Progression of coronary artery calcification in conventional hemodialysis, nocturnal hemodialysis, and kidney transplantation

Introduction Cardiovascular disease is the leading cause of death in end-stage renal disease (ESRD) and is strongly associated with vascular calcification. An important driver of vascular calcification is high phosphate levels, but these become lower when patients initiate nocturnal hemodialysis or receive a kidney transplant. However, it is unknown whether nocturnal hemodialysis or kidney transplantation mitigate vascular calcification. Therefore, we compared progression of coronary artery calcification (CAC) between patients treated with conventional hemodialysis, nocturnal hemodialysis, and kidney transplant recipients. Methods We measured CAC annually up to 3 years in 114 patients with ESRD that were transplantation candidates: 32 that continued conventional hemodialysis, 34 that initiated nocturnal hemodialysis (>= 4x 8 hours/week), and 48 that received a kidney transplant. We compared CAC progression between groups as the difference in square root transformed volume scores per year (Delta CAC SQRV) using linear mixed models. Reference category was conventional hemodialysis. Results The mean age of the study population was 53 +/- 13 years, 75 (66%) were male, and median dialysis duration was 28 (IQR 12-56) months. Median CAC score at enrollment was 171 (IQR 10-647), which did not differ significantly between treatment groups (P = 0.83). Compared to conventional hemodialysis, CAC progression was non-significantly different in nocturnal hemodialysis -0.10 (95% CI -0.77 to 0.57) and kidney transplantation -0.33 (95% CI -0.96 to 0.29) in adjusted models. Conclusions Nocturnal hemodialysis and kidney transplantation are not associated with significantly less CAC progression compared to conventional hemodialysis during up to 3 years follow-up. Further studies are needed to confirm these findings, to determine which type of calcification is measured with CAC in end-stage renal disease, and whether that reflects cardiovascular risk

Impact of Polypharmacy on Health-Related Quality of Life in Dialysis Patients

INTRODUCTION: Dialysis patients are often prescribed a large number of medications to improve metabolic control and manage coexisting comorbidities. However, some studies suggest that a large number of medications could also detrimentally affect patients' health-related quality of life (HRQoL). Therefore, this study aims to provide insight in the association between the number of types of medications and HRQoL in dialysis patients. METHODS: A multicentre cohort study was conducted among dialysis patients from Dutch dialysis centres 3 months after initiation of dialysis as part of the ongoing prospective DOMESTICO study. The number of types of medications, defined as the number of concomitantly prescribed types of drugs, was obtained from electronic patient records. Primary outcome was HRQoL measured with the Physical Component Summary (PCS) score and Mental Component Summary (MCS) score (range 0–100) of the Short Form 12. Secondary outcomes were number of symptoms (range 0–30) measured with the Dialysis Symptoms Index and self-rated health (range 0–100) measured with the EuroQol-5D-5L. Data were analysed using linear regression and adjusted for possible confounders, including comorbidity. Analyses for MCS and number of symptoms were performed after categorizing patients in tertiles according to their number of medications because assumptions of linearity were violated for these outcomes. RESULTS: A total of 162 patients were included. Mean age of patients was 58 ± 17 years, 35% were female, and 80% underwent haemodialysis. The mean number of medications was 12.2 ± 4.5. Mean PCS and MCS were 36.6 ± 10.2 and 46.8 ± 10.0, respectively. The mean number of symptoms was 12.3 ± 6.9 and the mean self-rated health 60.1 ± 20.6. In adjusted analyses, PCS was 0.6 point lower for each additional medication (95% confidence interval [95% CI]: −0.9 to −0.2; p = 0.002). MCS was 4.9 point lower (95% CI: −8.8 to −1.0; p = 0.01) and 1.0 point lower (95% CI: −5.1–3.1; p = 0.63) for the highest and middle tertiles of medications, respectively, than for the lowest tertile. Patients in the highest tertile of medications reported 4.1 more symptoms than in the lowest tertile (95% CI: 1.5–6.6; p = 0.002), but no significant difference in the number of symptoms was observed between the middle and lowest tertiles. Self-rated health was 1.5 point lower for each medication (95% CI: −2.2 to −0.7; p < 0.001). DISCUSSION/CONCLUSION: After adjustment for comorbidity and other confounders, a higher number of medications were associated with a lower PCS, MCS, and self-rated health in dialysis patients and with more symptoms

Trends in home dialysis use differ among age categories in past two decades: A Dutch registry study

