Timing Of Dialysis Initiation Research Articles

Level of high sensitivity troponin I and its correlation with hemodialysis vintage – A pilot study

Background: Renal replacement therapy (RRT) is advised in end-stage renal disease, the last stage of chronic kidney disease (CKD). RRT includes maintenance hemodialysis (MHD)/peritoneal dialysis/renal transplant. The requirement for MHD is annually escalating in India. It is important to note that over 80% of patients receiving MHD have at least one cardiac disease at the time of dialysis initiation, such as ischemic heart disease, congestive cardiac failure, and arrhythmias. Aims and Objectives: The present study aimed to study high-sensitivity cardiac troponin I (hs-cTnI) serum level as a marker of cardiovascular injury in patients receiving MHD. It was an attempt to envisage a correlation between serum hs-cTnI and hemodialysis (HD) vintage (duration since initiation of dialysis till date). Materials and Methods: We enrolled 40 patients. Group 1 included those who had received MHD for ≤24 months, and Group 2 included those who had received MHD for more than 24 months. Results: We found no significant difference between the two groups’ clinical characteristics and demographic features. The pre-and post-HD serum hs-cTnI values of all patients were recorded. The serum hs-cTnI levels were found to be elevated in 34 out of 40 patients’ post-dialysis, and the result was statistically significant (P=0.0001). Conclusion: The present study has encouraging results, with values of hs-cTnI raised in post-dialysis samples; however, the levels did not correlate with HD vintage. Further studies with larger sample sizes and longer follow-ups would provide more detailed information on hs-cTnI’s role as a marker for HD-induced cardiac damage.

Exposure and outcomes of aortic valve change in patients initiating dialysis.

Aortic stenosis (AS) and aortic valve calcification (AVC) are occasionally observed in patients receiving maintenance dialysis. However, their prevalence and factors associated with them in patients undergoing dialysis remain unknown. We aimed to elucidate the aortic valve status at the time of dialysis initiation and patient prognosis based on aortic valve status. We analyzed 289 patients initiating dialysis (hemodialysis: peritoneal dialysis = 275:14) between 2016 and 2023. "AS and/or AVC" was detected using echocardiography. AS was defined as a maximum transaortic velocity > 2.0m/s. Statistical analyses including multivariable logistic regression and Cox regression were used to assess the association between patient characteristics and survival outcomes. Aortic valve changes were observed in 121 (42%) patients, among which 33 (11%) met the AS criteria. The mean age of patients in the AS, AVC without AS, and control groups was 79.1 ± 8.9, 75.9 ± 9.2, and 68.3 ± 12.9, respectively (P < 0.001). Multivariable logistic regression models showed that only age was associated with aortic valve changes (P < 0.001). Age and other important factor-adjusted multivariable Cox regression models showed that AS was an independent risk factor for death after dialysis initiation (hazard ratio (HR): 1.95, 95% confidence interval (CI): 1.06 - 3.59, P = 0.04). However, aortic valve changes ("AS and/or AVC") were not a risk factor for death (HR: 1.51, 95% CI 0.95 - 2.39, P = 0.08). With the growing older population undergoing dialysis, aortic valve changes should be closely monitored. Particularly, AS is crucial because of its impact on patient prognosis.

Provision of transplant education for patients starting dialysis: Disparities persist

BackgroundAll patients starting dialysis should be informed of kidney transplant as a renal replacement therapy option. Prior research has shown disparities in provision of this information. In this study, we aimed to identify patient sociodemographic and dialysis facility characteristics associated with not receiving transplant information at the time of dialysis initiation. We additionally sought to determine the association of receiving transplant information with waitlist and transplant outcomes. MethodsWe retrospectively analyzed CMS-2728 forms filed from 2007 to 2019. The primary outcome was report of provision of information about transplant on the Centers for Medicare and Medicaid Services Form CMS-2728. For patients not informed at the time of dialysis, we collected the reported reason for not being informed (medically unfit, declined information, unsuitable due to age, psychologically unfit, not assessed, or other). Cox proportional-hazards model estimates were used to study determinants of addition to the waitlist and transplant (secondary outcomes). ResultsFifteen percent of patients did not receive information about transplant (N = 133,414). Non-informed patients were more likely to be older, female, white, and on Medicare. Patients informed about transplant had a shorter time between end-stage renal disease onset and addition to the waitlist; they also spent a shorter time on the waitlist before receiving a transplant. Patients at chain dialysis facilities were more likely to receive information, but this did not translate into higher waitlist or transplant rates. Patients at independent facilities acquired by chains were more likely to be informed but less likely to be added to the waitlist post acquisition. ConclusionsDisparities continue to persist in providing information about transplant at initiation of dialysis. Patients who are not informed have reduced access to the transplant waitlist and transplant. Maximizing the number of patients informed could increase the number of patients referred to transplant centers, and ultimately transplanted. However, policy actions should account for differences in protocols stemming from facility ownership.

