Starting Maintenance Hemodialysis Research Articles

#3249 BLOOD UREA NITROGEN TO CREATININE RATIO IS ASSOCIATED WITH HIGH MORTALITY IN ELDERLY PATIENTS STARTING HEMODIALYSIS: A KSGN RETROSPECTIVE COHORT

Abstract Background and Aims Previous studies have shown that increased blood urea nitrogen to creatinine ratio (BCR) is a poor prognostic marker in patients with some chronic diseases or in the general population. However, the clinical implication of BCR in elderly dialysis patients is unknown. The purpose of this study was to verify the association of BCR with the risk of death in elderly patients starting hemodialysis. Method The Korean Society of Geriatric Nephrology Retrospective Cohort consists of patients who started maintenance hemodialysis from January 1, 2010 to December 31, 2017 at 17 nephrology centers in Korea. After excluding patients with malignancy or estimated glomerular filtration rate 30 ml/min/1.73 m2 or greater, we retrospectively analyzed 2,183 patients. The main predictor was patients BCR at the time of hemodialysis initiation and subjects were divided into four groups according to their BCR quartile. The main outcome was all-cause mortality. Results During 7,545 person-years of follow-up, 1,382(63.3%) patients died. Patients in the high BCR group died more (60.9%, 59.3%, 62.5% and 70.5% for the 1st to 4th BCR quartiles, respectively, P=0.001). In multivariate Cox proportional hazard model, BCR increase by one was associated with increased risk of death (HR 1.01; 95% CI, 1.01-1.02). This model was adjusted for age, sex, body mass index, cause of renal disease, hypertension, diabetes, ischemic heart disease, cerebrovascular disease, congestive heart failure, eGFR, hemoglobin, albumin, calcium and phosphorus. Compared to 3rd quartile of BCR group, 4th quartile group was associated with increased risk of death (HR, 1.30; 95% CI, 1.12-1.51). Conclusion High BCR is a predictor of high mortality in elderly patients starting hemodialysis. This result suggests that more attention should be paid to elderly patients starting hemodialysis with high BCR.

#2567 ASSOCIATION OF IMBALANCE OF MYOCARDIAL OXYGEN SUPPLY/DEMAND WITH MYOCARDIAL INJURY IN END STAGE KIDNEY DISEASE PATIENTS

Abstract Background and Aims It is well known that oxygen transport ability is impaired in patients with anemia, low hemoglobin (Hb) level, whereas the double product (DP, bpm*mmHg), consisting of the systolic blood pressure (SBP) multiplied by the heart rate (HR), is an index of myocardial oxygen consumption. The combination of these two markers could be a potential marker for balance of myocardial oxygen supply and demand. Therefore, we hypothesized that the balance of these two markers may lead to myocardial damage in end-stage kidney disease (ESKD) patients who is susceptible to vulnerable heart in oxygen balance. The purpose of this study is to examine the association of balance of DP and Hb with myocardial injury in ESKD patients. Method A single-center, cross-sectional study has conducted. From December 2010 to November 2021, 327 consecutive ESKD patients started maintenance hemodialysis (HD). Among them, 44 patients met the exclusion criteria as follows: (1) missing data of cardiac troponin T (cTnT); (2) complicating acute cardiac syndrome; (3) death during hospitalization for HD initiation, a total of 283 ESKD patients were enrolled into the study finally. The patients were divided four groups according to the high or low of Hb level of 9 g/dL and DP 12500, a median of our patients, and named low-DP/high-Hb; G1, low-DP/low-Hb; G2, high-DP/high-Hb; G3, and high-DP/low-Hb; G4. The patients with G1 group were defined as a well oxygen balanced group, whereas those with G4 was defined as an imbalance of oxygen supply and demand group. Based on the results of previous study, cTnT cut off for myocardial injury was serum cTnT ≧0.15 ng/mL. Odds ratio (OR) for myocardial injury was calculated in each group compared with well oxygen balanced group by logistic regression analysis. Results Median age was 72 years, 71% of them were male, 52.6% had diabetes. Mean Hb level was 9.09 ± 1.61, and median DP was 12144 (25% tile 10540, 75% tile 14688). Median cTnT was 0.083 (25% tile 0.057 and 75% tile 0.13), and 20.4% of patients were defined as suffering from myocardial injury latently. In the adjusted model, the odds for myocardial injury was significantly increasing in high-DP compared with low-DP (OR: 1.87, p = 0.049), while low-Hb did not show significant increment of odds for myocardial injury compared with high-Hb. As shown in the Table 1, compared to well-balanced group (G1), OR increased by exposing only high-DP (G3), however it was not statistically significant (OR 1.20, p = 0.68). Interestingly, by exposing with high-DP with low-Hb simultaneously (G4), synergistic increased OR was found compared with well-balanced (G1) group (OR 3.07, 95%CI 1.24-7.62, p = 0.015). Furthermore, these associations were enhanced and weakened if Hb cut-off level became to be lower (Hb 8 g/dL) and higher (Hb 10 g/dL), as shown in Tables 2, 3. Conclusion Imbalance of oxygen supply (Hb) and demand (DP) was associated with myocardial injury in incident HD patients. Appropriate control of anemia, SBP and HR may have possibility to prevent myocardial injury. Especially we need to pay attention more to the Hb level if BP and HR control is insufficient. Tables 1, 2, 3. Odds ratio for cTnT≧0.15 in four groups divided by DP and Hb (adjusted for age, male, CRP, albumin, diabetes mellitus).

