Start Of Dialysis Treatment Research Articles

Coping strategies and its relationship with sexual dysfunction in adults receiving haemodialysis and peritoneal dialysis: A cross-sectional study.

To explore relationship coping strategies and sexual dysfunction, and the predictive factors of sexual dysfunction in adults receiving haemodialysis and peritoneal dialysis. Sexual dysfunction is a common problem in adults receiving haemodialysis and peritoneal dialysis. This problem may be related to psychological and physiological conditions. However, the association between psychological conditions such as coping strategies and sexual dysfunction is not clearly understood. This study is a cross-sectional study. The data were collected from November 2021 to July 2022 using the General Information Form, Arizona Sexual Experiences Scale: Female and Male Versions, and the Ways of Coping Inventory. Correlation and multiple regression analyses were conducted to investigate the relationship between coping strategies and sexual dysfunction. STROBE checklist. A total of 110 adults, 67 on haemodialysis and 43 on peritoneal dialysis, who met the eligibility criteria were included in this study. The optimistic, helpless and submissive approach sub-dimensions of coping strategies had positive correlation with sexual dysfunction in adults receiving haemodialysis. Among the sub-dimensions of the ways of coping inventory, helpless approach was positive predictor and seeking social support was negative predictor of sexual dysfunction in adults receiving haemodialysis. The coping strategies were not predictors of sexual dysfunction for adults receiving peritoneal dialysis. This study showed that helpless coping strategy increases sexual dysfunction, and seeking social support decreases sexual dysfunction in haemodialysis. According to this study, social support is effective coping strategy for reducing sexual dysfunction. Education and support for effective coping strategies should be provided to dialysis patients by healthcare professionals at the start of dialysis treatment. Effective coping strategies should be integrated into routine care standards and nursing or hospital policies. Adults receiving haemodialysis and peritoneal dialysis were involved in this study.

THE EVALUATION OF THE EFFECT OF THE TREATMENTS ON OXIDATIVE STRESS AND INFLAMMATION IN PATIENTS RECEIVING DIFFERENT DIALYSIS MODALITIES

ABSTRACT
 Aim: To evaluate the effects of different dialysis methods on oxidative stress and inflammation in patients with end-stage renal disease (ESRD) who are newly enrolled in a routine dialysis program.
 Material and Methods: In this prospective study, 138 ESRD patients and 30 healthy volunteers were evaluated. Fifty-four of 73 hemodialysis (HD) patients and 51 of 65 periton dialysis (PD) patients completed the study. Other patients were excluded from the study. The levels of superoxide dismutase (SOD) and total antioxidant capacity (TAC) were measured to determine the oxidative stress status, and IL-6, IL-10, and F2 isoprostane levels were measured to determine the inflammation status, just before the start of dialysis treatment and at 6 months.
 Results: At the beginning of the study, hs-CRP and IL-6 levels were significantly higher in the patient group compared to the control group (p

Influence of dialysis-related stigma on health-related indicators in Japanese patients undergoing hemodialysis.

Focusing on impacts to health-related indicators in older Japanese patients, this study analyzed both the direct influence of dialysis-related stigma and influences of its intersectionality with other stigmatized characteristics. Data were collected through a cross-sectional survey of 7461 outpatients in dialysis facilities. Other stigmatized characteristics include lower income, lower education, disabled activities of daily living, and diabetic end-stage renal disease (ESRD) as a cause for starting dialysis treatment. The average rate of an "agree" response on dialysis-related stigma items was 18.2%. Dialysis-related stigma significantly influenced all three health-related indicators, including suspected depression, informal networks, and compliance with dietary therapy. In addition, each interaction between dialysis-related stigma and educational attainment, gender, and diabetic ESRD significantly influence one health-related indicator. These results suggest that dialysis-related stigma has both a significant direct and synergic influence with other stigmatized characteristics on health-related indicators.

