Evaluation of unplanned dialysis as a predictor of mortality in elderly dialysis patients: a retrospective data analysis

Background

Increasing numbers of elderly patients are undergoing long-term dialysis. However, the role of dialysis in survival and quality of life is unclear, and poor outcomes may be associated with comorbidities rather than with age only. The initiation of unplanned dialysis in elderly patients with chronic kidney disease (CKD) has been reported to be associated with poor survival. We evaluated patient and practice factors associated with poor survival.

Methods

We performed a retrospective analysis of 90 consecutive elderly patients (≥75 years) with CKD initiated on long-term dialysis at our renal unit between October 2010 and February 2014. Six patients were excluded; data from 84 remaining patients (≥75 years) with end-stage renal disease undergoing planned or unplanned dialysis were analyzed. Patients were followed up until death or January 2015. Patient factors such as age at initiation of dialysis and comorbidities (i.e., diabetes mellitus, ischemic heart disease [IHD], peripheral vascular disease, cancer, chronic obstructive pulmonary disease, and cognitive dysfunction) were analyzed. Practice factors such as planned or unplanned initiation of dialysis were compared in relation to survival outcomes. “Unplanned dialysis” was defined as a patient with known CKD stage 4 or 5 who had not been evaluated by a nephrologist in the 3 months before dialysis initiation.

Results

The average age at dialysis initiation was 81.5?±?4.5 years), serum albumin level was 24.8?±?6 g/L, body mass index was 22.5?±?4.8 kg/m², and glycated hemoglobin A1c level was 6.3?±?1.3. Overall, 51 (61%) and 33 (39%) patients underwent unplanned and planned dialysis, respectively. On univariate analysis, the presence of IHD, peripheral vascular disease, ≥3 comorbidities, and unplanned initiation of dialysis were significantly related to death. On multivariate analysis, unplanned start of dialysis, ischemic heart diseases and peripheral vascular disease remained significant. Survival rates at 3 and 12 months were 38.6% vs. 90.9% and 14.4% vs. 73.6% for unplanned vs. planned dialysis, respectively (p?<?0.001). Unplanned dialysis was significantly associated with greater mortality.

Conclusions

In elderly dialysis patients, unplanned start of dialysis was associated with poor survival. Patient characteristics such as associated peripheral vascular disease and IHD were associated with poor survival.

     

Meeting KDOQI Guideline Goals at Hemodialysis Initiation and Survival during the First Year

Background and objectives: To determine, in a national cohort of incident hemodialysis patients, whether meeting a greater number of National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guideline goals at dialysis initiation was independently associated, in a graded manner, with lower first-year mortality rates.Design, setting, participants, & measurements: Patients who initiated hemodialysis between June 1, 2005, and May 31, 2007, in the US were included in this retrospective cohort analysis. Guidelines examined were (1) use of arteriovenous fistula or graft at initiation; (2) hemoglobin ≥11 g/dl; and (3) albumin at goal. The primary predictor variable was number of guideline goals (zero, one, two, or three) met at dialysis initiation. Cox regression analysis was used to compare time to death, adjusting for baseline characteristics.Results: At dialysis initiation, 59%, 31%, 9%, and 1.6% of patients met zero, one, two, or three guideline goals, respectively (total n = 192,307). After multivariate adjustment, mortality hazard ratios (95% confidence intervals) were 0.81 (0.80 to 0.83) for patients who met one, 0.53 (0.51 to 0.56) for patients who met two, and 0.34 (0.30 to 0.39) for patients who met three guideline goals, compared with patients who met none. Meeting each individual goal was also associated with lower mortality.Conclusions: These findings suggest a graded association between meeting a greater number of evidence-based guideline goals at dialysis initiation and lower risk of death during the first year on dialysis.The number of patients with end-stage renal disease (ESRD) requiring dialysis is increasing (1,2). Patients with ESRD have exceedingly high morbidity and mortality rates, particularly in the first year after dialysis initiation, when mortality exceeds 25% (1). To improve outcomes of patients with ESRD, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) developed evidence-based guidelines for the care of kidney disease patients. For patients with chronic kidney disease (CKD) approaching ESRD, the KDOQI guidelines recommend timely nephrology referral, nutritional consultation, fistula placement for dialysis access, and control of anemia, acidosis, and mineral and bone metabolism parameters (3). Evidence from prevalent dialysis patients (4) and from dialysis patients who survived on dialysis for at least 4 to 6 months (5,6) suggests that greater adherence to the KDOQI guidelines is associated with improved patient outcomes. Survival bias in these studies limits their generalizability to patients receiving renal replacement therapy who have survived beyond the initiation period. Whether guideline adherence at the time of dialysis initiation is associated with improved outcomes, particularly during the first year on dialysis, has not been examined.We aimed to determine, in a large nationally representative cohort of incident hemodialysis patients, whether meeting a greater number of KDOQI guideline goals, specifically goals related to vascular access, anemia management, and serum albumin, at dialysis initiation is independently associated, in a graded manner, with survival during the first dialysis year.     

