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Background and objectives There are inconsistent reports on the association of dietary protein intake with serum albumin and outcomes among patients on hemodialysis. Using a new normalized protein catabolic rate (nPCR) variable accounting for residual renal urea clearance, we hypothesized that higher baseline nPCR and rise in nPCR would be associated with higher serum albumin and better survival among incident hemodialysis patients. Design, setting, participants, & measurements Among 36,757 incident hemodialysis patients in a large United States dialysis organization, we examined baseline and change in renal urea clearance–corrected nPCR as a protein intake surrogate and modeled their associations with serum albumin and mortality over 5 years (1/2007–12/2011). Results Median nPCRs with and without accounting for renal urea clearance at baseline were 0.94 and 0.78 g/kg per day, respectively (median within-patient difference, 0.14 [interquartile range, 0.07–0.23] g/kg per day). During a median follow-up period of 1.4 years, 8481 deaths were observed. Baseline renal urea clearance–corrected nPCR was associated with higher serum albumin and lower mortality in the fully adjusted model (Ptrend Conclusions Among incident hemodialysis patients, higher dietary protein intake represented by nPCR and its changes over time appear to be associated with increased serum albumin levels and greater survival. nPCR may be underestimated when not accounting for renal urea clearance. Compared with the conventional nPCR, renal urea clearance–corrected nPCR may be a better marker of mortality.

Introduction Hypoalbuminemia is a predictor of poor outcomes in dialysis patients. Among hemodialysis patients, there has not been prior study of whether residual kidney function or decline over time impacts serum albumin levels. We hypothesized that a decline in residual kidney function is associated with an increase in serum albumin levels among incident hemodialysis patients. Methods In a large national cohort of 38,504 patients who initiated hemodialysis during 1/2007-12/2011, we examined the association of residual kidney function, ascertained by urine volume and renal urea clearance, with changes in serum albumin over five years across strata of baseline residual kidney function, race, and diabetes using case-mix adjusted linear mixed effects models. Findings Serum albumin levels increased over time. At baseline, patients with greater urine volume had higher serum albumin levels: 3.44 ± 0.48, 3.50 ± 0.46, 3.57 ± 0.44, 3.59 ± 0.45, and 3.65 ± 0.46 g/dL for urine volume groups of

Background: It is not clear whether peritoneal dialysis (PD) and home hemodialysis (HHD) have similar outcomes, and little is known about how mortality associated with HHD versus PD differs according to the duration of dialysis. Methods: We examined a national cohort of incident end-stage renal disease patients that was comprised of 1,993 and 16,514 patients transitioning to HHD and PD, respectively, from 2007 to 2011. The HHD patients were matched with PD patients using propensity score (PS). Demographics, comorbidities, duration of dialysis, and body mass index were adjusted for in logistic regression models using PS matching. We matched 1,915 HHD patients with 1,915 PD patients based on the PS. The patients were categorized by their vintage (duration of dialysis) at the time of the transition to HHD or PD (Results: In the matched cohort, 237 and 359 deaths occurred in the HHD and PD patients, respectively (cumulative incidence 9.6 vs. 12.9/100 patient-years, p < 0.001). PD patients who transitioned within 12 months of starting dialysis had similar mortality risks, while PD patients who transitioned >12 months after starting dialysis had an 83% higher risk for mortality (hazard ratio 1.83; 95% CI 1.33–2.52). Conclusions: Whereas there was no meaningful survival difference in the first 12 months between HHD and PD, patients who transitioned to PD after 12 months of dialysis had worse survival than their HHD counterparts. Additional studies are warranted to investigate clinical implications of these differences.

Background: Abnormalities in serum potassium are risk factors for sudden cardiac death and arrhythmias among dialysis patients. Although a previous study in hemodialysis patients has shown that race/ethnicity may impact the relationship between serum potassium and mortality, the relationship remains unclear among peritoneal dialysis (PD) patients where the dynamics of serum potassium is more stable. Methods: Among 17,664 patients who started PD between January 1, 2007 and December 31, 2011 in a large US dialysis organization, we evaluated the association of serum potassium levels with all-cause and arrhythmia-related deaths across race/ethnicity using time-dependent Cox models with adjustments for demographics. We also used restricted cubic spline functions for serum potassium levels to explore non-linear associations. Results: Baseline serum potassium levels were the highest among Hispanics (4.2 ± 0.7 mEq/L) and lowest among non-Hispanic blacks (4.0 ± 0.7 mEq/L). Among 2,949 deaths during the follow-up of median 2.2 (interquartile ranges 1.3–3.2) years, 683 (23%) were arrhythmia-related deaths. Overall, both hyperkalemia and hypokalemia (i.e., serum potassium levels >5.0 and Conclusion: Among incident PD patients, hypokalemia was consistently associated with all-cause and arrhythmia-related deaths irrespective of race/ethnicity. However, while hyperkalemia was associated with both death outcomes in non-Hispanic blacks and whites, it was not associated with either death outcome in Hispanic patients. Further studies are needed to demonstrate whether different strategies should be followed for the management of serum potassium levels according to race/ethnicity.

