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Since the publication of the first vascular access clinical practice guidelines in 1997, the global nephrology community has dedicated significant time and resources toward increasing the prevalence of arteriovenous fistulas and decreasing the prevalence of central venous catheters for hemodialysis. These efforts have been bolstered by observational studies showing an association between catheter use and increased patient morbidity and mortality. To date, however, no randomized comparisons of the outcomes of different forms of vascular access have been conducted. There is mounting evidence that much of the difference in patient outcomes may be explained by patient factors, rather than choice of vascular access. Some have called into question the appropriateness of fistula creation for certain patient populations, such as those with limited life expectancy and those at high risk of fistula-related complications. In this review, we explore the extent to which catheters and fistulas exhibit the characteristics of the "ideal" vascular access and highlight the significant knowledge gaps that exist in the current literature. Further studies, ideally randomized comparisons of different forms of vascular access, are required to better inform shared decision making. [ABSTRACT FROM AUTHOR]

Background: Older patients with end-stage renal disease (ESRD) are less likely to choose peritoneal dialysis (PD) over hemodialysis (HD). The reasons behind their choice of dialysis modality are not clear. This study seeks to determine the patient-perceived factors that influence ESRD patients' choice of dialysis modality among older ESRD patients who are deemed eligible for both PD and HD. Methods: All patients had completed a multidisciplinary modality assessment, were deemed eligible for both PD and HD, and had received modality education. Semi-structured interviews were conducted and transcripts were read repeatedly to derive potential codes using line-by-line textual analysis. The Capability, Opportunity,Motivation- Behaviour (COM-B) and Theoretical Domain Framework (TDF),validated tools that were developed for designing behavioral change interventions, were used to help guide the coding framework. Results: Among older ESRD patients who are deemed eligible for both PD and HD,factors relevant to their modality decision-making were identified with respect to physical strength/dexterity and having a sound mind (capability), external forces and constraints (opportunity), and values and beliefs (motivation). Often a combination of factors led to an individual's choice of a particular dialysis modality. However, preferences for PD were primarily based around convenience and maintaining a normal life,while a heightened sense of security was the primary reason for those who selected HD. Conclusions: We have identified patient-perceived factors that influence choice of dialysis modality in older individuals with ESRD who are eligible for PD and HD. These factors should be considered and/or addressed within PD programs seeking to promote PD. [ABSTRACT FROM AUTHOR]

Background. Although primary care physicians (PCPs) are often responsible for the routine care of older adults with chronic kidney disease (CKD), there is a paucity of evidence regarding their perspectives and practice of conservative (non-dialysis) care. We undertook a qualitative study to describe barriers, facilitators and strategies to enhance conservative, non-dialysis, CKD care by PCPs in the community. Methods. Semi-structured telephone and face-to-face interviews were conducted with PCPs from Alberta, Canada. Participants were identified using a snowball sampling strategy and purposively sampled based on sex, age and rural/urban location of clinical practice. Eligible participants had managed at least one patient =75 years with Stage 5 CKD (estimated glomerular filtration rate <15 mL/min/1.73 m², not on dialysis) in the prior year. Participant recruitment ceased when data saturation was reached. Transcripts were analyzed thematically using conventional content analysis. Results. In total, 27 PCPs were interviewed. The majority were male (15/27), were aged 40-60 years (15/27) and had practiced in primary care for >20 years (14/27). Perceived barriers to conservative CKD care included: managing expectations of kidney failure for patients and their families; dealing with the complexity of medical management of patients requiring conservative care; and challenges associated with managing patients jointly with specialists. Factors that facilitated conservative CKD care included: establishing patient/family expectations early; preserving continuity of care; and utilizing a multidisciplinary teamapproach. Suggested strategies for improving conservative care included having: direct telephone access to clinicians familiar with conservative care; treatment decision aids for patients and their families; and a conservative care clinical pathway to guide management. Conclusions. PCPs identified important barriers and facilitators to conservative care for their older patients with Stage 5 CKD. Further investigation of potential strategies that address barriers and enable facilitators is required to improve the quality of conservative care for older adults in the community. [ABSTRACT FROM AUTHOR]

