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Evidence-informed decision making in clinical care and policy in nephrology is undermined by trials that selectively report a large number of heterogeneous outcomes, many of which are not patient centered. The Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) Initiative convened an international consensus workshop on November 7, 2015, to discuss the identification and implementation of a potential core outcome set for all trials in hemodialysis. The purpose of this article is to report qualitative analyses of the workshop discussions, describing the key aspects to consider when establishing core outcomes in trials involving patients on hemodialysis therapy. Key stakeholders including 8 patients/caregivers and 47 health professionals (nephrologists, policymakers, industry, and researchers) attended the workshop. Attendees suggested that identifying core outcomes required equitable stakeholder engagement to ensure relevance across patient populations, flexibility to consider evolving priorities over time, deconstruction of language and meaning for conceptual consistency and clarity, understanding of potential overlap and associations between outcomes, and an assessment of applicability to the range of interventions in hemodialysis. For implementation, they proposed that core outcomes must have simple, inexpensive, and validated outcome measures that could be used in clinical care (quality indicators) and trials (including pragmatic trials) and endorsement by regulatory agencies. Integrating these recommendations may foster acceptance and optimize the uptake and translation of core outcomes in hemodialysis, leading to more informative research, for better treatment and improved patient outcomes.

Objective: To examine the prognostic values of systemic immune-inflammation indices of hemodialysis (HD) vascular access failure and develop a prediction model for vascular access failure based on the most pertinent systemic immuneinflammation index. Study design: A prospective cohort study. Setting & participants: Patients undergoing autogenous HD vascular access surgeries or arteriovenous graft as a permanent hemodialysis access in a tertiary center in southwest China from January 2020 to June 2022. Predictors: Systemic immune-inflammation indices, including NLR, dNLR, AAPR, SIRI, SII, PNI, PLR, and LIPI, and clinical variables. Outcomes: The outcome was defined as survival of the hemodialysis access, with both occluded and stenotic access being considered as instances of access failure. Analytical approach: Cox proportional hazard regression model. Results: 2690 patients were included in the study population, of whom 658 experienced access failure during the follow-up period. The median duration of survival for HD vascular access was 18 months. The increased systemic immuneinflammation indices, including dNLR, NLR, SII, PNI, SIRI, PLR, and LIPI, are predictive of HD access failure, with SII demonstrating the strongest prognostic value. A simple SII-based prediction model for HD access failure was developed, achieving C-indexes of 0.6314 (95% CI: 0.6249 - 0.6589) and 0.6441 (95% CI: 0.6212 - 0.6670) for predicting 6- and 12-month access survival, respectively. Conclusions: Systemic immune-inflammation indices are significantly and negatively associated with HD vascular access survival. A simple SII-based prediction model was developed and anticipates further improvement through larger study cohort and validation from diverse centers. [ABSTRACT FROM AUTHOR]

Background: There is controversy regarding the optimal renal-replacement therapy (RRT) modality for critically ill patients with acute kidney injury (AKI). Methods: We conducted a secondary analysis of the STandard versus Accelerated Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial to compare outcomes among patients who initiated RRT with either continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD). We generated a propensity score for the likelihood of receiving CRRT and used inverse probability of treatment with overlap-weighting to address baseline inter-group differences. The primary outcome was a composite of death or RRT dependence at 90-days after randomization. Results: We identified 1590 trial participants who initially received CRRT and 606 who initially received IHD. The composite outcome of death or RRT dependence at 90-days occurred in 823 (51.8%) patients who commenced CRRT and 329 (54.3%) patients who commenced IHD (unadjusted odds ratio (OR) 0.90; 95% confidence interval (CI) 0.75–1.09). After balancing baseline characteristics with overlap weighting, initial receipt of CRRT was associated with a lower risk of death or RRT dependence at 90-days compared with initial receipt of IHD (OR 0.81; 95% CI 0.66–0.99). This association was predominantly driven by a lower risk of RRT dependence at 90-days (OR 0.61; 95% CI 0.39–0.94). Conclusions: In critically ill patients with severe AKI, initiation of CRRT, as compared to IHD, was associated with a significant reduction in the composite outcome of death or RRT dependence at 90-days. [ABSTRACT FROM AUTHOR]

