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American Journal of Nephrology
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ISSN (Print) 0250-8095 - ISSN (Online) 1421-9670
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The optimization of outpatient hemodialysis management for AKI-D patients:
A quality improvement study
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  Abstract: Introduction: In 2017, the Centers for Medicare and Medicaid Services allowed survivors of hospitalized acute kidney injury requiring dialysis (AKI-D) who were ambulatory and still dependent on hemodialysis (HD) to receive treatment in outpatient dialysis facilities. This policy change generated the ongoing need to improve AKI-D care in the outpatient setting.Methods: Quality improvement study in adult patients admitted to an outpatient HD unit with the diagnosis of AKI-D. We developed a protocol to manage these patients that included: a) multidisciplinary evaluations; b) personalized 3-tier HD prescription for dose/ultrafiltration rate and frequency; c) weekly assessment of kidney recovery; and d) patient empowerment. Patient- and protocol-specific characteristics were described. We analyzed hourly HD data and protocol adherence, and relevant hemodynamic data were compared according to HD-free survival at 90 days. Results: A total of 457.3 hours of HD from nine patients under the AKI-D protocol were interrogated. Three out of nine patients were alive and liberated from HD within the first 90 days of outpatient HD. Overall protocol adherence was 53.8% and did not differ by HD-free survival (54.5% vs. 53.7% in those that recovered vs. not). Protocol adherence was associated with fewer intradialytic hypotension events (peak to nadir BP, p
  PubDate: Sat, 08 Apr 2023 09:12:03 +020
Work Experiences of the Interdisciplinary Dialysis Workforce in the United
States: A Cross-Sectional Survey
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  Abstract: Introduction: Suboptimal dialysis care may be in part due to staff issues such as job dissatisfaction, burnout, work overload, high staff turnover, and inconsistent training. Here, we leveraged data collected in a recent national survey to provide an initial, comprehensive description of current work experiences of U.S. dialysis care providers. Methods: We conducted a cross-sectional survey of 1240 active U.S. dialysis clinic staff members (physicians, advanced practice providers, nurse managers/clinic coordinators, nurses, social workers, dietitians, and patient care technicians), who were recruited via emails to society membership lists. Respondents were asked about a wide variety of work experiences, including job satisfaction, professional fulfillment and burnout (Stanford Professional Fulfillment Index), work culture, experiences of hostility and violence, and self-reported medical errors. Responses were summarized overall and compared by clinic role.Results: Most of the survey respondents, representing all 50 U.S. states, were aged 35-49 (58.3%) or ≥50 (23.5%), female (60.7%), and white (59.8%; 23.1% Black and 10.0% Asian); 82.1% had been in their current role for at least 1 year. Most U.S. dialysis staff responding to our survey reported being generally satisfied with their jobs (mean rating of 7.9 on 0-10 scale), but only 54.4% met criteria for professional fulfillment, and 32.8% met criteria for burnout, driven by high scores in the work exhaustion domain. Related issues, including high workloads, lack of respect (including experiences of violence and hostility), lack of autonomy, and suboptimal patient environments (in terms of both safety and patient-centeredness), were commonly reported among dialysis care providers, although their prevalence often differed by provider type.Conclusion: Our results suggest that the dialysis workforce may be at a critical point. Preventing further staff burn out, which could lead to even greater staffing shortages and worse working conditions among those who continue to provide dialysis care, is essential.
  
  PubDate: Fri, 07 Apr 2023 12:10:44 +020
Acute kidney injury in coronavirus disease and association with thrombosis
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  Abstract: Introduction: Coronavirus disease (COVID-19) is a global pandemic which continues to cause systemic inflammation leading to multi-system organ damage including acute kidney injury (AKI) and thrombotic complications. We hypothesize that D-dimer level predicts an increased risk of acute kidney injury and thrombotic complications in COVID-19. Methods: This was a retrospective cohort study performed at a single center academic center. Patients hospitalized with COVID-19 between Jan 1, 2020 through Jan 1, 2021 were included in the analysis. Demographics and associated medical records were reviewed from the electronic medical record. Statistical analysis was done to determine the incidence of AKI and thrombosis and if D-dimer was predictive of an adverse event. Results: The study included 389 patients with the diagnosis of COVID-19 who were hospitalized. Acute kidney injury was evident in 143 patients with 59 experiencing a thrombotic event. Factors associated with acute kidney injury included: age, chronic kidney disease, proteinuria, use of out-patient angiotensin blocking medications and D-dimer greater than 1.75 (p < 0.05). Factors associated with thrombosis included: use of outpatient anti-coagulants, elevated WBC, interleukin-6 (IL-6) and D-dimer greater than 1.75 (p< 0.05). When D-dimer was dichotomized at the median value for the entire data set (value greater than 1.75), there was good discrimination for AKI and very good discrimination for thrombosis.Discussion/Conclusions: Complications of acute renal failure and thrombosis are common in patients presenting with COVID-19. D-dimer was found to be predictive of both. Future studies to validate the association of these two events in patients presenting with COVID-19 are warranted as early treatment with antithrombotic agents may have a role in preventing adverse sequelae and outcomes.
  
