly lower odds of CVC use. Our findings suggest that proteinuria is an explanatory finding for CVC use but may not have pragmatic value for decision making. Patients with lower levels of proteinuria may have a higher risk of starting dialysis with a CVC.

Health policies on dialysis modality selection: a nationwide population cohort study

ObjectivesIn Taiwan, peritoneal dialysis (PD) and haemodialysis are fully accessible to patients with end-stage renal disease. However, the usage of PD is considered low in Taiwan. Since 2005, 4 major...

Practice pattern of hemodialysis among end-stage renal disease patients in Rural South India: A single-center experience.

Hemodialysis (HD) is the most common mode of renal replacement therapy for end-stage renal disease (ESRD) patients in India. However, the practice and pattern of dialysis in a hospital serving rural population is largely unknown. A prospective study of 127 ESRD patients initiated on HD between January 2013 and December 2014 was done. The study included 101 males and 26 females, with a mean age of 50.05 ± 13.80 years. Native kidney disease was unknown in 45.67% of patients as they presented very late in their disease course. Nearly 87.4% of patients had emergency dialysis. Only 6.30% of patients had started dialysis with an arteriovenous fistula while 93.70% with a temporary catheter. The mean creatinine and hemoglobin at the initiation of dialysis were 11.18 mg/dL and 6.8 g/dL, respectively. All patients underwent twice weekly HD of 4 h duration with achieved average single-pool Kt/V of 1.52. The hospitalization rate was 3.25 per patient-year. The outcomes in our cohort were as follows: 3.94% transferred to other centers, 16.54% died, 0.79% underwent transplantation, 33.07% continued on HD, and majority 45.67% stopped dialysis. The most common cause of death was sepsis. The Kaplan-Meier analysis showed median survival time on dialysis to be 64 days. Patients initiated on HD in rural area often present late with poor predialysis care leading to high morbidity. Prognosis is generally poor with majority of the patients stopping dialysis within few weeks.

The role of psychological factors in fatigue among end-stage kidney disease patients: a critical review.

Fatigue is a common and debilitating symptom, affecting 42–89% of end-stage kidney disease patients, persisting even in pre–dialysis care and stable kidney transplantation, with huge repercussions on functioning, quality of life and patient outcomes. This paper presents a critical review of current evidence for the role of psychological factors in renal fatigue. To date, research has concentrated primarily on the contribution of depression, anxiety and subjective sleep quality to the experience of fatigue. These factors display consistent and strong associations with fatigue, above and beyond the role of demographic and clinical factors. Considerably less research is available on other psychological factors, such as social support, stress, self-efficacy, illness and fatigue-specific beliefs and behaviours, and among transplant recipients and patients in pre-dialysis care. Promising evidence is available on the contribution of illness beliefs and behaviours to the experience of fatigue and there is some indication that these factors may vary according to treatment modality, reflecting the differential burdens and coping necessities associated with each treatment modality. However, the use of generic fatigue scales casts doubt on what specifically is being measured among dialysis patients, illness-related fatigue or post-dialysis-specific fatigue. Therefore, it is important to corroborate the available evidence and further explore, qualitatively and quantitatively, the differences in fatigues and fatigue-specific beliefs and behaviours according to renal replacement therapy, to ensure that any model and subsequent intervention is relevant and grounded in the experiences of patients.

Impact of the End Stage Renal Disease Prospective Payment System on the Use of Peritoneal Dialysis

IntroductionThe End Stage Renal Disease (ESRD) Prospective Payment System (PPS), implemented by the Centers for Medicare and Medicaid Services in January 2011, encouraged use of peritoneal dialysis (PD) through various financial incentives. Our goal was to determine whether PPS effectively increased PD use in incident dialysis patients.MethodsOur study used the United States Renal Data System (USRDS) to identify 430,927 adult patients who initiated dialysis between 2009 and 2012. The interrupted time series method was used to evaluate the association Centers for Medicare and Medicaid Services of PPS with PD use at dialysis initiation. We further stratified by patient demographics, predialysis care, and facility chain and profit status.ResultsInterrupted time series analysis indicated PPS was associated with increased PD use in the 2-year period after PPS (change in slope = 0.04, P < 0.0001), although there was no immediate change in the level of PD use at the beginning of PPS (P = 0.512). Stratified analyses indicated PPS led to increased PD use across all age, race, and sex groups (P < 0.05) although marginally among females (P = 0.09). Notably, small dialysis organizations and nonprofit organizations appeared to increase use of PD faster compared to large dialysis organizations and for-profit units, respectively.DiscussionImplementation of the Centers for Medicare and Medicaid Services ESRD payment reform was associated with an increased use of PD in the 2 years after PPS. Our findings highlight the role of financial incentives in changing practice patterns to increase use of a dialysis modality considered to be both more cost-effective and empowering to ESRD patients. However, even after PPS, rates of PD use remain low among the dialysis population in the USA.