Background: Although the number of patients with end-stage kidney disease is growing, the number of patients who perform dialysis at home has decreased during the past two decades. The aim of this study was to explore time trends in the use of home dialysis in the Netherlands. Methods: Dialysis episodes of patients who started dialysis treatment were studied using Dutch registry data (RENINE). The uptake of home dialysis between 1997 through 2016 was evaluated in time periods of 5 years. Home dialysis was defined as start with peritoneal dialysis or home haemodialysis, or transfer to either within 2 years of dialysis initiation. All analyses were stratified for age categories. Mixed model logistic regression analysis was used to adjust for clustering at patient level. Results: A total of 33 340 dialysis episodes in 31 569 patients were evaluated. Mean age at dialysis initiation increased from 62.5 ± 14.0 to 65.5 ± 14.5 years in in-centre haemodialysis patients, whereas it increased from 51.9 ± 15.1 to 62.5 ± 14.6 years in home dialysis patients. In patients <65 years, the uptake of home dialysis was significantly lower during each 5-year period compared with the previous period, whereas kidney transplantation occurred more often. In patients ≥65 years, the incidence of home dialysis remained constant, whereas mortality decreased. Conclusions: In patients <65 years, the overall use of home dialysis declined consistently over the past 20 years. The age of home dialysis patients increased more rapidly than that of in-centre dialysis patients. These developments have a significant impact on the organization of home dialysis

Polypharmacy and Quality of Life Among Dialysis Patients: A Qualitative Study

RATIONALE & OBJECTIVE: Almost all patients who receive dialysis experience polypharmacy, but little is known about their experiences with medication or perceptions toward it. In this qualitative study, we aimed to gain insight into dialysis patients' experiences with polypharmacy, the ways they integrate their medication into their daily lives, and the ways it affects their quality of life. STUDY DESIGN: Qualitative study using semistructured interviews. SETTING & PARTICIPANTS: Patients who received dialysis from 2 Dutch university hospitals. ANALYTICAL APPROACH: Interviews were transcribed verbatim and analyzed independently by 2 researchers through thematic content analysis. RESULTS: Overall, 28 individuals were interviewed (29% women, mean age 63 ± 16 years, median dialysis vintage 25.5 [interquartile range, 15-48] months, mean daily number of medications 10 ± 3). Important themes were as follows: (1) their own definition of what constitutes "medication," (2) their perception of medication, (3) medication routines and their impact on daily (quality of) life, and (4) interactions with health care professionals and others regarding medication. Participants generally perceived medication as burdensome but less so than dialysis. Medication was accepted as an essential precondition for their health, although participants did not always notice these health benefits directly. Medication routines and other coping mechanisms helped participants reduce the perceived negative effects of medication. In fact, medication increased freedom for some participants. Participants generally had constructive relationships with their physicians when discussing their medication. LIMITATIONS: Results are context dependent and might therefore not apply directly to other contexts. CONCLUSIONS: Polypharmacy negatively affected dialysis patients' quality of life, but these effects were overshadowed by the burden of dialysis. The patients' realization that medication is important to their health and effective coping strategies mitigated the negative impact of polypharmacy on their quality of life. Physicians and patients should work together continuously to evaluate the impact of treatments on health and other aspects of patients' daily lives. PLAIN-LANGUAGE SUMMARY: People receiving dialysis treatment are prescribed a large number of medications (polypharmacy). Polypharmacy is associated with a number of issues, including a lower health-related quality of life. In this study we interviewed patients who received dialysis treatment to understand how they experience polypharmacy in the context of their daily lives. Participants generally perceived medication as burdensome but less so than dialysis and accepted medication as an essential precondition for their health. Medication routines and other coping mechanisms helped participants mitigate the perceived negative effects of medication. In fact, medication led to increased freedom for some participants. Participants had generally constructive relationships with their physicians when discussing their medication but felt that physicians sometimes do not understand them

Health-related quality of life and symptom burden in patients on haemodialysis

BACKGROUND: Patients on haemodialysis generally experience poor health-related quality of life (HRQoL) and a broad range of physical and mental symptoms, but it is unknown whether this differs between younger and older patients. We aimed to describe the trajectories of HRQoL and symptom burden of patients &lt; 70 and ≥ 70 years old, and to assess the impact of symptom burden on HRQoL.METHODS: In incident Dutch haemodialysis patients, HRQoL and symptoms were measured with the 12-item Short Form Health Survey and Dialysis Symptom Index. We used linear mixed models for examining the trajectories of HRQoL and symptom burden during the first year of dialysis, and linear regression for the impact of symptom burden on HRQoL.RESULTS: In 774 patients, the trajectories of physical HRQoL, mental HRQoL, and symptom burden were stable during the first year of dialysis. Compared with patients aged &lt; 70 years, patients ≥ 70 years reported similar physical HRQoL (mean difference -0.61, 95% CI -1.86; 0.63), better mental HRQoL (1.77, 95% CI 0.54; 3.01), and lower symptom burden (-2.38, 95% CI -5.08; 0.32). With increasing symptom burden, physical HRQoL declined more in older than in younger patients (β -0.287 versus -0.189, respectively, p-value for interaction = 0.007). For mental HRQoL, this decrease was similar in both age groups (β -0.295 versus -0.288, P = 0.847).CONCLUSIONS: Older haemodialysis patients generally experience a better mental HRQoL and a (non-statistically significant) lower symptom burden, compared to younger patients. Their physical HRQoL declines more rapidly with increasing symptom burden.</p

