Turning the Tide: Improving Fluid Management in Dialysis through Technology

Over the last decade, components of fluid management have emerged as some of the most important modifiable risk factors for morbidity and mortality among individuals on maintenance dialysis. Hypervolemia, either chronic from long-term volume overload or episodic from large interdialytic weight gains, may increase the risk of left ventricular hypertrophy and its adverse downstream cardiovascular consequences. Conversely, hypovolemia from either too voluminous or too rapid of fluid removal may lead to multiorgan ischemia and associated clinical sequelae.3,4 Experts recognize the need for balance between the extremes of volume status and ultrafiltration, but inter-relationships among volume-related components, lack of data on their relative importance, and absence of relevant clinical trials hinder consensus guideline development. Notwithstanding the paucity of trial evidence in this arena, international experts and United States dialysis organization leaders concur that putting “volume first” is essential if the dialysis community is to successfully “turn the tide” on the unacceptably poor outcomes experienced by our patients

ASCENDing to New Heights in Our Understanding of the Treatment of Depression Among Individuals Receiving Hemodialysis.

Depression is the most common psychiatric condition among patients receiving maintenance hemodialysis. Depression negatively affects functional status and quality of life and is associated with increased treatment nonadherence, hospitalizations, and mortality (1). Despite the clinical and patient-reported significance of depression, clinicians often underrecognize and undertreat depressive symptoms

Using Patient Preference Information to Inform Regulatory Decision Making: An Opportunity to Spur Patient-Centered Innovation in Kidney Replacement Therapy Devices

Medical devices play an essential role in the health care system, often facilitating patients’ management of their own health. Such devices—items used for the “diagnosis. . .cure, mitigation, treatment, or prevention of disease that are not absorbed or metabolized by the body”—range in type and function from supportive equipment (e.g., walkers and wheelchairs) to life-sustaining therapies (e.g., cardiac defibrillators and dialysis machines). In the United States, over 500,000 individualswith kidney failure rely on dialysis machines and supportive vascular access and monitoring devices to perform the critical kidney functions of waste and fluid removal. Although dialysis therapy undoubtedly sustains life, its side effects and burdensome nature leave many with constrained livelihoods and diminished quality of life

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

BACKGROUND AND OBJECTIVES: Zolpidem, a nonbenzodiazepine hypnotic, and trazodone, a sedating antidepressant, are the most common medications used to treat insomnia in the United States. Both drugs have side effect profiles (e.g., drowsiness, dizziness, and cognitive and motor impairment) that can heighten the risk of falls and fractures. Despite widespread zolpidem and trazodone use, little is known about the comparative safety of these medications in patients receiving hemodialysis, a vulnerable population with an exceedingly high fracture rate. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using data from the United States Renal Data System registry (2013-2016), we conducted a retrospective cohort study to investigate the association between the initiation of zolpidem versus trazodone therapy and the 30-day risk of hospitalized fall-related fractures among Medicare-enrolled patients receiving maintenance hemodialysis. We used an active comparator new-user design and estimated 30-day inverse probability of treatment-weighted hazard ratios and risk differences. We treated death as a competing event. RESULTS: A total of 31,055 patients were included: 18,941 zolpidem initiators (61%) and 12,114 trazodone initiators (39%). During the 30-day follow-up period, 101 fall-related fractures occurred. Zolpidem versus trazodone initiation was associated with a higher risk of hospitalized fall-related fracture (weighted hazard ratio, 1.71; 95% confidence interval, 1.11 to 2.63; weighted risk difference, 0.17%; 95% confidence interval, 0.07% to 0.29%). This association was more pronounced among individuals prescribed higher zolpidem doses (hazard ratio, 1.85; 95% confidence interval, 1.10 to 3.01; and risk difference, 0.20%; 95% confidence interval, 0.04% to 0.38% for higher-dose zolpidem versus trazodone; and hazard ratio, 1.60; 95% confidence interval, 1.01 to 2.55 and risk difference, 0.14%; 95% confidence interval, 0.03% to 0.27% for lower-dose zolpidem versus trazodone). Sensitivity analyses using longer follow-up durations yielded similar results. CONCLUSIONS: Among individuals receiving maintenance hemodialysis, zolpidem initiators had a higher risk of hospitalized fall-related fracture compared with trazodone initiators

Ultrafiltration Rate and Residual Kidney Function Decline: Yet Another Good Reason to Ask About Urine