Supportive Care: Meeting the Needs of Patients with Advanced Chronic Kidney Disease.

Over the last several decades, despite advances in predialysis care and dialysis technology, people with advanced CKD continue to have a high symptom burden, shortened life expectancy, and substantial physical, emotional, and spiritual suffering ([1][1]). Unfortunately, most nephrologists are not

RENEW-a renal redesign project in predialysis patient care.

BackgroundAn ageing population and geographical growth, along with an increase in the number of people that reside in specific location, are increasing the demand for renal replacement therapies. Hospital-based haemodialysis units are struggling to cope with the associated physical, staffing and cost demands. Home-based dialysis therapies are known to be more cost effective with superior social, physical health and survival outcomes.Methods‘RENEW, a renal redesign project, examined the pre-dialysis health care experience of renal patients to find opportunities to improve patient care outcomes and increase the uptake of home-based dialysis therapies. This article details two crucial parts of the approach to change management: (i) diagnostics—an inclusive, client focused, multidisciplinary approach to identify issues relating to the pre-dialysis journey—and (ii) solution design—an inclusive problem-solving approach to identify and marry solutions to the issues identified during diagnostics.ResultsBased on feedback from patients/caregivers and staff interviews, utilizing a clinical redesign methodology, a new model of care was developed, implemented and subsequently embedded into clinical practice. The results have been evident via improved care coordination, enhanced patient preparation for dialysis, improved patient psychosocial welfare and, importantly, an increased number of patients planned for and commencing home dialysis. This has empowered patients by giving them the confidence, knowledge and skills to be actively engaged in their own care. The project resulted in significant expenditure avoidance.ConclusionChange management strategies with successful implementation are vital components of evolving clinical practice to achieve both clinical and organizational goals.

Pre-dialysis renal clinic visits and patients' outcomes on peritoneal dialysis.

To investigate the effect of pre-dialysis renal care on peritoneal dialysis (PD) patients' outcomes in China. In this retrospective cohort study, patients who started PD during January 1, 2006, to December 31, 2014, were included. Patients' medical charts were reviewed to extract the information. To explore the effect of pre-dialysis renal care on patients' outcomes, patient were divided into two groups according to whether or not they had frequent renal clinic visits: Group A (with frequent visits) and Group B (without frequent visits). A total of 668 patients were included. Patients who admitted to emergency room before PD initiations were significantly higher in Group B than in Group A (42.7 vs. 33%, p=0.01). However, there was no significant difference in the proportion of patients requiring emergency hemodialysis prior to PD commencement (20.5 vs. 24.6%, p=0.21), acute heart failure (30.2 vs. 35.4%, p=0.16) and pulmonary infection (15.4 vs. 12.1%, p=0.23) between groups. Both the mortality and technical failure rate in Group A were significantly lower as compared to Group B (p=0.003 and p<0.01, respectively). Multivariable Cox regression analysis showed frequent pre-dialysis renal clinic visits were associated with both lower mortality rate (HR 0.62, 95% CI 0.46-0.85, p=0.003) and technical failure on PD (HR 0.58, 95% CI 0.36-0.92, p=0.022). Pre-dialysis frequent clinic visits were associated with better PD outcomes. Pre-dialysis renal clinic management was suboptimal in the present cohort. More organized system to ensure people with established chronic kidney disease are well managed is necessary in China.

Discriminative value of frailty screening instruments in end-stage renal disease.

BackgroundNumerous frailty screening instruments are available, but their applicability for identifying frailty in patients with end-stage renal disease (ESRD) is unknown. We aimed to investigate the diagnostic accuracy of three instruments used for frailty screening in an ESRD population.MethodsThe study was conducted in 2013 in a teaching hospital in The Netherlands and included patients receiving haemodialysis, peritoneal dialysis and pre-dialysis care. We determined the sensitivity and specificity of three screening instruments: the Groningen Frailty Indicator (GFI), the Identification of Seniors at Risk–Hospitalized Patients (ISAR-HP) and the Veiligheidsmanagementsysteem (VMS), which is a safety management system for vulnerable elderly patients. The Frailty Index was the gold standard used.ResultsThe prevalence of frailty was 37% in a total of 95 participants with ESRD [mean age 65.2 years (SD 12.0), 57% male]. Frailty prevalence in participants ≥65 years of age and <65 years of age was 44% and 28%, respectively (P = 0.11). Sensitivity and specificity for frailty of the GFI were 89% and 57%, respectively; ISAR-HP 83% and 77%, respectively; and VMS 77% and 67%, respectively.ConclusionsAlthough the GFI showed the highest sensitivity, it is not yet possible to propose a firm choice for one of these screening instruments or specific items due to the small scale of the study. Since there is a high prevalence of frailty in ESRD patients, translation and testing of the effectiveness of screening using the GFI in the prognostication and prevention of development or deterioration of frailty in this population should be the next step.

