Survival In Hemodialysis Patients Research Articles

Death in Patients with Regular Hemodialysis Due to CKD in RSUD Dr. Soedono Madiun Not Correlated to Various Risk Factors

Background: Chronic Kidney Disease (CKD) indicated by the inability of the kidneys in maintaining homeostasis of the body.1 This causes the patient to undergo renal replacement therapy for life. Patients undergoing regular hemodialysis have a higher risk of death in the last 2 decades. The survival of hemodialysis patients is different because it is influenced by several factors, including age, sex, duration of hemodialysis, duration of hemodialysis and accompanying comorbid patients. Objective: To identify risk factors that affect mortality in patients with CKD undergoing regular hemodialysis.Method: This research is an observational research with case-control design. Research done in dr.Soedono Madiun Hospital in December 2016 with a sample size of 41 cases and 41 control. Data retrieved through the medical records of patients with CKD who undergo regular HD from January to November 2016. Data analysis was performed including analysis of univariate, �bivariate analysis using chi-square test with 95% CI, 5% significance level (a = 0.05) and analysis multivariste using logistic regression.Results: There was no significant relationship between age (p = 0.23; OR = 1.78; 95% CI 0.68 to 4.64), gender (p = 0.623; OR = 1.24; 95% CI 0, 49 to 3.18), long live HD (p = 0.12; OR = 0.50; 95% CI 0.20 to 1.20), duration of HD (p = 0.81, OR = 0.89; 95% CI 0.34 to 2.28), hypertension (p = 0.21; OR = 0.44; 95% CI 0.12 to 1.61), diabetes mellitus (p = 0.17; OR = 1 , 83, 95% CI 0.75 to 4.47), hemoglobin level (p = 0.26; OR = 1.66; 95% CI 0.68 to 4.05) and intradialitik complications (p = 0.81 , OR = 1.11; 95% CI 0.44 to 2.80) with mortality in patients with CKD. Conclusion: There is no significant relationship between age, gender, length undergoing hemodialysis, duration of HD, hypertension, diabetes, hemoglobin, and complications intradialitik in CKD patients undergoing hemodialysis in dr.Soedono Madiun Hospitals.��

Death in Patients with Regular Hemodialysis Due to CKD in RSUD Dr. Soedono Madiun Not Correlated to Various Risk Factors

Background: Chronic Kidney Disease (CKD) indicated by the inability of the kidneys in maintaining homeostasis of the body.1 This causes the patient to undergo renal replacement therapy for life. Patients undergoing regular hemodialysis have a higher risk of death in the last 2 decades. The survival of hemodialysis patients is different because it is influenced by several factors, including age, sex, duration of hemodialysis, duration of hemodialysis and accompanying comorbid patients.Objective: To identify risk factors that affect mortality in patients with CKD undergoing regular hemodialysis.Method: This research is an observational research with case-control design. Research done in dr.Soedono Madiun Hospital in December 2016 with a sample size of 41 cases and 41 control. Data retrieved through the medical records of patients with CKD who undergo regular HD from January to November 2016. Data analysis was performed including analysis of univariate, bivariate analysis using chi-square test with 95% CI, 5% significance level (α = 0.05) and analysis multivariste using logistic regression.Results: There was no significant relationship between age (p = 0.23; OR = 1.78; 95% CI 0.68 to 4.64), gender (p = 0.623; OR = 1.24; 95% CI 0, 49 to 3.18), long live HD (p = 0.12; OR = 0.50; 95% CI 0.20 to 1.20), duration of HD (p = 0.81, OR = 0.89; 95% CI 0.34 to 2.28), hypertension (p = 0.21; OR = 0.44; 95% CI 0.12 to 1.61), diabetes mellitus (p = 0.17; OR = 1 , 83, 95% CI 0.75 to 4.47), hemoglobin level (p = 0.26; OR = 1.66; 95% CI 0.68 to 4.05) and intradialitik complications (p = 0.81 , OR = 1.11; 95% CI 0.44 to 2.80) with mortality in patients with CKD.Conclusion: There is no significant relationship between age, gender, length undergoing hemodialysis, duration of HD, hypertension, diabetes, hemoglobin, and complications intradialitik in CKD patients undergoing hemodialysis in dr.Soedono Madiun Hospitals.