Association of Age, Frailty, and Strategy for Initiation of Renal-Replacement Therapy: A Post Hoc analysis of the STARRT-Acute Kidney Injury Trial

Plain Language SummaryThis study was designed to assess the association of age and frailty with clinical outcomes in patients with severe acute kidney failure using the data from an international randomized trial called the STARRT-AKI trial that examined the effect of timing of dialysis initiation on mortality in patients with acute kidney failure. In this study, older age was defined as ≥65 years, accounting for more than a half of the study population. This study demonstrated that older and frail patients carried higher mortality rates. However, age and frailty did not appear to have a significant impact on kidney recovery. Furthermore, in older or frail patients, timing of initiation of dialysis therapy did not affect mortality and kidney recovery. These findings will assist with triaging, prognostication, and management of older and frail patients with severe acute kidney failure in intensive care units.

Impact of Continuous Renal Replacement Therapy Initiation Time, Kidney Injury, and Hypervolemia in Critically Ill Children.

The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of dialysis initiation. Delay in the initiation of such therapy may increase mortality risk, prolong intensive care unit stay, and worsen clinical outcomes. In the pediatric intensive care unit of an urban level I trauma children's hospital, continuous renal replacement therapy initiation times and factors associated with delays in therapy were unknown. This quality improvement process involved a retrospective review of data on patients who received continuous dialysis in the pediatric intensive care unit from January 1, 2017, to December 31, 2021. The objectives were to examine the characteristics of the children requiring continuous renal replacement therapy, therapy initiation times, and factors associated with initiation delays that might affect unit length of stay and mortality. During the study period, 175 patients received continuous renal replacement therapy, with an average initiation time of 11.9 hours. Statistically significant associations were found between the degree of fluid overload and mortality (P < .001) and between the presence of acute kidney injury and prolonged length of stay (P = .04). No significant association was found between therapy initiation time and unit length of stay or mortality, although the average initiation time of survivors was 5.9 hours shorter than that of nonsurvivors. Future studies are needed to assess real time delays and to evaluate if the implementation of a standardized initiation process decreases initiation time.

#82 Serum zinc level is associated with aortic arch calcification in patients with incident dialysis

Abstract Background and Aims Aortic calcification is one of predictors of cardiovascular (CVD) events. Several studies show association between zinc deficiency and aortic calcification in patients with chronic kidney disease (CKD). However, there are few studies in patients with advanced CKD. Therefore, we investigated associations between serum zinc (s-Zn) levels and aortic arch calcification (AAC) in patients with incident dialysis. Method We analyzed data from 776 consecutive patients with CKD who started dialysis at our hospital between January 2013 and December 2022. We excluded 71 patients who were supplemented with zinc or who were not measured laboratory data including serum zinc at the time of dialysis initiation. AAC is graded from 0 (no calcification) to 3 on chest X-ray, as follows: grade 0, no visible calcification; grade 1, &amp;lt; 50% calcification in the arch; grade 2, &amp;gt; 50% calcification; grade 3, circumferential calcification. We defined grade 2 or 3 as severe calcification. Results The median s-Zn levels were 51, 47 and 44 μg/dL in patients with grade 0, 1 and 2-3 on AAC, respectively (p &amp;lt; 0.0001). The optimal cutoff value for s-Zn levels was 48 μg/dL in receiver operating characteristic (ROC) curves analysis. In multivariate analysis, low s-Zn level (s-Zn &amp;lt; 48 μg/dL) was independently associated with AAC [OR 2.36 (95% CI 1.55–3.60), p &amp;lt; 0.0001)], especially with severe AAC [OR 4.59 (95% CI 2.46–8.59), p &amp;lt; 0.0001)]. Addition to s-Zn level in a model with established factors on AAC improved the C-index (0.812 to 0.824, p = 0.0181), net reclassification improvement (NRI) (0.397, p &amp;lt; 0.0001) and integrated discrimination improvement (IDI) (0.020, p &amp;lt; 0.0001). More robust findings for the C-index (0.856 to 0.878, p = 0.0077), NRI (0.591, p &amp;lt; 0.0001) and IDI (0.045, p &amp;lt; 0.0001) were observed on severe AAC. Conclusion Low s-Zn level was independently associated with severity of AAC, also in patients with incident dialysis.

Perspectives on the optimal timing of advance care planning among Japanese patients undergoing dialysis and clinicians: a cross-sectional study.

The majority of dialysis patients and clinicians favor early advance care planning in our sample. Yet, there is a disconnect: only 11% of patients discussed future care with their clinicians. Our findings indicate Japanese dialysis patients and clinicians support proactive advance care planning at or before dialysis initiation. Little is known about the optimal timing of discussions about advance care planning among dialysis patients and clinicians engaged in dialysis care. We aimed to explore the preferred timing for advance care planning and assess actual participation in advance care planning among dialysis patients and their clinicians. A scenario-based survey on Japanese patients aged ≥65years on dialysis and clinicians involved in their dialysis care was performed. Participants were asked if they would feel prepared to engage in advance care planning with their clinicians, offering a choice among four hypothetical stages within the illness trajectory, extending from the initiation of dialysis to a later phase characterized by the patient's extreme frailty. Overall, 181 patients and 128 clinicians participated in the study. Among these, 131 (72%) patients, and 84 (66%) clinicians indicated that they would prefer to initiate advance care planning around the time of dialysis initiation. Only 20 patients (11%) indicated that they had participated in advance care planning with at least one clinician, including 11 (6%) who indicated that they had discussed their preferences around life-sustaining treatments and 8 (4%) who had discussed their preferences around dialysis continuation. While fewer than 11% of patients undergoing dialysis and their clinicians enrolled in our study had participated in advance care planning, most indicated that they would be comfortable initiating the discussion around the time of dialysis initiation. These findings suggest untapped opportunities to engage patients in advance care planning early in the course of their dialysis.

