On-line hemodiafiltration (HDF) has been associated with better inflammatory markers profile and survival than low-flux hemodialysis (HD). This study aimed at determining the effect of HDF vs HD on ...hs-TnT and echocardiography parameters evolution at one year follow-up.
Patients were randomized from 2007 to 2013 to HD or HDF in accordance with the CONvective TRAnsport STudy protocol initially as part of the Montreal cohort and subsequently as part of a local cohort. Pre-dialysis hs-TnT were analyzed at baseline and 1-year follow-up.
A total of 54 HDF patients and 59 HD patients were included. At baseline, median hs-TnT value was 49 ng/L (IQR 31-89) in the HDF group vs. 60 ng/L (36-96) in the HD group (p = 0.370). At one year follow-up, median hs-TnT remained stable in the HDF group (p = 0.707 vs. baseline), but significantly increased to 62 ng/L (40-104) in the HD group (p = 0.021 vs. baseline). The median variation (delta) in hs-TnT values was -3 ng/L (IQR -7-+8) in the HDF group vs. +8 ng/L (-5 -+25) in the HD group (p = 0.042). In the HDF group, LVEF increased from 60.0% (IQR 55.0-65.0) at baseline to 65.0% (60.0-65.5) at 1-year follow-up (p = 0.040) whereas it remained stable in the HD group (LVEF of 60.0% IQR 55.0-65.0 at baseline and 65.0% 55.0-65.0 at 1-year follow-up p = 0.312).
High-efficiency HDF is associated with stability in hs-TnT values, whereas low-flux HD is associated with significant increase in hs-TnT levels.
Residual kidney function (RKF) is associated with improved survival and quality of life in dialysis patients. Previous studies have suggested that initiation of peritoneal dialysis (PD) may slow RKF ...decline compared to the pre-dialysis period. We sought to evaluate the association between PD initiation and RKF decline in the Initiating Dialysis Early And Late (IDEAL) trial.
In this post hoc analysis of the IDEAL randomized controlled trial, PD participants were included if results from 24-hour urine collections had been recorded within 30 days of dialysis initiation, and at least one value pre- and one value post-dialysis commencement were available. The primary outcome was slope of RKF decline, calculated as mean of urinary creatinine and urea clearances. Secondary outcomes included slope of urine volume decline and time from PD initiation to anuria.
The study included 151 participants (79 early start, 72 late start). The slope of RKF decline was slower after PD initiation (-2.69±0.18mL/min/1.73m2/yr) compared to before PD (-4.09±0.33mL/min/1.73m2/yr; change in slope +1.19 mL/min/1.73m2/yr, 95%CI 0.48-1.90, p<0.001). In contrast, urine volume decline was faster after PD commencement (-0.74±0.05 L/yr) compared to beforehand (-0.57±0.06L/yr; change in slope -0.18L/yr, 95%CI -0.34--0.01, p = 0.04). No differences were observed between the early- and late-start groups with respect to RKF decline, urine volume decline or time to anuria.
Initiation of PD was associated with a slower decline of RKF compared to the pre-dialysis period.
Background:
Recent randomized clinical trials have demonstrated beneficial effects of hemodiafiltration (HDF) compared with hemodialysis (HD) on mortality and hemodynamic stability. Data on quality ...of life in HDF compared with HD is limited.
Objective:
This study aimed to determine whether patients receiving HD experience improvements in quality of life, hemodynamic and laboratory parameters after switching to HDF.
Design:
Observational controlled cohort study.
Setting & Patients:
Adult patients receiving maintenance dialysis were followed for 3 months both before and after transfer to a new unit, where they received HDF. Prior to transfer, control patients were already treated by HDF.
Methods:
Quality of life at baseline and follow-up was measured using the validated minutes to recovery (MR) question. Dialysis data were collected for 3 consecutive sessions monthly; laboratory values were collected monthly. Wilcoxon signed rank test and repeated measures analysis of covariance were used to evaluate pre/post transfer changes and quantile regression to identify predictors of change in recovery time.
Results:
Of 227 patients, 82 died, were transplanted, were hospitalized or did not transfer, leaving 123 subjects and 22 controls for analysis. MR did not improve with switching to HDF, although patients with MR > 60 min before transfer experienced a significant decrease in their MR, compared with controls. There was no improvement in intradialytic hypotension with HDF. There were no differences in laboratory values before vs after switch.
Limitations:
Nonrandomized single-center study, including only small numbers of patients and covering a short follow-up period; hemodynamic values only evaluated over 1 week per month; residual kidney function not recorded.
Conclusions:
In this Canadian experience of HDF, patients remained stable with respect to several laboratory and dialysis related parameters. Switch to HDF was associated with substantially reduced recovery time in patients with MR > 60 minutes at baseline.
For many organizations, limited budgets and phased funding restrict the development of digital health tools. This problem is often exacerbated by the ever-increasing sophistication of technology and ...costs related to programming and maintenance. Traditional development methods tend to be costly and inflexible and not client centered. The purpose of this study is to analyze the use of Agile software development and outcomes of a three-phase mHealth program designed to help young adult Quebecers quit smoking.