Validation of operational definitions of mortality in a nationwide hemodialysis population using the Health Insurance Review and Assessment Service databases of Korea.

Health Insurance Review and Assessment Service's (HIRA) claims data have been used in studies of hemodialysis patients even though information about mortality is not provided in this database. Mortality analysis using HIRA data has been conducted using various operational definitions that have not been validated. This study aimed to validate operational definitions of mortality for maintenance hemodialysis patients that have been used when analyzing the Korean HIRA database. This study utilized claims data of the Korean National Health Insurance Service (NHIS) between January 2008 and December 2019. We estimated mortality based on operational definitions applied in previous studies using the HIRA database and compared it with NHIS mortality information to validate accuracy. A total of 128,876 patients who started maintenance hemodialysis between January 2009 and December 2019 were analyzed. The accuracy of estimated mortality was the highest at 96% in the group where mortality was defined as an absence of claims data for 150 days. If the period of no claims data was set to 90 days or less, there was a risk of overestimating the mortality for the entire study period. When it was set to 180 days or more, there was a risk of underestimating the mortality, as the follow-up time was close to the end of the study period. When mortality analysis of maintenance hemodialysis patients is performed using HIRA data, it is most accurate to set the operational definition period as the absence of claims data for 150 days.

Serum Growth Differentiation Factor-15/Albumin Ratio as a 2-Year Survival Marker of End-Stage Renal Disease Patients Initiating Maintenance Hemodialysis.

It is important to identify risk factors related to mortality in end-stage renal disease (ESRD) patients starting renal replacement therapy. Recently, several studies proposed that growth-differentiation factor-15 (GDF-15) is a possible biomarker for the prognosis of patients on maintenance hemodialysis. Here, we investigated the predictive value of serum GDF-15/Albumin ratio on two-year mortality in ESRD patients initiating maintenance hemodialysis. The study was a single center, retrospective study on ESRD patients starting maintenance hemodialysis with a follow-up of two years. All patients completed laboratory test and bioimpedance spectroscopy prior to the initiation of the first dialysis. The patients were stratified into quartiles according to the quartiles of serum GDF-15/Albumin ratio. Among the 159 patients, the mean age was 61.78 ± 12.52 years and median survival was 20.03 ± 7.73 months. The highest GDF-15/Albumin quartile was significantly more associated with the increased risk of all-cause mortality than other quartiles (unadjusted hazard ratio (HR): 8.468, 95% CI 2.981–24.054, p < 0.001). Older age and a higher overhydration state were associated with GDF-15/Albumin ratio. The ROC analysis confirmed that the ability of the GDF-15/Albumin ratio to predict mortality was superior to GDF-15 or albumin alone. In conclusion, the GDF-15/Albumin ratio measured at the initial maintenance hemodialysis is an independent prognostic marker of two-year mortality in ESRD patients.