The Combination of Beta Blockers and Renin-Angiotensin System Blockers Improves Survival in Incident Hemodialysis Patients: A Propensity-Matched Study

IntroductionAlthough several studies suggest that the prognosis of hypertensive dialysis patients can be improved by using antihypertensive drug therapy, it is unknown whether the prescription of a particular class or combination of antihypertensive drugs is beneficial during hemodialysis.MethodsWe performed a propensity score matching study to compare the effectiveness of various classes of antihypertensive drugs on cardiovascular (CV) mortality in 2518 incident hemodialysis patients in Spain. The patients had initially received antihypertensive therapy with a renin-angiotensin system (RAS) blocker (728 patients), a ß-blocker (679 patients), antihypertensive drugs other than a RAS blocker or a ß-blocker (787 patients), or the combination of a ß-blocker and a RAS inhibitor (324 patients). These patients were followed for a maximum of 5 years (median: 2.21 yr; range: 1.04–3.34 yr).ResultsAfter adjustment for baseline CV risk covariates, no significant differences were observed in the risk of CV mortality between patients taking a RAS blocker and patients treated with ß-blocker–based antihypertensive therapy. The combination of a RAS blocker with a ß-blocker was associated with better CV survival than either agent alone (RAS blocker: hazard ratio [HR]: 1.68; 95% confidence interval [CI] 1.05–2.69; ß-blocker: HR: 1.59; 95% CI: 1.01–2.50; antihypertensive medication other than a RAS blocker or ß-blocker: HR: 1.67; 95% CI: 1.08–2.58).DiscussionOur data suggested that the combination of a RAS blocker and a ß-blocker could improve survival in hemodialysis patients. Further prospective randomized controlled trials are necessary to confirm the beneficial effects of this combination of antihypertensive drugs in patients undergoing hemodialysis.

Serum albumin level adjusted with C-reactive protein predicts hemodialysis patient survival

BackgroundMalnutrition-related conditions such as protein energy wasting are affecting poor outcome of the dialysis population. The serum albumin level is often used as a marker of wasting and malnutrition. However, the serum albumin level can be affected by the presence of inflammation as well as by nutritional status. We investigated associations between serum albumin values adjusted with C-reactive protein (CRP) and mortality in hemodialysis (HD) patients.MethodsA total of 397 HD patients were included in this study. The patient characteristics and laboratory data, including serum albumin and CRP levels, were obtained in July 2012. Survival as of the end of August 2014 (maximum follow-up period 25 months) was investigated. First, the regression line was obtained from the entire population between serum albumin and CRP levels. Next, the CRP-adjusted albumin levels were determined as a dichotomized variable with the patients having higher albumin values above the regression line. We investigated associations between three albumin indices (the actual values, the dichotomized index by median, and CRP-adjusted values) and mortality by using Cox proportional hazard models.ResultsThe average age of the 397 HD patients was 70.6 years old; 258 were male, and 44.6% were diabetic. Median dialysis vintage was 3.6 years. There were 73 deaths during the observation period. A univariate Cox analysis demonstrated that all three indices were associated with survival, and the hazard ratio (HR) was 0.40 (95% confidence interval (CI) 0.25–0.68) for increase in albumin level, 0.41 (95% CI 0.25–0.68) for higher dichotomized albumin level by median, and 0.46 (95% CI 0.28–0.74) for higher CRP-adjusted albumin level, but only higher CRP-adjusted albumin level was associated with better survival (HR 0.51, 95% CI 0.30–0.85). The degree to which the deviation of albumin was attributable to that of CRP was 12.6%. The analyses on cause-specific mortality revealed that lower albumin levels were associated significantly with infection-related mortality but were not significantly associated with death due to congestive heart failure.ConclusionsCRP-adjusted albumin was shown to be a better predictor of mortality among the HD patients. When assessing serum albumin values, inflammatory status should be taken into account. Malnutrition or wasting was shown to be associated with a poor outcome independent of inflammation.

