Effect of Timing of the First Cannulation on Survival of Arteriovenous Hemodialysis Grafts

The use of an arteriovenous graft as vascular access for hemodialysis is associated with a high rate of patency loss. The influence of timing of the first cannulation of the graft on graft survival has not been sufficiently studied. The purpose of this study was to investigate an association between the timing of the first cannulation of the polytetrafluoroethylene arteriovenous graft and the incidence of 12‐month failure. This is a retrospective study on a cohort of chronic hemodialysis patients treated in a single center. According to the time, in weeks, between graft construction and its first successful cannulation, the grafts were divided into six groups: 2nd, 3rd, 4th, 5th, 6th and 7th or more week after surgery. The primary outcome was primary graft failure at 12 months, defined as the first occurrence of graft thrombosis or any invasive access procedure. The secondary outcome was cumulative graft failure at 12 months, defined as complete loss of the access site for dialysis. Fifty‐eight patients with 64 newly‐created arteriovenous grafts were included in the study. In the whole cohort, the incidence of primary graft failure at 12 months was 72.2%, and the incidence of cumulative graft failure at 12 months was 40.7%. The incidences of primary graft failure and cumulative graft failure at 12 months did not differ significantly between the study groups. In our study, timing of the first cannulation of a new arteriovenous polytetrafluoroethylene graft had no significant impact on graft survival.     

Race/Ethnicity,Age, and Risk of Hospital Admission and Length of Stay during the First Year of Maintenance Hemodialysis

Background and objectives

Although patients undergoing maintenance hemodialysis have exceptionally high hospitalization rates, the risk factors for hospitalizations are unclear. This study sought to examine hospitalization rates among hemodialysis patients in the United States according to both race/ethnicity and age.

Design, setting, participants, & measurements

US Renal Data System data on 563,281 patients beginning maintenance hemodialysis between 1995 and 2009 were analyzed. Rates of hospital admission and number of hospital days for all-cause and cause-specific hospitalizations during the first year of dialysis were compared among blacks, whites, and Hispanics in the entire cohort and subgroups stratified by age.

Results

After multiple adjustments, compared with whites, Hispanics overall had lower rates of both all-cause hospital days (adjusted rate ratio [aRR], 0.91; 95% confidence interval [95% CI], 0.90 to 0.93; P<0.001) and hospital admissions (aRR, 0.89; 95% CI, 0.88 to 0.90; P<0.001), whereas blacks had a lower rate of all-cause admissions (aRR, 0.95; 95% CI, 0.94 to 0.96; P<0.001). The racial/ethnic differences, however, varied by age. Hispanics exhibited the lowest rates of hospital days and admissions for all age groups≤70 years, but those >80 years had higher rates than their white counterparts. The adjusted black-to-white rate ratios exhibited a U-shaped pattern with age, with higher rates for blacks in the younger and older age groups. Hospitalization rates for dialysis-related infections were markedly higher in blacks and Hispanics than whites, which were consistent in all age groups for blacks (aRRs for hospital days ranged from 1.09 to 1.36) and all ages>60 years for Hispanics (aRRs ranged from 1.20 to 1.38).

Conclusions

There are significant racial/ethnic differences in hospitalization rates within first year of dialysis, which are not consistent across the age groups and also differ by causes of hospitalization. Overall, blacks and Hispanics had lower rates of all-cause hospital admissions than whites. However, younger and older blacks and older Hispanics were at greatest risk.     