Thyroid dysfunction and insulin resistance in end-stage renal disease patients before and 1 year after starting maintenance hemodialysis: A prospective multicenter study.

Thyroid dysfunction and insulin resistance (IR) are common findings in patients with ESRD. We aimed to evaluate thyroid dysfunction and IR in ESRD before and after 1 year of starting hemodialysis (HD). This was a prospective study that recruited newly starting HD patients who fulfilled the inclusion criteria. Patients were evaluated for TSH, free T4, free T3, fasting insulin, fasting glucose, HOMA-IR, serum ferritin, and hs-CRP levels before starting their first dialysis session and after 1 year of regular HD. Eighty-one patients have completed the 1-year follow-up period. After 1 year of regular HD, there were statistically significant increments of hs-CRP, serum ferritin, and TSH levels. On the other hand, fasting insulin level and HOMA-IR showed statistically significant increments after 1 year of starting HD. After 1 year of regular HD, TSH level showed a positive correlation with hs-CRP and serum ferritin level, while free T3 was negatively correlated with HOMA-IR. On the other hand, there was a significant positive correlation between HOMA-IR, hs-CRP, and serum ferritin levels, while HOMA-IR was negatively correlated with Kt/V. This study suggests overlapping complex pathogenesis of thyroid dysfunction, chronic inflammation, and IR in chronic HD patients.

Outcome of Migrant Patients Starting Maintenance Hemodialysis in Switzerland

Outcome of Migrant Patients Starting Maintenance Hemodialysis in Switzerland

Occult Hepatitis B Infection in End-Stage Renal Disease Patients Starting Maintenance Hemodialysis at a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

Occult hepatitis B infection is defined as the presence of the hepatitis B virus deoxyribonucleic acid in liver tissues and/or serum in the absence of serum hepatitis B Virus surface antigen. The prevalence of occult hepatitis B infection in end-stage renal disease patients is largely unknown. The aim of the study is to determine the prevalence of occult hepatitis B infection in the hemodialysis population starting maintenance hemodialysis. A descriptive cross-sectional study was conducted in the department of Internal Medicine of a tertiary care hospital. Convenience sampling method was used; 50 consecutive end-stage renal disease patients, who started maintenance hemodialysis from March 2019 to March 2020, were enrolled in the study. The study was approved by the Institutional Review Committee of the hospital (reference number: 351/2019). Statistical Package for Social Sciences version 26.0 was used for statistical analysis. The mean age of the patients was 50.34±12.65 years, and 42 (84%) were male. About 4 (8%) patients were diagnosed having occult hepatitis B infection, 3 (6%) of them were seropositive and 1 (2%) seronegative. About 41 (82%) patients had no history of hepatitis B vaccination series before starting hemodialysis; 36 (72%) had anti-hepatitis B surface antibody titre <10 mIU/ml. About 44 (88%) patients received a blood transfusion during their hemodialysis sessions and 14 (28%) patients had a history of receiving hemodialysis at other centres. Our study demonstrated a high prevalence of occult hepatitis B infection among end-stage renal disease patients starting hemodialysis.

The effectiveness of a specialized team intervention on prognosis in patients undergoing continuous renal replacement therapy: A retrospective cohort study.

Limited evidence is available regarding the effectiveness of a specialized continuous renal replacement therapy (CRRT) team approach. Hence, we aimed to evaluate the effectiveness of a specialized CRRT team intervention in a Japanese hospital. We retrospectively identified adult patients who underwent CRRT in the intensive care unit (ICU) from July 2015 to June 2019 and divided them into two groups based on whether or not they received CRRT team intervention. We extracted data from the electronic medical record database. The concurrent effects of various factors on study outcomes were analyzed by multivariate analysis using a generalized linear model. A total of 540 patients were included. Baseline characteristics were similar in the two groups. In univariate analysis, no significant differences were found in in-hospital mortality (34.0 vs. 30.8%; risk difference, -3.2%; 95% confidence interval, -12.6 to 6.1), total duration of ICU stay, total CRRT time, and the proportion of patients starting maintenance hemodialysis during hospitalization between both groups. Multivariate analysis also indicated no significant differences. In this study, no significant difference was found in patient outcomes between both groups. The results suggest that the CRRT team should have integrated protocols and play a core role in CRRT management.

