Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for falls. However, it is not well ...established how great the risk is for falls and fractures for the different stages of CKD compared to the general population. The objective of this systematic review and meta-analysis was to assess whether, and in which degree, CKD was associated with falls and fractures in adults. A systematic search in PubMed, Embase, CINAHL, and The Cochrane Library was performed on 7 September 2018. All retrospective, cross-sectional, and longitudinal studies of adults (18 years of older) that studied the association between CKD, fractures, and falls were included. Additional studies were identified by cross-referencing. A total of 39 publications were included, of which two publications assessed three types of outcome and four publications assessed two types of outcome. Ten studies focused on accidental falling; seventeen studies focused on hip, femur, and pelvis fractures; seven studies focused on vertebral fractures; and thirteen studies focused on any type of fracture without further specification. Generally, the risk of fractures increased when kidney function worsened, with the highest risks in the patients with stage 5 CKD or dialysis. This effect was most pronounced for hip fractures and any type of fractures. Furthermore, results on the association between CKD and accidental falling were contradictory. Compared to the general population, fractures are highly prevalent in patients with CKD. Besides more awareness of timely fracture risk assessment, there also should be more focus on fall prevention.
Maximal conservative management (MCM) may be an appropriate alternative option for dialysis in some elderly patients with end-stage kidney disease (ESKD). Evidence about the impact of dialysis or MCM ...on quality of life (QoL) in older patients is sparse. In the GOLD (Geriatric assessment in OLder patients starting Dialysis) Study the trajectory of QoL was assessed in patients starting dialysis or MCM.
Patients ≥65 years old were included just prior to dialysis initiation or after decision for MCM. Baseline data included demographics, frailty as measured with a geriatric assessment, comorbidity (CIRS-G) and QoL, measured with the EQ-5D-3 L (EQ-5D Index and overall self-rated health). Six months follow-up data included QoL, hospitalizations and mortality. Change of QoL was assed with paired t-tests. Cox-regression was used to assess survival of MCM and dialysis patients.
The cohort comprised 192 dialysis and 89 MCM patients. The MCM patients were older (mean age 82 ± 6 vs. 75 ± 7 years, p < 0.01) and mean kidney function was better (eGFR 11.5 ± 4.0 vs. 8.0 ± 2.9 ml/min/1.73m
, p < 0.01). Baseline QoL did not differ significantly between the groups. After six months, EQ-5D Index did not improve significantly in the dialysis group with mean ± standard error (SE) 0.026 ± 0.014 (p = 0.10; not clinically relevant), but a small but clinically relevant decline was seen in the conservative group: 0.047 ± 0.022 (p < 0.01; between group difference p < 0.01). Hospitalization occurred in 50% of dialysis patients vs. 24% of conservative patients (p < 0.01). In patients over 80 years old, no survival benefit could be found for dialysis patients starting dialysis vs. MCM.
A small decline of QoL was found for conservative patients, while QoL did not change in dialysis patients. However, hospitalization rate was higher in patients starting dialysis. In patients over 80 years, no survival benefit was found.
IntroductionStarting dialysis not only has a major impact on the life of patients but also on their informal caregivers. Previous research shows greater burden and lower quality of life among ...caregivers of dialysis patients compared with the general population. Unfortunately, the evidence on the course of both positive and negative experience in caregivers of incident dialysis patients is scarce. Furthermore, well-designed, prospective, multicentre studies comparing caregiving of home dialysis patients with in-centre dialysis patients are lacking. This paper proposes a protocol to assess the trajectory of experiences (both positive and negative) and quality of life of caregivers of home dialysis patients compared with caregivers of in-centre dialysis patients.Methods and analysisThis paper presents a protocol for a prospective, observational, multicentre cohort study which extends the ongoing Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes (DOMESTICO). This study will include at least 200 adult caregivers of patients who start dialysis therapy and have been included in the DOMESTICO study. Positive experiences of the caregivers will be the primary outcome parameter of this study, and negative experiences and health-related quality of life the secondary outcome parameters. Required support will be investigated as an exploratory finding. Outcome parameters will be assessed at baseline, and at 6 and 12 months after start of dialysis using validated questionnaires.Ethics and disseminationEthical approval for this study has been obtained from the Medical Research Ethics Committee of the Amsterdam University Medical Centre. The results of this study will be disseminated by publication in a peer-reviewed journal and through presentations at conferences and seminars.
Varicella zoster virus (VZV) vasculopathy produces stroke secondary to viral infection of cerebral arteries. Not all patients have rash before cerebral ischemia or stroke. Furthermore, other ...vasculitides produce similar clinical features and comparable imaging, angiographic, and CSF abnormalities.
We review our 23 published cases and 7 unpublished cases of VZV vasculopathy. All CSFs were tested for VZV DNA by PCR and anti-VZV IgG antibody and were positive for either or both.