Background Acute kidney injury (AKI) caused by cast nephropathy is associated with increased morbidity and mortality among patients with multiple myeloma (MM). High cut-off haemodialysis (HCO-HD) has proven to be effective in the removal of serum light chains but the effect on clinical outcomes, especially renal recovery, remains uncertain. Methods A systematic review and meta-analysis were performed examining all randomized controlled trials (RCTs) and observational studies (OBSs) assessing the effect of HCO-HD on clinical outcomes of patients with MM complicated by cast nephropathy–induced severe AKI. The primary outcome was all-cause mortality at the end of the study. The secondary outcomes included all-cause mortality at 12 months, HD independence and serum kappa and lambda light chain reduction. Pooled analysis was performed using random effects models. Results We identified five studies, comprising two RCTs and three retrospective cohort studies, including 276 patients with a mean follow-up of 18.7 months. The majority of the studies were of suboptimal quality and underpowered. Compared with patients treated with conventional HD, HCO-HD was not associated with a survival benefit at 12 months {five studies, 276 patients, relative risk [RR] 1.02 [95% confidence interval (CI) 0.76–1.35], I 2 = 33.9%} or at the end of the studies at an average of 34 months [five studies, 276 patients, RR 1.32 (95% CI 0.71–2.45), I 2 = 62.0%]. There was no difference in HD independence at 90 days [two trials, 78 patients, RR 2.23 (95% CI 1.09–4.55)], 6 months [two studies, 188 patients, RR 1.19 (95% CI 0.68–2.06)] or 12 months [two studies, 188 patients, RR 1.14 (95% CI 0.58–2.26)]. Patients receiving HCO dialysis, however, had a greater reduction in serum kappa [two studies, 188 patients, weighted mean difference (WMD) 46.7 (95% CI 38.6–54.7), I 2 =  52.0%] and lambda [two studies, 188 patients, WMD 50.3 (95% CI 21.4–79.3), I 2 = 95.1%] light chain levels. Conclusion Current evidence from RCTs and OBSs suggests HCO dialysis is able to reduce serum free light chains but makes no significant improvement in all-cause mortality and renal outcomes compared with conventional HD for patients with myeloma cast nephropathy. However, there is a trend towards better renal outcomes with the use of HCO dialysis. The lack of long-term data and the small sample sizes of the included studies limit this analysis. Therefore further large-scale RCTs with longer follow-up are needed to assess the effect of HCO dialysis on clinical outcomes in patients with myeloma cast nephropathy. [ABSTRACT FROM AUTHOR]

Aim: Extended hours haemodialysis is associated with superior survival to standard hours. However, residual confounding limits the interpretation of this observation. We aimed to determine the effect of a period of extended hours dialysis on long‐term survival among participants in the ACTIVE Dialysis trial. Methods: Two‐hundred maintenance haemodialysis recipients were randomized to extended hours dialysis (median 24 h/wk) or standard hours dialysis (median 12 h/wk) for 12 months. Further pre‐specified observational follow up occurred at 24, 36 and 60 months. Vital status and modality of renal replacement therapy were ascertained. Results: Over the 5 years, 38 participants died, 30 received a renal transplant, and 6 were lost to follow up. Total weekly dialysis hours did not differ between standard and extended groups during the follow‐up period (14.1 hours [95%CI 13.4‐14.8] vs 14.8 hours [95%CI 14.1‐15.6]; P =.16). There was no difference in all‐cause mortality (hazard ratio for extended hours 0.91 [95%CI 0.48‐1.72]; P =.77). Similar results were obtained after censoring participants at transplantation, and after adjusting for potential confounding variables. Subgroup analysis did not reveal differences in treatment effect by region, dialysis setting or vintage (P‐interaction.51,.54,.12, respectively). Conclusion: Twelve months of extended hours dialysis did not improve long‐term survival nor affect dialysis hours after the intervention period. An urgent need remains to further define the optimal dialysis intensity across the broad range of dialysis recipients. SUMMARY AT A GLANCE: Twelve months of extended‐hour dialysis did not improve long‐term survival or affect dialysis hours after the intervention period among 200 patients. These results suggest that the optimal dialysis intensity across a broad range of dialysis recipients remains to be defined. [ABSTRACT FROM AUTHOR]