Preemptive kidney transplantation in patients with diabetes mellitus.

Kidney transplantation is the most preferred treatment for end-stage renal disease because it improves not only the patient's survival compared with dialysis, but also the quality of life. Preemptive transplantation is transplantation performed prior to the initiation of renal dialysis. Recent observational studies have shown increased patient and graft survival with preemptive transplantation, compared to patients receiving transplantation after the initiation of dialysis. Preemptive simultaneous pancreas and kidney transplantation in type 1 diabetic recipients has also been shown to improve patient survival. These results indicate the importance of early referral of patients who have chronic kidney disease to nephrologists and transplant centers.     

How to manage elderly patients with chronic renal failure: conservative management versus dialysis

Over the past decade the number of elderly patients reaching end-stage renal disease has more than doubled. A fundamental medical decision that nephrologists commonly have to make is when to start dialytic treatment in elderly patients. Evidence is needed to inform about decision-making for or against dialysis, in particular in those patients frequently affected by multiple comorbidities for which dialysis may not increase survival. In fact, this decision affects quality of life, incurs significant financial costs, and finally mandates use of precious dialysis resources. The negative consequence of initiating dialysis in this group of patients can be deleterious as elderly people are sensitive to lifestyle changes. Furthermore, among dialysis patients, the elderly suffer the highest overall hospitalization and complication rates and most truncated life expectancy on dialysis of any age group. Studies of the factors that affect outcomes in elderly patients on dialysis, or the possibility in postponing in a safe way the start of a dialytic treatment, were lacking until recent years. Recently in the literature, papers have been published that address these questions: the effects of dialysis on morbidity and mortality in elderly patients and the use of a supplemented very low protein diet (sVLPD) in postponing the start of dialysis in elderly. The first study demonstrated that, although dialysis is generally associated with longer survival in patients aged >75 years, those with multiple comorbidities, ischemic heart disease in particular, do not survive longer than those treated conservatively. The second one is a randomized controlled study that compared a sVLPD with dialysis in 112 non-diabetic patients aged >70 years. Survival was not different between the two groups and the number of hospitalizations and days spent in hospital were significantly lower in those on a sVLPD. These studies add to the limited evidence that is currently available to inform elderly patients, their carers and their physicians about the risk and the benefit of dialysis.     

p21 is decreased in polycystic kidney disease and leads to increased epithelial cell cycle progression: roscovitine augments p21 levels

Background

This study used a cross sectional survey to examine the effect of gender, age, and geographical location on the population prevalence of renal replacement therapy (RRT) provision in Wales.

Methods

Physicians in renal centres in Wales and in adjacent areas of England were asked to undertake a census of patients on renal replacement therapy on 30 June 2004 using an agreed protocol. Data were collated and analysed in anonymous form.

Results

2434 patients were on RRT in Wales at the census date. Median age of patients on RRT was 56 years, peritoneal dialysis 58 years, haemodialysis 66 years and transplantation 50 years. The three treatment modalities had significantly different age-specific peak prevalence rates and distributions. RRT age-specific prevalence rates peaked at around 70 years (1790 pmp), transplantation at around 60 years (924 pmp), haemodialysis at around 80 years (1080 pmp) and peritoneal dialysis did not have a clear peak prevalence rate. Age-specific incidence of RRT peaked at a rate of 488 pmp at 79 years, as did incidence rates for haemodialysis, which peaked at the same age. Age had less effect on the initiation of peritoneal dialysis, which had a broad plateau between the early fifties and late seventies. Kidney transplantation rates were highest in the early fifties but were markedly absent in old age.