Risk factors of pulmonary hypertension and analysis of survival in hemodialysis patients

One hundred and forty-two patients on maintenance hemodialysis were enrolled in the study.According to the guideline of American Society of Echocardiography 97 patients (68.3%) were classified as pulmonary artery hypertension [PAH, pulmonary artery systolic pressure (PASP)>35 mmHg(1 mmHg=0.133 kPa)] and 45 patients (31.7%) as non-PAH (PASP ≤ 35 mmHg). High sensitivity C-reactive protein (hs-CRP) and tumor necrosis factor-α (TNF-α) were measured by automatic analyzer and enzyme linked immunosorbent assay (ELISA), respectively.There were significant differences in CRP and TNF-α levels between PAH and non-PAH patients (P 45 mmHg was higher than that in patients with PASP ≤45 mmHg (log-rank test: χ2=6.58, P=0.010), the risk was 2.82-fold (HR=2.82, 95%CI: 1.38-5.77, P=0.004). Key words: Hypertension, pulmonary; Renal dialysis; Survival

Is Hemodialysis Patient Survival Dependent upon Small Solute Clearance (Kt/V)?: If So How Can Kt/V be Adjusted to Prevent Under Dialysis in Vulnerable Groups?

Small solute clearance achieved during a single hemodialysis session has been traditionally evaluated by urea clearance, normalized for total body water (Kt/Vurea) for more than 30 years. By consensus, the target sessional KtVurea for thrice weekly treatments has been increased from 0.9 to 1.2 over the years. Although this is supported by observational studies, there is a fundamental lack of prospective studies to support this threshold target. In clinical practice achieving sessional Kt/Vurea targets are most closely followed in the US. Yet there appears to be a paradox in that by following Kt/Vurea targets in the US hemodialysis patient survival is better for men and the obese, the opposite of what is seen in the general population. Delivery of a lower dose of hemodialysis to women and smaller men can be explained by underestimation of total body water. The advent of bioimpedance techniques which can measure both body water and body composition will potentially allow a rescaling and re-evaluation of the importance of small solute clearances (Kt/Vurea) in the hemodialysis patient population.

Renal function replacement by hemodialysis: forty-year anniversary and a glimpse into the future at hand.

From its introduction in 1943 and until the late 1970s, hemodialysis (HD) has been a lengthy and cumbersome treatment administered by a few skilled physicians and technicians to a very limited number of terminal kidney patients. The technological innovations introduced over the years made HD a treatment administered and supervised by nursing personnel to a very large numbers of kidney patients, hopefully until recovery of kidney functions or kidney transplantation. In 2013, it is estimated that 2.250.00 kidney patients were treated worldwide, and their number is steadily increasing. Shortage of transplant kidneys and quality of current treatments has contributed to increasing the survival of HD patients. Today, it is not unusual to find patients who have been on HD for longer than twenty years. All this generated the feeling that performance of membranes and dialysis technology has reached its limit. Recently, the increasing economic burden of healthcare caused by people ageing and the increasing incidence of degenerative diseases (e.g. diabetes and cardiovascular diseases), and the economic crisis has pushed many governments and health insurances to cut resources for healthcare. The main consequence is that investments in research and development in HD have been significantly reduced. The question is whether there is indeed no need for innovation in HD.In this paper, it is discussed how the paradigm of HD has changed and what possibly are now the drivers for innovation in HD. A few ideas are proposed that could be developed by adapting existing technologies to the future needs of HD.

A Simpler Creatinine Index Can Predict Long-Term Survival in Chinese Hemodialysis Patients.

BackgroundLow lean body mass (LBM) is an indicator of malnutrition inflammation syndrome, which is common in hemodialysis (HD) patients. The creatinine index (CI) has been validated as a reliable method to estimate LBM and evaluate the protein-energy status of HD patients. However, the traditional creatinine index formula was complex. We sought to investigate the impact of CI derived from a new simple formula on Chinese HD patient outcomes.MethodsIn this retrospective cohort study, we enrolled 1269 patients who initiated HD between February 1981 and February 2012 and followed them until the end of February 2013. CI was calculated using the simple creatinine kinetic model (CKM) formula. Multiple linear regression analysis and Cox regression proportional hazard analysis were used to define independent variables and compare survival between groups.ResultsThe 1269 HD patients were categorized into 3 groups according to the tertiles of calculated CI between men and women. Each group consisted of 423 patients (50.6% men, 49.4% women). Patients in the highest sex-specific tertile of CI had longer overall survival (HR, 0.46; P 0.002). BMI did not significantly associate with survival after adjustment (HR,0.99; P 0.613).ConclusionsCI derived from the simple CKM formula serves as a good parameter than BMI to predict the survival of HD patients. The formula could extend its convenient use in clinical practice for HD patients.

Association of multiple ischemic strokes with mortality in incident hemodialysis patients: an application of multistate model to determine transition probabilities in a retrospective observational cohort.

