Longitudinal associations of depressive symptoms and pain with quality of life in patients receiving chronic hemodialysis

Depressive symptoms and pain are common in patients on chronic hemodialysis (HD), yet their associations with quality of life (QOL) are not fully understood. We sought to characterize the longitudinal associations of these symptoms with QOL. As part of a trial comparing two symptom management strategies in patients receiving chronic HD, we assessed depressive symptoms using the Patient Health Questionnaire‐9 (PHQ‐9), and pain using the Short Form McGill Pain Questionnaire (SF‐MPQ) monthly over 24 months. We assessed health‐related QOL (HR‐QOL) quarterly using the Short Form 12 (SF‐12) and global QOL (G‐QOL) using a single‐item survey. We used random effects linear regression to analyze the independent associations of depressive symptoms and pain, scaled based on 5‐point increments in symptom scores, with HR‐QOL and G‐QOL. Overall, 286 patients completed 1417 PHQ‐9 and SF‐MPQ symptom assessments, 1361 SF‐12 assessments, and 1416 G‐QOL assessments. Depressive symptoms were independently and inversely associated with SF‐12 physical HR‐QOL scores (β = ?1.09; 95% confidence interval [CI]: ?1.69, ?0.50, P < 0.001); SF‐12 mental HR‐QOL scores (β = ?4.52; 95% CI: ?5.15, ?3.89, P < 0.001); and G‐QOL scores (β = ?0.64; 95%CI: ?0.79, ?0.49, P < 0.001). Pain was independently and inversely associated with SF‐12 physical HR‐QOL scores (β = ?0.99; 95% CI: ?1.30, ?0.68, P < 0.001) and G‐QOL scores (β = ?0.12; 95%CI: ?0.20, ?0.05, P = 0.002); but not with SF‐12 mental HR‐QOL scores (β = ?0.16; 95%CI: ?0.050, 0.17, P = 0.34). In patients receiving chronic HD, depressive symptoms and to a lesser extent pain, are independently associated with reduced HR‐QOL and G‐QOL. Interventions to alleviate these symptoms could potentially improve patients' HR‐QOL and G‐QOL.     

Long‐term effects of daily hemodialysis on vascular access outcomes: A prospective controlled study

Daily hemodialysis has been associated with surrogate markers of improved survival among hemodialysis patients. A potential disadvantage of daily hemodialysis is that frequent vascular access cannulations may affect long‐term vascular access patency. The study design was a 4‐year, nonrandomized, contemporary control, prospective study of 77 subjects in either 3‐h daily hemodialysis (six 3‐h dialysis treatments weekly; n = 26) or conventional dialysis (three 4‐h dialysis treatments weekly; n = 51). Outcomes of interest were vascular access procedures (fistulagram, thrombectomy and access revision). Total access procedures (fistulagram, thrombectomy and access revision) were 543.2 (95% confidence interval [CI]: 432.9, 673.0) per 1000 person‐years in the conventional dialysis group vs. 400.8 (95% CI: 270.2, 572.4) per 1000 person‐years in the daily hemodialysis dialysis group (incidence rate ratio = 0.74 with 95% CI: from 0.40 to 1.36, P = 0.33), after adjusting for age, gender, diabetes status, serum phosphorus, hemoglobin level and erythropoietin dose, there was no significant differences in incidence rate of total access procedures (P‐value > 0.05). There was no difference in time to first access revision between the daily dialysis and the conventional dialysis groups after adjustment for covariates (hazard ratio = 0.99 95% CI: 0.42, 2.36, P = 0.96). Daily hemodialysis is not associated with increased vascular access complications, or increased vascular access failure rates.     