Timing of Dialysis Initiation and Survival in ESRD

Background and objectives: The optimal time of dialysis initiation is unclear. The goal of this analysis was to compare survival outcomes in patients with early and late start dialysis as measured by kidney function at dialysis initiation.Design, setting, participants, & measurements: We performed a retrospective analysis of patients entering the U.S. Renal Data System database from January 1, 1995 to September 30, 2006. Patients were classified into groups by estimated GFR (eGFR) at dialysis initiation.Results: In this total incident population (n = 896,546), 99,231 patients had an early dialysis start (eGFR >15 ml/min per 1.73 m²) and 113,510 had a late start (eGFR ≤5 ml/min per 1.73 m²). The following variables were significantly (P < 0.001) associated with an early start: white race, male gender, greater comorbidity index, presence of diabetes, and peritoneal dialysis. Compared with the reference group with an eGFR of >5 to 10 ml/min per 1.73 m² at dialysis start, a Cox model adjusted for potential confounding variables showed an incremental increase in mortality associated with earlier dialysis start. The group with the earliest start had increased risk of mortality, wheras late start was associated with reduced risk of mortality. Subgroup analyses showed similar results. The limitations of the study are retrospective study design, potential unaccounted confounding, and potential selection and lead-time biases.Conclusions: Late initiation of dialysis is associated with a reduced risk of mortality, arguing against aggressive early dialysis initiation based primarily on eGFR alone.Despite the widespread use of chronic dialysis, there remains a lack of consensus about the optimal time at which renal replacement therapy should be initiated. Recommendations from the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) are generally used as a guideline, although they have been predominantly opinion-based (1). Initial NKF-DOQI guidelines suggested beginning dialysis at a GFR of ∼10.5 ml/min per 1.73 m², equivalent to a creatinine clearance of 9 to 13 ml/min (2). Updated NKF-DOQI guidelines in 2006 emphasized the need for a risk-benefit analysis when patients reach stage 5 chronic kidney disease or even earlier in certain circumstances (3). Although these guidelines suggest using clinical judgment, in practice, renal function at the time of dialysis initiation has been increasing over time (4). Early dialysis was believed to decrease mortality, hospitalization, and costs of treatment (5). However, early initiation creates lifestyle hardships, can be a limiting factor for employment and travel, and impacts the quality of life of patients and their families (6). Furthermore, multiple studies from the United States and Europe reported a lower level of renal function at dialysis initiation than recommended by the NKF-DOQI guidelines (7,8).Because randomized prospective controlled trials addressing this important practical point are lacking, the goal of this project was to study the mortality associated with early compared with late dialysis initiation based on retrospective data from the U.S. Renal Data System (USRDS).     

Do Older People Accurately Estimate the Length of Their First Step during Gait Initiation?

Background/Study Context: Advancing age is associated with a decrease in step length. In line with previous studies showing that older adults often overestimate their motor abilities, we investigate whether older adults overestimate the length of their first step during gait initiation. The underlying effect could be a failure to update the internal model of motor action as a function of age-related motor decline.

Methods: Without taking a step, community-dwelling older women (n = 22, age range: 68–87 years) and younger women (n = 19, age range: 19–33 years) estimated the length of their first step for both preferred step length and largest step length, which were performed without endangerment. Thereafter, the participants performed real gait initiation for both types of steps. The estimated step lengths were compared to the actual step lengths.

Results: Older adults judged their first step as larger than it was (mean error: 30% for the preferred step and 9% for the largest step). A fine-grained analysis showed that this effect mainly concerned those for whom an increased risk of falling was suspected. These older adults were also among those who performed the shortest steps, and they presented with a slight decrease in cognitive functioning. Younger participants underestimated their preferred step length. Overall, the estimates were more accurate for the largest steps than for the preferred-length steps.

Conclusion: Step length estimation revealed powerful evidence for overestimation in older adults. Those who overestimated step length presented with more signs of motor decline. While this result sustains the idea of an insufficient actualization of the motor-action model, the explanation also refers to more global appraisal processes. Further research should explore the relevance of this task as a clinical laboratory tool for assessing gait capacity and the risk of falling.     