Fractures in CKD Patients—Risk Analysis in RRT Lombardy Patients

The increase in the number of patients with CKD starting dialysis treatment has become a major health problem in recent years. Osteoporosis is a typical feature of advanced age, which, in the dialysis population, is almost always accompanied by uremic osteodystrophy (CKD-MBD). These two factors are involved in the pathogenesis of fractures, which represent an important risk factor for the outcome of patients. The real consistency of fractures in CKD patients on kidney replacement therapy (KRT) requiring hospitalization in the Lombardy region (over 9,000,000 inhabitants) was analyzed using data from the regional administrative databases in the years 2011–2012. Among 8109 prevalent patients, 251 (45.8% women), with fractures after 1 January 2011, entered the analysis. A follow-up of two years (2011–2012) was considered to evaluate the incidence of more frequent fractures (femur, pelvis, hip, and spine) using ICD-9-CM codes. The most frequent sites of fractures were the femur (68.5%), hip and pelvis (47.4%), and vertebrae (12%). The patients on hemodialysis (HD) had more events than PD (3.3% vs. 1.4%; p = 0.03), while patients undergoing kidney transplantation (KTx) had a significantly lower percentage of fractures (0.6% vs. 3.3%; p < 0.001). Observed mortality was very high: the estimated gross mortality rate for any cause was 25.9% at 90 days and 34.7% at 180 days. Diabetes, peripheral vasculopathy, and heart failure were associated with a numerical increase in fractures, although this was not significant. Proton pump inhibitor drugs (PPI), vitamin K antagonists, and diphosphonates were more frequently associated with fracture occurrence. The average total cost of fractured patients was 11.4% higher than that of non-fractured patients. On multivariate analysis, age >65 years, female gender, PPI therapy, and cerebrovascular disease were found to be strongly associated with fractures in dialysis patients, whereas undergoing renal transplantation presented a reduced risk.

Return to work after deceased donor kidney transplant under the kidney allocation system.

The Kidney Allocation System (KAS) includes a scoring system to match transplant candidate life expectancy with expected longevity of the donor kidney, and a backdating policy that gives waitlist time credit to patients waitlisted after starting dialysis treatment (post-dialysis). We estimated the effect of the KAS on employment among patient subgroups targeted by the policy. We used a sample selection model to compare employment after transplant before and after KAS implementation among patients on the kidney-only transplant waitlist between December 4, 2011 and December 31, 2017. Post-dialysis transplant recipients aged 18-49 were significantly more likely to be employed 1-year post transplant in the post-KAS era compared to the pre-KAS era. Transplant recipients aged 35-64 with no dialysis treatment were significantly less likely to be employed 1year after transplant in the post-KAS era compared to the pre-KAS era. This study provides the first assessment of employment after DDKT under the KAS and provides important information about both the methods used to measure employment after transplant and the outcome under the KAS. Changes in employment after DDKT among various patient subgroups have important implications for assessing long-term patient and societal effects of the KAS and organ allocation policy.

FC 117TIME TRENDS IN PROBABILITY OF STARTING HOME DIALYSIS OVER A 20 YEAR PERIOD: A DUTCH REGISTRY STUDY

Abstract Background and Aims A growing number of patients suffers from End Stage Kidney Disease(ESKD), causing a logistical and economic burden to the healthcare system. Utilization of home dialysis is low in many countries worldwide, although home dialysis has several advantages including higher quality of life and possibly lower costs. The aim of this study is to explore time trends in the use of home dialysis in the Netherlands. Method Anonymized registry data from the Dutch Renal Registry (RENINE) were used for this study. All dialysis episodes of adult patients who started dialysis treatment between 1997 through 2016 in the Netherlands were included, including those who previously underwent kidney transplantation. Dialysis episodes shorter than 90 days were excluded. The probability of starting home dialysis between 1997 through 2016 was evaluated in time periods of 5 years, using logistic regression analysis. Home dialysis was defined as start with peritoneal dialysis or home haemodialysis, or transfer to either within 2 years after dialysis start. A logistic multilevel model was used to adjust for clustering at patient level. The cumulative incidence function of start of home dialysis in incident patients was estimated with a competing risk model with recovery of kidney function, kidney transplantations, and all-cause mortality as competing events. All analyses were stratified for age categories at dialysis start: 20-44 years, 45-64 years, 65-74 years and ≥75 years. Results A total of 33,340 dialysis episodes in 31,569 patients were evaluated. Between 1997 and 2016, mean age at start of dialysis treatment increased from 62.5±14.0 to 65.5±14.5 years in in-centre haemodialysis patients, whereas it increased from 51.9±15.1 to 62.5±14.6 years in home dialysis patients. In patients < 65 years, the probability of starting home dialysis was significantly lower during each 5-year period compared to the previous period, and kidney transplantation occurred more often. In patients ≥ 65 years, incidence of home dialysis remained constant, whereas mortality decreased. Conclusion In patients < 65 years, the overall probability of starting home dialysis declined consistently over the past 20 years. The age of home dialysis patients increased more rapidly than that of in-centre dialysis patients, implying that pre-dialysis education and organization of home dialysis must be adapted to the needs of the elderly patient. These developments have a significant impact on the organisation of home dialysis for patients with ESKD.