The effect of extended‐hours hemodialysis on outcomes: A systematic review and meta‐analysis

Extended‐hours hemodialysis is associated with improvements in quality of life (QoL) and mortality, but it may accelerate the loss of residual kidney function (RKF) and increase vascular access complications. Multiple established databases were systematically searched; randomized and non‐randomized studies were pooled separately. QoL outcomes were assessed using standardized mean difference (SMD), vascular access adverse events and mortality were assessed with relative risk ratios (RR). Four hundred seventy‐six patients from six trials were eligible. Data from randomized controlled trials (RCTs) could only be synthesized for vascular access adverse events and mortality, which demonstrated no significant change in vascular access adverse events (RR 1.25, 95% CI 0.88 to 1.77) or mortality (RR 2.29, 95% CI 0.60 to 8.71). Pooled data from non‐randomized trials demonstrated no significant difference in QoL (SF‐36 Physical Component Summary SMD 0.61, 95% CI ?0.10 to 1.31, SF‐36 Mental Component Summary SMD ?0.04, 95% CI ?0.61 to 0.54). RKF was assessed in one report which demonstrated a potential reduction over 12 months with extended‐hours hemodialysis. The majority of trials had high risk of bias. Extended‐hours hemodialysis was not associated with improved QoL or mortality, or increased vascular access events. Adequately powered RCTs are needed to fully assess extended‐hours hemodialysis.     

Intestinal parasites in hemodialysis patients from developing countries: A systematic review and meta‐analysis

Intestinal parasitic infection (IPI) is the main cause of gastrointestinal complications in hemodialysis patients due to their impaired immune systems. We conducted a systematic review and meta‐analysis to evaluate the prevalence and odds ratio (OR) of IPIs in this population. Relevant eligible studies were identified by searching the PubMed, Science Direct, Scopus, Web of Science, and Google scholar databases up to January 30, 2019. A random‐effects meta‐analysis model was used to estimate the pooled prevalence, OR, and 95% confidence intervals (CI). Twenty‐two studies, from Turkey, Iran, Brazil, Egypt, Saudi Arabia, Pakistan, and Malaysia met eligibility criteria for analysis, and included 11 using a case–control design (980 patients and 893 controls) and 11 studies using a cross‐sectional design (a total of 1455 participants). Cross‐sectional studies suggested that the pooled prevalence of IPIs in hemodialysis patients was 24% (95% CI, 14–36%; 307/1455). In studies using a case–control design, the pooled prevalence of IPIs in hemodialysis patients (30%, 330/980) was found to be significantly higher than controls (10%, 115/893) (OR, 3.40; 95%CI, 2.37–4.87). With respect to the parasites, Cryptosporidium spp. (OR, 4.49; 95%CI, 2.64–7.64) and Blastocystis sp. (OR, 4.03; 95%CI, 1.20–13.51) were significantly higher in hemodialysis patients compared to the controls. The current study revealed a high prevalence of IPIs in hemodialysis patients from countries in which the baseline prevalence of parasitic infection is high. We recommend that periodic screenings for IPIs in such countries should be incorporated into the routine clinical care of hemodialysis patients.     

Effects of frequent hemodialysis on blood pressure: Results from the randomized frequent hemodialysis network trials

Hypertension is a common complication of chronic kidney disease and persists among most patients with end‐stage renal disease despite the provision of conventional thrice weekly hemodialysis (HD). We analyzed the effects of frequent HD on blood pressure in the randomized controlled Frequent Hemodialysis Network trials. The daily trial randomized 245 patients to 12 months of 6× (“frequent”) vs. 3× (“conventional”) weekly in‐center hemodialysis; the nocturnal trial randomized 87 patients to 12 months of 6× weekly nocturnal HD vs. 3× weekly predominantly home‐based hemodialysis. In the daily trial, compared with 3× weekly HD, 2 months of frequent HD lowered predialysis systolic blood pressure by ?7.7 mmHg [95% confidence interval (CI): ?11.9 to ?3.5] and diastolic blood pressure by ?3.9 mmHg [95% CI: ?6.5 to ?1.3]. In the nocturnal trial, compared with 3× weekly HD, 2 months of frequent HD lowered systolic blood pressure by ?7.3 mmHg [95% CI: ?14.2 to ?0.3] and diastolic blood pressure by ?4.2 mmHg [95% CI: ?8.3 to ?0.1]. In both trials, blood pressure treatment effects were sustained until month 12. Frequent HD resulted in significantly fewer antihypertensive medications (daily: ?0.36 medications [95% CI: ?0.65 to ?0.08]; nocturnal: ?0.44 mediations [95% CI: ?0.89 to ?0.03]). In the daily trial, the relative risk per dialysis session for intradialytic hypotension was lower with 6×/week HD but given the higher number of sessions per week, there was a higher relative risk for intradialytic hypotensive requiring saline administration. In summary, frequent HD reduces blood pressure and the number of prescribed antihypertensive medications.     