Epidemiologic studies examining ultrafiltration rate (UFR) and adverse outcomes in thriceweekly hemodialysis patients have linked rapid UFRs to higher risks of mortality, mesenteric ischemia,3 and new-onset dementia. Data from mechanistic studies support these findings, demonstrating that hemodialysis-induced circulatory stress can cause ischemic injury to end-organs including the heart, gut, brain, and kidneys. Based on consistent observational data and strong biological plausibility, the United States (US) Centers for Medicare & Medicaid Services incorporated a UFR reporting metric into the 2020 End-Stage Renal Disease Quality Incentive Program, heightening the dialysis community’s awareness of fluid removal practices

Thirty-Day Hospital Readmissions in the Hemodialysis Population: A Problem Well Put, But Half-Solved

In recent years, United States policymakers have made 30-day hospital readmission reduction a centerpiece of efforts to curb Medicare costs. In the general Medicare population, 15% of patients are readmitted to the hospital within 30 days of discharge (1), and unplanned rehospitalizations cost >$20 billion per year (2). In fiscal year 2013, Medicare began levying financial penalties against hospitals with higher than expected readmission rates via the Affordable Care Act’s Hospital Readmissions Reduction Program. The readmission problem is even more dire among individuals receiving maintenance dialysis; 30-day hospital readmission rates are >35% in this vulnerable group (3). To incentivize readmission reduction in the dialysis population, the Centers for Medicare and Medicaid Services implemented the standardized readmission ratio, a pay for performance quality measure for outpatient dialysis clinics, in 2017

Assessing Clinical Relevance of Uremic Toxins

Standard hemodialysis works. Indeed, this procedure maintains life in hundreds of thousands of people with little or no kidney function. Moreover, severe symptoms of uremia—coma, seizures, acidosis, hyperkalemia, and pulmonary edema—are readily reversed by dialysis. However, it is also now conspicuous that life on maintenance hemodialysis is short, with about 20%of the ESKDpopulation in the United States dying each year, yielding a 3–5years survival rate of only 50%. Although mortality is appallingly high, patient symptom burden is great, and for many patients, these symptoms are more daunting than the dismal mortality prospects. Quality of life has remained consistently poor for patients on hemodialysis. A recent survey reported that the physical symptoms of insomnia, fatigue, andcramping, andmoodsymptoms of anxiety, depression, and frustration were paramount concerns among patient

Dialysate Sodium: Rationale for Evolution over Time

Oligo-anuric individuals receiving hemodialysis (HD) are dependent on the dialysis machine to regulate sodium and water balance. Interest in adjusting the dialysate sodium concentration to promote tolerance of the HD procedure dates back to the early years of dialysis therapy. Evolution of dialysis equipment technologies and clinical characteristics of the dialysis population have prompted clinicians to increase the dialysate sodium concentration over time. Higher dialysate sodium concentrations generally promote hemodynamic stabilization and reduce intradialytic symptoms but often do so at the expense of stimulating thirst and promoting volume expansion. The opposite may be true for lower dialysate sodium concentrations. Observational data suggest that the association between dialysate sodium and outcomes may differ by serum sodium levels, supporting the trend toward individualization of the dialysate sodium prescription. However, lack of randomized controlled clinical trial data, along with operational safety concerns related to individualized dialysate sodium prescriptions, have prevented expert consensus regarding the optimal approach to the dialysate sodium prescription

Dialysis Care around the World: A Global Perspectives Series.

Introduction Worldwide, ESKD prevalence per million population (PMP) has steadily increased from 2003 to 2016 (1), with the greatest proportional increases occurring in lower- and middle-income countries (2). Although dialysis is a lifesaving therapy, it is also extraordinarily expensive, so its use is limited in lower-income countries with less resources available for healthcare. Specifically, the prevalence of dialysis in 2010 was 1176 PMP in higher-income countries, 688 PMP in upper-middle-income countries, 170 PMP in lowerincome countries, and 16 PMP in lower-income countries (2). The most common modality of kidney replacement therapy globally is dialysis (78%) and, among patients receiving dialysis, only 11% receive peritoneal dialysis (3

Cumulative Exposure to Frequent Intradialytic Hypotension Associates With New-Onset Dementia Among Elderly Hemodialysis Patients

To the Editor: Cognitive impairment, including dementia, affects up to 70% of individuals receiving maintenance hemodialysis, a prevalence that exceeds that of the elderly general population by 3- to 7-fold. Cardiometabolic risk factors for dementia, such as diabetes, hypercholesterolemia, hypertension, and vascular disease, are highly prevalent in end-stage kidney disease. However, the rate of new-onset dementia is higher among hemodialysis patients compared with peritoneal dialysis patients, suggesting that aspects of the hemodialysis procedure may contribute to the development of dementia