November 15, 2013
Survival after Dialysis Discontinuation and Hospice Enrollment for ESRD
Author(s): O’Connor NR, Dougherty M, Harris PS, Casarett DJ.
Journal Citation: Clin J Am Soc Nephrol. 8: 2117–2122, 2013.
Between 2008 and 2010, more than 50,000 patients in the United States discontinued dialysis, a right which has been affirmed by several practice guidelines. A large proportion of these patients enroll in hospice, and this care could be enhanced by a detailed understanding of factors that determine post‑dialysis survival time. The authors of this study investigated survival among end‑stage renal disease (ESRD) patients admitted to hospice after discontinuation of dialysis, and the study defined independent predictors of survival time. Patient data were obtained from electronic medical records of 10 hospices in the Coalition Hospices Organized to Investigate Comparative Effectiveness (CHOICE) network. For the 1,947 evaluated ESRD patients, mean survival was 7.4 days after hospice admission as compared to 54.4 days for the nonrenal control patients (n = 124,673). Additionally, a Cox proportional hazards model identified 7 independent predictors of early mortality, including male gender, referral from a hospital, lower functional status, and presence of peripheral edema. The authors expect that discontinuation of dialysis will become more common with increased prevalence of ESRD, and the authors conclude by recommending additional investigations to define survival trajectories, involvement of advanced directives, and family experience of the process. Read more…
Patency Rates of the Arteriovenous Fistula for Hemodialysis: A Systematic Review and Meta-analysis
Author(s): Al-Jaishi AA, Oliver MJ, Thomas SM, Lok CE, Zhang JC, Garg AX, Kosa SD, Quinn RR, Moist LM.
Journal Citation: Am J Kidney Dis. 2013; Epub ahead of print.
Arteriovenous fistulas (AVFs) are endorsed as the preferred form of vascular access for hemodialysis. Knowledge of AVF performance informs patient consent and quality improvement initiatives and also guides patient and clinician decision making. The authors conducted a systematic review and meta‑analysis of AVF primary failure as well as primary and secondary patency rates at 1 and 2 years. Estimates were obtained from English‑language studies (2000-2012) of 100 or more AVFs: estimates were pooled using a random-effects model and sources of heterogeneity were explored using meta‑regression. From 46 articles (62 cohorts; N = 12,383), the AVF primary failure rate was 23% (95% confidence intervals [CI], 18%-28%), The primary patency rate (including primary failures) was 60% (95% CI, 56%‑64%) at year 1 and 51% (95% CI, 44%‑58%) at year 2. Additionally, the authors found that approximately one-quarter to one-third of created AVFs were never used (with even higher rates in the elderly and patients using a lower-arm AVF), and by 1 year, 40% of all AVFs failed or required at least 1 intervention. The authors concluded that there is a substantial decrease in AVF performance over time, and current data highlighted a higher risk of primary failure and low to moderate primary and secondary patency rates. Read more…
Dialysis Dose and Intradialytic Hypotension: Results from the HEMO Study
Author(s): Mc Causland FR, Brunelli SM, Waikar SS.
Journal Citation: Am J Nephrol. 2013; Epub ahead of print.
Intradialytic hypotension (IDH) is an abrupt decline in blood pressure during a hemodialysis (HD) treatment session, and by definition IDH results in symptoms and/or requires clinical intervention. IDH has been associated with numerous adverse events, and IDH has been attributed to transient intradialytic osmotic gradients, resulting from rapid removal of urea, sodium, and other substances from the intravascular compartment during dialysis. In the current study, the authors tested the hypothesis that higher dialysis dose is associated with greater risk of IDH. The authors performed a post hoc analysis of the HEMO study – a multicenter, randomized clinical study in maintenance HD that randomized patients to higher versus standard Kt/V and higher versus lower membrane flux. In the study population (N = 1,825 individuals; 62,095 unique HD session), IDH events occurred more frequently in the higher-Kt/V group (18.3% vs. 16.8%; p < 0.001). Participants randomized to higher-target Kt/V had a greater adjusted risk of IDH than those randomized to standard Kt/V (odds ratio [OR] 1.12; 95% confidence interval [CI] 1.01–1.25). Higher vs. lower dialyzer mass transfer-area coefficient for urea and rate of urea removal were associated with greater adjusted odds of IDH (OR 1.15; 95% CI 1.04–1.27 and OR 1.05; 95% CI 1.04– 1.06 per mg/dl/h, respectively). The authors concluded that a higher dialysis dose appeared to increase the risk for IDH, supporting the idea that rapidity of intradialytic plasma osmolality reductions may mediate hemodynamic instability. Further, the authors advocated for targeted strategies to mitigate the rapidity of the plasma osmolality changes. Read more…