Background. Poisson regression is commonly used to analyze hospitalization data when outcomes are expressed as counts (e.g. number of days in hospital). However, data often violate the assumptions on which Poisson regression is based. More appropriate extensions of this model, while available, are rarely used. Methods. We compared hospitalization data between 206 patients treated with hemodialysis (HD) and 107 treated with peritoneal dialysis (PD) using Poisson regression and compared results from standard Poisson regression with those obtained using three other approaches for modeling count data: negative binomial (NB) regression, zero-inflated Poisson (ZIP) regression and zero-inflated negative binomial (ZINB) regression. We examined the appropriateness of each model and compared the results obtained with each approach. Results. During a mean 1.9 years of follow-up, 183 of 313 patients (58%) were never hospitalized (indicating an excess of 'zeros'). The data also displayed overdispersion (variance greater than mean), violating another assumption of the Poisson model. Using four criteria, we determined that the NB and ZINB models performed best. According to these two models, patients treated with HD experienced similar hospitalization rates as those receiving PD {NB rate ratio (RR): 1.04 [bootstrapped 95% confidence interval (CI): 0.49-2.20]; ZINB summary RR: 1.21 (bootstrapped 95% CI 0.60-2.46)}. Poisson and ZIP models fit the data poorly and had much larger point estimates than the NB and ZINB models [Poisson RR: 1.93 (bootstrapped 95% CI 0.88-4.23); ZIP summary RR: 1.84 (bootstrapped 95% CI 0.88-3.84)]. Conclusions. We found substantially different results when modeling hospitalization data, depending on the approach used. Our results argue strongly for a sound model selection process and improved reporting around statistical methods used for modeling count data. [ABSTRACT FROM AUTHOR]

Background: Unfractionated heparin is the most common anticoagulant used in haemodialysis (HD), although it has many potential adverse effects. Citrate dialysate (CD) has an anticoagulant effect which may allow reduction in cumulative heparin dose (CHD) compared to standard acetate dialysate (AD). Methods: This double-blinded, randomised, cross-over trial of chronic haemodialysis patients determines if CD allows reduction in CHD during HD compared with AD. After enrolment, intradialytic heparin is minimised during a two-week run-in period using a standardised protocol based on a visual clotting score. Patients still requiring intradialytic heparin after the run-in period are randomised to two weeks of HD with AD followed by two weeks of CD (Sequence 1) or two weeks of HD with CD followed by two weeks of AD (Sequence 2). The primary outcome is the change in CHD with CD compared with AD. Secondary outcomes include metabolic and haemodynamic parameters, and dialysis adequacy. Discussion: This randomised controlled trial will determine the impact of CD compared with AD on CHD during HD. Trial registration: ClinicalTrials.gov NCT01466959 [ABSTRACT FROM AUTHOR]

Background Fluid removal during dialysis, also known as ultrafiltration (UF), leads to intradialytic hypotension (IDH) in a significant number of patients treated with hemodialysis (HD) and is associated with an increase in morbidity and mortality. At present, there are no accepted standards of practice for the prevention or treatment of IDH. Relative blood volume monitoring (BVM) is based on the concept that the hematocrit increases with UF, relative to the patient's baseline hematocrit. The use of BVM biofeedback, whereby the HD machine automatically adjusts the rate of UF based on the relative blood volume, has been proposed for the prevention of IDH. Methods/Design This is a 22-week randomized crossover trial. Participants undergo a 4-week run-in phase to standardize medications and dialysis prescriptions. Subsequently, participants are randomized to standard HD or to BVM biofeedback for a period of 8 weeks followed by a 2-week washout phase before crossing over. The dialysis prescription remains identical for both arms. The primary outcome is the frequency of symptomatic IDH as defined by an abrupt drop in the systolic blood pressure of =20 mm Hg accompanied by headache, dizziness, loss of consciousness, thirst, dyspnea, angina, muscle cramps or vomiting. Secondary outcomes include the number of symptomatic IDH episodes and any reduction in IDH episodes, nursing interventions, dialysis adequacy, total body water, extra- and intracellular fluid volumes, brain natriuretic peptide and cardiac troponin levels, blood pressure, antihypertensive medication use, patient symptoms and quality of life. Discussion Our study will determine the impact of using BVM biofeedback to prevent IDH and other serious adverse events in susceptible patients. [ABSTRACT FROM AUTHOR]

The article discusses the Initiating Dialysis Early and Late study which discussed the previous guidelines on dialysis initiation by the Canadian Society of Nephrology. Topics include the target audience and population, the guideline panel composition, and the guideline development methods. Also noted are the lack of evidence or rationale to support separate recommendations for patients initiating peritoneal versus hemodialysis and the recommendation for an intent-to-defer approach to dialysis.