Conclusion

Differences in the provision of RRT are evident, particularly in the very elderly, where the gender difference for haemodialysis is particularly marked. The study illustrates that grouping patients over 75 years into a single age-band may mask significant diversity within this age group. Significant numbers of very elderly patients who are currently not receiving RRT may wish to receive RRT as the elderly population increases, and as technology improves survival and quality of life on RRT. The study suggests that if technologies that are more effective were developed, and which had a lower impact on quality of life, there might be up to a 17% increase in demand for RRT in those aged over 75 years; around 90% of this increased demand would be for haemodialysis.     

Late Dialysis Start Did Not Affect Long‐Term Outcome in Japanese Dialysis Patients: Long‐Term Prognosis From Japanese Society of Dialysis Therapy Registry

Early initiation of dialysis had been considered one of the most important methods for better prognosis of dialysis patients. One of the reasons for this was that long‐term as well as short‐term prognosis was poor with late initiation of dialysis. In this study, we analyzed the effects of residual renal function and comorbidity on both short‐ and long‐term outcomes of ESRD patients. The subjects of this study were 20 854 patients who started renal replacement therapy (RRT) in 1989 and 1990, when we conducted national surveillance for new ESRD patients. The effects of glomerular filtration rate (GFR) at dialysis start and comorbidity conditions on survival were measured. Mortality hazard ratio (HR) was calculated using a Cox proportional hazard model. Multivariate analysis included pre‐dialysis estimated GFR, age, sex, and underlying renal disease. The mean age of the subjects was 57.7 years old. Mean GFR at dialysis initiation was 5.00 mL/min per 1.73 m² and GFR was significantly higher in patients with diabetes. The median survival time from the start of dialysis was 69 months, excluding subjects who died within 3 months; 1‐year survival was 89.7%, while 2‐year, 3‐year, 5‐year, 10‐year, and 15‐year cumulative survival rates were 79.3%, 71.1%, 57.8%, 37.3%, and 26.1%, respectively. For mortality risks, the higher the GFR at dialysis initiation, the worse the HR for mortality in both short‐term and long‐term prognoses by unadjusted analysis. However, after adjustments for age, gender, underlying renal diagnosis, and symptom at dialysis initiation, both late and early initiation of RRT did not affect long‐term prognosis.     

Timing of dialysis initiation in transplant-naive and failed transplant patients

Over the past two decades, most guidelines have advocated early initiation of dialysis on the basis of studies showing improved survival in patients starting dialysis early. These recommendations led to an increase in the proportion of patients initiating dialysis with an estimated glomerular filtration rate (eGFR) >10 ml/min/1.73 m(2), from 20% in 1996 to 52% in 2008. During this period, the percentage of patients starting dialysis with an eGFR ≥15 ml/min/1.73 m(2) increased from 4% to 17%. However, recent studies have failed to substantiate a benefit of early dialysis initiation and some data have suggested worse outcomes for patients starting dialysis with a higher eGFR. Several reasons for this seemingly paradoxical observation have been suggested, including the fact that patients requiring early dialysis are likely to have more severe symptoms and comorbidities, leading to confounding by indication, as well as biological mechanisms that causally relate early dialysis therapy to adverse outcomes. Patients with a failing renal allograft who reinitiate dialysis encounter similar problems. However, unique factors associated with a failed allograft means that the optimal timing of dialysis initiation in failed transplant patients might differ from that in transplant-naive patients with chronic kidney disease. In this Review, we discuss studies of dialysis initiation and compare risks and benefits of early versus late initiation and reinitiation of dialysis therapy.     