Efficacy of the Essential Amino Acids and Keto-Analogues on the CKD progression rate in real practice in Russia - city nephrology registry data for outpatient clinic.

BackgroundRenal replacement therapy (RRT) is growing by 10 % per year in Russia, but pre-dialysis care which can retard CKD progression and delay the start of RRT remains limited. We evaluate the effect of Essential Amino Acids and Keto-analogues (EAA/KA) on CKD progression.MethodsThe effect of low protein diet (LPD), supplemented by EAA/KA, on GFR slope changes between first and second treatment period (five sequential visits per period) in 96 patients withs CKD Stage 3B-5 was compared to GFR slope changes in the control group of 96 patients, randomly selected from matched (by gender, age, diagnosis and CKD Stage) cohort of 320 patients from the city Registry. The mean baseline eGFR was 23 ± 9 ml/min/1.73 m2; 29 % had CKD3B, 45 % - CKD4, 26 % - CKD5.ResultsThe rate of eGFR decline changed from −2.71 ± 2.38 to −2.01 ± 2.26 ml/min/1.73 m2 per year in the treatment group and from −2.18 ± 2.01 to −2.04 ± 2.18 ml/min/1.73 m2 per year in the control group. Only in the treatment group the difference was significant (p = 0.04 and p = 0.6). Standardized effect size for intervention was significant in treatment group: −0.3 (of pooled SD), 95 % CI −0.58 ÷ −0.02 and non-significant in control group: −0.07 (−0.35 ÷ +0.22). The univariate and multivariate analysis of EAA/KA therapy effect demonstrated that it was probably more effective in patients of older age, with higher time-averaged proteinuria (PU), lower phosphate level, in patients with glomerular v. interstitial diseases, and in females. Only the latter factor was significant at pre-specified level (<0.05).ConclusionsLPD combined with EAA/KA supplementation lead to the decrease of the CKD progression both in well-designed clinical study and in real nephrology practice in wide variety diseases and settings. Registry data can be helpful to reveal patients with optimal chances for beneficial effect of LPD supplemented by EAA/KA.Trial registrationISRCTN28190556 06/05/2016.

Pre-dialysis decline of measured glomerular filtration rate but not serum creatinine-based estimated glomerular filtration rate is a risk factor for mortality on dialysis.

Monitoring of renal function is important in patients with chronic kidney disease progressing towards end-stage renal failure, both for timing the start of renal replacement therapy and for determining the prognosis on dialysis. Thus far, studies on associations between estimated glomerular filtration rate (eGFR) measurements in the pre-dialysis stage and mortality on dialysis have shown no or even inverse relations, which may result from the poor validity of serum creatinine-based estimation equations for renal function in pre-dialysis patients. As decline in renal function may be better reflected by the mean of the measured creatinine and urea clearance based on 24-h urine collections (mGFR by C Cr-U ), we hypothesize that in patients with low kidney function, a fast mGFR decline is a risk factor for mortality on dialysis, in contrast to a fast eGFR decline. For 197 individuals, included from the multicentre NECOSAD cohort, pre-dialysis annual decline of mGFR and eGFR was estimated with linear regression, and classified according to KDOQI as fast (>4 mL/min/1.73 m 2 /year) or slow (≤4 mL/min/1.73 m 2 /year). Cox regression was used to adjust for potential confounders. Patients with a fast mGFR decline had an increased risk of mortality on dialysis: crude hazard ratio (HR) 1.84 (95% confidence interval: 1.13-2.98), adjusted HR 1.94 (1.11-3.36). In contrast, no association was found between a fast eGFR decline in the pre-dialysis phase and mortality on dialysis: crude HR 1.20 (0.75-1.89), adjusted HR 1.14 (0.67-1.94). This study demonstrates the importance of mGFR decline (by C Cr-U ) as opposed to eGFR decline in patients with low kidney function, and gives incentive for repeated mGFR measurements in patients on pre-dialysis care.