Effect of altitude on mortality of end-stage renal disease patients on hemodialysis in Peru.

BackgroundIn Latin America, the prevalence of end-stage kidney disease (ESKD) has risen tremendously during the last decade. Previous studies have suggested that receiving dialysis at high altitude confers mortality benefits; however, this effect has not been demonstrated at >2000 m above sea level (masl) or in developing countries.MethodsThis historical cohort study analyzed medical records from six Peruvian hemodialysis (HD) centers located at altitudes ranging from 44 to 3827 masl. Adult ESKD patients who started maintenance HD between 2000 and 2010 were included. Patients were classified into two strata based on the elevation above sea level of their city of residence: low altitude (<2000 masl) and high altitude (≥2000 masl). Death from any cause was collected from national registries and Cox proportional hazards models were built.ResultsA total of 720 patients were enrolled and 163 (22.6%) resided at high altitude. The low-altitude group was significantly younger, more likely to have diabetes or glomerulonephritis as the cause of ESKD and higher hemoglobin. The all-cause mortality rate was 84.3 per 1000 person-years. In the unadjusted Cox model, no mortality difference was found between the high- and low-altitude groups {hazard ratio [HR] 1.20 [95% confidence interval (CI) 0.89–1.62]}. After multivariable adjustment, receiving HD at high altitude was not significantly associated with higher mortality, but those with diabetes as the cause of ESKD had significantly higher mortality [HR 2.50 (95% CI 1.36–4.59)].ConclusionsIn Peru, patients receiving HD at high altitudes do not have mortality benefits.

P152590 DAY MORTALITY DATA OF PATIENTS INITIATING MAINTENANCE HEMODIALYSIS AT A TERTIARY CARE FACILITY IN PAKISTAN

Abstract Background and Aims Mortality of end stage renal disease patients is 10 to 30 times higher than that of the general population. Timing of death related to dialysis vintage remains unclear. Mortality risk among hemodialysis patients may be highest soon after initiation of hemodialysis, the reason for which remains elusive. Additionally mortality on initiating hemodialysis is related to arteriovenous vascular access. Poor planning for dialysis initiation may contribute to hemodialysis catheter use and the associated high rate of infections. This study was carried out to determine the 90-day mortality in patients starting maintenance hemodialysis at a tertiary care facility in Pakistan. Method This is a cross sectional study which included all consecutive patients who initiated maintenance hemodialysis at Bahria Town Hospital Lahore. A total of 485 participants were included and the collected data was entered into the SPSS software and their mortality rate was calculated within 90 days after initiation of maintenance hemodialysis. Additionally 90-day mortality based on type of vascular access at initiation was also noted. Results The mean age of the participants included in the study was 44 with 50% of the patients were male. The 90-day mortality of patients initiating maintenance hemodialysis at our centre was found to be 37%. 90% of the patients initiating maintenance hemodialysis started through a double lumen temporary dialysis catheter. Amongst these patients the mortality rate was 39%. 10% of the patients initiating maintenance hemodialysis started through an arteriovenous fistula. Amongst these the mortality rate was 19%. Conclusion Our study showed that the mortality rate is high in patients undergoing hemodialysis with in first 90 days. Early planning for permanent vascular access may result in a reduction of mortality.

Cancer incidence according to the National Health Information Database in Korean patients with end-stage renal disease receiving hemodialysis.