Abstract: Background: Acute kidney injury frequently arises within an acute care hospitalization. Outcomes among acute kidney injury survivors following hospital discharge are poorly documented. Methods: We conducted a population-based cohort study between 1996 and 2006 of all adult patients in Ontario with acute kidney injury who did not require in-hospital dialysis, and who survived free of dialysis ≥30 days after discharge. Those with acute kidney injury (n=41,327) were matched 1:1 to patients without acute kidney injury during their index hospitalization. Matching was by age (±1 year), sex, history of chronic kidney disease, receipt of mechanical ventilation during the index hospitalization, and a propensity score for developing acute kidney injury. The primary outcome was subsequent need for chronic dialysis. The secondary outcomes were all-cause mortality and rehospitalization. Results: Mean age was 70 years, and median follow-up was 2 years (maximum 10 years). The incidence of chronic dialysis was 1.78 per 100 person-years among those with acute kidney injury and 0.74 per 100 person-years among unaffected controls (adjusted hazard ratio [HR]; 2.70, 95% confidence interval [CI], 2.42-3.00). Rates also were higher for all-cause mortality (15.34 vs 14.51 per-100 person-years; adjusted HR 1.10; 95% CI, 1.07-1.13) and rehospitalization (44.93 vs 37.18 per 100 person-years; adjusted HR 1.21; 95% CI, 1.18-1.24). Conclusion: Even when acute dialysis is not required, survivors of acute kidney injury remain at higher risk of receipt of chronic dialysis thereafter. The absolute risk of death was more than 8 times the rate of chronic dialysis. [Copyright &y& Elsevier]

Background. Beta-blockers may be cardioprotective in patients receiving chronic dialysis. We examined cardiovascular outcomes among incident dialysis patients receiving beta-blocker therapy.Methods. We conducted a retrospective cohort study employing linked healthcare databases in Ontario, Canada. We studied all consecutive chronic dialysis patients aged ≥66 years who initiated dialysis between 1 July 1991 and 31 July 2007. Patients were divided into three groups according to new medication use after the initiation of chronic dialysis. The three groups were patients initiated on beta-blockers, calcium channel blockers and statins only. Patients in the beta-blocker and calcium channel blocker groups could also be concurrently receiving a statin. The primary outcome was time to a composite endpoint of death, myocardial infarction, stroke or coronary revascularization.Results. There were a total of 1836 patients (504 beta-blocker, 570 calcium channel blocker and 762 statin-only users). Compared to statin-only use, beta-blocker use was not associated with improved cardiovascular outcomes [adjusted hazard ratio (aHR) 1.07, 95% confidence interval (CI) 0.92–1.23]. As expected, calcium channel blocker use was also not associated with improved cardiovascular outcomes (aHR 0.91, 95% CI 0.79–1.06). Among all subgroup analyses by beta-blocker attributes, only high-dose beta-blocker therapy was associated with better cardiovascular outcomes as compared to low-dose beta-blockers (aHR 0.50, 95% CI 0.29–0.88).Conclusions. We observed no beneficial effect of beta-blocker use among patients receiving chronic dialysis relative to our comparator groups. Given current uncertainty around the cardioprotective benefits of beta-blockers in patients receiving dialysis, a large randomized clinical trial is warranted. [ABSTRACT FROM PUBLISHER]

Background. Patients choosing between hemodialysis (HD) and peritoneal dialysis (PD) should be well informed of the risks and benefits of each modality. Invasive access interventions are important outcomes because frequent interventions lower patient’s quality of life and consume limited resources. The objective of this study was to compare the risk of access interventions between the two modalities. Methods. Three hundred and sixty-nine incident chronic dialysis patients were prospectively enrolled at four Canadian centers that were eligible for both modalities, received at least 4 months of pre-dialysis care and started dialysis electively as an outpatient. Two hundred and twenty-four (61%) chose PD and 145 (39%) chose HD. Patients were followed for an average of 1.3 years (range 0.07–3.6 years). Results. In the PD group, there were fewer access interventions (2.5 versus 3.1 interventions per patient, adjusted odds ratio of 0.79 for PD versus HD, P = 0.005) and a lower intervention rate (2.3 versus 1.9 per patient-year, adjusted rate ratio of 0.81 for PD versus HD, P = 0.04). PD catheters were less likely to experience primary failure (4.6 versus 32%, P < 0.0001), showed a trend toward lower intervention rates during use (0.8 versus 1.2 per patient-year, P = 0.06), and had equal patency compared to fistulae (1-year patency of 84 versus 88%, P = 0.48). Patients managed exclusively with HD catheters (28% of the HD group) required 1.7 interventions per patient and an intervention rate of 1.9 per patient-year. Conclusion. Patients who choose PD require fewer access interventions to maintain dialysis access than patients choosing HD. [ABSTRACT FROM AUTHOR]