Spirituality,Social Support,and Survival in Hemodialysis Patients

Background and objectives: No studies have evaluated the relationship among spirituality, social support, and survival in patients with ESRD. This study assessed whether spirituality was an independent predictor of survival in dialysis patients with ESRD after controlling for age, diabetes, albumin, and social support.Design, setting, participants, & measurements: A total of 166 patients who had ESRD and were treated with hemodialysis completed questionnaires on psychosocial variables, quality of life, and religious and spiritual beliefs. The religious variables were categorized into three scores on a 0 to 20 scale (low to high levels): Spirituality, religious involvement, and religion as coping. Social support was assessed using the Multidimensional Scale for Perceived Social Support. Analyses were also performed including and excluding patients with HIV infection. Religious variables were categorized on the basis of means, medians, and tertiles.Results: In analyses that used religious variables, only the responses on the spirituality scale split at the mean were associated with survival. The association of other religious variables with survival did not reach significance. Social support correlated with spirituality, religion as coping, and religious involvement measures. Only social support and age were associated with survival when controlling for diabetes, albumin concentration, HIV infection, and spirituality.Conclusions: These data suggest that the effects of spirituality may be mediated by social support. Larger, multicenter, prospective studies that use well-validated tools to measure religiosity and spirituality are needed to determine whether there is an independent association of spirituality variables with survival in patients with ESRD.Relationships between spirituality and mortality have been investigated in medical populations but remain controversial (1–13). Variable associations have been found depending on definitions of spirituality and patient populations studied (1–11). Miller and Thoreson (12) explored nine different hypotheses regarding the relationship among religious beliefs, spirituality, and mortality. The only hypothesis that they found to be supported by persuasive evidence stated that “church/service attendance protects [only] healthy people against death.” Studies supporting a similar link in patients with chronic illnesses have also shown mixed results. Koenig et al. (14) evaluated approximately 4000 elderly patients to determine whether attendance at religious services during a 6-yr period was associated with survival. In adjusted analyses, there was a significantly lower mortality in patients who frequently attended church services.Many researchers have suggested a publication bias, whereby only the studies that indicate a significant relationship are published (13). Most studies cited the need for more research on the relationship between spirituality and mortality before any firm conclusions can be reached. In addition, the health dimensions of lack of belief have not been well explored.There also exists considerable debate on how to operationalize religiosity and spirituality. Whereas the first term often is associated with participation in social institutions and adherence to specific beliefs and practices, the latter is a broader term that typically pertains to life''s vital qualities and an overall broad belief in the immaterial features of life (12). Spirituality relates to transcendent values and relationships and the way people find meaning, purpose, and hope in life and in the midst of suffering (15). A person may be spiritual and not religiously observant or observe rituals without a spiritual focus.Few studies have specifically evaluated the potential association between spirituality and survival in patients with ESRD (16,17). We (18) previously showed that religious and spiritual beliefs are associated with decreased perception of burden of illness, decreased depressive affect, increased perception of social support, and higher satisfaction with life and perception of quality of life in an urban, predominantly black ESRD population. We also found that a “spiritual beliefs scale” correlated with several quality-of-life measures in patients with ESRD (19). Even though many of these psychosocial measures have been shown to be related to survival independently, no study to our knowledge has demonstrated a link between spirituality and survival in this population.We determined whether three variables related to spirituality, religious beliefs, and practices and faith (spirituality, religious involvement, and religion as a coping measure) were independently associated with survival in hemodialysis patients with ESRD. We then assessed the relationship between social support and survival, regardless of whether the spiritual variables were included in analyses. We hypothesized that spiritual variables would be associated with survival in patients with ESRD.     

Nutritional Competence and Resilience among Hemodialysis Patients in the Setting of Dialysis Initiation and Hospitalization

Background and objectives

Dialysis patients have a high risk for inadequate nutrition. Their nutritional status is particularly susceptible to deterioration when faced with intercurrent events such as hospitalization. This study was conducted to improve the understanding of the temporal evolution of nutritional parameters as a foundation for rational and proactive nutritional intervention.

Design, setting, participants, & measurements

A retrospective cohort study was performed to investigate the temporal evolution of nutritional parameters (serum albumin, serum phosphate, serum creatinine, equilibrated normalized protein catabolic rate, and interdialytic weight gain) and a composite nutritional score derived from these parameters, in two populations: (1) incident hemodialysis (HD) patients who started HD between January 2006 and December 2011 and were followed for up to 54 months (median 16.3), and (2) prevalent patients with HD vintage ≥2.5 years who were hospitalized between January 2006 and December 2011 and followed from 6 months before to 6 months after hospitalization.

Results

In incident patients (n=126,964), each of the nutritional parameters improved after HD initiation, with a mean composite nutritional score at the 24th percentile at the start of HD and reaching a plateau at the 57th percentile toward the end of the second year on dialysis. Nutritional parameters increased more rapidly and reached higher values among patients who survived longer. In hospitalized patients (n=14,193), the nutritional parameters and the composite score began to decline 1–2 months before hospitalization, reached their lowest level in the month after hospitalization, and then partially recovered in the subsequent 5 months. The degree of recovery of the nutritional score was inversely related to the number of rehospitalizations.

Conclusions

This study increases the understanding of nutritional resilience and its determinants in HD patients. Application of the nutritional score, pending further validation, may facilitate targeted and timely interventions to avert the negative consequences of inadequate nutrition in chronic HD patients.     