Glomerular Filtration Rate and Initiation of Dialysis

The proportion of patients with advanced chronic kidney disease (CKD) initiating dialysis at higher glomerular filtration rate (GFR) has increased over the past decade. Recent data suggest that it may be associated with increased mortality. The goal of this analysis was to compare survival outcomes in patients with early and late start dialysis. We performed a retrospective analysis of hemodialysis (HD) incident patients from 1 January 2010 to 30 September 2014. Patients were classified into two groups by estimated GFR at dialysis initiation (eGFR ≥10: early start and <10 mL/min per 1.73m²: late start). Logistic regression was used to evaluate factors associated with early and late dialysis start, and Kaplan–Meier graphs and Cox regression models in survival analysis. In this total incident population (N = 235), 42 patients had an early dialysis start. Compared with the group with an eGFR of <10 mL/min per 1.73 m² at dialysis start, a Cox model showed an incremental increase in mortality associated with earlier dialysis start (P = 0.027). Independent factors (P < 0.05) associated with mortality in the multivariable Cox model in early dialysis start were: hypertension (HR 9.32, CI: 1.34–17.87), diabetes (HR 1.8, CI: 0.4–13.2) and albumin <3.5 g/dL (HR 1.5, CI: 0.8–6.2). Older patients (HR 0.084, CI: 0.008–0.863) with low phosphorus levels (HR 0.02, CI: 0.0–0.527) also had statistically significant results, although they showed a reduced risk of mortality. Early dialysis initiation was associated with an increased mortality risk, arguing against aggressive early dialysis initiation based primarily on eGFR alone.     

���긹Ĥ͸������������

??Abstract??The elderly CKD patients constitute the fast-growing population reaching end-stage renal disease (ESRD) and commencing dialysis therapy.Peritoneal dialysis (PD) has many advantages on elderly patients such as home-based therapy??relatively stable hemodynamics??etc.However??elderly patients have multiple complicated disorders and are more susceptible to malnutrition??which are very important prognostic factors for survival of patients.A high burden of physical and cognitive impairment in elderly patients may increase the risk of peritonitis and technique failure.Intensive care should be taken to cope with the comorbidities and malnutrition in the elderly.Offering assisted peritoneal dialysis to unstable or frail elderly ESRD patients will help to perform the procedure at home and improve the technique survival.All these strategies for the care of elderly PD patients will result in better survival and quality of life.     

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).     

Epidemiology and management of end-stage renal disease in the elderly

Elderly patients with end-stage renal disease (ESRD) are at increased risk of developing aging-related problems, such as frailty, impaired physical function, falls, poor nutrition and cognitive impairment. These factors affect dialysis outcomes, which can be very poor in frail, elderly patients who often experience a decline in overall health and physical function and have short survival. The default treatment option for these patients is hospital-based hemodialysis, often with little consideration of how this modality will affect the survival or quality of life of individual patients. A comparison of quality of life of elderly patients on hemodialysis versus peritoneal dialysis shows that those on peritoneal dialysis have less illness intrusion. Assisted peritoneal dialysis enables a greater number of frail, elderly patients to have dialysis in their own homes. Dialysis may not extend survival for those with multiple comorbidities, so conservative care (nondialysis treatment) should be considered. To improve the outcomes of elderly patients with ESRD, it is necessary to develop a realistic approach to overall prognosis, quality of life and how the patient copes with the disabilities associated with aging. This approach includes having discussions regarding choice of treatment and end-of-life goals with patients and families.     

Rehabilitation of the elderly patient on dialysis

Rehabilitation for geriatric patients, as well as rehabilitation for patients with a chronic disease, strives to mobilize individuals' residual capacity for optimal function in their usual environment. It is clear from observational studies that chronic dialysis patients often experience marked limitations in physical functioning, and these limitations tend to increase with patients' age. However, both prospective studies and controlled trials conducted with elderly persons demonstrate that muscle strengthening and cardiovascular exercise are related to improved physical functioning, and there is evidence that dialysis patients can also benefit from many of these interventions. Inpatient rehabilitation in a specialized geriatric unit has been shown to be associated with better functional outcomes and decreased need for institutionalization among elderly persons; the process of comprehensive geriatric assessment may also have beneficial outcomes. More controlled studies are needed in order to better specify the effectiveness of various geriatric interventions, for elderly subjects in general and for elderly dialysis patients specifically.     

Dialysis versus Nondialysis in Patients with AKI: A Propensity-Matched Cohort Study

Background and objectives

The benefit of the initiation of dialysis for AKI may differ depending on patient factors, but, because of a lack of robust evidence, the decision to initiate dialysis for AKI remains subjective in many cases. Prior studies examining dialysis initiation for AKI have examined outcomes of dialyzed patients compared with other dialyzed patients with different characteristics. Without an adequate nondialyzed control group, these studies cannot provide information on the benefit of dialysis initiation. To determine which patients would benefit from initiation of dialysis for AKI, a propensity-matched cohort study was performed among a large population of patients with severe AKI.