Mortality risk in hemodialysis patients according to anemia control and erythropoietin dosing

There is no consensus about the toxicity of erythropoiesis‐stimulating agents among hemodialysis patients. We aimed to calculate the risk of death according to anemia control and erythropoietin (EPO) dosing among end‐stage renal disease patients undergoing hemodialysis. We retrospectively studied 156 end‐stage renal disease patients on hemodialysis from a single renal unit during 12 months. Participants were classified according to anemia control into four groups: excellent (A), good (B), moderate (C) and bad (D) control. They were also classified according to EPO dosing into two groups: usual and high EPO dosing. The Cox proportional hazards regression model, adjusted for the difference in age, sex, time on dialysis, comorbidity, albumin, and Kt/V index, was performed to calculate the risk of death according to anemia control and EPO dosing profiles. Multivariate analysis by backward stepwise logistic regression was used to calculate the risk of death according to the variables that differed in the comparison between survivors and nonsurvivors. The hazard ratio of death was not significant according to anemia control profile C/D vs. A/B, but hazard ratio was 2.967 (95% confidence interval [CI] = 1.132–7.777; P = 0.027) for high EPO dosing profile patients. The multivariate analysis showed comorbidity (odds ratio [OR] = 8.958; 95% CI = 2.843–26.223; P < 0.001], high EPO dosing profile (OR = 5.172; 95% CI = 1.663–16,081; P = 0.005), age (OR = 1.056; 95% CI = 1.020–1.094; P = 0.002), and mean hemoglobin (OR = 0.435; 95% CI = 0.267–0.709; P = 0.001) to be predictive of death. Even though we cannot conclude that mortality risk is due to EPO toxicity, hemodialysis patients using high EPO dosing must be seen as at risk.     

Effect of personalized nutritional counseling in maintenance hemodialysis patients

Monitoring nutritional parameters is an integral part of hemodialysis (HD) patient treatment program. The purpose of this study was to evaluate the impact of the personalized nutritional counseling (PNC) on calcium–phosphorus metabolism, potassium, albumin, protein intake, interdialytic weight gain (IDWG), body composition parameters and fluid overload in HD patients. This was a multicenter longitudinal intervention study with 6 months of follow‐up and 731 patients on maintenance HD from 34 dialysis units in Portugal were enrolled. Biochemical and body composition parameters were measured at baseline, 1, 3 and 6 months after the PNC. Patient's mean age was 64.9 (95% confidence interval [CI]: 63.8–66.0) years and mean HD time was 59.8 (95% CI: 55.3–64.3) months. Regarding data comparison collected before PNC vs. 6 months after, we obtained, respectively, the following results: patients with normalized protein catabolic rate (nPCR) ≥ 1 g/kg/day = 66.5% vs. 73.5% (P = 0.002); potassium > 5.5 mEq/L = 52% vs. 35.8% (P < 0.001); phosphorus between 3.5 and 5.5 mg/dL = 43.2% vs. 52.5% (P < 0.001); calcium/phosphorus (Ca/P) ratio ≤ 50 mg/dL = 73.2 % vs. 81.4% (P < 0.001); albumin ≥ 4.0 g/dL = 54.8% vs. 55% (P = 0.808); presence of relative overhydration = 22.4% vs. 25% (P = 0.283); IDWG > 4.5% = 22.3% vs. 18.2% (P = 0.068). PNC resulted in a significant decrease in the prevalence of hyperkalemia, hypophosphatemia and also showed amelioration in Ca/P ratio, nPCR and an increase in P of hyphosphatemic patients. Our study suggests that dietetic intervention contributes to the improvement of important nutritional parameters in patients receiving hemodialysis treatment.     