Sarcopenia Predicts Reduced Survival in Patients with Hepatocellular Carcinoma at First Diagnosis

BackgroundSarcopenia is a complication and independent risk factor for mortality in patients with liver cirrhosis.AimTo assess the prevalence and influence of sarcopenia on overall survival in a cohort of cirrhotic patients with hepatocellular carcinoma managed in a tertiary center.Material and MethodsAbdominal computed tomography of 92 consecutive hepatocellular carcinoma cirrhotic patients, enrolled and followed from 2004 to 2014, were retrospectively studied with a software analyzing the cross-sectional areas of muscles at third lumbar vertebra level. Data was normalized for height, skeletal muscle index (SMI) calculated and presence of Sarcopenia measured. Sarcopenia was defined by SMI ≤ 41 cm²/m² for women and ≤ 53 cm²/m² for men with body mass index (BMI) ≥ 25, and ≤ 43 cm²/m² for men and women with BMI < 25, respectively.ResultsMedian age at diagnosis was 71.9 years (30.7-86.4) and BMI 24.7 (17.5-36.7), comparable in women 23.1, (17.5-36.7) and men 24.7 (18.4-36.7). A class of CHILD score and BCLC A prevailed (55.4% and 41.3%, respectively); metastatic disease was found in 12% of cases. Sarcopenia was present in 40.2% of cases, mostly in females (62.9%; p = 0.005). Mean overall survival was reduced in sarcopenic patients, 66 (95% CI 47 to 84) vs. 123 (95% CI 98 to 150) weeks (p = 0.001). At multivariate analysis, sarcopenia was a predictor of reduced overall survival, independent of age (p = 0.0027).ConclusionsThis retrospective study shows high prevalence of sarcopenia among cirrhotic patients with hepatocellular carcinoma. Presence of sarcopenia was identified as independent predictor of reduced overall survival. As easily measurable by CT, sarcopenia should be determined for prognostic purposes in this patient population.     

维持性血液透析中心律失常的治疗对策

目的探讨维持性血液透析中心律失常的诊治方法。方法回顾性分析149例维持性血液透析患者发生心律失常的临床过程。结果本组病例于血液透析中出现心律失常的发生率为15．1%,抢救成功率为99．7%。结论心律失常是维持性血液透析中的常见并发症。应用综合治疗措施可使绝大部分的心律失常能抢救成功,完成透析治疗。     

Zolpidem Versus Trazodone Initiation and the Risk of Fall-Related Fractures among Individuals Receiving Maintenance Hemodialysis

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Effect of Alfacalcidol Therapy on the Survival of Chronic Hemodialysis Patients

The aim of this study was to determine the relationship between alfacalcidol therapy and the outcomes of chronic hemodialysis (HD) patients. We collected demographic and clinical baseline data from 190 prevalent HD patients in a regional Japanese cohort. A 5‐year survival analysis was performed according to whether the patients were receiving calcitriol analog therapy. Alfacalcidol therapy at a mean dose of 5.2 ± 1.8 µg/week was performed in 89 (46.8%) of the 190 patients. We recorded 38 deaths during the follow‐up period, including 19 deaths from cardiovascular events. A Kaplan–Meier analysis demonstrated that the alfacalcidol users had a significantly lower rate of all‐cause mortality and cardiovascular mortality than the non‐users. According to a multivariate Cox proportional hazards model, in addition to the use of alfacalcidol (HR=0.347 [0.155–0.714]; P = 0.0035), serum CRP levels (HR= 1.746 [1.184–2.442]; P = 0.0071) and non‐HDL‐cholesterol levels (HR=1.012 [1.001–1.022]; P = 0.0267) were identified as independent predictors of all‐cause mortality, and the presence of diabetes mellitus (HR=3.720 [1.182–12.398]; P = 0.0246) was identified as an independent predictor of cardiovascular mortality. These findings suggest that low‐dose alfacalcidol therapy provides a survival advantage to chronic HD patients.     

Genetic Analysis of SARS-CoV-2 Variants in Mexico during the First Year of the COVID-19 Pandemic

During the first year of the SARS-CoV-2 pandemic in Mexico, more than two million people were infected. In this study, we analyzed full genome sequences from 27 February 2020 to 28 February 2021 to characterize the geographical and temporal distribution of SARS-CoV-2 lineages and identify the most common circulating lineages during this period. We defined six different geographical regions with particular dynamics of lineage circulation. The Northeast and Northwest regions were the ones that exhibited the highest lineage diversity, while the Central south and South/Southeast regions presented less diversity with predominance of a certain lineage. Additionally, by late February 2021, lineage B.1.1.519 represented more than 89% of all circulating lineages in the country.     