Background: Myocardial pathology is common in patients undergoing hemodialysis. To explore the effects of differing aspects of dialysis treatment on its evolution, we examined the impact of change in markers of volume status, hemodynamics and solute clearance on left ventricular (LV) parameters in a randomized trial of extended hours dialysis.Methods and Results: A Clinical Trial of IntensiVE (ACTIVE) Dialysis randomized 200 patients undergoing hemodialysis to extended dialysis hours (≥ 24 hours/week) or standard hours (12-18 hours/week) for 12 months. In a prespecified substudy, 95 participants underwent cardiac magnetic resonance imaging (CMR) at baseline and at the study's end. Generalized linear regression was used to model the relationship between changes in LV parameters and markers of volume status (normalized ultrafiltration rate and total weekly interdialytic weight gain), hemodynamic changes (systolic and diastolic blood pressure) and solute control (urea clearance, dialysis hours and phosphate). Randomization to extended hours dialysis was not associated with change in any CMR parameter. Reduction in ultrafiltration rate was associated with reduction in LV mass index (P = 0.049) and improved ejection fraction (P = 0.024); reduction in systolic blood pressure was also associated with improvement in ejection fraction (P = 0.045); reduction in interdialytic weight gain was associated with reduced stroke volume (P = 0.038). There were no associations between change in urea clearance, phosphate or total hours per week and CMR parameters.Conclusions: Reduction in ultrafiltration rate and blood pressure are associated with improved myocardial parameters in hemodialysis recipients independently of solute clearance or dialysis time. These findings underscore the importance of fluid status and related parameters as potential treatment targets in this population. [ABSTRACT FROM AUTHOR]

Background: The influence of health insurance systems on the treatment of end‐stage kidney disease (ESKD) patients ispoorly understood. Aim: We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalitiesand patient outcomes. The influence of health insurance systems on the treatment of end‐stage kidney disease (ESKD) patients is poorly understood. We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalities and patient outcomes. Methods: All adult patients commencing ESKD treatment in New South Wales, Australia from 2000 to 2010 were identified using the Australia and New Zealand Dialysis and Transplant Registry. Data were linked to the state hospitalisation dataset to obtain insurance status, allowing the comparisons of mortality, ESKD treatment modality and health service utilisation between privately insured and public patients. Results: The cohort of 5737 patients included 38% (n = 2152) with PHI. At 1 year after ESKD treatment initiation, PHI patients had lower mortality (hazard ratio 0.84, 95% confidence interval (CI) 0.74–0.95, P = 0.01), were more likely to be receiving home haemodialysis (HD) (odds ratio (OR) 1.38, 95% CI 1.01–1.89, P = 0.04), to have been transplanted (OR 1.75, 95% CI 1.25–2.46, P = 0.001) and used fewer hospital days (incidence rate ratio 0.85, 95% CI 0.74–0.96, P = 0.01). After adjustment, PHI patients were more likely to initiate ESKD treatment with facility‐based HD (OR 1.22, 95% CI 1.01–1.46, P = 0.03) but were less likely to be started on peritoneal dialysis (OR 0.81, 95% CI 0.67–0.98, P = 0.03). Conclusion: Our findings suggest that supplemental PHI in Australia is associated with lower‐risk ESKD treatment attributes and improved health outcomes. A greater understanding of the treatment pathways that deliver these outcomes may inform treatment for the broader ESKD treatment population. [ABSTRACT FROM AUTHOR]

Background. There is no consensus whether higher intensity dose renal replacement therapy (RRT) compared with standard intensity RRT has survival benefit and achieves better renal recovery in acute kidney injury (AKI). Methods. In an individual patient data meta-analysis, we merged individual patient data from randomized controlled trials (RCTs) comparing high with standard intensity RRT in intensive care unit patients with severe AKI. The primary outcome was allcause mortality. The secondary outcome was renal recovery assessed as the proportion of patients who were RRT dependent at key trial endpoints and by time to the end of RRT dependence. Results. Of the eight prospective RCTs assessing different RRT intensities, seven contributed individual patient data (n=3682) to the analysis. Mortality was similar between the two groups at 28 days [769/1884 (40.8%) and 744/1798 (41.4%), respectively; P=0.40] after randomization. However, more participants assigned to higher intensity therapy remained RRT dependent at themost common key study point of 28 days [e.g. 292/983 (29.7%) versus 235/943 (24.9%); relative risk 1.15 (95% confidence interval 1.00-1.33); P=0.05]. Time to cessation of RRT through 28 days was longer in patients receiving higher intensity RRT (log-rank test P=0.02) and when continuous renal replacement therapy was used as the initialmodality of RRT (log-rank test P=0.03). Conclusions. In severe AKI patients, higher intensity RRT does not affectmortality but appears to delay renal recovery. [ABSTRACT FROM AUTHOR]