The long-term effect of cinacalcet hydrochloride treatment on parathyroid gland (PTG) volume has been scarcely investigated in patients with moderate to advanced secondary hyperparathyroidism (SHPT). The present study was a prospective observational study to determine the effect of cinacalcet treatment on PTG volume and serum biochemical parameters in 60 patients with renal SHPT, already treated with intravenous vitamin D receptor activator (VDRA). Measurement of biochemical parameters and PTG volumes were performed periodically, which were analyzed by stratification into tertiles across the baseline parathyroid hormone (PTH) level or PTG volume. We also determined the factors that can estimate the changes in PTG volume and the achievement of the target PTH range by multivariable analyses. Two years of cinacalcet treatment significantly decreased the serum levels of PTH, calcium, and phosphate, followed by the improvement of achieving the target ranges for these parameters recommended by the Japanese Society for Dialysis Therapy. Cinacalcet decreased the maximal and total PTG volume by about 30%, and also decreased the serum PTH level independent of the baseline serum PTH level and PTG volume. Ten out of 60 patients showed 30% increase in maximal PTG after 2 years. Multivariable analysis showed that patients with nodular PTG at baseline and patients with higher serum calcium and PTH levels at 1 year were likely to exceed the target range of PTH at two years. In conclusion, cinacalcet treatment with intravenous VDRA therapy decreased both PTG volume and serum intact PTH level, irrespective of the pretreatment PTG status and past treatment history.

Background: Higher serum ferritin levels may be influenced by iron use and inflammation, and are associated with higher mortality in hemodialysis (HD) patients. We hypothesized that a major rise in serum ferritin is associated with a higher risk of mortality, irrespective of baseline serum ferritin in incident HD patients. Methods: In a cohort of 93,979 incident HD patients between 2007 and 2011, we examined the association of change in serum ferritin from the baseline patient quarter (first 91 days from dialysis start) to the subsequent quarter with mortality. Multivariable adjustments were done for case-mix and markers of the malnutrition, and inflammation complex and intravenous iron dose. Change in serum ferritin was stratified into 5 groups: Results: The median change in serum ferritin was 89 ng/mL/quarter (interquartile range -55 to 266 ng/mL/quarter). Compared to stable serum ferritin (-100 to Conclusions: During the first 6-months after HD initiation, a major rise in serum ferritin in those with a baseline ferritin ≥200 ng/mL and even a slight rise in serum ferritin in those with a baseline ferritin ≥800 ng/mL are associated with higher mortality.

Previous epidemiological evidence has suggested that responsiveness to erythropoiesis-stimulating agents (ESAs) is related to prognosis in hemodialysis (HD) patients. We investigated the effects of hyporesponsiveness to ESA on mortality and cardiovascular events in Japanese HD patients, taking modifying factors into account.A total of 2,905 Japanese HD patients aged ≥18 years who received ESA treatment were prospectively followed up for 4 years. Responsiveness to ESA was estimated using an erythropoietin resistance index (ERI), defined as erythropoietin dosage per week divided by post-HD weight and hemoglobin value (U/kg/week/g/dl). Patients were divided into three groups by tertiles of ERI levels: low ERI, ≤5.10; intermediate ERI, 5.11-9.43; high ERI, ≥9.44. Risk estimates were calculated by a Cox proportional hazards model, adjusting for potential confounders.During follow-up, 482 patients died from any causes. The 4-year survival rate decreased linearly with higher ERI levels, being 87.5, 82.9, and 72.0% for low, intermediate, and high ERI group (p for trend0.001). Compared with the low ERI group, the multivariate-adjusted hazard ratio (mHR) was significantly higher in the high ERI group [mHR, 1.64 (95% confidence interval, 1.27-2.11)]. In the high ERI group, patients with Kt/V ≥ 1.57 had a significantly lower risk of death from any causes compared with those with Kt/V ≤ 1.56 [mHR, 0.73 (0.54-0.98)].Our findings suggest that ESA responsiveness can be considered a significant prognostic factor in Japanese HD patients.

Objectives Among kidney disease patients ≥80 years progressing to end-stage renal disease, there is growing interest in conservative nondialytic management approaches. However, among those who have initiated hemodialysis, little is known about the impact of withdrawal from dialysis on mortality, nor the patient characteristics associated with withdrawal from dialysis. Study design Historical cohort study. Setting and participants We examined 133,162 incident hemodialysis patients receiving care within a large national dialysis organization from 2007 to 2011. Measures We identified patients who withdrew from dialysis, either as a listed cause of death or censor reason. Incidence rates and subdistribution hazard ratios for withdrawal from dialysis as well as 4 other censoring reasons were examined across age groups. In addition, demographic and clinical characteristics associated with withdrawal from dialysis therapy among patients ≥80 years old was assessed using logistic regression analysis. Results Among 17,296 patients aged ≥80 years, 10% of patients withdrew from dialysis. Duration from the last hemodialysis treatment to death was 10 [interquartile range 6-16] days in patients with available data. Withdrawal from dialysis was the second and third most common cause of death among patients aged ≥80 years and Conclusion/Implications Among very-elderly incident hemodialysis patients, dialysis therapy withdrawal exhibits wide variations across age, race and ethnicity, regions, cognitive status, dialysis vascular access, and nutritional status. Further studies examining implications of withdrawal from dialysis in older patients are warranted