Unstable Housing and Mortality Among US Veterans Receiving Dialysis

Housing status is an important health determinant, yet little is known about unstable housing among individuals receiving dialysis. To determine factors associated with unstable housing among US veterans receiving dialysis and to estimate the association of unstable housing with risk of death. This retrospective cohort study used data from the US Veterans Health Administration (VHA) and the US Renal Data System for patients who initiated dialysis between October 1, 2012, and December 31, 2018. Veterans were included if they used VHA outpatient services and completed 1 or more unstable housing screenings within a 3-year period before starting dialysis. Data analysis was conducted from January 24 to June 16, 2023. Unstable housing was defined as self-report of not having stable housing within the past 2 months or having concerns about stable housing in the next 2 months. The main outcome was all-cause mortality. Characteristics associated with unstable housing at the time of dialysis initiation were examined. The multivariate Fine and Gray cumulative incidence model was used, treating transplant as a competing risk and age as an effect modifier, to examine the risk of death associated with unstable housing. This study included 25 689 veterans, with a median age of 68 (IQR, 62-74) years. Most participants were men (98%), and more than half (52%) were White. There were 771 veterans (3%) with a positive screen for unstable housing within a 3-year period before starting dialysis. Compared with veterans with stable housing, those with unstable housing were younger (mean [SD] age, 61 [8] vs 68 [10] years), were more likely to be Black (45% vs 32%) or Hispanic (9% vs 7%), and were more likely to start dialysis with a central venous catheter (77% vs 66%), receive in-center hemodialysis (96% vs 91%), and have non-Medicare insurance (53% vs 28%). Factors associated with unstable housing included Hispanic ethnicity, non-arteriovenous fistula vascular access, lack of predialysis nephrology care, and non-Medicare insurance. Veterans with unstable housing had higher all-cause mortality (adjusted hazard ratio [AHR], 1.20 [95% CI, 1.04 to 1.37] for a median age of 68 years), and risks increased with age (P = .01 for interaction). In age-stratified analyses, unstable housing was associated with higher mortality among veterans aged 75 to 85 years (AHR, 1.64 [95% CI, 1.18 to 2.28]), but associations were not observed for other age groups. In this cohort study of veterans receiving dialysis, unstable housing experienced before starting dialysis was associated with increased risk of all-cause mortality, and risks increased with age. Further efforts are needed to understand the experiences of older adults with unstable housing and to estimate the scope of unstable housing among all individuals receiving dialysis.

#4731 THE CHANGING HAEMODIALYSIS POPULATION IN A SINGLE UK CENTRE: A POST PANDEMIC PHENOMENON?

Abstract Background and Aims Following the Covid-19 pandemic, UK dialysis centres have seen a sharp increase in numbers of patients requiring renal replacement therapy (RRT) particularly haemodialysis (HD). This has resulted in pressures on dialysis capacity and staffing. There may also have been negative effects on other aspects of quality of care, such as a fall in the proportion of patients dialysing via an Arterio-venous fistula (AVF) or worsening anaemia. To study this further, we conducted a retrospective observational study to describe the incident and prevalent HD populations in the post-Covid pandemic period and compare these against pre-pandemic patterns, in a single UK dialysis centre. Method We reviewed data on prevalent HD patient numbers across our service. We specifically collected data from all patients commencing HD between January 2021 and December 2022 using electronic medical records. We collected information on time known to renal prior to starting dialysis, clinic data including which types of clinic attended, documentation of pre-dialysis decisions about modality as well as vascular access referrals, vascular access clinics and vascular access surgery as well as haemoglobin (Hb) at first dialysis. We compared figures with published pre-pandemic data from the 23rd annual UK Renal Registry report on data collected to December 2019 for our centre. We defined a planned start to dialysis as patients who were known to renal &amp;gt;90 days. This aligns with the registry definition. We compared proportional data using the chi square test. Results Comparing prevalent data in Dec. 2022 with Dec 2019, there was a 17% increase in the prevalent HD population from 298 to 349. The proportion of patients dialysing via an AVF fell from 88% to 80% (p = 0.006). The spread across different types of HD in Dec.2022 remained static at 71% In-Centre HD (72% in Dec 2019), 11% Satellite HD (9% in 2019) and 17% HHD (18% 2019) with overall numbers rising across all HD modalities (p for trend = 0.37). PD numbers also rose from 58 to 71 keeping the total percentage on home therapies stable at 31% in our unit. From Jan. 2021- Dec. 2022 inclusive 147 people commenced HD of whom 115 (78%) had planned starts. This compares to 58 starting HD in 2019 and 79% planned (p = 0.85). There was a significant fall in the proportion of planned start HD patients who commenced dialysis with an AVF/AVG, from 81% in 2019 to 56% in 2021-22 (p = 0.003). Themes emerged n planned starters who did not start HD with an AVF/AVG and are detailed in Figure 1. Median Hb level of planned starts on HD was lower at only 94 for 2021-22 and 99 in 2019. Looking in detail at those missing appointments in clinics, 33% had prior documented evidence of fear of Covid-19. Delays in AVF surgery consisted of delayed and cancelled theatre dates, failed AVF requiring re-do or AVF awaiting further intervention at time of dialysis initiation. In the group with a last minute change in decision sighted reasons included: worsening eyesight, development of dementia in partner, reducing mobility. Others changed their mind after further input from the PD team. Despite attending the Advanced Kidney Clinic (AKC) there were still a number of patients with no decision at all. Cancellation of group sessions for dialysis education persisted in our centre until mid-2022 and may have contributed to reduced timely decision making as well as late modality switches. All those with an early failure of PD (defined as &amp;lt; 90 days) had chosen PD prior to the Covid-19 pandemic with intervening remote visits in AKC. Conclusion Following the Covid-19 pandemic, unexpected and unprecedented changes in the HD incident population have been observed, resulting in pressures on dialysis services. In particular, we report an increase in absolute number of dialysis patients, a significant fall in the proportion of patients initiating dialysis with definitive vascular access and a rise in those starting anaemic. This was not related to a change in the proportion of patients with planned starts but may be related to delayed shared decision making as a result of remote consultations and greater delays in vascular access surgery. We have identified a number of areas for service improvement.