Aim To compare comorbidity recording and predictive power of comorbidities for mortality between a clinical renal registry and a state-based hospitalisation dataset. Methods All patients that started renal replacement therapy (dialysis or transplant - RRT) in New South Wales between 1/07/2001 and 31/7/2010 were identified using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and linked to the State Admitted Patient Data Collection (APDC) and the Death Registry. Comorbidities (diabetes mellitus, coronary artery disease (CAD), chronic lung disease, peripheral vascular disease and cerebrovascular disease) were identified at the start of RRT in both datasets and compared using kappa statistics (κ). Survival was calculated using cox proportional hazards models from the start of RRT to death date or end of study (31/07/2011). Four multivariable models were adjusted for age, gender and comorbidities to estimate the predictive power of the comorbidities as recorded in ANZDATA, APDC, either or both datasets Results We identified 6285 people (23,845 person-years follow-up). Diabetes recording had excellent agreement (94.5%, κ = 0.88), CAD had fair to good agreement (80. 6, κ = 0.56), with poor agreement between the two datasets for the other comorbidities. Deaths totalled 2594 (41.3%). Median follow up time was 3.3 years (IQR 1.7 to 5.4). All five comorbidities were powerful predictors of poor survival in all four models. All models had a similar predictive ability (Harrell's c = 0.71-0.72). Conclusion Variable agreement exists in comorbidity recording between the ANZDATA and APDC. The comorbidities have a similar predictive ability, irrespective of dataset of origin in an End Stage Kidney Disease (ESKD) population. [ABSTRACT FROM AUTHOR]

Aim Elderly people comprise a large and growing proportion of the global dialysis population. Regional differences in rates of dialysis in the elderly suggest multiple factors influence treatment decision-making including beliefs about the relative benefits and harms of dialysis and supportive (non-dialysis) care. We therefore systematically reviewed the literature reporting survival of elderly patients treated with either treatment pathway. Methods Systematic review and meta-analysis of cohort studies or randomized controlled trials identified in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials published before July 2014. Survival by treatment modality was calculated. Subgroup analyses by study design, study size, patient age and cohort era were conducted. Results Eighty-nine studies published between 1976 and 2014 reported on 294 921 elderly end-stage kidney disease ( ESKD) patients. There was a paucity of data for supportive care (724 patients or 0.2% of the total patients) and supportive care studies were susceptible to lead-time bias. One-year survival for elderly patients treated with undifferentiated dialysis was 73.0% (95% confidence interval ( CI) 66.3-79.7%), 78.4% (95% CI 75.2-81.6) for haemodialysis and 77.9% (95% CI 73.8-81.9) for peritoneal dialysis. Supportive care patients had a 1-year survival of 70.6% (95% CI 63.3-78.0%). Residual heterogeneity remained within individual treatment modalities despite subgroup analyses. Conclusions While the available literature demonstrates a broadly similar 1-year survival in elderly ESKD patients, it does not allow a confident estimate of the relative survival benefits of dialysis or supportive care. This uncertainty needs urgent attendance by further prospective data, which avoid bias and allow comparisons of quality of life and survival. [ABSTRACT FROM AUTHOR]