Background/AimsThe aim of this study was to investigate incidence, survival, and risk factors of cancer in end-stage renal disease (ESRD) patients with hemodialysis using information from the National Health Information Database (NHID).MethodsUsing the NHID, we identified ESRD patients who started maintenance hemodialysis between 2003 and 2005 in Korea. Patients were followed from initiation of hemodialysis to renal transplantation, death, or December 31, 2016, whichever came first. We calculated the incidence, survival, and risk factors of cancer.ResultsOf the total 14,382 ESRD patients, 1,124 (7.82%; men:women, 728:396) were diagnosed with cancer during follow-up. The mean duration from the start of hemodialysis to new cancer identification was 64.40 ± 41.81 months. Significant risk factors for the development of new cancer were old age, male sex, and liver disease. Conversely, patients with diabetes showed low risk for new cancer. The colorectum (17.31%) was the most common primary site of cancer in men, followed by the liver (15.8%), stomach (14.29%), lung (13.6%), and kidney (10.3%). In women, the colorectum (14.65%) was also the most common primary site of cancer, followed by the breast (12.88%), thyroid (12.63%), stomach (10.86%), and lung (8.08%). According to the primary site of cancer, breast cancer showed the longest median survival duration (130.93 months), followed by thyroid, kidney, colorectum, bladder, stomach, liver, and lung cancer. On multivariate analyses, overall survival was affected by age and diabetes.ConclusionsThe cancer incidence of chronic hemodialysis patients was relatively high. Thus, careful monitoring and a specific cancer screening program are needed for chronic hemodialysis patients.

Ability to Work among Patients with ESKD: Relevance of Quality Care Metrics

Enabling patient ability to work was a key rationale for enacting the United States (US) Medicare program that provides financial entitlement to renal replacement therapy for persons with end-stage kidney disease (ESKD). However, fewer than half of working-age individuals in the US report the ability to work after starting maintenance hemodialysis (HD). Quality improvement is a well-established objective in oversight of the dialysis program, but a more patient-centered quality assessment approach is increasingly advocated. The ESKD Quality Incentive Program (QIP) initiated in 2012 emphasizes clinical performance indicators, but a newly-added measure requires the monitoring of patient depression—an issue that is important for work ability and employment. We investigated depression scores and four dialysis-specific QIP measures in relation to work ability reported by a multi-clinic cohort of 528 working-age maintenance HD patients. The prevalence of elevated depression scores was substantially higher among patients who said they were not able to work, while only one of the four dialysis-specific clinical measures differed for patients able/not able to work. Ability to work may be among patients’ top priorities. As the parameters of quality assessment continue to evolve, increased attention to patient priorities might facilitate work ability and employment outcomes.

Survival analysis of conservative vs. dialysis treatment of elderly patients with CKD stage 5.

Elderly patients represent a growing population among people suffering from ESRD. So far only limited data on actual survival benefits of elderly adults initiating dialysis have been published. Besides the high burden of preexisting comorbidities, dialysis treatment itself may be associated with a further deterioration in functional status in this population. We retrospectively analyzed the Austrian Dialysis and Transplant Registry and identified 8,622 patients who started maintenance hemodialysis after the age of 65 years between 2002 and 2009. We compared this data set to a cohort of 174 patients aged over 65 years with CKD stage 5 who progressed to an eGFR < 10ml/min/ and were managed conservatively in the same era. All patients who died of malignant disease were excluded from this analysis. The risk of mortality was analyzed using multivariable Cox proportional hazards models. Furthermore, a parametric model of time to event analysis was used for visualization of changing risk over time and precise calculation of time to equal risk assuming a Weibull distribution. Hemodialysis treatment was associated with a decreased risk for death with a HR of 0.23 (95% CI 0.18 to 0.29; p<0.001) compared to conservative treatment. The time to event analysis however showed, that although survival was initially superior in the hemodialysis group, hazards crossed thereafter. Time to equal risk was 2.9 months and 1.9 months for female and male patient aged 65, respectively, and decreased to one month in the very elderly aged 95. Elderly patients with ERSD did benefit from initiation of hemodialysis, as the conservative group showed a very high initial mortality rate. This survival benefit of dialysis treatment however did not persist beyond the first two months compared to survivors of the conservative group.