Background: The 2006 Kidney Disease Outcomes Quality Initiative guidelines suggest twice-weekly or incremental hemodialysis for patients with substantial residual kidney function (RKF). However, in most affluent nations de novo and abrupt transition to thrice-weekly hemodialysis is routinely prescribed for all dialysis-naïve patients regardless of their RKF. We review historical developments in hemodialysis therapy initiation and revisit twice-weekly hemodialysis as an individualized, incremental treatment especially upon first transitioning to hemodialysis therapy. Summary: In the 1960's, hemodialysis treatment was first offered as a life-sustaining treatment in the form of long sessions (≥10 hours) administered every 5 to 7 days. Twice- and then thrice-weekly treatment regimens were subsequently developed to prevent uremic symptoms on a long-term basis. The thrice-weekly regimen has since become the ‘standard of care' despite a lack of comparative studies. Some clinical studies have shown benefits of high hemodialysis dose by more frequent or longer treatment times mainly among patients with limited or no RKF. Conversely, in selected patients with higher levels of RKF and particularly higher urine volume, incremental or twice-weekly hemodialysis may preserve RKF and vascular access longer without compromising clinical outcomes. Proposed criteria for twice-weekly hemodialysis include urine output >500 ml/day, limited interdialytic weight gain, smaller body size relative to RKF, and favorable nutritional status, quality of life, and comorbidity profile. Key Messages: Incremental hemodialysis including twice-weekly regimens may be safe and cost-effective treatment regimens that provide better quality of life for incident dialysis patients who have substantial RKF. These proposed criteria may guide incremental hemodialysis frequency and warrant future randomized controlled trials.

Kienböck's disease is a rare disorder that presents with wrist pain and limitation of motion and is caused by avascular necrosis of the lunate bone. Dialysis patients occasionally present with wrist pain. However, Kienböck's disease is rarely reported in dialysis patients. We report a case of 52-year-old woman with a 28-year history of hemodialysis who presented with acute wrist pain. T1-weighted magnetic resonance imaging showed diffuse low intensity of the lunate bone, consistent with the diagnosis of Kienböck's disease. Because this disease can lead to chronic debilitating wrist pain, prompt diagnosis, accurate staging, and provision of appropriate treatment is mandatory.

Secondary hyperparathyroidism is a common complication for patients with end-stage renal disease (ESRD). When it progresses, it is associated with morbidity and mortality [1]. Phosphate binders and vitamin D can be used to prevent the progression of secondary hyperparathyroidism. However, these conservative treatments often fail to control severe hyperparathyroidism. In such cases, parathyroidectomy is required. Despite medical management after parathyroidectomy, persistent or recurrent hyperparathyroidism can occur. One of the causes of recurrent hyperparathyroidism is parathyromatosis, which has been described as multiple nodules or rests of hyperfunctioning parathyroid tissue that become evident following parathyroidectomy. We describe a female haemodialysis patient diagnosed with secondary hyperparathyroidism, which was probably caused by parathyromatosis. Treatment with cinacalcet, a calcimimetic agent, in combination with vitamin D was extremely effective.

The treatment according to the Japanese Society for Dialysis Therapy guidelines was performed in 189 patients on maintenance dialysis in our clinic. The mean age of the patients was 64.9 years and the mean dialysis period was 6.3 years. The underlying disease was diabetic nephropathy in 40.7% of the patients, chronic glomerulonephritis in 30.2%, and nephrosclerosis in 13.8%. In May 2006 before the use of JSDT guidelines, patients with phosphorus and calcium concentrations in the control goal range were most frequently observed (69.8%), followed in order by those with a high concentration of phosphorus alone (13.8%), those with a low concentration of phosphorus alone (2.6%), those with a high concentration of calcium alone (10.1%), those with high concentration of both phosphorus and calcium (3.7%). Treatment according to JSDT guidelines was performed for 6 months in these patients. In January 2007, the group with both phosphorus and calcium concentrations in the goal range accounted for 82.2%, showing improvement. The intact PTH concentration in patients with normal phosphorus and calcium concentration was in the reference range (60-180 pg/ml) in about 50% of the patients, high (180 pg/ml) in 35%, low (60 pg/ml) in 10% during the study periods. The intact PTH concentration was often about 40 pg/ml in patients with a concentration60 pg/ml, 120 pg/ml in those with a concentration of 60-180 pg/ml, and 200-250 pg/ml in those with a concentration180 pg/ml. The concentration of NTx was significantly higher in the patients with an intact PTH concentration180 pg/ml than in those with a concentration of60 pg/ml or those with a concentration of 60-180 pg/ml and significantly increased with time.