In Phase I, literature reviews, focus groups, interviews, and behavior change theory were used in the adaption and re-launch of an existing evidence-based mHealth platform. Based on analysis of user comments and utilization data from Phase I, the second phase expanded the service to allow participants to live text-chat with counselors. Phase II evaluation led to the third and current phase, in which algorithms were introduced to target pregnant smokers, substance users, students, full-time workers, those affected by mood disorders and chronic disease.
Data collected throughout the three phases indicate that the incremental evolution of the intervention has led to increasing numbers of smokers being enrolled while making functional enhancements. In Phase I (240 days) 182 smokers registered with the service. 51% (n = 94) were male and 61.5% (n = 112) were between the ages of 18-24. In Phase II (300 days), 994 smokers registered with the service. 51% (n = 508) were male and 41% (n = 403) were between the ages of 18-24. At 174 days to date 873 smokers have registered in the third phase. 44% (n = 388) were male and 24% (n = 212) were between the ages of 18-24.
Emerging technologies in behavioral science show potential, but do not have defined best practices for application development. In phased-based projects with limited funding, Agile appears to be a viable approach to building and expanding digital tools.
Cardiovascular disease is a leading cause of mortality in kidney failure (KF). Patients with KF from atheroembolic disease are at higher risk of cardiovascular disease than other causes of KF. This ...study aimed to determine survival on dialysis for patients with KF from atheroembolic disease compared with other causes of KF.
All adults (≥ 18 years) with KF initiating dialysis as the first kidney replacement therapy between 1 January 1990 and 31 December 2017 according to the Australia and New Zealand Dialysis and Transplant registry were included. Patients were grouped into either: KF from atheroembolic disease and all other causes of KF. Survival outcomes were assessed by the Kaplan-Meier method and Cox regression analysis adjusted for patient-related characteristics.
Among 65,266 people on dialysis during the study period, 334 (0.5%) patients had KF from atheroembolic disease. A decreasing annual incidence of KF from atheroembolic disease was observed from 2008 onwards. Individuals with KF from atheroembolic disease demonstrated worse survival on dialysis compared to those with other causes of KF (HR 1.80, 95% confidence interval CI 1.61-2.03). The respective one- and five-year survival rates were 77 and 23% for KF from atheroembolic disease and 88 and 47% for other causes of KF. After adjustment for patient characteristics, KF from atheroembolic disease was not associated with increased patient mortality (adjusted HR 0.93 95% CI 0.82-1.05).
Survival outcomes on dialysis are worse for individuals with KF from atheroembolic disease compared to those with other causes of KF, probably due to patient demographics and higher comorbidity.
Background:
Estimated glomerular filtration rate (eGFR) at dialysis initiation is increasingly recognized as a key quality indicator (QI) for patients with end-stage kidney disease (ESKD). ...Specifically, guidelines recommend assessing deferral of dialysis initiation until symptoms arise or if the eGFR is ≤6 mL/min/1.73 m2. Despite the recognition of the importance of this QI, how eGFR at the time of dialysis initiation is defined, collected, and tracked at dialysis centers across Canada remains unknown.
Objectives:
To identify how provincial renal programs define eGFR at dialysis initiation, to compare practice across Canadian provinces, and to determine if there is a consistent benchmark for deferred dialysis start.
Design:
Cross-sectional survey distributed to the medical leads of each provincial renal program, administered from July 2021 to November 2021. Quebec was not included given it did not yet participate in Canadian Organ Replacement Register (CORR) data submission.
Setting:
The survey was designed and distributed by the Canadian Society of Nephrology Quality Improvement & Implementation Science Committee (CSN-QUIS) Indicator Working Group.
Methods:
The survey asked respondents on how eGFR is defined, collected, reported, and perceived barriers to QI data collection. The National Senior Renal Leaders Forum helped identify the key provincial medical leads to disseminate the survey for completion.
Results:
Surveys were distributed to the medical leads of the 9 provincial renal programs that participate in CORR. In total, there were 8 responses. Five provinces submit eGFR for all new dialysis starts and 3 provinces only submit this information for chronic patients. There is variation in determining when a patient with acute kidney injury requiring dialysis is classified as a chronic patient. Four provinces use a 30-day trigger, 3 provinces use a 90-day trigger, and the patient’s nephrologist makes this determination in 1 province. The creatinine used for the eGFR at dialysis initiation was the value measured on the first dialysis session (ie, day 0) for 5 provinces; the last outpatient clinic creatinine value in 2 provinces, and 1 province did not have a standard definition. Three provinces did not have a benchmark target for eGFR at dialysis initiation, 1 province had a target of <9.5 mL/min/1.73 m2, 3 provinces had a target of <10 mL/min/1.73 m2, 1 province had a target of <15 mL/min/1.73 m2. All 8 responding provincial medical leads support the establishment of a national benchmark for this measure.
Limitations:
This survey was restricted to provincial medical leads and therefore is unable to determine practice at individual dialysis sites. The survey was not anonymous, so it may be subject to conformity bias.
