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

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

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

Evaluation and treatment of renal artery stenosis: Impact on blood pressure and renal function

The conventional non-invasive tests to diagnose renal artery stenosis in a general hypertensive population are not accurate enough for screening purposes. Magnetic resonance angiography might become the new gold standard, with the advantages of the absence of contrast toxicity, good accuracy, and information on flow characteristics. With regard to the treatment of hypertension in patients with renal artery stenosis, intervention is advised only when blood pressure cannot be controlled by at least three antihypertensive drugs. Patency after stenting is superior to angioplasty, although its clinical benefit has not been proved. As for renal function, evidence - although from uncontrolled studies - for the preservation of renal function by intervention is accumulating, especially in those patients with bilateral stenosis or stenosis in a single functioning kidney

Cannulating in haemodialysis: Rope-ladder or buttonhole technique?

Background. The standard technique for fistula cannulation, the rope-ladder technique, is problematic for patients with short fistula lengths and for patients in whom the fistula is difficult to cannulate. The buttonhole technique, cannulation of exactly the same site, offers the advantage of an easy cannulation procedure. However, it can be used only in native fistulas and cannulation is preferably executed by a 'single-sticker'. This study was conducted to compare these cannulation techniques using objective parameters. Methods. We introduced the buttonhole technique for self-cannulating home haemodialysis patients and compared it with baseline data obtained with the rope-ladder technique. Thirty-three patients with a native arteriovenous fistula were observed prospectively during 18 months on the following parameters: cannulating ease, number of bad sticks, pain, time of compression after cannula removal, bleeding, infectious complications and aneurysm formation. Results. With the buttonhole method, cannulating ease improved distinctly, which was especially favourable in patients with a short fistula vein. Reported cannulation pain did not change significantly. The incidence of bad sticks decreased significantly, as well as time of compression after cannula removal, without increased incidence of bleeding. Three patients developed a local skin infection of their buttonhole during the study, after which the disinfection routine prior to cannulation was changed. Conclusions. Compared with the rope-ladder technique, the buttonhole method offers the advantage of an easier cannulation procedure with less bad sticks, which has a special benefit for patients with limited access cannulation sites or with a fistula which is difficult to cannulate. Prolonged compression times or re-bleeding episodes did not occur, but precautions have to be taken in order to prevent infectious complications. The buttonhole method can contribute considerably to the cannulating ease of self-cannulating patients, thus providing a better quality of life

Physical performance in patients treated with nocturnal hemodialysis

Background: Patients treated with conventional hemodialysis have poor physical performance, explained by insufficient metabolic clearance and shortage of time by time-consuming dialysis. Nocturnal hemodialysis improves metabolic control and results in increased spare time. Our aim is to investigate whether physical performance in nocturnal hemodialysis is superior to conventional hemodialysis. Methods: A systematic search was conducted in MEDLINE, Embase, CINAHL, PhycInfo and Web of Science until January 2018. Primary outcomes were physical performance, activity, strength and muscle mass in home or in-center nocturnal hemodialysis. Methodological quality was assessed with the Newcastle-Ottawa scale. Results: Ten studies met the inclusion criteria, including 2 RCTs, evaluating 526 nocturnal hemodialysis patients with a mean follow-up of 15, 3 months. The methodological quality of 4 studies was limited. Physical capacity tests were done in 3 studies with different methodology: short-physical performance battery, exercise spirometry and 6-min walk test. The latter 2 showed significant improvements in physical performance. Four studies assessed lean mass using dual-energy X-ray absorptiometry (2×) and bioelectrical impedance analysis (2×), of which 1 demonstrated increased lean body and skeletal muscle mass. In 5 studies a Quality of Life questionnaire was used, of which 2 showed improved physical component score. Conclusions: The evidence on the effect of nocturnal hemodialysis on physical performance is either of insufficient methodological quality or only measures isolated aspects of physical performance. As literature emphasizes the importance of physical activity on clinical outcomes, it is necessary to conduct larger studies of high methodological quality using capacity tests for answering the question whether nocturnal hemodialysis can improve physical performance of patients with end-stage renal disease. Trial registration: NTR4715, Netherlands Trial Register. Registered 30 July 2014

Is progression of coronary artery calcification influenced by modality of renal replacement therapy? : A systematic review

Background: Progression of coronary artery calcification is an important marker for cardiovascular morbidity in end-stage renal disease patients. Therefore, we reviewed the evidence on coronary artery calcification progression in different renal replacement therapies. Methods: MEDLINE (PubMed), Embase and TRIP databases were searched from 1999 - 2016. Additionally, bibliographies were searched by hand and citation tracking of key publications was performed. Prospective studies were included that examined coronary artery calcification with two or more multislice computed tomography scans ≥6 months apart in patients 18-75 years old receiving any renal replacement therapy, including kidney transplantation. Reporting of separate scores for different modalities was required. Two researchers extracted data independently with pilot-tested forms and assessed the risk of bias using a validated tool. Results: We identified 29 eligible studies that assessed coronary artery calcification progression in end-stage renal disease patients, of which 19 studies evaluated haemodialysis and 8 kidney transplantation. Evidence on progression in peritoneal dialysis (three studies) and nocturnal haemodialysis (one study) was limited. Meta-analysis was not possible due to diverse reporting methods of coronary artery calcification scores and definitions of progression. Median coronary artery calcification scores were considerably higher in haemodialysis cohorts at baseline, presumably due to a generally higher age and dialysis vintage. Median coronary artery calcification progressed universally. Visual inspection suggested the least progression in kidney transplant recipients. Conclusions: There is insufficient evidence to compare the influence of renal replacement therapies on coronary artery calcification progression. We advocate the adoption of a standardized reporting method of coronary artery calcification progression

Good practices for dialysis education, treatment, and eHealth: A scoping review

Background Recommendations regarding dialysis education and treatment are provided in various (inter)national guidelines, which should ensure that these are applied uniformly in nephrology and dialysis centers. However, there is much practice variation which could be explained by good practices: practices developed by local health care professionals, which are not evidence-based. Because an overview of good practices is lacking, we performed a scoping review to identify and summarize the available good practices for dialysis education, treatment, and eHealth. Methods Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words 'kidney failure', 'dialysis', and 'good practice'. Relevant articles were structured according to the categories dialysis education, dialysis treatment or eHealth, and assessed for content and results. Results Nineteen articles (12 for dialysis education, 3 for dialysis treatment, 4 for eHealth) are identified. The good practices for education endorse the importance of providing complete and objective predialysis education, assisting peritoneal dialysis (PD) patients in adequately performing PD, educating hemodialysis (HD) patients on self-management, and talking with dialysis patients about their prognosis. The good practices for dialysis treatment focus mainly on dialysis access devices and general quality improvement of dialysis care. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life. Conclusion Our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients' contribution in the implementation of their dialysis treatment, and advanced care planning. Copyright