Overhydration measured by bioimpedance analysis and the survival of patients on maintenance hemodialysis: a single-center study

BackgroundBioimpedance analysis (BIA) helps measuring the constituents of the body noninvasively. Prior studies suggest that BIA-guided fluid assessment helps to predict survival in dialysis patients. We aimed to evaluate the clinical usefulness of BIA for predicting the survival rate of hemodialysis patients in Korea. MethodsWe conducted a single-center retrospective study. All patients were diagnosed with end-stage renal disorder and started maintenance hemodialysis between June 2009 and April 2014. BIA was performed within the 1st week from the start of hemodialysis. The patients were classified into 2 groups based on volume status measured by the body composition monitor (BCM; Fresenius): an overhydrated group [OG; overhydration/extracellular water (OH/ECW) >15%] and a nonoverhydrated group (NOG; OH/ECW ≤15%). ResultsA total of 344 patients met the inclusion criteria. Of these, 252 patients (73.3%) were categorized into the OG and 92 patients (26.7%) into the NOG. Age- and sex-matching patients were selected with a rate of 2:1. Finally, 160 overhydrated patients and 80 nonoverhydrated patients were analyzed. Initial levels of hemoglobin and serum albumin were significantly lower in the OG. During follow-up, 43 patients from the OG and 7 patients from the NOG died (median follow-up duration, 24.0 months). The multivariate-adjusted all-cause mortality was significantly increased in the OG (odds ratio, 2.569; P = 0.033) and older patients (odds ratio, 1.072/y; P < 0.001). No significant difference of all-cause or disease-specific admission rate was observed between the 2 groups. ConclusionThe ratio of OH/ECW volume measured with body composition monitor is related to the overall survival of end-stage renal disorder patients who started maintenance hemodialysis.

Usefulness of an Upright T-Wave in Lead aVR for Predicting the Short-Term Prognosis of Incident Hemodialysis Patients: A Potential Tool for Screening High-Risk Hemodialysis Patients

Background/Aims: An upright T-wave in lead aVR (aVRT) has recently been reported to be associated with cardiovascular death and mortality among the general population and patients with prior cardiovascular disease (CVD). However, evidence for the predictive ability of aVRT in patients with chronic kidney disease is lacking. Therefore, a hospital-based, prospective, cohort study was conducted to evaluate the predictive ability of an upright aVRT for the short-term prognosis in incident hemodialysis patients. Methods: Among 208 patients who started maintenance hemodialysis, 79 with preexisting CVD (CVD cohort) and 129 with no history of CVD (non-CVD cohort), were studied. An upright and non-upright aVRT were defined as a wave with a positive deflection in amplitude of ≥0 mV and a negative deflection in amplitude of <0 mV, respectively. The endpoint was all-cause death. Results: Overall, the prevalence of an upright aVRT was 22.6% at baseline. During the mean follow-up period of 2.1 ± 1.0 years, 33 deaths occurred. Cumulative survival rates at 3 years after starting dialysis in patients with an upright and non-upright aVRT were 50.0 and 80.7%, respectively, in the CVD cohort and 92.0 and 91.3%, respectively, in the non-CVD cohort. In the CVD cohort, multivariate Cox regression analysis showed that an upright aVRT was an independent predictor of death after adjusting for confounding variables. Conclusion: Among Japanese hemodialysis patients at high risk for CVD, an upright aVRT seems to be useful for predicting death.

Clinical characteristics of very elderly patients at hemodialysis initiation.

The patient's clinical features at hemodialysis initiation can affect their prognosis in the subsequent dialysis period; however, these features have not been fully elucidated in very elderly subjects. The purpose of this study was to clarify the clinical characteristics associated with cardiovascular and chronic kidney disease at hemodialysis initiation. Twenty consecutive very elderly patients with end-stage renal disease (ESRD) (≥80 years; VE group) and 35 consecutive control patients with ESRD (<60 years; control group) were included in this study. All patients had started maintenance hemodialysis therapy at our institution. We evaluated the clinical characteristics, laboratory data, thoracic aortic calcification (TAC) and echocardiographic parameters, including aortic valve calcification (AVC), mitral valve calcification and mitral annular calcification (MAC). The diastolic blood pressure was significantly lower and pulse pressure values were significantly higher in the VE group than in the control group, whereas the estimated glomerular filtration rate and cardiac function were comparable between the two groups. Despite having lower serum phosphate and calcium-phosphate product levels, the VE group exhibited more severe TAC, AVC and MAC than the control group. Furthermore, the duration of hospitalization was significantly shorter in the very elderly patients followed by nephrologists than in those who were not. Our findings suggest that atherosclerotic lesions are more severe in very elderly patients at hemodialysis initiation.