Among 30 patients, rash occurred in 19 (63%), CSF pleocytosis in 20 (67%), and imaging abnormalities in 29 (97%). Angiography in 23 patients revealed abnormalities in 16 (70%). Large and small arteries were involved in 15 (50%), small arteries in 11 (37%), and large arteries in only 4 (13%) of 30 patients. Average time from rash to neurologic symptoms and signs was 4.1 months, and from neurologic symptoms and signs to CSF virologic analysis was 4.2 months. CSF of 9 (30%) patients contained VZV DNA while 28 (93%) had anti-VZV IgG antibody in CSF; in each of these patients, reduced serum/CSF ratio of VZV IgG confirmed intrathecal synthesis.
Rash or CSF pleocytosis is not required to diagnose varicella zoster virus (VZV) vasculopathy, whereas MRI/CT abnormalities are seen in almost all patients. Most patients had mixed large and small artery involvement. Detection of anti-VZV IgG antibody in CSF was a more sensitive indicator of VZV vasculopathy than detection of VZV DNA (p < 0.001). Determination of optimal antiviral treatment and benefit of concurrent steroid therapy awaits studies with larger case numbers.
Elderly patients with end-stage kidney disease (ESKD) are at high risk for fractures. However, the prevalence of vertebral fractures and hyperkyphosis is not studied well. This is relevant, because ...in the general population, both vertebral fractures and hyperkyphosis are associated with poor outcome. Therefore, the primary aim of our study was to assess the prevalence of vertebral fractures and hyperkyphosis in the ESKD population. The secondary aim was to assess if patients with vertebral fractures and/or hyperkyphosis more often have poor outcome after starting dialysis, such as accidental falling, functional decline and mortality compared to the patients without vertebral fractures and/or hyperkyphosis.
This study included patients ≥65 years with ESKD who were enrolled in the Geriatric assessment in Older patients starting Dialysis (GOLD) study of whom a lateral chest radiograph was available. Chest radiographs were scored independently by two observers for vertebral fractures (Genant ≥1) and hyperkyphosis (≥50 degrees). The relation between vertebral fractures and hyperkyphosis with clinical outcomes (falls, decline in ADL and IADL, mortality) was studied using the Chi-square test.
Of the 196 enrolled patients, chest radiographs were available for 160 patients. Mean age was 75.3 (SD ±6.9), and 35% were female. The prevalence of vertebral fractures was 43% and of hyperkyphosis 22%. Patients with hyperkyphosis had a higher one-year mortality compared to patients without hyperkyphosis (20% vs. 8%, p = 0.04). No differences were observed between patients with and without hyperkyphosis, vertebral fractures and the remaining outcomes after six months of follow-up.
In patients ≥65 years old with ESKD starting dialysis, vertebral fractures are highly prevalent. In contrast to the general population, patients with vertebral fractures did experience poor outcome as often as patients without vertebral fractures. Remarkably, patients with hyperkyphosis did have a higher one-year mortality. However, these patients did not experience more functional decline or accidental falls.
•43% of incident dialysis patients had prevalent vertebral fractures•22% of incident dialysis patients had hyperkyphosis•16% of incident dialysis patients had both vertebral fractures and hyperkyphosis•Hyperkyphosis is associated with a higher one year mortality•No association was seen between vertebral fractures and falls, functional decline and mortality
Summary
The risk of vertebral fracture is unclear in end-stage renal disease. We report a high vertebral fracture prevalence and incidence in transplantation-eligible patients on dialysis, suggesting ...that these patients may benefit from radiographic screening for vertebral fractures. Parathyroid hormone had a U-shaped association with vertebral fracture risk.
Introduction
Vertebral fractures are often overlooked, but even undiagnosed vertebral fractures negatively impact physical functioning, quality of life, and mortality. The risk of vertebral fractures in end-stage renal disease (ESRD) patients is unclear, and parathyroid hormone (PTH) might play a role in the development of vertebral fractures. We therefore determined vertebral fracture prevalence and incidence in ESRD patients and assessed associations of vertebral trabecular bone mineral density (BMD) and PTH with vertebral fracture.
Methods
In 146 transplantation-eligible patients on dialysis, we determined vertebral fractures on lateral chest radiographs, which image the thoracic and upper lumbar spine. We determined incident vertebral fractures in 70 patients with follow-up radiographs (23 received a kidney transplant) after median 1.8 years. Vertebral trabecular BMD was measured with computed tomography, and PTH measured with 2-site immunoassays, categorized in tertiles with the middle tertile as reference. We used Poisson regression to assess associations of vertebral trabecular BMD and PTH with vertebral fracture.
Results
Mean age of the study population was 52 ± 13 years, and 98 (67%) were male. Median dialysis duration was 26 (IQR 13–55) months. Vertebral fractures were present in 50/146 patients (34%) and incident vertebral fractures occurred in 20/70 patients (29%). Vertebral trabecular BMD was not associated with vertebral fracture prevalence (relative risk 0.97, 95% CI 0.89 to 1.04). For the lowest PTH tertile (< 11 pmol/L), the relative risk of vertebral fracture was greater although not significant (2.28, 95% CI 0.97 to 5.97) and was significantly greater for the highest PTH tertile (≥ 30 pmol/L; 2.82, 95% CI 1.22 to 7.27) after adjustment for potential confounders.