Coronal mode ultrasound guided hemodialysis cannulation: A pilot randomized comparison with standard cannulation technique

Background: Infiltrations from cannulation result in significant morbidity including loss of hemodialysis (HD) vascular access (VA). Cannulation is dependent on personnel skill and VA characteristics. Surface marking of VA lacks real‐time information and traditional ultrasound (US) devices are large, expensive, requiring skilled operators. Sonic Window© (Analogic Ultrasound, Peabody, MA, USA) is a coronal mode ultrasound device (CMUD) approved for VA cannulation. Methods: Single center randomized, prospective pilot study comparing handheld US‐guided cannulation of new arteriovenous fistula (AVF) to standard cannulation practices. Patients with end stage renal disease (ESRD) on in‐center HD who had a new AVF cleared for cannulation and dialysis were enrolled. Patients with new AVF received either standard cannulation (control group) or image guidance using CMUD (study group) for 3 weeks. Ultrasound characteristics of VA, cannulation practices and complications end points were obtained. Results: An infiltration rate of 9.7% was noted during the study. Slightly lower odds ratio (OR) of infiltration was observed in the study group (OR 0.94, 95% CI: 0.26–3.41, P value = 0.93). Study group yielded longer time for assessment (101.8 ± 80.2 vs. 22.3 ± 22.5 seconds, P = < 0.001), increased cannulation time (41.1 ± 70.6 vs. 25.0 ± 27.9 seconds, P = 0.04), and increased patient satisfaction (94.6% vs. 82%, P = 0.04) compared to control group. Number of cannulation attempts, needle size, arterial or venous needle insertion, and tourniquet usage between groups were not statistically different. Conclusion: Handheld ultrasound is a safe and useful aid in cannulation of dialysis access.     

Usefulness of assisted procedures for arteriovenous fistula maturation without compromising access patency

Introduction: To increase the rate of arteriovenous fistula (AVF) use, assisted procedures for immature AVF have been strenuously performed. However, this is controversial in that an AVF matured by these assisted procedures may require more frequent intervention to maintain its patency, and have decreased long‐term patency. Methods: Eighty four AVFs that were matured with assisted maturation procedures and 266 AVFs that matured spontaneously without intervention, created between November 2009 and March 2013 from the hemodialysis (HD) vascular access (VA) cohort, were compared retrospectively and we also investigated the factors that may influence AVF long‐term patency. Median follow‐up was 26.8 months (interquartile range, 6.6–45.0 months). Findings: Access survival did not differ between AVFs matured by assisted procedures and spontaneously mature AVFs (P = 0.29). In multivariate Cox regression analysis of AVF survival, age (HR, 1.029; 95% CI, 1.004–1.056; P = 0.024), maturation without assisted procedures 4–6 weeks after AVF creation (HR, 0.233; 95% CI, 0.107–0.506; P < 0.001), and AVF thrombosis (HR, 26.511; 95% CI, 10.986–63.978; P < 0.001) were significantly associated with AVF survival. Performance of assisted procedures to induce AVF maturation did not influence AVF survival (HR, 0.437; 95% CI, 0.191–1.002; P = 0.05). Discussion: Our results support that idea that assisted maturation procedures can ensure the success of immature AVF without compromising long‐term patency. These procedures can be considered more positively for increasing AVF use for VA placement in HD patients.     