Background: Administrative health care databases offer an efficient and accessible, though as-yet unvalidated, approach to studying outcomes of patients with chronic kidney disease and end-stage renal disease (ESRD). The objective of this study is to determine the validity of outpatient physician billing derived algorithms for defining chronic dialysis compared to a reference standard ESRD registry. Methods: A cohort of incident dialysis patients (Jan. 1 - Dec. 31, 2008) and prevalent chronic dialysis patients (Jan 1, 2008) was selected from a geographically inclusive ESRD registry and administrative database. Four administrative data definitions were considered: at least 1 outpatient claim, at least 2 outpatient claims, at least 2 outpatient claims at least 90 days apart, and continuous outpatient claims at least 90 days apart with no gap in claims greater than 21 days. Measures of agreement of the four administrative data definitions were compared to a reference standard (ESRD registry). Basic patient characteristics are compared between all 5 patient groups. Results: 1,118,097 individuals formed the overall population and 2,227 chronic dialysis patients were included in the ESRD registry. The three definitions requiring at least 2 outpatient claims resulted in kappa statistics between 0.60-0.80 indicating "substantial" agreement. "At least 1 outpatient claim" resulted in "excellent" agreement with a kappa statistic of 0.81. Conclusions: Of the four definitions, the simplest (at least 1 outpatient claim) performed comparatively to other definitions. The limitations of this work are the billing codes used are developed in Canada, however, other countries use similar billing practices and thus the codes could easily be mapped to other systems. Our reference standard ESRD registry may not capture all dialysis patients resulting in some misclassification. The registry is linked to on-going care so this is likely to be minimal. The definition utilized will vary with the research objective. [ABSTRACT FROM AUTHOR]

The article focuses on a population-based cohort study which assessed the risk of chronic dialysis and all-cause mortality in individuals who experience an episode of acute kidney injury requiring dialysis. The researchers used adult patients in Ontario with acute kidney injury who required in-hospital dialysis and survived free dialysis for at least 30 days after discharge between July 1, 1996 and December 31, 2006. The study found a 10.10 and 10.85 all-cause mortality rates per 100 person-years, respectively. It concluded that there is an association between acute kidney injury necessitating in-hospital dialysis with increased risk of chronic dialysis, but not all-cause mortality.

Background: Nocturnal hemodialysis (NHD) is an alternative to conventional three times per week hemodialysis (CvHD) and has been reported to improve several health outcomes. To date, no randomized controlled trial (RCT) has compared NHD and CvHD. We have undertaken a multi-center RCT in hemodialysis patients comparing the effect of NHD to CvHD on left ventricular (LV) mass, as measured by cardiac magnetic resonance imaging (cMR). Methodology/design: All patients in Alberta, Canada, expressing an interest in performing NHD are eligible for the study. Patients enrolled in the study will be randomized to either NHD or CvHD for a six month period. All patients will have a full clinical assessment, including collection of biochemical and cMR data at baseline and at 6 months. Both groups of patients will be monitored biweekly to optimize blood pressure (BP) to a goal of <130/80 mmHg post-dialysis using a predefined BP management protocol. The primary outcome is change in LV mass, a surrogate marker for cardiac mortality, measured at baseline and 6 months. The high sensitivity and reproducibility of cMR facilitates reduction of the required sample size and the time needed between measures compared with echocardiography. Secondary outcomes include BP control, anemia, mineral metabolism, health-related quality of life, and costs. Discussion: To our knowledge, this study will be the first RCT evaluating health outcomes in NHD. The impact of NHD on LV mass represents a clinically important outcome which will further elucidate the potential benefits of NHD and guide future clinical endpoint studies. [ABSTRACT FROM AUTHOR]