The Impact of COVID-19 on the mental health of dialysis patients

Background: Studies have shown increased anxiety, depression, and stress levels among different populations during the coronavirus disease 2019 (COVID-19) pandemic. However, the impact of the pandemic on the mental health of dialysis patients remains unknown. The aim of this study was to investigate the mental health of dialysis patients during the COVID-19 pandemic compared to the period preceding the pandemic. Methods: Data originate from the ongoing multicentre observational Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes (DOMESTICO). Patients who filled in a health-related quality of life (HRQoL) questionnaire during the pandemic and six to three months prior were included. The mean difference in Mental Component Summary (MCS) score of the Short Form 12 (SF-12) was analysed with multilevel linear regression. A McNemar test was used to compare presence of mental health-related symptoms during and prior to the COVID-19 pandemic. Results: A total of 177 patients were included. The mean MCS score prior to COVID-19 was 48.08 ± 10.15, and 49.00 ± 10.04 during the COVID-19 pandemic. The adjusted mean MCS score was 0.93 point (95% CI − 0.57 to 2.42) higher during the COVID-19 pandemic than during the period prior to the pandemic. Furthermore, no difference in the presence of the following mental health-related symptoms was found during the COVID-19 pandemic: feeling anxious, feeling sad, worrying, feeling nervous, trouble falling asleep, and trouble staying asleep. Conclusions: The mental health of dialysis patients appears to be unaffected by the COVID-19 pandemic. Dialysis patients may be better able to cope with the pandemic, since they have high resilience and are less impacted by social distancing measures. Trial registration number: Netherlands Trial Register NL6519, date of registration: 22 August 2017. Graphic abstract: [Figure not available: see fulltext.

Value of patient decision aids for shared decision-making in kidney failure

Background: It is unknown how often Dutch patient decision aids are used during kidney failure treatment modality education and what their impact is on shared decision-making. Objectives: We determined the use of Three Good Questions, ‘Overviews of options’, and Dutch Kidney Guide by kidney healthcare professionals. Also, we determined patient-experienced shared decision-making. Finally, we determined whether the experience of shared decision-making among patients changed after a training workshop for healthcare professionals. Design: Quality improvement study. Participants: Healthcare professionals answered questionnaires regarding education/patient decision aids. Patients with estimated glomerular filtration rate <20 mL/min/1.73 m2 completed shared decision-making questionnaires. Data were analysed with one-way analysis of variance and linear regression. Results: Of 117 healthcare professionals, 56% applied shared decision-making by discussing Three Good Questions (28%), ‘Overviews of options’ (31%–33%) and Kidney Guide (51%). Of 182 patients, 61%–85% was satisfied with their education. Of worst scoring hospitals regarding shared decision-making, only 50% used ‘Overviews of options’/Kidney Guide. Of best scoring hospitals 100% used them, needed less conversations (p = 0.05), provided information about all treatment options and more often provided information at home. After the workshop, patients' shared decision-making scores remained unchanged. Conclusions: The use of specifically developed patient decision aids during kidney failure treatment modality education is limited. Hospitals that did use them had higher shared decision-making scores. However, the degree of shared decision-making experienced by patients remained unchanged after healthcare professionals were trained on shared decision-making and the implementation of patient decision aids