Reduction of carbamylated albumin by extended hemodialysis

Introduction Among conventional hemodialysis (CHD) patients, carbamylated serum albumin (C‐Alb) correlates with urea and amino acid deficiencies and is associated with mortality. We postulated that reduction of C‐Alb by intensive HD may correlate with improvements in protein metabolism and cardiac function. Methods One‐year observational study of in‐center nocturnal extended hemodialysis (EHD) patients and CHD control subjects. Thirty‐three patients receiving 4‐hour CHD who converted to 8‐hour EHD were enrolled, along with 20 controls on CHD. Serum C‐Alb, biochemistries, and cardiac MRI parameters were measured before and after 12 months of EHD. Findings EHD was associated with reduction of C‐Alb (average EHD change ?3.20 mmol/mol [95% CI ?4.23, ?2.17] compared to +0.21 [95% CI ?1.11, 1.54] change in CHD controls, P < 0.001). EHD was also associated with increases in average essential amino acids (in standardized units) compared to CHD (+0.38 [0.08, 0.68 95%CI]) vs. ?0.12 [?0.50, 0.27, 95% CI], P = 0.047). Subjects who reduced C‐Alb more than 25% were found to have reduced left ventricular mass, increased urea reduction ratio, and increased serum albumin compared to nonresponders, and % change in C‐Alb significantly correlated with % change in left ventricular mass. Discussion EHD was associated with reduction of C‐Alb as compared to CHD, and reduction of C‐Alb by EHD correlates with reduction of urea. Additional studies are needed to test whether reduction of C‐Alb by EHD also correlates with improved clinical outcomes.     

Pulmonary hypertension in patients on chronic hemodialysis and with heart failure

Pulmonary hypertension (PH) is linked to chronic kidney disease. However, few studies have examined the prevalence, risk factors, or outcomes of PH in patients with chronic hemodialysis and concomitant heart failure. This retrospective cohort study enrolled 160 patients with a history of acute decompensated heart failure after maintenance hemodialysis therapy. All patients were prospectively observed until December 2013 or death. PH was defined as pulmonary artery systolic pressure >35 mmHg, as determined through echocardiography. Fifty‐one (32%) patients had PH, more of whom were female (70% vs. 52%, P = 0.04). The patients with PH had a lower body mass index (21.8 vs. 23.0, P = 0.03), higher cardiothoracic ratio (55% vs. 52%, P = 0.006), larger left atrium (38.5 vs. 35.7 mm, P = 0.01), and an increased proportion of mitral regurgitation (MR) (73% vs. 38%, P < 0.001) compared with the patients who did not have PH. In the multivariate regression analysis, MR was associated most strongly with PH (odds ratio 3.75, 95% confidence interval [CI]: 1.67–8.43, P = 0.001). In the multivariate Cox proportional hazard models, PH was related independently to all‐cause mortality (hazard ratio [HR], 3.11; 95% CI, 1.53–6.31; P = 0.002) and combined cardiovascular events (HR, 2.71; 95% CI, 1.66–4.44; P < 0.001) after the model was adjusted for conventional cardiovascular risk factors. PH is related to MR and independently associated with increased all‐cause mortality and cardiovascular events in patients with chronic hemodialysis and heart failure.     