Design, setting, participants, & measurements

Adults admitted to one of three acute care hospitals within the University of Pennsylvania Health System from January 1, 2004, to August 31, 2010, who subsequently developed severe AKI were included (n=6119). Of these, 602 received dialysis. Demographic, clinical, and laboratory variables were used to generate a time-varying propensity score representing the daily probability of initiation of dialysis for AKI. Not-yet-dialyzed patients were matched to each dialyzed patient according to day of AKI and propensity score. Proportional hazards analysis was used to compare time to all-cause mortality among dialyzed versus nondialyzed patients across a spectrum of prespecified variables.

Results

After propensity score matching, covariates were well balanced between the groups, and the overall hazard ratio for death in dialyzed versus nondialyzed patients was 1.01 (95% confidence interval, 0.85 to 1.21; P=0.89). Serum creatinine concentration modified the association between dialysis and survival, with a 20% (95% confidence interval, 9% to 30%) greater survival benefit from dialysis for each 1-mg/dl increase in serum creatinine concentration (P=0.001). This finding persisted after adjustment for markers of disease severity. Dialysis initiation was associated with more benefit than harm at a creatinine concentration≥3.8 mg/dl.

Conclusions

Dialysis was associated with increased survival when initiated in patients with AKI who have a more elevated creatinine level but was associated with increased mortality when initiated in patients with lower creatinine concentrations.     

The 2006 K/DOQI guidelines for peritoneal dialysis adequacy are not adequate

The 2006 National Kidney Foundation K/DOQI guidelines have lowered the peritoneal dialysis adequacy standard of Kt/V(urea) from 2.1 to 1.7 in anuric patients, largely based on the patient survival results of 2 clinical trials in Mexico and Hong Kong. It is our contention that the guidelines may be misleading since they have chosen to ignore the bias in these trials and have ignored the adverse outcomes in control groups in the trials on which the guidelines are based, as well as the body size of the subjects in these trials. Body size has changed in the US and Canada over the last few decades and there are similar changes worldwide. We suggest that the minimum targets for peritoneal dialysis be reinstituted at the previous standard Kt/V(urea) of 2.0.     

Kidney Transplantation as Primary Therapy for End-Stage Renal Disease: A National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQI?) Conference

Background and objectives: Kidney transplantation is the most desired and cost-effective modality of renal replacement therapy for patients with irreversible chronic kidney failure (end-stage renal disease, stage 5 chronic kidney disease). Despite emerging evidence that the best outcomes accrue to patients who receive a transplant early in the course of renal replacement therapy, only 2.5% of incident patients with end-stage renal disease undergo transplantation as their initial modality of treatment, a figure largely unchanged for at least a decade.Design, setting, participants, & measurements: The National Kidney Foundation convened a Kidney Disease Outcomes Quality Initiative (KDOQI) conference in Washington, DC, March 19 through 20, 2007, to examine the issue. Fifty-two participants representing transplant centers, dialysis providers, and payers were divided into three work groups to address the impact of early transplantation on the chronic kidney disease paradigm, educational needs of patients and professionals, and finances of renal replacement therapy.Results: Participants explored the benefits of early transplantation on costs and outcomes, identified current barriers (at multiple levels) that impede access to early transplantation, and recommended specific interventions to overcome those barriers.Conclusions: With implementation of early education, referral to a transplant center coincident with creation of vascular access, timely transplant evaluation, and identification of potential living donors, early transplantation can be an option for substantially more patients with chronic kidney disease.Transplantation was the first successful modality of renal replacement therapy (RRT) for irreversible chronic kidney disease (CKD; stage 5); however, its broad applicability has been limited by immunologic rejection, adverse effects of immunosuppressant agents, and a relative shortage of available organs. After implementation of Medicare funding for RRT in 1972, long-term dialysis rapidly evolved as first-line treatment. In 1978, Rennie (1) summarized the prevailing situation: “Even although it offers a much better quality of life while it works, a transplant in most cases (of kidney failure) can be considered only a temporary respite from the basic form of treatment, which is dialysis.” Despite many remarkable advances during the past three decades, with transplantation now viewed unequivocally as offering the best survival and quality of life for candidates across all demographic groups, current practice remains that described by Rennie (2). Notwithstanding strong evidence that transplantation is most successful when implemented before onset of long-term dialysis, only 2.5% of patients with end-stage renal disease undergo transplantation as initial RRT (3–5).This persistent finding has been subject to numerous explanations, often subjective and speculative, and thus far not amenable to remedy. In response to this conundrum, the National Kidney Foundation (NKF) convened a conference to address the issue of early transplantation within its Kidney Disease Outcomes Quality Initiative (KDOQI) framework, held in Washington, DC, March 19 through 20, 2007. Fifty-two participants representing transplant centers, dialysis providers, and payers were divided into three working groups. The first (work group 1) addressed the issue of how optimally to position kidney transplantation within the current CKD staging and treatment paradigms (6). Work group 2’s task was to formulate recommendations regarding educational and training implications required to promote early transplantation. Finally, given the critical importance of fiscal issues in RRT, work group 3 evaluated how finances might impede access to transplantation for patients with CKD and was charged with formulating potential remedies. This article is a summary of the deliberations, findings, and recommendations of these three work groups.The first challenge for the conference was to determine the focus of deliberations: Was preemptive (before the onset of dialysis) or early (performed within the first 6 to 12 mo after initiation of dialysis) transplantation to be the primary concern? It was noted that both terms (preemptive and early) are adjectives that refer to the timing of transplantation and impart urgency to the process. Current data indicate recipient and allograft survival benefits for patients who receive a transplant within the first year of RRT; with each additional year of dialysis therapy, survival is compromised (7). Whether there are additional advantages associated with true preemptive transplantation, after correction for multiple interrelated risk factors, is less certain (8,9). Even so, it seems that patients and payers benefit from preemptive transplantation by avoiding medical complications and costs associated with initiation of dialysis, vascular access, and loss of employment; therefore, the participants chose to emphasize preemptive transplantation as the ideal, with the understanding that the unpredictability of advanced CKD and the shortage of organs from deceased donors necessitates that the next best option for many candidates will be transplantation as early in the course of RRT as possible.     