#5533 DOES AV FISTULA FORMATION DELAY TIMING OF INITIATION OF KIDNEY REPLACEMENT THERAPY IN PATIENTS WITH STAGE 5 CHRONIC KIDNEY DISEASE?

Abstract Background and Aims Several retrospective observational studies have supported kidney protective effects of arteriovenous fistula (AVF) formation. However, these studies were limited by immortal time and selection biases. We investigated whether AVF formation delays the initiation of kidney replacement therapy (KRT) in patients with stage 5 CKD by applying target trial emulation methods, which do not suffer from these biases. Method We included adult patients who had an eGFR ≤15 mL/min/1.73m2, attended the ‘low clearance’ nephrology clinic in the West of Scotland between January 1st 2010 and May 1st 2022, and had no prior AVF or AV graft formation. Available data were obtained from the Strathclyde Electronic Renal Patient Record. The target trial would randomize patients to either receive an AVF immediately or to not receive an AVF. To emulate this trial, we matched each patient who underwent AVF formation to patients who had not undergone AVF formation but remained eligible to participate in the trial, and were matched in sex, age (within 5 years) and eGFR (within 0.5 ml/min/1.73m2). Inverse probability of treatment weighting was used to adjust for baseline confounders, including age, sex, comorbidities, medication use, serum and urine biochemical measurements (eGFR CKD-EPI, eGFR CKD-EPI slope for 6 months preceding trial, haemoglobin, C-reactive protein, albumin, phosphate, adjusted calcium, ferritin, urine protein:creatinine ratio), and blood pressure. The primary outcome was kidney replacement therapy. The eGFR slope closest to the time of AVF creation was estimated as a co-primary endpoint. We estimated hazard ratios using Cox regression and estimated restricted mean survival time (RMST) from the Kaplan-Meier curves. The eGFR slope co-primary endpoint was analysed with a mixed-effects model. Results Among 2,988 included patients (55% men; mean [SD] age 64 [15] years), AVF formation was associated with a higher risk of KRT (HR 1.45; CI 1.20–1.49, p &amp;lt;0.001, Figure 1) and a lower risk of death (HR 0.68; (0.64–0.80, p = 0.001). The AVF group had a lower KRT-free survival with an estimated RMST difference of 265 days (95% CI −331 to −199, p &amp;lt;0.001) and higher overall survival (RMST difference of 191 days; 95% CI 57 to 326, p = 0.005). Finally, we used a mixed-effects model to analyse the association between eGFR CKD-EPI, time, and AVF formation. AVF formation and time were both associated with a negative slope in the model (estimates −1.28; 95% CI −1.36 to −1.19, p&amp;lt;0.001 and −0.01; 95% CI −0.01 to −0.01, p&amp;lt;0.001, respectively, Figure 2). Their interaction was also associated with a negative slope (estimate −0.001; 95% CI −0.0022 to −0.0004, p &amp;lt;0.001), suggesting those undergoing AVF formation had a more rapid eGFR decline compared to the control group. Conclusion Unlike what was observed in previously published work, we did not identify a kidney protective effect of AVF formation. The estimated time of dialysis initiation remains the main determinant for timing of access surgery. These findings illustrate the usefulness of target trial emulation in approaching research questions where randomised controlled trials would be impractical.

Update of dialysis initiation timing in end stage kidney disease patients: is it a resolved question? A systematic literature review