Conclusions
The prevalence and incidence of vertebral fractures is high even in relatively young and healthy ESRD patients. Vertebral trabecular BMD is not associated with vertebral fracture, and the association of PTH with vertebral fracture risk appears U-shaped. Nevertheless, our study did not measure vertebral BMD using DXA and assessed vertebral fractures using lateral chest radiographs and not spine radiographs.
In older patients with kidney failure (KF) starting dialysis, there is a high rate of functional decline. Not much is known about the functional trajectory of patients receiving conservative kidney ...management (CKM). Therefore, the aim of this study is to assess this functional trajectory and explore clinical parameters associated with functional decline.PURPOSEIn older patients with kidney failure (KF) starting dialysis, there is a high rate of functional decline. Not much is known about the functional trajectory of patients receiving conservative kidney management (CKM). Therefore, the aim of this study is to assess this functional trajectory and explore clinical parameters associated with functional decline.The functional trajectory of patients choosing CKM was evaluated using data from the Geriatric Assessment in Older Patients Starting Dialysis (GOLD) study, which included patients aged ≥ 65 years with KF at the moment of decision-making. Functional status was assessed using a combined score for activities of daily living (ADL) and instrumental activities of daily living (iADL) dependency at baseline and after six months of follow-up. Change in functional status was divided into improvement (gain of one or more domains in functional status), stable (no change), decline (loss of one or more domains in functional status), and death at follow-up. The association between functional status at baseline and functional decline after six months was assessed with chi-squared test or Fisher's exact test. Furthermore, caregiver experiences were explored using self perceived pressure of informal care (SPPIC) at baseline and 6-month follow-up.METHODSThe functional trajectory of patients choosing CKM was evaluated using data from the Geriatric Assessment in Older Patients Starting Dialysis (GOLD) study, which included patients aged ≥ 65 years with KF at the moment of decision-making. Functional status was assessed using a combined score for activities of daily living (ADL) and instrumental activities of daily living (iADL) dependency at baseline and after six months of follow-up. Change in functional status was divided into improvement (gain of one or more domains in functional status), stable (no change), decline (loss of one or more domains in functional status), and death at follow-up. The association between functional status at baseline and functional decline after six months was assessed with chi-squared test or Fisher's exact test. Furthermore, caregiver experiences were explored using self perceived pressure of informal care (SPPIC) at baseline and 6-month follow-up.Follow-up data were available for 86 patients. Mean age was 82 ± 6 years and 43% were women. At baseline, 12% of the patients were independent, 55% were mild/moderately dependent, and 34% severely dependent. After 6 months of follow-up, 9% of all patients had improved, 35% remained stable, 41% had declined, and 15% had died. No significant associations were found between baseline characteristics and the composite outcomes.RESULTSFollow-up data were available for 86 patients. Mean age was 82 ± 6 years and 43% were women. At baseline, 12% of the patients were independent, 55% were mild/moderately dependent, and 34% severely dependent. After 6 months of follow-up, 9% of all patients had improved, 35% remained stable, 41% had declined, and 15% had died. No significant associations were found between baseline characteristics and the composite outcomes.In patients aged ≥ 65 years receiving CKM, functional decline and death are highly prevalent. No association was found between poor outcome ("decline/death") and different potential risk factors.CONCLUSIONIn patients aged ≥ 65 years receiving CKM, functional decline and death are highly prevalent. No association was found between poor outcome ("decline/death") and different potential risk factors.
Aerosol optical depth (AOD), Ångström Exponent (AE), and single scattering albedo (SSA) simulated by a new aerosol-coupled version of Nonhydrostatic ICosahedral Atmospheric Model (NICAM) have been ...compared with corresponding AERONET retrievals over a total of 196 sites during the 2006–2008 period. The temporal and spatial distributions of the modeled AODs and AEs match those of the AERONET retrievals reasonably well. For the 3-year mean AODs and AEs for all sites show the correlations between model and AERONET of 0.753 and 0.735, respectively, and 82.1% of the modeled AODs agree within a factor of two with the retrieved AODs. The primary model deficiency is an underestimation of fine mode aerosol AOD and a corresponding underestimation of AE over pollution region. Compared to the retrievals, the model underestimates the global 3-year mean AOD and AE by 0.022 (10.5%) and 0.329 (31.2%), respectively. The probability distribution function (PDF) of the modeled AODs is comparable to that of the retrieved ones, however, the model overestimates the occurrence frequencies of small AEs and SSAs.
•We simulate aerosol key optical properties using a new aerosol transport model.•The correlations between model and AERONET are strong for both AOD and AE.•82.1% of the simulated AODs agree within a factor of two with the measurements.•Model underestimates both the global 3-year mean AOD and AE.
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