The Incidence and Pathophysiology of the Obesity Paradox: Should Peritoneal Dialysis and Kidney Transplant Be Offered to Patients with Obesity and End-Stage Renal Disease?

Purpose of Review

To educate nephrologists and primary-care physicians about the incidence, pathophysiology, and survival benefits of the obesity paradox in end-stage renal disease (ESRD). This review also discusses the future of kidney transplant and peritoneal dialysis in obese dialysis patients.

Recent Findings

Obesity paradox in ESRD was first reported three decades ago, and since then, there have been several epidemiological studies that confirmed the phenomenon. Regardless of the anthropometric indices used to define obesity in ESRD patients, these markers serve to predict the dialysis patient’s survival. The pathophysiology of obesity paradox tends to be multifactorial. Recent cohort studies demonstrated a survival benefit in all race and ethnic groups, but Hispanics and blacks experienced increased survival rates when compared to non-Hispanic whites. Obese dialysis patients should be offered peritoneal dialysis, especially if they are new to dialysis and have an adequate renal residual function. Several studies have shown that the benefit of receiving kidney transplant in obese patients exceeds the risks. The robotic-assisted kidney transplant (RAKT) procedure is the latest innovation that could offer hope for obese dialysis patients who have been denied or are waiting for kidney transplant.

Summary

The obesity paradox phenomenon in ESRD is a unique illustration of survival benefit in a population that has a high overall annual mortality. Peritoneal dialysis should be encouraged for obese patients who have preserved residual renal function. Kidney transplant centers should encourage RAKT utilization in obese dialysis patients instead of denying them a kidney transplant.

     

An overview of regular dialysis treatment in Japan (as of 31 December 2001)