Background: Chronic kidney disease is a significant contributor to mortality and morbidity worldwide, and the number of people who require dialysis or transplantation continues to increase. People on dialysis are 15 times more likely to die than the general population. Dialysis is also costly, intrusive, and time-consuming and imposes an enormous burden on patients and their families. This escalating problem has spurred a proliferation of trials in dialysis, yet health and quality of life remain poor. The reasons for this are complex and varied but are attributable in part to problems in the design and reporting of studies, particularly outcome selection. Problems related to outcomes include use of unvalidated surrogates, outcomes of little or no relevance to patients, highly variable outcome selection limiting comparability across studies, and bias in reporting outcomes. The aim of the Standardised Outcomes in Nephrology-Haemodialysis (SONG-HD) study is to establish a core outcome set for haemodialysis trials, to improve the quality of reporting, and the relevance of trials conducted in people on haemodialysis. Methods/design: SONG-HD is a five-phase project that includes the following: a systematic review to identify outcomes that have been reported in haemodialysis systematic reviews and trials; nominal group technique with patients and caregivers to identify, rank, and describe reasons for their choices; qualitative stakeholder interviews with patients, caregivers, clinicians, researchers, and policy makers to elicit individual values and perspectives on outcomes for haemodialysis trials; a three-round Delphi survey with stakeholder groups to distil and generate a prioritised list of core outcomes; and a consensus workshop to establish a core outcome set for haemodialysis trials. Discussion: Establishing a core outcome set to be consistently measured and reported in haemodialysis trials will improve the integrity, transparency, usability, and contribution of research relevant to patients requiring haemodialysis; ensure that outcomes of relevance to all stakeholders are consistently reported across trials; and mitigate against outcome reporting bias. Ultimately, patients will be more protected from potential harm, patients and clinicians will be better able to make informed decisions about treatment, and researchers and policy makers will be more able to maximise the value of research to the public. [ABSTRACT FROM AUTHOR]

Aim Long-term prospective studies of health outcomes for dialysis patients are common in many parts of the world but have been rare in India. As renal replacement therapy becomes more widespread and more affordable, the measurement of patient outcomes and comparison with national and international benchmarks will be a valuable tool in planning health services and demonstrating effective use of resources. To this end, we describe a pilot study of dialysis outcomes in India which could form the basis of a comprehensive national programme of data collection. Methods One hundred incident patients commencing chronic haemodialysis in two north Indian nephrology centres will be followed prospectively for 12 months. Clinical outcome data will be collected comparable with that used by established dialysis registries in other countries. The economic impact of dialysis upon patients is central to the use of this treatment, so data will be collected on the direct and indirect costs of the treatment and the economic impact of dialysis on the patient and their family. Value of Project This prospective cohort study of dialysis outcomes in northern India is a pilot for the collection of similar comparative data in dialysis centres in different states across the country with a view to the development of a national dialysis registry. The information on the economic impact of dialysis on patients and their families will provide one of the first detailed insights into this critical aspect of dialysis services. [ABSTRACT FROM AUTHOR]

Aims Observational reports suggest extended dialysis hours are associated with improved outcomes. These findings are confounded by better prognostic characteristics among people practising extended hours. The aim of this article is to provide an overview of the methods and baseline characteristics for ACTIVE Dialysis Study participants. Methods This multicentre, randomized, open-label, blinded endpoint-assessment trial randomized participants receiving maintenance haemodialysis therapy to either extended (≥24 h) or standard (12-18 h) weekly haemodialysis for 12 months. A web-based randomization system used minimization to ensure balanced allocation across regions, dialysis setting and dialysis vintage. The primary outcome is the change in quality of life over 12 months of study treatment assessed by EQ-5D. Secondary outcomes include change in left ventricular mass index assessed by magnetic resonance imaging and safety outcomes including dialysis access events. Results A total of 200 participants were recruited between 2009 and 2013 from Australia (29.0%), China (62.0%), Canada (5.5%) and New Zealand (3.5%). Participants had a mean age of 52 (± 12) years and 11.5% were dialysing at home, with a mean duration of 13.9 h per week over a median of three sessions. At baseline, 32.5% had a history of cardiovascular disease and 36.5% had diabetes. Conclusion The ACTIVE Dialysis Study has met its planned recruitment target. The participant population are drawn from a range of health service settings in a global context. The study will contribute important evidence on the benefits and harms of extending weekly dialysis hours. The trial is registered at clinicaltrials.gov ( NCT00649298). [ABSTRACT FROM AUTHOR]