BackgroundLittle is known about the effect of multiple, or subsequent, ischemic strokes in patients receiving hemodialysis.MethodsWe undertook a retrospective cohort study of incident hemodialysis patients with Medicare coverage who had experienced a first ischemic stroke. Factors associated with either a subsequent ischemic stroke or death following a first new stroke were modeled. A multistate model with Cox proportional hazards was used to predict transition probabilities from first ischemic stroke to either subsequent stroke or to death, and the demographic and clinical factors associated with the respective transition probabilities were determined. Effect of a subsequent ischemic stroke on survival was quantified.ResultsOverall, 12,054 individuals (mean age 69.7 years, 41.3 % male, 53.0 % Caucasian and 34.0 % African-American) experienced a first new ischemic stroke. Female sex was associated with an increased risk of having a subsequent ischemic stroke (adjusted hazard ratio 1.37, 95 % confidence intervals 1.20 – 1.56, P < 0.0001); African-Americans, as compared to Caucasians, had lower likelihood of dying after a first new ischemic stroke (0.81, 0.77 – 0.85, P < 0.0001). A subsequent stroke trended towards having a higher likelihood of transitioning to death compared to a first new ischemic stroke on dialysis (1.72, 0.96 – 3.09, P = 0.071). When a subsequent ischemic stroke occurs at 24 months, probability of survival dropped >15 %, in absolute terms, from 0.254 to 0.096, with substantial drops observed at subsequent time points such that the probability of survival was more than halved.ConclusionsLikelihood of subsequent ischemic stroke and of survival in hemodialysis patients appears to vary by sex and race: females are more likely than males to experience a subsequent ischemic stroke, and Caucasians are more likely than African-Americans to die after a first new ischemic stroke. The risk of a transitioning to a subsequent stroke (after having had a first) increases until about 1 year, then decreases. Subsequent strokes are associated with decreased probability of survival, an effect which increases as time since first stroke elapses. This information may be of assistance to clinicians when counseling hemodialysis patients about the implications of recurrent ischemic stroke.

Application of Parametric Models to a Survival Analysis of Hemodialysis Patients

BackgroundHemodialysis is the most common renal replacement therapy in patients with end stage renal disease (ESRD).ObjectivesThe present study compared the performance of various parametric models in a survival analysis of hemodialysis patients.MethodsThis study consisted of 270 hemodialysis patients who were referred to Imam Khomeini and Fatima Zahra hospitals between November 2007 and November 2012. The Akaike information criterion (AIC) and residuals review were used to compare the performance of the parametric models. The computations were done using STATA Software, with significance accepted at a level of 0.05.ResultsThe results of a multivariate analysis of the variables in the parametric models showed that the mean serum albumin and the clinic attended were the most important predictors in the survival of the hemodialysis patients (P < 0.05). Among the parametric models tested, the results indicated that the performance of the Weibull model was the highest.ConclusionsParametric models may provide complementary data for clinicians and researchers about how risks vary over time. The Weibull model seemed to show the best fit among the parametric models of the survival of hemodialysis patients.

Survival Analysis of Hemodialysis Patients

Survival analysis as a collection of statistical procedures for analyzing the data that its outcome variable was the time to occurrence of an event. Kaplan-Meier method is a type of survival analysis technique, this method is often called the Product Limit Method. Chronic Kidney Disease (CKD) became one of the public health problem throughout the world, including Indonesia. The number of hemodialysis patients has increased every year and have an impact on increasing the number of death in General Hospital Ibnu Sina Gresik. This study was determine the survival of hemodialysis patients using Kaplan-Meier analysis techniques. Non-reactive research with a retrospective cohort using the calculations right censoring. 155 population were taken randomly and sample size of 111. Data were collected using a checklist. The estimated survival time of female, adult age, further education, patients work, patients without insurance, patients with normal nutritional status, patients with a history of disease, patient with hypertention and patient with diabetic had a better survival time. The insurance status, nutritional status, hypertension, and diabetes mellitus were significant difference to the survival time (p-value &amp;lt;0.05). It was necessary special treatment for CKD patients through giving information, education to families and patients to maintain healthy lifestyle.