Conclusions:
There is wide variability in how eGFR at dialysis initiation is measured and reported across Canada. Additionally, there is no consensus on a benchmark target for an intent-to-defer dialysis strategy. Standardization of target eGFR at dialysis initiation may facilitate national reporting and quality improvement initiatives.
Background:
Chronic kidney disease following liver transplantation is a major long-term complication. Most liver transplant recipients with kidney failure will be treated with dialysis instead of ...kidney transplantation due to noneligibility and shortage in organ availability. In this population, the role of peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) remains unclear.
Objective:
To determine the feasibility regarding safety, technique survival, and dialysis efficiency of PD in liver transplant recipients requiring KRT for maintenance dialysis.
Design:
Systematic review.
Setting:
Interventional and observational studies reporting the use of PD after liver transplantation.
Patients:
Adult liver transplant recipients with kidney failure treated with maintenance KRT.
Measurements:
Extracted data included eligibility criteria, study design, demographics, and PD modality. The following outcomes of interest were extracted: rate of peritonitis and microorganisms involved, noninfectious peritoneal complications, technique survival, and kidney transplantation-censored technique survival. Non-PD complications included overall survival, liver graft dysfunction, and hospitalization rate.
Methods:
The following databases were searched until July 2020: MedLine/PubMed, EMBASE, CINAHL, and Cochrane Library. Two reviewers independently screening all titles and abstracts of all identified articles. Due to the limited sample size, observational designs and study heterogeneity expected, no meta-analysis was pre-planned. Descriptive statistics were used to report all results.
Results:
From the 5263 identified studies, 4 were included in the analysis as they reported at least 1 outcome of interest on a total of 21 liver transplant recipients, with an overall follow-up duration on PD of 19.0 (Interquartile range IQR: 9.5-29.5) months. Fifteen episodes of peritonitis occurred in a total cumulative PD follow-up of 514 patient-months, representing an incidence rate of 0.35 per year. These episodes did not result in PD technique failure, mortality, or impairment of liver graft function.
Limitations:
Limitations include the paucity of studies in the field and the small number of patients included in each report, a risk of publication bias and the impossibility to directly compare hemodialysis to PD in this population. These results, therefore, must be interpreted with caution.
Conclusions:
Based on limited data reporting the feasibility of PD in liver transplant recipients with kidney failure, no signal was associated with an increased risk of infectious complications. Long-term studies evaluating this modality need to be performed.
Registration (PROSPERO):
CRD42020218374.
Background:
The differential diagnosis of acute kidney injury (AKI) episodes is often challenging. Novel AKI biomarkers have shown their utility to improve prognostic prediction and diagnostic ...assessment in various research populations but their implementation in standard clinical practice is still rarely reported.
Objective:
To report the differential diagnostic ability and associated clinical utility of the neutrophil gelatinase-associated lipocalin (NGAL) testing in a real-life setting of a heterogeneous AKI population.
Design:
This is a retrospective cohort study combined with a clinical audit using questionnaires distributed to consultant nephrologists following NGAL results.
Setting:
The first 250 consecutive patients with a confirmed AKI where an NGAL test (plasma NGAL pNGAL or urine NGAL uNGAL) was ordered from a large academic center in Montreal, Canada from January 2021 to August 2021.
Patients:
Patients were classified into 3 groups based on the final AKI etiology category (functional, intrarenal, and postrenal) following definitive adjudication by 2 independent nephrologists.
Methods:
The ability of plasma NGAL (pNGAL), urine NGAL (uNGAL), and uNGAL-to-creatinine ratio (uNGAL/Cr) to discriminate intrarenal from functional AKI etiologies was compared to standard urine chemistry (FENa) and proteinuria. A logistic regression was used to evaluate the association between intrarenal AKI and increased biomarker levels. The overall clinical utility and appreciation of the NGAL test was evaluated using a questionnaire completed prospectively by the consultant nephrologist at the time of receiving the NGAL result. The NGAL results were prospectively available to clinicians with a median time of 2.9 (1.3-7.4) hours from the initial order.
Results:
A total of 214 uNGAL and 44 pNGAL were ordered from 100 functional, 139 intrarenal and 11 postrenal AKI episodes after final adjudication. The discriminative ability of FENa (AUC 0.68 95% CI: 0.61-0.75) was lower than uNGAL (AUC 0.80 95% CI: 0.73-0.86) and uNGAL/Cr (AUC 0.83 95% CI: 0.77-0.88) but better than pNGAL (AUC 0.66 95% CI: 0.48-0.85). According to consultant nephrologists, the NGAL testing has led to a change in clinical management in 42% of cases.
Limitations:
Data reported came from a single center and NGAL was reserved for more complex cases, which limits generalizability. No biopsy has been performed for most AKI cases as the final adjudication was based on a retrospective review of the hospitalization episode.
Conclusions:
Neutrophil gelatinase-associated lipocalin testing can be successfully integrated as part of the diagnostic workup for AKI in clinical practice. The integration of tubular damage biomarkers to functional biomarkers can further improve the differential diagnostic assessment. However, the impact of such biomarkers on AKI management and associated outcomes still needs further validation.
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