Background Nephrologists often face difficult decisions when recommending dialysis or non-dialysis (supportive) care for elderly patients, given the uncertainty around survival and the burden of dialysis. Discrete choice experiments (DCEs) mimic real-world decisions through simultaneous consideration of multiple variables. We aimed to determine the relative influence of patient characteristics on dialysis recommendations. Methods We conducted a DCE among Australasian nephrologists consisting of 12 scenarios of two patients (described in terms of age, gender, cognition, comorbidity, life expectancy, current quality of life (QOL), expected QOL with dialysis, social support, patient and family inclination). Nephrologists indicated which patient they preferred recommending dialysis for, or whether they preferred ‘neither’. Mixed logit models determined the odds of recommending dialysis over no dialysis. Trade-offs between QOL and survival were calculated. Results A total of 159 nephrologists participated (34% aged 40–49 years, 62% male and 69% Caucasian). All patient characteristics except gender significantly affected the likelihood of dialysis recommendation. Nephrologists were more likely to recommend dialysis for patients with preserved cognition (odds ratio [OR]: 68.3; 95% confidence interval [CI]: 33.4–140.0), lower comorbidity (OR: 2.1; 95% CI: 1.1–4.1), increased life expectancy (OR: 2.8; 95% CI: 2.1–3.7), high current QOL (OR: 2.8; 95% CI: 2.0–3.8) and positive patient and family dialysis inclination (OR: 27.5; 95% CI: 16.2–46.8 and OR: 2.0; 95% CI: 1.3–3.3, respectively). Nephrologists aged >65 were more likely (OR: 11.7; 95% CI: 1.8–77.2) to recommend dialysis. Nephrologists were willing to forgo 12 months of patient survival to avoid substantial QOL decrease with dialysis. Conclusion Nephrologists avoided dialysis recommendation if it was expected to considerably reduce QOL. To inform elderly patients' dialysis decisions, systematic and longitudinal cognition and QOL evaluations are needed as well as better research into understanding patient preferences. [ABSTRACT FROM AUTHOR]

Background Catheter malfunction (CM), including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter-related bacteraemia (CRB) and mortality. The role of alternative anticoagulant regimens for CM prevention remains uncertain. Methods A systematic review and meta-analysis were performed examining all randomized controlled trials (RCTs) assessing interventions acting via an anticoagulant mechanism compared with conventional care for the prevention of CM in adult patients receiving haemodialysis for end-stage kidney disease. Medline, EMBASE and the Cochrane Register were searched to November 2012. The primary outcome was CM. Secondary outcomes were CRB, all-cause mortality and bleeding events (all bleeding events reported or as defined by authors). Relative risks with 95% confidence intervals (CIs) for individual trials were pooled using random effects models for treatment classes. Results The search yielded 28 trials including 3081 patients. Therapies assessed were alternative anticoagulant locking solutions (ALSs), systemic warfarin and low/no dose heparin locking solutions (normal saline locks). No significant effect on CM (18 trials, 1579 participants) was observed for alternative ALSs (9 trials, 887 participants, RR 0.85, 95% CI 0.68–1.07), or low/no dose heparin (4 trials, 231 participants, RR 0.99, CI 0.60–1.62), compared with heparin locking solutions (5000 units). Similarly, no significant effect was observed for warfarin (5 trials, 479 participants, RR 0.59, 95% CI 0.28–1.22) compared with placebo. No significant effect on CRB was observed (15 trials, 2367 participants) for alternative ALSs (11 trials, 2010 participants, RR 0.57, 95% CI 0.30–1.10), warfarin (1 trial, 174 participants, RR 2.40, 95% CI 0.88–6.52) or low/no dose heparin (3 trials, 183 participants, RR 0.76, 95% CI 0.35–1.64). All-cause mortality was not affected by alternative ALSs (9 trials, 1719 participants, RR 0.83, 95% CI 0.56–1.24) or warfarin (3 trials, 403 participants, RR 0.78, 95% CI 0.37–1.65). Bleeding events were only reported in seven trials, including only two trials of warfarin, with no clear effect demonstrated. Within the alternative ALSs group, the only agent with a reduction in CM was recombinant tissue plasminogen activator (rt-PA)-locking solution (RR 0.52, 95% CI 0.32–0.86) based on the results of a single trial. Trials were mainly of high risk of bias. Conclusions There is uncertainty on the benefits and harms of anticoagulant therapies over conventional care for prevention of CM. Further high-quality randomized trials, including safety outcomes, are needed. [ABSTRACT FROM PUBLISHER]