Coronary Artery Calcification in Hemodialysis and Peritoneal Dialysis

Background: Vascular calcification is seen in most patients on dialysis and is strongly associated with cardiovascular mortality. Vascular calcification is promoted by phosphate, which generally reaches higher levels in hemodialysis than in peritoneal dialysis. However, whether vascular calcification develops less in peritoneal dialysis than in hemodialysis is currently unknown. Therefore, we compared coronary artery calcification (CAC), its progression, and calcification biomarkers between patients on hemodialysis and peritoneal dialysis. Methods: We measured CAC in 134 patients who had been treated exclusively with hemodialysis (n = 94) or peritoneal dialysis (n = 40) and were transplantation candidates. In 57 of them (34 on hemodialysis and 23 on peritoneal dialysis), we also measured CAC progression annually up to 3 years and the inactive species of desphospho-uncarboxylated matrix Gla protein (dp-ucMGP), fetuin-A, osteoprotegerin. We compared CAC cross-sectionally with Tobit regression. CAC progression was compared in 2 ways: with linear mixed models as the difference in square root transformed volume score per year (CAC SQRV) and with Tobit mixed models. We adjusted for potential confounders. Results: In the cross-sectional cohort, CAC volume scores were 92 mm(3) in hemodialysis and 492 mm(3) in peritoneal dialysis (adjusted difference 436 mm(3); 95% CI -47 to 919; p = 0.08). In the longitudinal cohort, peritoneal dialysis was associated with significantly more CAC progression defined as CAC SQRV (adjusted difference 1.20; 95% CI 0.09 to 2.31; p = 0.03), but not with Tobit mixed models (adjusted difference in CAC score increase per year 106 mm(3); 95% CI -140 to 352; p = 0.40). Peritoneal dialysis was associated with higher osteoprotegerin (adjusted p = 0.02) but not with dp-ucMGP or fetuin-A. Conclusions: Peritoneal dialysis is not associated with less CAC or CAC progression than hemodialysis, and perhaps with even more progression. This indicates that vascular calcification does not develop less in peritoneal dialysis than in hemodialysis

Survival of patients treated with extended-hours haemodialysis in Europe : an analysis of the ERA-EDTA Registry

Background. Previous US studies have indicated that haemodialysis with >= 6-h sessions [extended-hours haemodialysis (EHD)] may improve patient survival. However, patient characteristics and treatment practices vary between the USA and Europe. We therefore investigated the effect of EHD three times weekly on survival compared with conventional haemodialysis (CHD) among European patients. Methods. We included patients who were treated with haemodialysis between 2010 and 2017 from eight countries providing data to the European Renal Association-European Dialysis and Transplant Association Registry. Haemodialysis session duration and frequency were recorded once every year or at every change of haemodialysis prescription and were categorized into three groups: CHD (three times weekly, 3.5-4h/treatment), EHD (three times weekly, >= 6h/treatment) or other. In the primary analyses we attributed death to the treatment at the time of death and in secondary analyses to EHD if ever initiated. We compared mortality risk for EHD to CHD with causal inference from marginal structural models, using Cox proportional hazards models weighted for the inverse probability of treatment and censoring and adjusted for potential confounders. Results. From a total of 142 460 patients, 1338 patients were ever treated with EHD (three times, 7.10.8h/week) and 89 819 patients were treated exclusively with CHD (three times, 3.9 +/- 0.2h/week). Crude mortality rates were 6.0 and 13.5/100 person-years. In the primary analyses, patients treated with EHD had an adjusted hazard ratio (HR) of 0.73 [95% confidence interval (CI) 0.62-0.85] compared with patients treated with CHD. When we attributed all deaths to EHD after initiation, the HR for EHD was comparable to the primary analyses [HR 0.80 (95% CI 0.71-0.90)]. Conclusions. EHD is associated with better survival in European patients treated with haemodialysis three times weekly.Peer reviewe

Iron deficiency, anemia, and patient-reported outcomes in kidney transplant recipients

Kidney transplant recipients (KTRs) experience more fatigue, anxiety, and depressive symptoms and lower concentration and health-related quality of life (HRQoL) compared with the general population. Anemia is a potential cause that is well-recognized and treated. Iron deficiency, however, is often unrecognized, despite its potential detrimental effects related to and unrelated to anemia. We investigated the interplay of anemia, iron deficiency, and patient-reported outcomes in 814 outpatient KTRs (62% male, age 56 ± 13 years) enrolled in the TransplantLines Biobank and Cohort Study (Groningen, The Netherlands). In total, 28% had iron deficiency (ie, transferrin saturation &lt; 20% and ferritin &lt; 100 μg/L), and 29% had anemia (World Health Organization criteria). In linear regression analyses, iron deficiency, but not anemia, was associated with more fatigue, worse concentration, lower wellbeing, more anxiety, more depressive symptoms, and lower HRQoL, independent of age, sex, estimated glomerular filtration rate, anemia, and other potential confounders. In the fully adjusted logistic regression models, iron deficiency was associated with an estimated 53% higher risk of severe fatigue, a 100% higher risk of major depressive symptoms, and a 51% higher chance of being at risk for sick leave/work disability. Clinical trials are needed to investigate the effect of iron deficiency correction on patient-reported outcomes and HRQoL in KTRs.</p