  PubDate: Wed, 05 Apr 2023 08:44:31 +020
Non-pharmacological Interventions to Improve Physical Function in Patients
with End-stage Renal Disease: A Network Meta-analysis
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  Abstract: Introduction: Chronic kidney disease is estimated to become the fifth leading cause of death globally by 2040. Due to the high incidence of fatigue in patients with end-stage renal disease without reliable pharmacological treatments, more and more studies on non-pharmacological interventions to improve physical function appear, which might be the best approach, unknown. This study aims to compare and rank the efficacy of all known non-pharmacological interventions on improving physical function from multiple outcomes for adults with end-stage renal disease.Methods: This systematic review and network meta-analysis included searches of PubMed, Embase, CINAHL, and Cochrane Library from inception to September 1, 2022, for randomized controlled trials of non-pharmacological interventions to improve physical function in adults with end-stage renal disease. Literature screening, data extraction, and quality appraisal were performed systematically by two independent reviewers. The frequentist random-effect network meta-analysis was adopted to pool the evidence from five outcomes, namely 6-minute walk test, handgrip strength, knee extension strength, physical component summary, and mental component summary, respectively.Results: A total of 1921 citations were identified by this search, of which 44 eligible trials enrolled 2250 participants, and 16 interventions were identified. All subsequent figures refer to comparisons with usual care. For increasing walking distance, the combined resistance and aerobic exercise with virtual reality or music were the most effective interventions, with a mean difference plus 95% confidence interval of 90.69 (8.92 to 172.46) and 92.59 (23.13 to 162.06), respectively. Resistance exercise with blood flow restriction (8.13, 0.09 to 16.17) was the best treatment to improve handgrip strength. Combined resistance and aerobic exercise (11.93, 3.63 to 20.29) and whole-body vibration (6.46, 1.71 to 11.20) were associated with improving knee extension strength. For life quality, all treatment effects did not show statistically significant differences.Conclusions: It was found via network meta-analysis that combined resistance and aerobic exercise is the most effective intervention. Besides, if virtual reality or music is added to the training, there will be better results. Resistance exercise with blood flow restriction and whole-body vibration might be good alternative treatments for improving muscle strength. None of the interventions improved quality of life, suggesting a need for alternative interventions in this regard. The results of this study contribute evidence-based data to decision-making.
  
  PubDate: Thu, 30 Mar 2023 08:25:31 +020
Role of Sodium-Glucose Cotransporter 2 inhibitors for management of
diabetes mellitus in renal transplant recipients; and management
strategies for post-transplant hypertension
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  Abstract: BackgroundDiabetes mellitus and hypertension are the leading causes of cardiovascular disease in renal transplant recipients. This review looks at the potential role of sodium-glucose co-transporter 2 inhibitors (SGLT2is) and reviews the management strategies for hypertension in this population.SummaryLarge-scale clinical trials are needed to study the potential cardiorenal benefits and risks of complications in renal transplant recipients. Future clinical trials are also needed to define optimal blood pressure treatment goals and therapies and how they influence graft and patient survival.Key MessagesMultiple recent prospective randomized clinical trials have shown the benefits of using SGLT2is to improve cardiorenal outcomes in patients with chronic kidney disease with or without diabetes mellitus. Renal transplant recipients were not included in these trials due to concerns about genitourinary complications. Hence the role of these agents in this population is unclear. A number of small studies have highlighted the safety of using these agents in renal transplant recipients. Post-transplant hypertension is a complex problem requiring individualized management. Recent guidelines recommend using a calcium channel blocker or angiotensin receptor blocker as the first-line anti-hypertensive agents in adult renal transplant recipients.
  