Survival Analysis of Hemodialysis Patients

Survival analysis as a collection of statistical procedures for analyzing the data that its outcome variable was the time to occurrence of an event. Kaplan-Meier method is a type of survival analysis technique, this method is often called the Product Limit Method. Chronic Kidney Disease (CKD) became one of the public health problem throughout the world, including Indonesia. The number of hemodialysis patients has increased every year and have an impact on increasing the number of death in General Hospital Ibnu Sina Gresik. This study was determine the survival of hemodialysis patients using Kaplan-Meier analysis techniques. Non-reactive research with a retrospective cohort using the calculations right censoring. 155 population were taken randomly and sample size of 111. Data were collected using a checklist. The estimated survival time of female, adult age, further education, patients work, patients without insurance, patients with normal nutritional status, patients with a history of disease, patient with hypertention and patient with diabetic had a better survival time. The insurance status, nutritional status, hypertension, and diabetes mellitus were significant difference to the survival time (p-value &amp;lt;0.05). It was necessary special treatment for CKD patients through giving information, education to families and patients to maintain healthy lifestyle.

Multiphasic effects of blood pressure on survival in hemodialysis patients

Dialysis patients exhibit an inverse, L- or U-shaped association between blood pressure and mortality risk, in contrast to the linear association in the general population. We prospectively studied 9333 hemodialysis patients in France, aiming to analyze associations between predialysis systolic, diastolic, and pulse pressure with all-cause mortality, cardiovascular mortality, and nonfatal cardiovascular endpoints for a median follow-up of 548 days. Blood pressure components were tested against outcomes in time-varying covariate linear and fractional polynomial Cox models. Changes throughout follow-up were analyzed with a joint model including both the time-varying covariate of sequential blood pressure and its slope over time. A U-shaped association of systolic blood pressure was found with all-cause mortality and of both systolic and diastolic blood pressure with cardiovascular mortality. There was an L-shaped association of diastolic blood pressure with all-cause mortality. The lowest hazard ratio of all-cause mortality was observed for a systolic blood pressure of 165 mmHg, and of cardiovascular mortality for systolic/diastolic pressures of 157/90 mmHg, substantially higher than currently recommended values for the general population. The 95% lower confidence interval was approximately 135/70 mmHg. We found no significant correlation for either systolic, diastolic, or pulse pressure with myocardial infarction or nontraumatic amputations, but there were significant positive associations between systolic and pulse pressure with stroke (per 10-mm Hg increase: hazard ratios 1.15, 95% confidence interval 1.07 and 1.23; and 1.20, 1.11 and 1.31, respectively). Thus, whereas high pre-dialysis blood pressure is associated with stroke risk, low pre-dialysis blood pressure may be both harmful and a proxy for comorbid conditions leading to premature death.

Management of hypertension for patients undergoing dialysis therapy

Hypertension is very prevalent among patients undergoing dialysis therapy: hemodialysis (HD) and peritoneal dialysis (PD). Although it is recognized as a great risk of cardiovascular mortality for these populations, how to regulate blood pressure (BP) is poorly understood. For HD patients, we should pay much attention to methods of measuring BP. Out-of-center BP levels and BP variability should be evaluated by ambulatory BP monitoring and home BP measurement because they are closely associated with cardiovascular mortality. Although target BP levels are not clear, several clinical guidelines suggest <140/90 mmHg. However, it must be determined for each individual patient with careful considerations about comorbidities. Based on the underling pathophysiology of hypertension in patients on dialysis, maintaining an appropriate volume of body fluid by dietary salt restriction and optimization of dry weigh should be considered as a first line therapy. Inhibitors for renin-angiotensin system may be suitable to reduce BP and mortality for those patients on dialysis. These drugs may also be effective for preserving residual renal function and peritoneal function for PD patients. β-blockers may have potentials to improve survival for HD patients and can be added to anti-hypertensive medications. Lacking large-scale and good quality clinical trials, there are many questions to be answered. Much effort should continuously be made to create evidences for better management of hypertension for patients on dialysis therapy.

Antibodies to hepatitis B virus surface antigen and survival of hemodialysis patients – a prospective study

ABSTRACTBackground: Antibodies to hepatitis B virus (HBV) surface antigen (anti-HBs) may develop in response to HBV vaccination or infection. We investigated whether anti-HBs are an independent predictor of survival in hemodialysis (HD) patients.Methods: A 6-year prospective study was conducted in 532 HD patients. Survival analyses were performed using the Kaplan-Meier method and the Cox proportional hazard model.Results: In HBV non-infected patients, age (P = 0.005), coronary artery disease (P = 0.002), and non-response to HBV vaccine (P = 0.008) were the independent risk factors of all-cause mortality. In HBV infected patients, the only independent predictor of all-cause mortality was coronary artery disease (P = 0.002).Conclusion: The ability to produce the protective anti-HBs titer in response to HBV vaccine is a positive predictor of survival in HBV non-infected HD patients.