BK Virus–Associated Urothelial Carcinoma of a Ureter Graft in a Renal Transplant Recipient: A Case Report

BackgroundUrothelial carcinomas of ureter grafts in renal transplant patients are rare. Here we report our experience with a case of BK virus–associated urothelial carcinoma in a ureter graft. Case ReportA 47-year-old man developed chronic renal failure secondary to diabetes mellitus and started maintenance hemodialysis in September 2007. Two months later, the patient received a renal transplant from his 70-year-old mother. The patient developed BK virus–associated nephropathy 1 year after transplantation and presented with a decline in renal function and hydronephrosis in the transplanted kidney 4 years 6 months after transplantation. Cystoscopy and retrograde pyelography revealed an irregular filling defect in the ureter graft. Cytologic diagnosis of his urine revealed a high-grade urothelial carcinoma. Computerized tomography showed a cT2 ureteral tumor and no involvement of other organs. The patient subsequently underwent a transplant nephroureterectomy with bladder cuff resection. Histopathologic findings revealed a high-grade urothelial carcinoma, pT2, in the ureter graft with SV40-positive staining. The patient was closely observed without adjuvant chemotherapy therapy and remained disease free 1 year after surgery. Renal transplant recipients with BK virus infection are at high risk of developing urologic malignancies. Close attention is necessary to diagnose post-transplantation urologica malignancies as early as possible.

Cardiac biomarkers and health-related quality of life in new hemodialysis patients without symptomatic cardiac disease.

BackgroundHealth Related Quality of Life (HRQOL) is impaired in hemodialysis patients and cardiac biomarkers are elevated, but their relationship is uncertain.ObjectivesTo determine whether the cardiac biomarkers, troponin T and N terminal pro-B type natriuretic peptide (NT-proBNP), predict deterioration in the physical domains of HRQOL.DesignA prospective cohort study of patients in a randomized controlled clinical trial of correction of anemia with erythropoietin.SettingMultiple hemodialysis centers located throughout Canada and Europe.ParticipantsPatients who started maintenance hemodialysis within the previous 3–18 months, with no clinical evidence or prior history of symptomatic cardiac failure or ischemic heart disease, and left ventricular volume < 100 ml/m2.MeasurementsPredictor: Baseline concentrations of Troponin T and NT-proBNP. Outcomes: Physical function and vitality scores using the SF-36 questionnaire and fatigue scores using the FACIT questionnaire at baseline and after 24, 48, and 96 weeks follow-up.MethodsUnivariate analysis of the association between baseline variables and baseline HRQOL scores and change in scores over time was undertaken using linear regression. Multivariate models were created using multiple linear regression, and it was pre-specified that these include the variables which were associated with the outcome at a p < 0.05 in the univariate regression.ResultsBaseline median (interquartile range) physical function score was 70 (50–85), vitality 55 (40–75), and fatigue 73 (58–86). The 75th percentile for Troponin T was 0.05 ng/mL and for NT-proBNP 652 ng/mL. High Troponin T levels were significantly associated with deterioration in the 3 physical domains, independent of other risk factors, whereas high NT-proBNP were not associated. In multivariate models baseline Troponin T > 0.05 ng/mL were significantly associated with the change from baseline to 96 weeks follow-up for SF-36 vitality and FACIT-fatigue scores, and approached statistical significance for SF-36 physical function (0.056).LimitationsNot possible to confirm whether Troponin T associations were independent of subsequent cardiac events.ConclusionsIn hemodialysis patients without prior symptomatic cardiac disease and without a dilated left ventricle at baseline, elevated baseline Troponin T levels, but not NT-pro BNP, were independently associated with deterioration in the physical domains of HRQOL.Electronic supplementary materialThe online version of this article (doi:10.1186/2054-3581-1-16) contains supplementary material, which is available to authorized users.