Questionnaire forms for an annual survey conducted at the end of 2001 were sent out to 3520 institutions, and 3485 replies were received (response rate, 99.00%). According to the survey, the dialysis population of Japan at year end was 219 183 patients, up 6.3% (13 049) over the year before. This equals 1721.9 dialysis patients per million population. The gross mortality rate was 9.3% for the year extending from the end of 2000 to the end of 2001. The mean age of patients beginning dialysis was 64.2 years (+/- 13.7 SD). The mean age of the overall dialysis population in the study year was 61.6 years (+/- 13.1 SD), which was also a higher age than the year before. Among dialysis patients, the primary disease was diabetic nephropathy in 38.1% of patients, slightly down from 39.1% the previous year. Chronic glomerulonephritis was the primary disease in 32.4% of cases, a decrease from 34.7% the previous year. This survey included for the first time the items of the lowest blood pressure during hemodialysis session, vasopressor therapy before dialysis and vasopressor therapy during dialysis session. An analysis of the relationship between the type of vascular access used at the initiation of dialysis and the survival prognosis revealed a significantly higher risk of death in patients undergoing dialysis with synthetic arterio-venous (AV) fistula, AV shunt, or catheter implantation into a central vein than in those receiving dialysis treatments with a native fistula. There was a significantly lower risk of death in the patient group in whom the vascular access was created at 3-6 months before initiation of dialysis than in those in whom such access was created at the time of initiation or within 3 months before the initiation of dialysis. An analysis of the risk factors affecting survival prognosis in maintenance hemodialysis patients showed that risk factors for death are post-dialysis systolic blood pressure over 180 mm Hg and lower than 120 mm Hg, blood pressure elevating progressively from the start to the end of dialysis, serum high density lipoprotein cholesterol concentration of less than 30 mg/dL, and a higher ultrafiltration rate. In comparisons of the death risk between the patient group with a history of intervention for ischemic heart disease and the patient group with a history of myocardial infarction or heart failure but without such intervention, among diabetes patients, those who underwent percutaneous transluminal coronary angioplasty had a significantly lower risk of death than those in whom no intervention was made.     

An integrated review of "unplanned" dialysis initiation: reframing the terminology to "suboptimal" initiation

Background

Ideally, care prior to the initiation of dialysis should increase the likelihood that patients start electively outside of the hospital setting with a mature arteriovenous fistula (AVF) or peritoneal dialysis (PD) catheter. However, unplanned dialysis continues to occur in patients both known and unknown to nephrology services, and in both late and early referrals. The objective of this article is to review the clinical and socioeconomic outcomes of unplanned dialysis initiation. The secondary objective is to explore the potential cost implications of reducing the rate of unplanned first dialysis in Canada.

Methods

MEDLINE and EMBASE from inception to 2008 were used to identify studies examining the clinical, economic or quality of life (QoL) outcomes in patients with an unplanned versus planned first dialysis. Data were described in a qualitative manner.

Results

Eight European studies (5,805 patients) were reviewed. Duration of hospitalization and mortality was higher for the unplanned versus planned population. Patients undergoing a first unplanned dialysis had significantly worse laboratory parameters and QoL. Rates of unplanned dialysis ranged from 24-49%. The total annual burden to the Canadian healthcare system of unplanned dialysis in 2005 was estimated at $33 million in direct hospital costs alone. Reducing the rate of unplanned dialysis by one-half yielded savings ranging from $13.3 to $16.1 million.

Conclusion

The clinical and socioeconomic impact of unplanned dialysis is significant. To more consistently characterize the unplanned population, the term suboptimal initiation is proposed to include dialysis initiation in hospital and/or with a central venous catheter and/or with a patient not starting on their chronic modality of choice. Further research and implementation of initiatives to reduce the rate of suboptimal initiation of dialysis in Canada are needed.     

Dialyse und ethische Probleme beim sehr alten Patienten

Background

Over the course of one decade the prevalence of elderly patients on dialysis therapy has doubled. Currently the age group over 75 years old shows the highest incidence in patients starting dialysis treatment. This paper focuses on the treatment and ethical issues resulting from the different treatment options for elderly patients with chronic kidney disease (CKD).

Methods

A selective literature search was carried out with reference to the elderly, CKD, dialysis, palliative care and ethics.

Results

Both conservative and active forms of treatment are options for elderly CKD patients. Selection of treatment is based on the extent of coincidental comorbidities in this group. Treatment should focus on the quality of life rather than prolongation of life. In the highest comorbidity group the life expectancy is similar for conservative and active (dialysis) treatment. Palliative treatment should be part of the end of life care for the elderly with CKD. The ethical issues of this aspect will be discussed.

Conclusion

Care for the elderly CKD population must focus on the quality of life rather than extending life by treatment. Indications for starting dialysis are strongly dependent on comorbidities which define survival in this patient group. Both conservative and active forms of treatment must include the conception of palliative care. To integrate this concept into daily nephrological treatment is strongly recommended.