Peripheral artery disease at the time of dialysis initiation and mortality: a prospective observational multicenter study

ObjectivesPatients with peripheral artery disease (PAD) are reported to have a poorer prognosis than those without PAD. PAD is sometimes found at dialysis initiation, but its influence on the prognosis...

P1469HOW LONG ELDERLY ESRD PATIENTS CAN UNDERGO DIALYSIS TREATMENT?; A NATIONWIDE POPULATION-BASED COHORT STUDY

Abstract Background and Aims Elderly population is increasing and the age starting dialysis treatment is also increasing. It could be an ethical issue that we should do or not do start dialysis treatment in the oldest old people such as 10th decade. We investigated duration of dialysis therapy via patients age using National Health Insurance calim data to know dialysis survival of patients via their age. Method Korean National Health Insurance Database was used and excerpted data from the insurance claim of ICD code of dialysis. We included all new patients starting dialysis more than 3 months between 2004 and 2013 and compared dialysis duration among the age group. Patients on dialysis before 2003 were excluded, and patients on kidney transplantation were also excluded. Results Total 208,202 dialysis patients were included via dialysis insurance calim code from about 50,000,000 South Korean population during the year 2003 to 2015. 126,448 patients were excluded due to dialysis before 2003, < 3 months of dialysis duration, kidney transplatation, and to have missing data. Among the final 81,754 patients, 73,969 were hemodialysis and 7,785 were peritoneal dialysis. 47,798 were men and 33,956 were wemen. Observed median dialysis duration of each aged group of 20-40, 41-50, 51-60, 61-70, 71-80, 81-90, and >90 were 5.4 (2.2 - 18.3), 5.0 (1.8 - 17.7), 4.2 (1.5 - 15.1), 3.5 (1.2 - 12.6), 2.7 (0.9 - 10.1), 1.8 (0.5 - 7.1), 1.3 (0.3 - 4.9) years, respectively (p < 0.0001). Comparing with age under 40, dialysis survival hazard ratio of > 40, > 50, > 60, > 70, > 80, and > 90 were 1.493, 2.452, 3.762, 6.113, 9.787, and 15.326, respectively (p < 0.0001). Survival probability of the patients by the age was demonstrated in the figure 1. Lowest socio-econonic status and highest Charson-Comorbidity group showed highest hazard ratio of dialysis mortality, and peritoneal dialysis showed longer dialysis duration (HR 0.704, 95% CI of 0.69 - 0.74, p < 0.0001). Conclusion We concluded that dialysis durability by the age was rapidly decreased after 70 years old. As the longest patients survival of > 90 years were less than 5 years, we should consider patients’ general performance when starting dialysis of oldest old patients.

Depression, anxiety and health-related quality of life amongst patients who are starting dialysis treatment.

Chronic kidney disease (CKD) has a severe impact on patients' health-related quality of life (HRQL). The start of renal replacement therapy (RRT) significantly influences psychological, physical and social aspects of life. To analyse the HRQL and psychological status (anxiety and depression) at the start of RRT. We undertook an observational descriptive cross-sectional study. A total of 152 patients starting RRT were recruited for the study. HRQL was measured by the Kidney Disease and Quality of Life Short Form questionnaire. Levels of anxiety and depression were assessed by the Hospital Anxiety and Depression Scale questionnaire. Comorbidities and sociodemographic and clinical factors were also evaluated. HRQL in patients with end-stage kidney disease (ESKD) is significantly affected by the initiation of RRT in all respects. States of anxiety and depression were present in 26.6% and 27% of patients, respectively. These states are significantly related to the emotional component of the quality of life. The initiation of RRT has a strong impact on HRQL in comparison with a reference population and with other stages of CKD. The early detection of an altered psychological state is important, as this condition should be treated from the first stages of the disease, as it can significantly affect the subsequent development of RRT and the patient's quality of life.