Effect of Predialysis Recombinant Human Erythropoietin on Early Survival After Hemodialysis Initiation in Patients With Chronic Kidney Disease: Co‐JET Study

Progression of anemia in patients with chronic kidney disease (CKD) is associated with an increased risk of death and hospitalization. It is not sufficiently clear whether treating renal anemia with recombinant human erythropoietin (rHuEPO) has a beneficial effect on early survival after hemodialysis (HD) initiation in patients with CKD. The study was an open‐label multicenter retrospective cohort study to evaluate the relationship between rHuEPO treatment and early survival after HD initiation in patients with CKD. Predialysis patients with CKD were divided into two groups: an rHuEPO‐treated group (rHuEPO group) and a non‐treatment group. The primary endpoint was all‐cause mortality in the year after HD initiation. A total of 3261 patients were enrolled (2275 in the rHuEPO group and 986 in the non‐treatment group). One‐year survival was 95.36% in the rHuEPO group and 90.36% in the non‐treatment group. The survival rate was significantly higher in the rHuEPO group (P < 0.0001). The results of multivariate analysis confirmed that predialysis treatment with rHuEPO is a predictor for reduced mortality risk (hazard ratio = 0.61, 95% confidence interval: 0.42–0.87, P = 0.006). Risk for the composite event of death/hospitalization was also lower in the rHuEPO group (hazard ratio = 0.88, 95% confidence interval: 0.78–0.98, P = 0.026). The results of this study suggest that treatment with rHuEPO can decrease early mortality risk after initiation of HD in patients with CKD. A prospective study is needed to further investigate early survival after HD initiation.     

Balloon Aortic Valvuloplasty in the First Year of Life

Between February 1988 and September 1993 balloon aortic valvuloplasty was attempted in 33 consecutive patients in the first year of life: 20 patients (61%) were younger than J month. Major associated anomalies such as mitral stenosis, coarctation, and hypoplastic left ventricle were found in 11 cases (33%). The balloon dilation of the aortic valve was accomplished through the right carotid cut-down approach in neonates and patients with body weight < 5 kg, through a percutaneous femoral approach in the others; the procedure was completed in all. The peak systolic gradient across the aortic valve measured at catheterization fell from 80 ± 33 mmHg (range 25–165) before the dilation to 27 ± 17 mmHg (range 0–65), afterwards (P < 0.0001). The left ventricular ejection fraction increased from 44%± 26% to 61%± 17%, 24–48 hours after the procedure (P < 0.0001). Aortic insufficiency developed in 17 cases, being moderate in 2, mild in 6, and trivial in 9. Seven patients (21%), all in the first month of life, died within 30 days from the valvuloplasty; major associated anomalies were present in six; the death was due to a procedure related complication in one. No mortality was observed among the patients undergoing valvuloplasty beyond the first month of life. On follow-up (6 months to 6 years) aortic restenosis occurred in 3 cases; 1 was treated by surgical valvotomy, 2 by repeat balloon valvotomy; in another 2 cases, a subvalvular aortic obstruction developed and was relieved by surgical resection. There was no late mortality. Thus, balloon valvuloplasty appears to be an effective palliation for critical aortic stenosis in infancy. Early mortality is mainly related to associated anomalies.     

首届海峡两岸消化论坛获得圆满成功

首届海峡两岸消化论坛由福建省医学会、消化病学分会、消化内镜学分会、肝病学分会主办,厦门市医学会、厦门大学附属中山医院,厦门大学消化疾病研究所,厦门市消化疾病诊治中心承办,哈佛大学麻省总医院、香港大学玛丽医院、北京协和医院、台湾中山医学大学附设医院、台湾高雄医学大学附设医院、澳门镜湖医院、上海交通大学仁济医院、上海交通大学瑞金医院、北京解放军总医院、武汉大学人民医院等多家医院以及中华消化杂志、中华消化内镜杂志、胃肠病学、世界华人消化杂志协办.     

Estimating the Effectiveness of Shielding during Pregnancy against SARS-CoV-2 in New York City during the First Year of the COVID-19 Pandemic

Pregnant patients have increased morbidity and mortality in the setting of SARS-CoV-2 infection. The exposure of pregnant patients in New York City to SARS-CoV-2 is not well understood due to early lack of access to testing and the presence of asymptomatic COVID-19 infections. Before the availability of vaccinations, preventative (shielding) measures, including but not limited to wearing a mask and quarantining at home to limit contact, were recommended for pregnant patients. Using universal testing data from 2196 patients who gave birth from April through December 2020 from one institution in New York City, and in comparison, with infection data of the general population in New York City, we estimated the exposure and real-world effectiveness of shielding in pregnant patients. Our Bayesian model shows that patients already pregnant at the onset of the pandemic had a 50% decrease in exposure compared to those who became pregnant after the onset of the pandemic and to the general population.