BackgroundThe exact optimal timing of dialysis for ESKD patients remains unknown. This study systematically reviewed the available evidence with regard to the optimal initiation of maintenance dialysis in ESKD patients.MethodsAn electronic search was performed in Embase, PubMed and the Cochrane Library in order to find studies investigating associations between variables reference to “start of dialysis” and outcomes. Quality assessment and bias assessment were performed by the Newcastle–Ottawa scale and the ROBINSI tool. Due to the heterogeneity of studies, a meta-analysis could not be performed.ResultsThirteen studies were included; four studies included only haemodialysis patients, three peritoneal dialysis, six both; study outcomes included mortality, cardiovascular events, technique failure, quality of life and others. Nine studies mainly focused on the optimal GFR of maintenance dialysis initiation; five studies showed none association between GFR and mortality or other adverse outcomes, two studies showed dialysis initiation at higher GFR levels were with poor prognosis, and 2 studies showed higher GFR levels with better prognosis. Three studies paid attention to comprehensive assessment of uremic signs and/or symptoms for optimal dialysis initiation; uremic burden based on 7 uremic indicators (hemoglobin, serum albumin, blood urea nitrogen, serum creatinine, potassium, phosphorus, and bicarbonate) were not associated with mortality; another equation (combination of sex, age, serum creatinine, blood urea nitrogen, serum albumin, haemoglobin, serum phosphorus, diabetes mellitus, and heart failure) based on fuzzy mathematics to assess the timing of haemodialysis initiation was accuracy to prognose 3-year survival; the third study found that volume overload or hypertension was associated with the highest risk for subsequent mortality. Two studies compared urgent or optimal start in dialysis, a study reported increased survival in optimal start patients, another reported no differences between Urgent-Start-PD and Early-Start-PD regarding 6-month outcomes. Limitations: Heterogeneity among the studies was quite high, with differences in sample size, variable and group characteristics; no RCT studies were included, which weakened the strength of evidences.ConclusionsThe criteria for dialysis initiation were varied. Most studies proved that GFR at dialysis initiation was not associated with mortality, timing of dialysis initiation should not be based on GFR, assessments of volume load and patient’s tolerance to volume overload are prospective approaches.

Sex differences in risk factors for end-stage kidney disease and death in type 2 diabetes: A retrospective cohort study.

This study investigated the sex differences in the risk of end-stage kidney disease (ESKD) and mortality, as well as the effect modification of sex on associated factors in patients with type 2 diabetes. This multicenter observational cohort study included 4328 patients with type 2 diabetes. Hazard ratios (HRs) with 95% confidence intervals (CIs) of sex for ESKD and death were estimated using Cox proportional regression with adjustment for baseline covariates. For assessing risk modification, HRs and incidence rates for ESKD and death were compared between sexes across patient characteristics using Cox proportional and Poisson regression models. During a median follow-up of 7 years, 276 patients (70% men) developed ESKD, and 241 patients (68% men) died. Men had higher risks of ESKD (HR 1.34; 95% CI 1.02-1.75; p=.034) and death (HR 1.64; 95% CI 1.24-2.16; p=.001) versus women after adjusting for multiple covariates. Among patients with microalbuminuria, men had a substantially higher risk of ESKD versus women, compared to those with normo- and macroalbuminuria (p for interaction .04). Incidence rates were also increased in men versus women with albuminuria of around 300 mg/g. No differences were detected in the association of sex and death across baseline patient subgroups. In type 2 diabetes, men had an increased risk of ESKD and death versus women. Moderately increased albuminuria was strongly associated with sex difference in developing ESKD.

Variability in Reporting eGFR at Dialysis Initiation in Canada: A Research Letter.

Estimated glomerular filtration rate (eGFR) at dialysis initiation is increasingly recognized as a key quality indicator (QI) for patients with end-stage kidney disease (ESKD). Specifically, guidelines recommend assessing deferral of dialysis initiation until symptoms arise or if the eGFR is ≤6 mL/min/1.73 m2. Despite the recognition of the importance of this QI, how eGFR at the time of dialysis initiation is defined, collected, and tracked at dialysis centers across Canada remains unknown. To identify how provincial renal programs define eGFR at dialysis initiation, to compare practice across Canadian provinces, and to determine if there is a consistent benchmark for deferred dialysis start. Cross-sectional survey distributed to the medical leads of each provincial renal program, administered from July 2021 to November 2021. Quebec was not included given it did not yet participate in Canadian Organ Replacement Register (CORR) data submission. The survey was designed and distributed by the Canadian Society of Nephrology Quality Improvement & Implementation Science Committee (CSN-QUIS) Indicator Working Group. The survey asked respondents on how eGFR is defined, collected, reported, and perceived barriers to QI data collection. The National Senior Renal Leaders Forum helped identify the key provincial medical leads to disseminate the survey for completion. Surveys were distributed to the medical leads of the 9 provincial renal programs that participate in CORR. In total, there were 8 responses. Five provinces submit eGFR for all new dialysis starts and 3 provinces only submit this information for chronic patients. There is variation in determining when a patient with acute kidney injury requiring dialysis is classified as a chronic patient. Four provinces use a 30-day trigger, 3 provinces use a 90-day trigger, and the patient's nephrologist makes this determination in 1 province. The creatinine used for the eGFR at dialysis initiation was the value measured on the first dialysis session (ie, day 0) for 5 provinces; the last outpatient clinic creatinine value in 2 provinces, and 1 province did not have a standard definition. Three provinces did not have a benchmark target for eGFR at dialysis initiation, 1 province had a target of <9.5 mL/min/1.73 m2, 3 provinces had a target of <10 mL/min/1.73 m2, 1 province had a target of <15 mL/min/1.73 m2. All 8 responding provincial medical leads support the establishment of a national benchmark for this measure. This survey was restricted to provincial medical leads and therefore is unable to determine practice at individual dialysis sites. The survey was not anonymous, so it may be subject to conformity bias. There is wide variability in how eGFR at dialysis initiation is measured and reported across Canada. Additionally, there is no consensus on a benchmark target for an intent-to-defer dialysis strategy. Standardization of target eGFR at dialysis initiation may facilitate national reporting and quality improvement initiatives.