Vascular access in diabetic patients. Are these patients "difficult"?

Diabetics with stage V chronic kidney disease (CKD) on hemodialysis (HD) are considered as "difficult patients", because of problems with creation of the vascular access. There is controversy regarding the results and recommendations for preparation of the vascular access in these patients. The aim of this retrospective study was to evaluate the results of creating different types of arteriovenous fistula (AVFs) in consecutive series of patients starting dialysis treatment. The analysis was performed in 741 patients (385 females and 356 males), average age 61.4±7 years, who started dialysis treatment in our department between January 2005 and December 2012. Native AVFs were created in all patients. No patients received an AVF requiring synthetic graft material. The number of patients with diabetic nephropathy was 166 (22.4%). Among them, 30 (18%) had type 1 diabetes and 136 (82%) type 2. In this group the occurrence of calcification in the forearm artery was estimated on the basis of physical examination, Allan's test, Doppler ultrasound and forearm X-ray. In a subgroup of patients with atherosclerotic changes in the arterial system the frequency of failed AVFs was analyzed. These results were compared with the group without diabetes. The number of procedures necessary for successfu AVF creation and type of access was counted in both groups. The assessment of the procedure frequency and AVF location in diabetic and in non-diabetic patients was made by χ² test with Yates correction. In the group of 166 patients with diabetes, in 100 cases (60%) atherosclerotic changes in forearm arteries were observed. In a subgroup of 30 patients with type 1 diabetes atherosclerosis was observed in 17 adults (57%). In this subgroup creation of a suitable forearm AVF in the first procedure in 9 patients was possible and in the other 8 cases the atherosclerotic changes necessitated repeated procedures and were an important obstacle to create the AVF. In the subgroup of 136 patients with type 2 diabetes, atherosclerosis in the forearm artery was observed in 83 cases (61%). In this subgroup the creation of a native AVF was possible in 40 patients during the first procedure and in 43 cases additional intervention was needed, but only in 8 cases was atherosclerosis the cause of fistula failure. Generally, among 166 patients only in 16 cases (10%) did atherosclerosis present an important obstacle for AVF creation, but the number of necessary procedures to create one functioning AVF was significantly greater in this population (2 v 2.7, p=0.0001). A functioning AVF in patients with diabetes was found significantly frequently in the arm localization in comparison to non-diabetic patients (4.3 v 2%, p=0.0478). Atherosclerotic changes in forearm arteries in diabetic patients appear in 60% of hemodialysis patients and make it difficult to create an AVF only in 10% of diabetic patients, but it is possible to create a native AVF in 90% of diabetic patients, although this requires more procedures. In patients with diabetes, AVF in the wrist region should be preferred.

The impact of nutritional status, physical function, comorbidity and early versus late start in dialysis on quality of life in older dialysis patients

Background: For the majority of the older patients in dialysis, the treatment will be lifelong. Thus, quality of life (QoL) is a crucial outcome. Our aim was to assess the QoL of older Norwegian dialysis patients and to investigate the impact of early (estimated glomerular filtration rate, eGFR ≥10 mL/min) versus late (eGFR <10 mL/min) start in dialysis, comorbidity, nutritional status and physical capacity. Methods: A self-report questionnaire including SF-36 (QoL) and the Subjective Global Assessment (SGA; nutritional status) was mailed to all patients (n = 320) ≥75 years registered in the Norwegian Renal Registry (NRR) as being in dialysis by September 2009. Reply was received from 233 patients (73%). Medical data including comorbidities and eGFR at dialysis start (obtained for 194 patients) were retrieved from the NRR. Functional capacity was determined from the SGA. Results: Compared to reports from younger dialysis patients, our patients scored poorer on all SF-36 subscales. Early start in dialysis was registered for 52 patients, 142 patients started late, 51.4% were well nourished (SGA A), 32.3% moderately malnourished (SGA B) and 16.4% were severely malnourished (SGA C). No significant association between any SF-36 scores and early versus late start, nutritional status or comorbidity was found. Better physical function was significantly associated with better scores on all SF-36 scales. Conclusions: Our results indicate that physical function is important to all QoL aspects. Increased focus on physical rehabilitation seems pertinent. Early start of dialysis treatment was not associated with better long term QoL scores.

