PowerPoint Slides for: Intensive Home Hemodialysis Results in Regression of Left Ventricular Hypertrophy and Better Clinical Outcomes

<i>Background:</i> Left ventricular hypertrophy (LVH) is an independent risk factor for mortality and cardiovascular events in patients with end-stage renal disease. Studies have shown that frequent hemodialysis leads to LVH regression, but the impact of left ventricular mass (LVM) regression on clinical outcomes remains unknown.<i>Methods:</i> This observational cohort study assessed the impact of LVH regression on the composite outcome of time to all-cause mortality, technique failure or cardiovascular hospitalization in patients on home hemodialysis. LVH regression was defined as either a reduction of more than 10% in LVM in patients with LVH at baseline or prevention of LVH in those without LVH at baseline. Risk factors associated with progression of LVM were also examined. <i>Results:</i> We studied 144 intensive hemodialysis patients between 1999 and 2012 with a mean follow-up of 4.7 years. Eighty-seven patients (60.4%) had LVH regression or prevention and 57 patients (39.6%) had LVH progression. In a multivariate analysis, smoking (OR 2.78, 95% CI 1.06-7.36) and presence of LVH at baseline (OR 2.21, 95% CI 1.06-4.59) were significant predictors for LVM progression. Sixteen patients (18.4%) in the regressor group and 19 patients (33.3%) in the progressor group developed the composite end point. When adjusted for age and diabetes, regression was significantly associated with a decreased risk (hazards ratio (HR) 0.42, 95% CI 0.21-0.84) for the composite end point. Regression was also significantly associated with a decreased risk of death in the adjusted analysis (HR 0.20, 95% CI 0.06-0.67). <i>Conclusions:</i> Regression of LVH with intensive hemodialysis is associated with favorable clinical outcomes

Supplementary Material for: Suboptimal Initiation of Home Hemodialysis: Determinants and Clinical Outcomes

<p><b><i>Background/Aims:</i></b> Suboptimal initiation of conventional hemodialysis is associated with poor clinical outcomes. In this study, we aimed to ascertain the determinants and adverse events associated with suboptimal starts in home hemodialysis (HHD). <b><i>Methods:</i></b> We conducted a retrospective cohort study including consecutive incident HHD patients from January 1996 to December 2011. All patients had HHD as their first renal replacement therapy or returned to HHD after kidney transplantation. A suboptimal start was defined by dialysis initiation as an inpatient or with a central venous catheter. The primary outcome was time to first hospitalization, technique failure or death. Secondary outcomes included hospitalization rate, hospital days and determinants of suboptimal starts. Suboptimal starts were further categorized as unavoidable as adjudicated by two independent observers with prespecified criteria. <b><i>Results:</i></b> Among 95 incident HHD patients, 44 (46%) and 51 (54%) had optimal and suboptimal starts, respectively. A suboptimal start was associated with a shorter time to the primary outcome (log-rank p < 0.001). In a multivariable Cox proportional hazards model, the hazard ratio for the composite outcome (comparing suboptimal to optimal starts) was 2.94 (95% confidence interval, CI, 1.49-5.78, p = 0.002). Transplantation clinic follow-up (OR 3.18, 95% CI 1.15-8.79) and the Charlson comorbidity index (OR 1.47, 95% CI 1.09-1.97) were associated with higher odds of suboptimal start. <b><i>Conclusion:</i></b> Suboptimal initiation of HHD is associated with adverse clinical events including early hospitalization. Given the high proportion of suboptimal starts in patients returning from transplantation, better incorporation of dialysis planning and renal replacement therapy education is warranted.</p

Supplementary Material for: Improving Care after Acute Kidney Injury: A Prospective Time Series Study

<strong><em>Background:</em></strong> Acute kidney injury (AKI) complicates 15-20% of hospitalizations, and AKI survivors are at increased risk of chronic kidney disease and death. However, less than 20% of patients see a nephrologist within 3 months of discharge, even though a nephrologist visit within 90 days of discharge is associated with enhanced survival. To address this, we established an AKI Follow-Up Clinic and characterized the patterns of care delivered. <b><i>Methods:</i></b> We conducted a prospective time series study. All hospitalized patients who developed Kidney Disease Improving Global Outcomes (KDIGO) stage 2 or 3 AKI were eligible. The pre-intervention period consisted of electronic reminders to the nephrology consults and cardiovascular surgery services to refer to the AKI Follow-Up Clinic. In the post-intervention period, eligible patients were automatically scheduled into the AKI Follow-Up Clinic at discharge. The primary outcome was the percentage of KDIGO stages 2-3 AKI survivors assessed by a nephrologist within 30 days of discharge. <b><i>Results:</i></b> In the pre-intervention period, 8 of 46 patients (17%) were seen by a nephrologist within 30 days after discharge, and no additional patients were seen for 90 days. In the post-intervention period, 17 of 69 patients (25%) were seen by a nephrologist within 30 days after discharge (p = 0.36), with an additional 30 patients seen in 90 days (47 of 69, 68%, p < 0.001). The mean serum creatinine was 99 (SD 35) µmol/l prior to hospitalization and 133 (58) µmol/l at 3 months. Fifty-five of 79 patients (70%) received at least 1 medical intervention at their first AKI Follow-Up Clinic visit. <b><i>Conclusions:</i></b> An AKI Follow-Up Clinic with an automatic referral process increased the proportion of patients seen at 90 days, but not 30 days post discharge. Being seen in the AKI Follow-Up Clinic was associated with interventions in most patients. Future research is needed to evaluate the effect of the AKI Follow-Up Clinic on patient-centered outcomes, but physicians should be aware that AKI survivors may benefit from close outpatient follow-up and a multipronged approach to care similarly for other high-risk populations