Impact of Drugs and Patient Characteristics on Life Expectancy during the Induction Phase of Dialysis

Various factors affect the prognosis of dialysis patients. Analysis of the drugs used and clinical and demographic characteristics of the patient at the time of dialysis initiation is a useful means of estimating prognosis. In this study, we investigated the drugs used by dialysis patients during the induction phase of dialysis and performed a detailed analysis of variables predictive of prognosis. Patients who underwent dialysis between June 1998 and January 2019 and died during this period were included in the study (n = 118). The induction phase of dialysis was defined as the first month after dialysis began. Dialysis duration was defined as the time between dialysis initiation and death. A univariate regression analysis was performed, with dialysis duration as the objective variable and the drugs used during the induction phase of dialysis, blood laboratory values, age at start of dialysis, sex, body height, body weight, medical history and cause of death as the explanatory variables. In addition, multiple logistic regression analysis with stepwise variable selection of significant factors was performed to determine the factors related to dialysis duration. Antihypertensives, hemoglobin (Hb), and age at start of dialysis were found to have significant effects on dialysis duration. It was posited that antihypertensives prolong dialysis duration, thereby improving life expectancy. The regression model developed allowed estimation of prognosis based on the drugs used during the induction phase of dialysis and patient characteristics. These findings may be used to improve drug adherence in dialysis patients and guide physicians in their treatment.

The Use of Putative Dialysis Initiation Time in Comparative Outcomes of Patients with Advanced Chronic Kidney Disease: Methodological Aspects.

The latest data from the United States Renal Data Systems show over 134,000 individuals with end-stage kidney disease (ESKD) starting dialysis in the year 2019. ESKD patients on dialysis, the default treatment strategy, have high mortality and hospitalization, especially in the first year of dialysis. An alternative treatment strategy is (non-dialysis) conservative management (CM). The relative effectiveness of CM with respect to various patient outcomes, including survival, hospitalization, and health-related quality of life among others, especially in elderly ESKD or advanced chronic kidney disease patients with serious comorbidities, is an active area of research. A technical challenge inherent in comparing patient outcomes between CM and dialysis patient groups is that the start of follow-up time is "not defined" for patients on CM because they do not initiate dialysis. One solution is the use of putative dialysis initiation (PDI) time. In this work, we examine the validity of the use of PDI time to determine the start of follow-up for longitudinal retrospective and prospective cohort studies involving CM. We propose and assess the efficacy of estimating PDI time using linear mixed effects model of kidney function decline over time via simulation studies. We also illustrate how the estimated PDI time can be used to effectively estimate the survival distribution.

316.16: Which Patients Over 60 Years Old Are Candidates for a Kidney Transplant? Usefulness of a Mortality Predictive Score

Introduction: The decision to indicate a kidney transplant (KT) to an elderly patient with end-stage chronic kidney disease is not simple due to the high morbidity and mortality associated. The Dusseux et al. score was originally developed in France to predict 3-year post kidney transplant mortality in subjects older than 70 years. The objective of this study was to evaluate the usefulness of this score to predict 1-year post KT mortality in patients older than 60 years and to identify the best cut-off point. Methods: A retrospective cohort study was performed. All patients over 60 years old who received a KT at Hospital Privado Universitario de Córdoba between January 2009 and December 2015 were consecutively included. A one-year post-KT follow-up was carried out and variables associated with mortality were analyzed. The Dusseux et al. score considers as predictive variables: sex, age, etiology of chronic kidney disease, comorbidities, mobility status, body mass index and the presence of a temporary catheter at the time of dialysis initiation. The t test or Mann-Whitney test were used to evaluate differences between continuous variables t, and chi2 or Fisher’s test for categorical variables, as appropriate. To evaluate the predictive capacity, the area under the curve (AUC) was used and the Youdex Index J was applied to identify the best cut-off point, with its sensitivity and specificity. Kaplan Meier survival curves were made and then compared with the logRank test. A value of p<0.05 was considered statistically significant. Results: We included 111 patients aged 66.2 ± 5.2 years, 54.9% were men. As relevant comorbidities, 30.7% were diabetic and 13.5% had ischemic heart disease. 82% received a cadaveric KT. As induction, 100% were given steroids, 60.3% basiliximab, 22.5% thymoglobulin and 9.9% gamma globulin. As maintenance, 93.7% were treated with steroids, tacrolimus and mycophenolate. Mortality during follow-up was 9.9% (n:11; 8 due to infectious etiology and 3 from cardiovascular disease). The patients who died were older (70.3 ± 6.6 vs 65.8 ± 4.9; p=0.05), had a greater history of ischemic heart disease (36.7% vs 11%; p=0.04), and had a higher mortality predictive score (9.4 ± 3 vs 6.8 ± 2.5, p=0.02). There were no differences in the rest of the variables. This score obtained a high AUC to predict mortality (AUC=0.75; p<0.01; figure 1) and the best cut-off point was 8, with a sensitivity of 72.7% and a specificity of 78%. Subjects with a score >8 had higher mortality than those with a score ≤8 (26.7% vs 3.7% respectively; p<0.01). There were significant differences between the survival curves of these groups (p<0.01; figure 2). Conclusion: This clinical score is a good predictor of mortality 1-year after KT in patients over 60 years old. The best cut-off point of the score was 8 points. This could be a useful and simple tool to help in the decision to indicate a KT in this type of patients. Fundación Nefrológica de Córdoba.