Hemodialysis vascular access: everything you always wanted to know about it (but were afraid to ask)

Vascular accesses are essential for effective dialysis treatment. Arteriovenous fistulas, grafts and central venous catheters are the options available to the nephrologist, but they all have their pros and cons. All of the 3 types of vascular access share the same complications but at different rates, and their costs vary enormously, with on balance the arteriovenous fistula being the best choice. Nevertheless, recently the number of incident patients starting dialysis treatment with a venous catheter as vascular access has been steadily increasing. This is true even for more advanced countries such as the United States, where despite the efforts made to promote the use of fistulas, their prevalence is still low compared with Europe. Moreover, nowadays nephrologists are required to master technical skills that once were those of surgeons and to perform interventions to preserve the patency of the access. The aim of this paper is to review the prevalence, benefits and complications of the different vascular accesses in light of the most recent findings.

Considerations in the optimal preparation of patients for dialysis

Every year, more than 110,000 Americans are newly diagnosed with end-stage renal disease and in the overwhelming majority, maintenance dialysis therapy is initiated. However, most patients, having received no predialysis nephrology care or dietary counseling, are inadequately prepared for starting treatment; furthermore, the majority of patients do not have a functioning permanent dialysis access. Annualized mortality in the USA in the first 3 months after starting dialysis treatment is approximately 45%; this high rate is possibly in part due to inadequate preparation for renal replacement therapy. Data from the Dialysis Outcomes and Practice Patterns study suggest that similar challenges exist in many parts of the world. Implementation of strategies that mitigate the risk of adverse consequences when starting dialysis are urgently needed. In this Review we present a step-by-step approach to tackling inadequate patient preparation, which includes identifying individuals with chronic kidney disease (CKD) who are most likely to need dialysis in the future, referring patients for education, timely placement of dialysis access and timely initiation of dialysis therapy. Treatment with dialysis might not be appropriate for some patients with progressive CKD; these individuals can be optimally managed with nondialytic, maximum conservative management.

Comparison of Outcomes on Continuous Ambulatory Peritoneal Dialysis versus Automated Peritoneal Dialysis: Results from a USA Database

Automated peritoneal dialysis (APD) is being increasingly used as an alternative to continuous ambulatory peritoneal dialysis (CAPD). However, there has been concern regarding reduced sodium removal leading to hypertension and resulting in a faster decline in residual renal function (RRF). The objective of the present study was to compare patient and technique survival and other relevant parameters between patients treated with APD and patients treated with CAPD. Data for incident patients were retrieved from the database of the Renal Research Institute, New York. Treatment modality was defined 90 days after the start of dialysis treatment. In addition to technique and patient survival, RRF, blood pressure, and laboratory parameters were also compared. 179 CAPD and 441 APD patients were studied. Mean as-treated survival was 1407 days [95% confidence interval (CI) 1211 - 1601] in CAPD patients and 1616 days (95% CI 1478 - 1764) in APD patients. Adjusted hazard ratio (HR) for mortality was 1.31 in CAPD compared to APD (95% CI 0.76 - 2.25, p = NS). Unadjusted as-treated technique survival was lower in CAPD compared to APD, with HR 2.84 (95% CI 1.65 - 4.88, p = 0.002); adjusted HR was 1.81 (95% CI 0.94 - 3.57, p = 0.08). Peritonitis rate was 0.3 episodes/patient-year for CAPD and APD; exit-site/tunnel infection rate was 0.1 and 0.3 episodes/patient-year for CAPD and APD respectively (p = NS). Patient survival was not significantly different between APD and CAPD patients, whereas technique survival appeared to be higher in APD patients and could not be explained by differences in infectious complications. No difference in blood pressure control or decline in RRF was observed between the 2 modalities. Based on these results, APD appears to be an acceptable alternative to CAPD, although technique prescription should always follow individual judgment.