Electrocardiographic left ventricular hypertrophy and outcome in hemodialysis patients.

Background and AimsElectrocardiography (ECG) is the most widely used initial screening test for the assessment of left ventricular hypertrophy (LVH), an independent predictor of cardiovascular mortality in patients with end-stage renal disease (ESRD). However, traditional ECG criteria based only on voltage to detect LVH have limited clinical utility for the detection of LVH because of their poor sensitivity.MethodsThis prospective observational study was undertaken to compare the prognostic significance of commonly used ECG criteria for LVH, namely Sokolow-Lyon voltage (SV) or voltage-duration product (SP) and Cornell voltage (CV) or voltage-duration product (CP) criteria, and to investigate the association between echocardiographic LV mass index (LVMI) and ECG-LVH criteria in ESRD patients, who consecutively started maintenance hemodialysis (HD) between January 2006 and December 2008.ResultsA total of 317 patients, who underwent both ECG and echocardiography, were included. Compared to SV and CV criteria, SP and CP criteria, respectively, correlated more closely with LVMI. In addition, CP criteria provided the highest positive predictive value for echocardiographic LVH. The 5-year cardiovascular survival rates were significantly lower in patients with ECG-LVH by each criterion. In multivariate analyses, echocardiographic LVH [adjusted hazard ratio (HR): 11.71; 95% confidence interval (CI): 1.57–87.18; P = 0.016] and ECG-LVH by SP (HR: 3.43; 95% CI: 1.32–8.92; P = 0.011) and CP (HR: 3.07; 95% CI: 1.16–8.11; P = 0.024) criteria, but not SV and CV criteria, were significantly associated with cardiovascular mortality.ConclusionsThe product of QRS voltage and duration is helpful in identifying the presence of LVH and predicting cardiovascular mortality in incident HD patients.

Glycemic Control and the Risk of Death in 1,484 Patients Receiving Maintenance Hemodialysis

It is controversial whether tighter glycemic control is associated with better clinical outcomes in people with kidney failure. We aim to determine whether worse glycemic control, measured using serum glucose and hemoglobin A(1c) (HbA(1c)) levels, is independently associated with higher mortality in patients undergoing maintenance hemodialysis. Retrospective cohort study. 1,484 patients starting maintenance hemodialysis therapy in Alberta, Canada, between 2001 and 2007. Serum glucose and HbA(1c) levels. All-cause mortality. Monthly casual glucose levels from specimens drawn immediately before the first dialysis treatment were averaged over 3 months before and after hemodialysis therapy initiation. Similarly, monthly HbA(1c) values in patients with or at risk of diabetes were averaged. Overall, median age was 66 years, 41% were women, 75% were white, and 55% had diabetes. All-cause mortality during 8 years (median, 1.5 years) was 43%; it was 49% in those with diabetes. There was no relation between average glucose level and mortality in unadjusted analysis (HR, 1.00 per 18 mg/dL [1 mmol/L]; P = 0.4) or after adjustment for confounders (HR, 0.98 per 18 mg/dL; 95% CI, 0.96-1.01; P = 0.2). Higher HbA(1c) level was not associated with mortality when analyzed in the unadjusted analysis (HR, 1.01 per 1% HbA(1c); P = 0.9) or after adjustment for confounders (HR, 0.98 per 1% HbA1c; 95% CI, 0.88-1.08; P = 0.7). Results were similar when HbA(1c) values were divided into prespecified categories (adjusted P > 0.6 for trend). Markers of malnutrition-inflammation (albumin, hemoglobin, and white blood cell values) or the presence of diabetes did not influence the relation between glycemic control and death (all P for interaction > 0.2). Registry data; casual serum glucose measurements; HbA(1c) values available for only a subset of participants. Higher casual glucose and HbA(1c) levels were not associated with mortality in maintenance hemodialysis patients with or without diabetes. This may have implications for recommended glycemic targets, quality indicators, and how best to assess glycemic control in this high-risk population.