  PubDate: Fri, 24 Mar 2023 03:14:11 +010
Association of four types of vascular access including arterial
superficialization with mortality in maintenance hemodialysis patients: a
nationwide cohort study in Japan
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  Abstract: Introduction: Vascular access usage varies widely across countries. Previous studies have evaluated the association of clinical outcomes with the three types of vascular access, namely arteriovenous fistula (AVF), arteriovenous graft (AVG), and tunneled and cuffed central venous catheter (TC-CVC). However, little is known regarding the association between arterial superficialization (AS) and the mortality of patients. Methods: A nationwide cohort study was conducted using data from the Japanese Society for Dialysis Therapy Renal Data Registry (2006–2007). We included patients aged ≥20 years undergoing hemodialysis with a dialysis vintage ≥6 months. The exposures of interest were the four types of vascular access: AVF, AVG, AS, and TC-CVC. Cox proportional hazards models were used to evaluate the associations of vascular access types with 1-year all-cause and cause-specific mortality. Results: A total of 183,490 maintenance hemodialysis patients were included: 90.7% with AVF, 6.9% with AVG, 2.0% with AS, and 0.4% with TC-CVC. During the 1-year follow-up period, 13,798 patients died. Compared to patients with AVF, those with AVG, AS, and TC-CVC had a significantly higher risk of all-cause mortality after adjustment for confounding factors; adjusted hazard ratios (95% confidence intervals): 1.30 (1.20–1.41), 1.56 (1.39–1.76), and 2.15 (1.77–2.61), respectively. Similar results were obtained for infection-related and cardiovascular mortality. Conclusion: This nationwide cohort study conducted in Japan suggested that AVF usage may have the lowest risk of all-cause mortality. The study also suggested that the usage of AS may be associated with better survival rates compared to those of TC-CVC in patients who are not suitable for AVF or AVG.
  
  PubDate: Tue, 14 Mar 2023 18:44:37 +010
Contents Vol. 53, 2022
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  Abstract:
  Am J Nephrol 2022;53:I–X
  PubDate: Thu, 09 Mar 2023 11:23:02 +010
Acknowledgement to Reviewers
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  Abstract:
  Am J Nephrol 2022;53:860–861
  PubDate: Thu, 09 Mar 2023 11:22:45 +010
Triglycerides and Renal Outcomes according to Albuminuria and in
Consideration of other Metabolic Syndrome Components in Diabetic US
Veterans
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  Abstract: Objective: Hypertriglyceridemia, a component of the metabolic syndrome, is a known independent predictor of albuminuria and chronic kidney disease (CKD) in the general population. Previous studies have shown that the relationship of triglycerides with outcomes changes across stages of CKD. Our objective is to examine the association of triglycerides independent of other metabolic syndrome components with renal outcomes in diabetic patients with or without CKD. Research Design and Methods: This retrospective cohort study included diabetic US veteran patients with valid data on triglycerides (TG), estimated glomerular filtration rate (eGFR) and albuminuria (UACR), between fiscal years 2004 to 2006. Using Cox models adjusted for clinical characteristics and laboratory markers, we evaluated the relationship of TG with incident albuminuria (stratified by eGFR category) and based on eGFR (stratified by baseline albuminuria categories). To evaluate the relationship of TG with time to end-stage renal disease (ESRD), we stratified models by baseline CKD stage (eGFR category) and baseline albuminuria stage ascertained at time of TG measurement.Results: In a cohort of 138,675 diabetic veterans, the mean±SD age was 65±11 years old, and included 3% females and 14% African Americans. The cohort also included 28% of patients with non-dialysis dependent CKD (eGFR
  PubDate: Wed, 08 Mar 2023 08:20:04 +010
Extremely Low Dose of Erythropoiesis-Stimulating Agent May be Associated
with Increased Mortality in Hemodialysis Patients
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  Abstract: Introduction: Although high dose erythropoiesis-stimulating agent (ESA) has been shown to increase mortality risk and adverse cardiovascular events in hemodialysis patients, the safety of extremely low dose ESA is unclear. Methods: We retrospectively analyzed the association between ESA dose and mortality in the monthly dosing range of 0-43,000 U of equivalent epoetin alpha in 304 Taiwan hemodialysis patients by using Cox proportional hazard model and cubic spline model.Results: Compared with mean monthly ESA dose of 15,000-25,000 U (mean ± standard deviation 20,609 ± 2,662 U), monthly ESA dose of less than 15,000 U (mean ± standard deviation 7,413 ± 4,510 U) is associated with increased mortality. Monthly ESA dose of 25,001-43,000 U (mean ± standard deviation 31,160 ± 4,304 U) is not associated with higher mortality risk than monthly ESA dose of 15,000-25,000 U. The results were consistent in Cox proportional hazard models and cubic spline models. Subgroup analyses showed no significant heterogeneities among prespecified subgroups. Conclusions: Extremely low dose of ESA in hemodialysis patients may be associated with increased mortality risk. Future studies are warranted to prove this association.
  
  PubDate: Tue, 28 Feb 2023 18:08:04 +010

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