An association between depressive symptoms and survival in incident dialysis patients

Depression in end-stage renal disease patients is detrimental to quality of life, and is also associated with adverse clinical outcomes. The aim of this study was to examine whether depression symptoms in 'incident dialysis' patients predicted survival. One hundred and sixty incident haemodialysis and peritoneal dialysis patients completed a self-report depression questionnaire (Beck Depression Inventory-II, BDI) at a point soon after dialysis initiation. Over the study period (May 2007-December 2009), patients were followed up with all-cause mortality recorded as the end point. The median follow-up time for the cohort was 511 days (min 47 days and max 1027 days). There were 27 deaths (16.9%). Depression symptoms were evaluated both as a continuous variable and using a defined cut-off for depressed patients (BDI ≥ 16). In a Cox proportional hazards model, adjusted for several covariates including albumin and extra renal comorbidity, depression score was an independent predictor of mortality (HR = 1.07, 95% CI 1.02-1.11, P = 0.002). In an additional adjusted model, a BDI score ≥ 16 was associated with a 2.7 times increase in the hazard for death (HR = 2.7, 95% CI 1.06-6.8, P = 0.037). The severity of depression symptoms following the start of dialysis treatment is an independent predictor of survival. Further studies will be required to determine whether the treatment of depression would alter health-related outcomes, including survival.

Comparable Outcomes in Type 2 Diabetic Patients with Diabetic or Vascular Nephropathy Treated by Hemodialysis

Aim: The aim of the present study was to find out any differences in the progression of macroangiopathic diseases and patient survival in diabetic patients with diabetic nephropathy (DN) or diabetic renal vasculopathy (DV) under hemodialysis therapy. Methods: We compared 24 type 2 diabetic patients under hemodialysis with DV and 102 type 2 diabetic patients under hemodialysis with DN. Observation period was the first 3 years after initiating dialysis therapy. Results: Patients with DN were younger and their diabetes duration was longer (p < 0.05) than in the DV patients. The prevalence of vascular diseases at the start of dialysis treatment as well as after 3 years was not significantly different between both groups. The 3-year mortality was 50% in the DN group and 46% in the DV patients Conclusion: Patients with DN and DV show a similar poor outcome during the first 3 years of hemodialysis therapy.

Renal transplantation vs hemodialysis: Cost-effectiveness analysis

Chronic renal insufficiency (CRI), diabetes, hypertension, autosomal dominant polycystic kidney disease (ADPKD) are the main reasons for starting dialysis treatment in patients having kidney function failure. At present, dialysis treatments are performed in about 4,100 patients at 46 institutions in Serbia, out of which 90% are hemodialyses. At end-stage renal disease (ESRD) the only correct selection is kidney transplantation. The basic aim of the planned research was to compare ratio of costs and effects (Cost Effectiveness Analysis - CEA) of hemodialysis and kidney transplantation in patients at ESRD. As the main issue of treatment in patients from both groups the life quality measured by the validated McGill Questionary, was used. The study included 150 patients totally, divided into two groups. The study group consisted of 50 patients with kidney transplantation performed at the Clinical Center of Serbia and the control group consisted of 100 patients on hemodialysis at Clinical Center of Serbia, Clinical Hospital Center Zemun, Clinical Hospital Center "Zvezdara", Clinical Center Kragujevac and Health Center "Studenica", Kraljevo, comparable with respect to sex, age and length of treatment with the study group. Effect of kidney transplantation in relation to hemodialysis being selection of treatment is expressed in the form of incremental ratio of costs and effects (Incremental Cost-Effectiveness Ratio - ICER). It is clear from the enclosed tables that the strategy of kidney transplantation is far more profitable considering the fact that it represents saving of EUR 132,256.25 per one year of contribution Quality Adjusted Life Years (QALY) within the period of 10 years. According to all aspects of live quality (physical symptoms and problems, physical well-being, phychological symptoms, existential well-being and support), difference is statistically important in favour of transplant patents. The costs of patient therapy by hemodialysis at end-stage renal disease is far greater than by performing therapy of transplantation and maintenance, by almost three and a half times. Difference in total quality aspects of human life (physical, emotional, social, spiritual and financial) between dialysed and transplant patients is statistically significant and by 18.12% greater in transplant patients than in patients on hemodialysis.