The joint association of malnutrition and activities of daily living dependence with adverse health outcomes among patients initiating maintenance dialysis

While prior work has examined activities of daily living (ADL) dependence and malnutrition separately, the additive effects of these conditions remain uncertain. Therefore, the purpose of this study was to evaluate the joint association of malnutrition and ADL dependence with poor health outcomes in incident dialysis patients. 1457 patients from the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis database were identified for inclusion in this longitudinal study. The geriatric nutritional risk index and Barthel index were used as the evaluation tool for nutritional status and functional ability. Combined classifications of malnutrition and ADL dependence were generated with four subgroups derived. Associations between these exposures and health outcomes, including all-cause mortality, major adverse cardiovascular events (MACE), and infection-related death were investigated using Cox-proportional hazard models and competing risk survival models, respectively. 39.5% of the participants were not malnourished nor ADL dependent (normal), 30.3% were malnourished, 10.5% ADL dependent and 19.8% as having both malnutrition and ADL dependence. During 4752 person-years of follow-up, 367 (25.2%) died and 650 (44.6%) patients suffered a MACE. Compared with the reference group (ADL dependency and no-malnutrition), the combination malnourished/ADL dependent showed the strongest association with all cause death (fully-adjusted HR 2.64, 95% CI 1.79-3.89), mortality from infection (fully-adjusted HR 4.41, 95% CI 1.88-10.40), and MACE incidence (fully-adjusted HR 1.81, 95% CI 1.36-2.42). This relationship remained credible and robust in several subgroup and sensitivity analyses. Additionally, we identified this associations were higher in patients aged 75 and older. The concurrent presence of malnutrition and ADL dependence at the time of dialysis initiation has significant detrimental impacts.

MO486: Comparison of Hospitalization Lengths of Stay Among a National Cohort of Advanced CKD Patients Treated With Conservative Management Vs. Dialysis

Abstract BACKGROUND AND AIMS While dialysis has been the prevailing treatment paradigm in advanced CKD patients progressing to ESRD, this treatment approach may lead to a decline in physical function, loss of independence, and greater healthcare utilization among certain subgroups. We sought to compare the impact of dialysis versus conservative dialysis-free management on hospitalization lengths of stay (LOS) in advanced CKD patients. METHOD We examined a national cohort of advanced CKD patients (≥2 eGFRs &amp;lt;25 mL/min/1.73 m2 separated by ≥90 days) treated with conservative management (CM) versus dialysis over 1 January 2007—30 June 2020 from the OptumLabs® Data Warehouse (OLDW), which contains de-identified administrative claims, including medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, as well as electronic health record data. In primary analyses, patients were categorized according to receipt of CM, defined as those who did not receive dialysis within 2-years of the index eGFR (1st eGFR &amp;lt;25 mL/min/1.73 m2), versus receipt of dialysis. In secondary analyses, we examined finer gradations of the timing of dialysis, defined as late versus early transition (eGFRs &amp;lt;15 versus ≥15 mL/min/1.73 m2 respectively, at the time of dialysis initiation). We compared LOS among patients treated with CM versus dialysis who were hospitalized within 2 years of their index eGFR using linear mixed effects models that separately considered a fixed age of the cohort (65-years old), with varying times of hospitalization from the index eGFR date, as well as a fixed time of hospitalization from the index eGFR date (12 months) with varying age. RESULTS Among 169 479 advanced CKD patients who were hospitalized within 2-years of their index eGFR, there were a total of 620 168 hospitalizations over this time period. In primary analyses that considered a fixed age of the cohort, dialysis patients experienced longer average LOS versus those treated with CM, with differences attenuating over time (∆ of + 1.5-days for hospitalizations 1-month from the index eGFR; Fig. 1A, upper panel). In secondary analyses, differences in average LOS were even greater for those treated with early dialysis versus CM (∆ of + 2-days for hospitalizations 1-month from the index eGFR, Fig. A, lower panel). In primary analyses that considered a fixed time of hospitalization from the index eGFR, dialysis patients &amp;gt;20-years old had longer average LOS versus those treated with CM, with differences increasing with older age (∆ of + 1.25-days for hospitalizations for patients 70-years old; Fig. 1B, upper panel). In secondary analyses, differences in average LOS were even greater for those treated with early dialysis versus CM (∆ of + 1.87-days for patients 70-years old, Fig. 1B, lower panel). CONCLUSION In a nationally representative CKD cohort, compared with dialysis, those treated with CM as an alternative patient-centered treatment strategy had shorter LOS across varying time points and age groups. Further studies are needed to examine the comparative effectiveness of CM versus dialysis transition on CKD outcomes.