Establishing and maintaining hemodialysis access are major challenges in dialysis patient care. The impact of implementing guideline recommendations around vascular access surveillance, which lacks strong evidence, is poorly understood. We report the results of a vascular access surveillance and early intervention program upon hemodialysis thrombosis rates for all patients hemodialyzing in a single center between January 2005 and March 2011. Data were derived from hospital records and the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). Data were collected of 227 prevalent patients over the 6-year period. Crude ultrasound and angiography intervention rates increased from 23 and 57 per 100 prevalent patients per quarter (/100 pts/qtr) to 31 and 83/100 pts/qtr, respectively, during the study. Crude thrombosis rates fell from 21 to 2/100 pts/qtr during the study. After adjustment for comorbidities, mean ultrasound use increased by 4.6% per quarter (95% CI: 2.4-6.9, p < 0.001), mean interventional angiography increased by 2.6% per quarter (95% CI: 1.1-4.2, p = 0.001), and the predicted mean of the number of thromboses decreased by 8.4% per quarter (95% CI: 5.6-11.1, p < 0.001). Implementation of a vascular access surveillance increases service utilization and is associated with a reduction in vascular access thrombosis. [ABSTRACT FROM AUTHOR]

A significant proportion of peritoneal dialysis ( PD) patients will have abrupt technique failure requiring conversion to haemodialysis, often using temporary vascular catheters as bridging access. However, vascular catheter use has been associated with increased mortality and great effort has been made to reduce their use. Just under two decades ago, a trial of dual arteriovenous fistula ( AVF) formation and Tenckhoff catheter insertion reported only 4% of those in whom back-up fistulae were formed ever used them. Patient demographic, surgical technique and fistula care over those decades have changed substantially, potentially making this practice feasible. Thirty-five selected patients at Concord Repatriation and General Hospital had AVF formed at the time of Tenckhoff insertion and were entered prospectively into a vascular access database. We retrospectively examined this database with a median follow up of 345 days (interquartile range 183-658). Thirty-one per cent of all patients used the preformed AVF, and a further 19% who were still on PD had clinically functioning AVF. The vast majority (62%) had abrupt PD technique failure. This is a marked difference to dated reports of AVF use after concurrent PD and AVF formation. It raises the possibility that the formation of back-up fistula may be another method to reduce the need for vascular catheter use. [ABSTRACT FROM AUTHOR]

Introduction In a tertiary Australian teaching hospital, patients on haemodialysis (HD) requiring surgery are routinely scheduled for HD on the day prior to surgery.The existing protocol requires patients to remain at the hospital for an additional four hours following dialysis, to have a blood sample taken to assess serum electrolytes prior to surgery. There is little evidence to support this practice. We sought to examine the kinetics of serum potassium changes following routine dialysis in our unit, with a view to understanding the optimal time for post-dialysis electrolyte sampling. Method Following routine dialysis in otherwise stable patients (n=30), blood samples for serum potassium were collected at pre-dialysis, end dialysis (0 minutes) and 30, 60, 120 and 240 minutes post-dialysis. Data were plotted against time, to determine a clinically relevant interval before sampling. Results The major, clinically relevant shift in potassium levels was observed in the first hour following dialysis. Mean serum potassium levels (+/- SD) at pre, 0, 30, 60, 120 and 240 minutes were 4.3 (0.63) mmol/L, 3.26 (0.43) mmol/L, 3.36 (0.42) mmol/L, 3.5 (0.37) mmol/L, 3.54 (0.46) mmol/L and 3.76 (0.53) mmol/L respectively. Conclusion We conclude that a four-hour wait for sampling is longer than necessary and that a reasonable estimate of serum potassium for clinical purposes should be apparent 60 minutes following routine dialysis. [ABSTRACT FROM AUTHOR]

Variability in implementing research evidence into clinical practice is widespread, including in the management of patients with kidney disease. There are numerous well-known barriers and facilitators to evidence implementation identified in other clinical settings and a few chronic kidney disease studies. The necessary changes to health systems that support evidence implementation take time to design, apply and to have a measurable effect. Measurement against an agreed standard is fundamental to this process. We use the example of renal anaemia management across a dialysis unit to illustrate an approach to these issues. [ABSTRACT FROM AUTHOR]

The article discusses a study which aimed to examine the association between mean daily fluid balance and patient outcomes in the randomized evaluation of normal versus augmented level of replacement therapy trial. Results show that a negative fluid balance is associated with a decreased risk of death at 90 days. It concluded that fluid balance may be a target for specific manipulation in future interventional trials of critically ill patients receiving renal replacement therapy.