Tunnelled haemodialysis catheter and haemodialysis outcomes: a retrospective cohort study in Zagreb, Croatia

ObjectivesStudies have reported that the tunnelled dialysis catheter (TDC) is associated with inferior haemodialysis (HD) patient survival, in comparison with arteriovenous fistula (AVF). Since many cofactors may also affect survival...

Association of Increased Serum Ferritin With Impaired Muscle Strength/Quality in Hemodialysis Patients

We reported previously that muscle quality and muscle strength provide clinically relevant predictors for better survival in hemodialysis patients. Iron overload might impair muscle function by its accumulation in muscle in such patients. Serum ferritin, a marker for body iron store, was examined for its association with handgrip strength (HGS) and muscle quality which was defined as the ratio of HGS to arm lean mass measured with dual-energy X-ray absorptiometry. In 300 Japanese hemodialysis patients, age, hemodialysis duration, body mass index, and serum albumin were 58.0 ±12.0 (mean ± standard deviation) years, 4.2 (1.8-10.4) (median [25th-75th percentile]) years, 20.4 ± 2.8 kg/m(2), 4.0 ± 0.3 g/dL, respectively. Hemoglobin and hematocrit were 8.9 ± 1.2 g/dL, and 28.8 ± 3.9%, respectively, whereas transferrin saturation and serum ferritin were 29.8 ± 11.0% and 100 (54-172) ng/mL, respectively. Serum ferritin significantly correlated in a positive manner with the total dose of iron orally administered during the previous 6 months (r = 0.185, P = .0013). HGS and muscle quality were 23.1 ± 10.4 kg and 11.6 ± 3.8 kg/kg, respectively. In multivariate analysis to elucidate the factors associated with HGS and muscle quality in 300 hemodialysis patients, which included transferrin saturation and log serum ferritin, in addition to age, gender, hemodialysis duration, the presence/absence of diabetes, body mass index as independent variables, log serum ferritin emerged as a significant and independent factor which associated in a negative fashion with HGS (β = -0.091, P = .0395) and tendency toward negative association with muscle quality (β = -0.100, P = .0754). In summary, the present study demonstrated the significant association of serum ferritin with HGS and muscle quality in hemodialysis patients and thus suggested that we should be careful of iron overload to avoid its possible harmful effect on muscle in such patients.

Malondialdehyde can predict survival in hemodialysis patients.

Background and aimsCardiovascular (CV) disease is the leading cause of morbidity and mortality in hemodialysis (HD) patients. Kidney disease is associated with increased oxidative stress (OS), a nontraditional CV risk factor. Few studies evaluate the effect of OS markers on CV events (CVE) and survival in HD patients. The aim of this study is to examine potential determinants of OS markers and their predictive role on survival and CV morbidity and mortality in HD patients during a long-term follow-up (108 months).MethodsWe conducted an analytical cross-sectional prospective observational study, carried on a cohort of randomly selected HD patients. We registered in 44 HD patients baseline characteristics, OS markers, mortality and CVE over a period of 108 months and we used statistical analysis (descriptive, Kaplan-Meier, univariate and multivariate Cox model) for interpretation.ResultsBound malondialdehyde (bMDA) was positively correlated with serum calcium, protein carbonyls (PC) were inversely correlated with diastolic blood pressure (DBP) and directly correlated with ferritin, NOx was directly correlated with ceruloplasmin) and serum albumin. Of the measured OS markers only bMDA was related to survival (HR=3.29 95% CI (1.28–8.44), p=0.01), and approached statistical significance in the effect on CV mortality (HR=2.85 95% CI (0.88–9.22), p=0.07). None of the measured OS markers was associated with CVE.ConclusionsbMDA has a strong predictive value on survival in HD patients in a long-term follow-up (9 years). Its value is correlated with CV mortality but is not a predictor of CV events. Regular assessment of MDA in HD patients and the development of strategies aimed at reducing oxidative stress in these patients might be beneficial.