MO834: The Epidemiology of Hepatitis B And C Infection in Hemodialysis Patients in Kazakhstan

Abstract BACKGROUND AND AIMS Hemodialysis patients are more likely than the general population to contract hepatitis B virus and hepatitis C virus. In Kazakhstan, there is no research on HBV and HCV in this population. The major goal of this study is to find out how common HBV and HCV infections are among hemodialysis patients in Kazakhstan, as well as their risk factors, the impact of hepatitis on the survival of patients with ESRD undergoing hemodialysis survival analysis was conducted using Kaplan–Meier method and Cox proportional hazards regression modelling. Data from the Unified National Electronic Health System (UNEHS) for the period of 2014–9 were used to study the epidemiology of viral hepatitis in patients with ESRD receiving hemodialysis in Kazakhstan. METHOD The study population consisted of 9310 patients with ESRD undergoing hemodialysis, whose individual records were obtained from the ‘Registry of Chronic Kidney Disease’ (RCKD) within UNEHS for the period of 2014–8. This cohort was cross-referenced with a cohort of hepatitis patients based on population registry number (RPN) for the purpose of identifying ESRD patients undergoing hemodialysis who had been diagnosed with hepatitis before the end of 2018. Utilizing one-to-one closest neighbor propensity score matching, a control group from among the dialysis patients with no diagnosed hepatitis was derived with sufficient bias reduction based on age, gender, education, region and ethnicity. Crude survival analysis was conducted using Kaplan–Meier method to compare the survivability of dialysis patients based on the presence of hepatitis and relative time of hepatitis diagnosis. Hepatitis diagnoses that took place in the 120 days since dialysis initiation were classified as prior hepatitis. Any later hepatitis diagnoses were considered as infection developed after the start of dialysis. All statistical analyses were conducted using STATA 15 MP/IC Version (STATA Corporation, College Station, TX). The study was approved by the Institutional Review Ethics Committee (NU-IREC 203/29 112 019), with exemption from informed consent. RESULTS Among the dialysis patients, 500 were diagnosed with hepatitis in 2014–8 or earlier. Propensity score matching resulted in a loss of two cases due to lack of appropriate controls, resulting in a final cohort of 996 patients with 498 cases and 498 controls. Within this cohort, survival analysis was conducted. Figure 1 illustrates the Kaplan–Meier survival probability curves, where a consistently and significantly lower survivability is apparent among dialysis patients without hepatitis, as compared with those with hepatitis. Figure 2 shows the comparison of survival probabilities of patients diagnosed with prior or consequent hepatitis infection, relative to the time of dialysis initiation. A significantly lower survivability is visible among patients with prior hepatitis infection, as compared with those with consequent hepatitis infection. Both graphs are limited to 5 years of follow-up, with dates of patients’ dialysis initiation as the start points of individual follow-up periods. Both graphs contain the P-values of log-rank significance tests of the difference between the survival curves. CONCLUSION Viral hepatitis continues to be a serious complication in patients with HD, with HCV being the most common. Internationally, HCV infection is almost never treated in patients on HD. Our data inform in incident (&amp;lt;120 days) patients undergoing HD, HCV prevalence was around 5.4%. Patients with HBV and HCV on HD survival rate is higher than in patients without hepatitis receiving HD. The key to reducing the incidence of viral hepatitis in patients with HD is the development of an infection control system and interaction between the dialysis center and the hepatology center.

Dialysis Initiation in Patients With Chronic Coronary Disease and Advanced Chronic Kidney Disease in ISCHEMIA-CKD.

BackgroundIn participants with concomitant chronic coronary disease and advanced chronic kidney disease (CKD), the effect of treatment strategies on the timing of dialysis initiation is not well characterized.Methods and ResultsIn ISCHEMIA‐CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease), 777 participants with advanced CKD and moderate or severe ischemia were randomized to either an initial invasive or conservative management strategy. Herein, we compare the proportion of randomized participants with non–dialysis‐requiring CKD at baseline (n=362) who initiated dialysis and compare the time to dialysis initiation between invasive versus conservative management arms. Using multivariable Cox regression analysis, we also sought to identify the effect of invasive versus conservative chronic coronary disease management strategies on dialysis initiation. At a median follow‐up of 23 months (25th–75th interquartile range, 14–32 months), dialysis was initiated in 18.9% of participants (36/190) in the invasive strategy and 16.9% of participants (29/172) in the conservative strategy (P=0.22). The median time to dialysis initiation was 6.0 months (interquartile range, 3.0–16.0 months) in the invasive group and 18.2 months (interquartile range, 12.2–25.0 months) in the conservative group (P=0.004), with no difference in procedural acute kidney injury rates between the groups (7.8% versus 5.4%; P=0.26). Baseline clinical factors associated with earlier dialysis initiation were lower baseline estimated glomerular filtration rate (hazard ratio [HR] associated with 5‐unit decrease, 2.08 [95% CI, 1.72–2.56]; P<0.001), diabetes (HR, 2.30 [95% CI, 1.28–4.13]; P=0.005), hypertension (HR, 7.97 [95% CI, 1.09–58.21]; P=0.041), and Hispanic ethnicity (HR, 2.34 [95% CI, 1.22–4.47]; P=0.010).ConclusionsIn participants with non–dialysis‐requiring CKD in ISCHEMIA‐CKD, randomization to an invasive chronic coronary disease management strategy (relative to a conservative chronic coronary disease management strategy) is associated with an accelerated time to initiation of maintenance dialysis for kidney failure.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT01985360.