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Eighty-two percent (82%) of patients initiating hemodialysis in the United States in 2006 did so with a catheter as the functioning access. Even in patients who have been followed by nephrologists for 6 months or more, 74% of patients initiated dialysis with a catheter. This is a multifactoral problem that requires attention and solutions from all stakeholders, including the nephrologist, the vascular surgeon, the hospital, and the insurance industry, as well as the patient and family. We propose a series of specific proposals that include a process for the timely referral and timely placement of a permanent access based on the patient's estimated or measured glomerular filtration rate (GFR), and a ‘pay-for-performance’ measure for vascular surgeons and nephrologists who admit patients with functional permanent accesses; such pay for performance would place a higher value for patients who are admitted with a functional arteriovenous (AV) fistula than for patients who are admitted with an AV graft. We also propose that hospitals develop a less permissive process for placement of PICC (peripherally inserted central catheters) lines in patients with GFR <60 ml/min and to consider surgery for access placement as ‘urgent’. Finally, a more proactive educational process for patients and their families, including an ‘informed non-consent’ for patients who defer placement of a permanent access needs to be considered. The morbidity, mortality, and health-care costs associated with prolonged catheter use mandate urgent attention to this problem. [ABSTRACT FROM AUTHOR]

Use of intradialytic oral nutritional supplements (ONS) improve nutritional biomarkers but an association with survival has not been proven. We evaluated mortality, comparing patients with serum albumin ≤3.5 g/dL who received monitored ONS (at no patient cost) during chronic outpatient hemodialysis (HD) as part of a standardized national program in Fresenius Medical Care, North America facilities, with eligible patients who did not receive ONS (controls). Participation was promoted but not mandatory. Study enrolment covered Q4‐2009 and follow‐up was until 12/31/10. Patients who received ONS outside of the program or started during 2010 were excluded. Two protein bars and two liquid formulations of ONS options were offered, which were available until albumin was ≥ 4.0 g/dL. Crude mortality in the ONS group (N= 7,264) was 29.4% vs. 36.6% for controls (N= 13,853), p<0.001. Compared to controls, the unadjusted mortality hazard ratio for ONS was 0.70 (0.67, 0.74) and after adjustment for baseline case‐mix and 5 quality indicators was 0.68 (0.64, 0.71). Although limited by the observational design, these results indicate favorable survival associated with ONS use in malnourished chronic HD patients with albumin ≤3.5 g/dL. [ABSTRACT FROM AUTHOR]

We hypothesized that glycosylated hemoglobin (HghA1c) that is averaged for a period of 1 year is relatively stable within hemodialysis (HD) patients and maintains a good correlation with the yearlong averaged random pre-dialysis blood glucose. HD patients in the database of a large dialysis organization with a diagnosis of diabetes and ≥3 HgbA1c results during 2002 who were present from Jan. 1, 2003 to Jan. 1, 2004 formed the study cohort. All available HgbA1c values and pre-dialysis blood glucose measurements were included in computing the averages. There were 18, 867 patients with mean age 63.9 ± 12 years, 52% female, 51% white and 39% black, 90% type 2 diabetes, with mean HgbA1c 6.8 ± 1.5% (median 6.5%) and mean glucose 169 ± 68 mg/dL (median 156 mg/dL). The distribution of the standard deviations (SD) of the HgbA1c in individual patients is shown below. Eighteen percent of patients had HghA1c SD > 1%. The association with random pre-dialysis blood glucose averaged over 1 year is R=0.68 (p < 0.001). The HgbA1c appears stable over the course of the year for most patients with median HgbA1c SD at 0.5%. The prognostic significance of high vs. low HgbA1c variability remains to be determined. [ABSTRACT FROM AUTHOR]

Mortality rates for maintenance hemodialysis patients are much higher than the general population and are even greater soon after starting dialysis. Here we analyzed mortality patterns in 86,886 patients in 11 countries focusing on the early dialysis period using data from the Dialysis Outcomes and Practice Patterns Study, a prospective cohort study of in-center hemodialysis. The primary outcome was all-cause mortality, using time-dependent Cox regression, stratified by study phase adjusted for age, sex, race, and diabetes. The main predictor was time since dialysis start as divided into early (up to 120 days), intermediate (121-365 days), and late (over 365 days) periods. Mortality rates (deaths/100 patient-years) were 26.7 (95% confidence intervals 25.6-27.9), 16.9 (16.2-17.6), and 13.7 (13.5-14.0) in the early, intermediate, and late periods, respectively. In each country, mortality was higher in the early compared to the intermediate period, with a range of adjusted mortality ratios from 3.10 (2.22-4.32) in Japan to 1.15 (0.87-1.53) in the United Kingdom. Adjusted mortality rates were similar for intermediate and late periods. The ratio of elevated mortality rates in the early to the intermediate period increased with age. Within each period, mortality was higher in the United States than in most other countries. Thus, internationally, the early hemodialysis period is a high-risk time for all countries studied, with substantial differences in mortality between countries. Efforts to improve outcomes should focus on the transition period and the first few months of dialysis. [ABSTRACT FROM AUTHOR]

To compare the relative effectiveness of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in reducing cardiovascular mortality in chronic hemodialysis patients, we conducted an observational analysis of all patients initiated on ACEI or ARB therapy undergoing chronic hemodialysis at a large dialysis provider. Survival curves with mortality hazard ratios (HRs) were generated using the Kaplan-Meier method and Cox regression. Outcomes were compared using inverse probability of treatment weighting and propensity score matching. Over 6 years, 22,800 patients were newly initiated on an ACEI and 5828 on an ARB after at least 60 days of chronic hemodialysis. After adjustment for baseline cardiovascular risk factors, there was no significant difference in the risk of cardiovascular, all-cause, or cerebrovascular mortality in patients initiated on an ARB compared with an ACEI (HR of 0.96). A third of 28,628 patients, newly started on an ACEI or ARB, went on to another antihypertensive medication in succession. After adjustment for risk factors, 701 patients initiated on combined ACEI and ARB therapy (HR of 1.45) or 6866 patients on ACEI and non-ARB antihypertensive agent (HR of 1.27) were at increased risk of cardiovascular death compared with 1758 patients initiated on an ARB and non-ACEI antihypertensive therapy. Thus, an ARB, in combination with another antihypertensive medication (but not an ACEI), may have a beneficial effect on cardiovascular mortality. As observational studies may be confounded by indication, even when adjusted, randomized clinical trials are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Dialysis patients have a greater number of hospitalization events compared to patients without renal failure. Here we studied the relationship between different post-discharge interventions and repeat hospitalization in over 126,000 prevalent hemodialysis patients to explore outpatient strategies that minimize the risk of repeat hospitalization. The primary outcome was repeat hospitalization within 30 days of discharge. Compared to pre-hospitalization values, the levels of hemoglobin, albumin, phosphorus, calcium, and parathyroid hormone and weight were significantly decreased after hospitalization. Using covariate-adjusted models, those patients whose hemoglobin was monitored within the first 7 days after discharge, followed by modification of their erythropoietin dose had a significantly reduced risk for repeat-hospitalization when compared to the patients whose hemoglobin was not checked, nor was the dose of erythropoietin changed. Similarly, administration of vitamin D within the 7 days following discharge was significantly associated with reduced repeat hospitalization when compared to patients on no vitamin D. Therefore, it appears that immediate re-evaluation of anemia management orders and resumption of vitamin D soon after discharge may be an effective way to reduce repeat hospitalization.Kidney International (2009) 76, 331–341; doi:10.1038/ki.2009.199; published online 10 June 2009 [ABSTRACT FROM AUTHOR]