Intradialytic parenteral nutrition in maintenance hemodialysis patients suffering from protein-energy wasting. Results of a multicenter, open, prospective, randomized trial

Protein-energy wasting (PEW) is increasingly becoming a clinical problem in maintenance hemodialysis patients and guidelines call for nutritional interventions. Serum prealbumin (transthyretin) represents a critical nutritional marker positively correlated with patient survival and negatively correlated with morbidity. Nutritional counseling, oral supplementation as well as intradialytic parenteral nutrition (IDPN) are recommended to fight PEW, however clinical trials on their use are scarce. We conducted a prospective, multicenter, randomized, open-label, controlled, parallel-group Phase IV clinical trial in 107 maintenance hemodialysis patients suffering from PEW to assess the impact of IDPN on prealbumin and other biochemical and clinical parameters reflecting nutritional status. Patients randomized to the intervention group received standardized nutritional counseling plus IDPN three times weekly over 16 weeks followed by a treatment-free period of 12 weeks. The control group received standardized nutritional counseling only. Main trial inclusion criteria included moderate to severe malnutrition (SGA score B or C), maintenance hemodialysis therapy (3 times per week) for more than six months, and presence of two out of the following three criteria: albumin <35g/L, prealbumin <250mg/L, phase angle alpha <4.5° assessed by bioelectrical impedance analysis (BIA). Changes in serum prealbumin, albumin, transferrin, phase angle alpha, subjective global assessment (SGA) score and health-related quality of life using the 12-item short form health survey (SF-12) were investigated. IDPN significantly increased prealbumin (p<0.05), showing rapid rise within 16 weeks of treatment and sustained response thereafter. In the full analysis set (n=83), 41.0% of 39 patients receiving IDPN achieved a relevant (i.e., at least ≥15%) increase in prealbumin over baseline at week 4 compared to 20.5% of 44 patients in the control group. Considerably more patients with IDPN therapy achieved an increment of prealbumin >30mg/L at week 16 (48.7% vs. 31.8%). Prealbumin response to IDPN therapy was more prominent in patients suffering from moderate malnutrition (SGA score B) compared to patients with severe malnutrition (SGA score C). The results of this trial demonstrate for the first time that IDPN therapy, given three times weekly in a 16-week short-term intervention, results in a statistically significant and clinically relevant increase in mean serum prealbumin, a surrogate marker for outcome and survival in hemodialysis patients suffering from PEW, and is superior to nutritional counseling. Clinical trial registry:www.clinicaltrials.gov (NCT00501956).

The role of natriuretic peptides in volume assessment and mortality prediction in Haemodialysis patients.

BackgroundMaintaining optimal fluid balance is essential in haemodialysis (HD) patients but clinical evaluation remains problematic. Other technologies such as bioimpedance are emerging as valuable adjuncts. This study was undertaken to explore the potential utility of the natriuretic peptides – atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) in the assessment of fluid status and cardiovascular risk in this setting.MethodsThis was a cross-sectional study carried out in an unselected cohort of 170 prevalent HD patients. Volume status was assessed by clinical parameters – the presence or absence of peripheral oedema, raised jugular venous pressure and basal lung crepitations; by extracellular fluid volume (ECFV) status determined by whole body bioimpedance; and by serum levels of BNP and ANP (pre- and post –dialysis). The relationships of ANP and BNP levels to clinical and bioimpedance parameters of volume status was determined. Patients were followed up for 5 years to assess the relationship of natriuretic peptide levels to mortality.ResultsBioimpedance estimates of ECFV expansion (>105 % of ideal ECFV) was present in 52 % of patients pre-dialysis. A significant proportion (21 %) of pre-dialysis patients had a depleted ECFV (<95 % of ideal ECFV) pre-dialysis. The situation was reversed post-dialysis. A raised JVP >3 cm was the most reliable clinical sign of ECFV expansion inferred from bioimpedance measurements and natriuretic peptide levels. The vast majority of patients with this sign also had lung crepitations or peripheral oedema or both. BNP was a stronger predictor of ECFV expansion than either pre- or post-dialysis ANP. BNP was also a stronger predictor of five-year survival.ConclusionSerum levels of BNP have a strong relationship to both volume status and survival in HD patients. We found no clear role for measurement of ANP, though changes in blood levels may be a sensitive indicator of acute changes in volume status. Whether monitoring levels of these peptides has a role in the management of volume status and cardiovascular risk requires further study.