Dialysis or not in the very elderly ESRD patient

Nephrology societies and dialysis registries are reporting a dramatic increase in the number of elderly patients who require dialysis. During the last decade the number of patients starting renal replacement therapy (RRT) has increased for all ages but the increase for patients over the age of 75 years has been particularly dramatic, with a 4.3-fold rise in the USA [1]. In view of this development, it is necessary to examine more closely the quality of the results (survival, selected technique, and morbidity) of kidney replacement therapy in this age group. Despite the fact that very old patients raise the most difficult problems with respect to indication and dialysis therapy management because of their multiple comorbidities and presumed short life expectancy, there are few studies devoted to very old end-stage renal disease (ESRD) patients and their conclusions are rather discordant. Some studies report very poor survival of very old patients on dialysis, whereas others report more favorable outcomes. Moreover, specific predictive factors that could help in deciding whether dialysis would offer pre-ESRD old patients substantial prolongation of life expectancy with an acceptable quality of life are lacking [2]. Below we discuss in more depth the reasons why, in general, dialysis should not be withheld from patients above 75 years of age. Let us first consider the title of this controversy: ‘‘The dilemma of renal replacement therapy in patients over 75 years.’’ Is this actually a dilemma? Basically, a dilemma is characterized by the need to choose between two evils, or in the present case between two possibilities. If the question is posed ‘‘should 75-year-old patients be started on dialysis: yes or no?’’ it is sensible to ask the question the other way round. What could be the reasons for not providing them with dialysis? Is the survival time too short? Is the quality of life that can be achieved unsatisfactory? Are there so many old people above 75 years of age and dialysis facilities are insufficient? Do financial constraints make age a matter of rationing? Good survival on dialysis for the very old is currently well documented. Shaefer and Rohrich showed that survival in very old patients after 12 months from the start of dialysis treatment was 70.5%, and after 24 months 50.3%, and after 60 months 18.5%. These results provide no rationale for withholding dialysis treatment, even when life expectancy of over 75-year-old dialysis patients is compared with that of younger dialysis patients. In fact 75-year-old dialysis patients have a life expectancy of only 36% of age-matched healthy controlled individuals. Therefore, the remaining life time is, M. Busuioc P. Gusbeth-Tatomir A. Covic (&) Nephrology Clinic and Dialysis Center, Parhon University Hospital, ‘‘Gr.T. Popa’’ University of Medicine and Pharmacy, Carol 1st Blvd. Nr. 50, Iasi 700503, Romania e-mail: acovic@xnet.ro

Development of a predictive model for early death in diabetic patients entering hemodialysis: a population-based study

The aim of this study was to investigate whether early death following the start of dialysis treatment can be explained by predialysis comorbid conditions, and to develop a prognostic model to predict early death in these patients. All patients with diabetes mellitus (DM) over 19 years of age entering hemodialysis in Catalonia in the 1997-2002 period (n = 1,365) were assessed from prospectively obtained data in the Catalan Renal Registry. Logistic regression was used to identify the risk factors associated with mortality at 3, 6 and 12 months of hemodialysis. Mortality at 3 months was found to be associated with age (RR: 1.53/10 years), low grades of functional autonomy, defined as "limited" (RR: 2.28) or "special care" (RR: 4.60), heart disease (RR: 2.23), and use of a catheter as the first vascular access (RR: 2.45). Malignant conditions and malnutrition were found to be additional significant risk factors for mortality at 12 months (RR: 1.68 and 1.74, respectively). Based on the multivariate analysis results, an individual prognostic model was formulated. This study confirms previous data suggesting that predialysis comorbid conditions are significantly associated with mortality in DM patients on dialysis and provides a prognostic model to help clinicians focus on various factors that may require attention before initiating this treatment.

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