Association between antiinflammatory cytokine,IL‐10, and sleep quality in patients on maintenance hemodialysis

Elevated proinflammatory cytokines have been attributed to poor sleep quality in patients receiving hemodialysis. This is the first investigation about the relationship between sleep quality and circulating levels of antiinflammatory markers in these patients. A total of 72 patients who were receiving maintenance hemodialysis were enrolled in this cross‐sectional study. The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality. Patients were divided into two groups: good sleepers (PSQI score < 5) and poor sleepers (PSQI score ≥ 5). Assessments were made for serum biochemical parameters (albumin, parathyroid hormone), inflammatory (interleukin [IL]‐6, tumor necrosis factor‐alpha [TNF‐α], and high‐sensitivity c‐reactive protein [hs‐CRP] ) and antiinflammatory (IL‐10) markers. Fifty‐four patients (75%) were classified as poor sleepers. Poor sleepers showed significantly lower levels of serum IL‐10 and higher serum triglyceride and parathyroid hormone concentrations. These patients were more likely to have more comorbidities. The global PSQI score was significantly correlated with serum IL‐10 (p = 0.03) and triglyceride levels (p = 0.01). Multivariate logistic regression analysis showed a direct correlation between PSQI and having comorbidities (p = 0.011, odds ratio [OR] = 3.918; confidence interval 95% [CI] = 2.742–19.031), between PSQI and serum triglyceride (p = 0.027, OR = 1.027 [95% CI = 1.007–1.048] ), and an inverse correlation between PSQI and serum IL‐10 level (p = 0.021, OR = 0.424 [95% CI = 0.195–0.922]). Reduced circulating levels of the antiinflammatory cytokine IL‐10 were significantly associated with poor sleep quality in hemodialysis patients. Factors including serum IL‐10 and triglyceride concentrations and having comorbidities may predict patients prone to poor sleep quality.     

Factors predicting failure of AV “fistula first” policy in the elderly

An arteriovenous fistula (AVF) is the preferential hemodialysis (HD) access. The goal of this study was to identify factors associated with pre‐dialysis AVF failure in an elderly HD population. We used United States Renal Data System + Medicare claims data to identify patients ≥67 years old who had an AVF as their initial vascular access placed pre‐dialysis. Failure of the AVF to be used for initial HD, was used as the outcome. Logistic regression model was used to identify factors associated with AVF failure. The study cohort consisted of 20,360 subjects (76.2 ± 6.02 year old, 58.5% men). Forty‐eight percent of patients initiated dialysis using an AVF, while 52% used a catheter or an AVG. The following variables found to be associated with AVF failure when an AVF was created at least 4 months pre‐HD initiation: older age (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.00–1.02), female gender (OR 1.69; 95% CI 1.55–1.83), black race (OR 1.41; 95% CI 1.26–1.58), history of diabetes (OR 1.22; 95% CI 1.06–1.39), cardiac failure (OR 1.26; 95% CI 1.15–1.37), and shorter duration of pre–end‐stage renal disease (ESRD) nephrology care (OR for a nephrology care of less than 6 months prior to ESRD of 1.22 compared with a pre‐ESRD nephrology follow up of more than 12 months; 95% CI 1.07–1.38). OR for AVF failure for the entire cohort showed similar findings. In an elderly HD population, there is an association of older age, female gender, black race, diabetes, cardiac failure and shorter pre‐ESRD nephrology care with predialysis AVF failure.     

Quality of life development during initial hemodialysis therapy and association with loss of residual renal function

Introduction: Health related quality of life (HRQOL) is markedly reduced in hemodialysis patients compared to the general population. We investigated the course of self‐reported HRQOL over time and the association with selected factors, focusing on changes in glomerular filtration rate (GFR). Methods: Eighty‐two newly started hemodialysis patients from the SAFIR cohort filled out the Kidney Disease Quality of Life Short Form Version 1.3 (KDQOL‐SF^TM) questionnaire at baseline, 6 and 12 months. The SAFIR study was a randomized, placebo‐controlled, double‐blind intervention study, examining the effects of the angiotensin II receptor blocker irbesartan. HRQOL was a secondary outcome measure. Main inclusion criteria: Dialysis vintage <1 year, left ventricular ejection fraction >30% and urinary output >300 mL/day. GFR was measured with mean creatinine and urea clearance from 24‐hour urine collections at baseline, 6 and 12 months. Findings: Irbesartan treatment did not affect HRQOL. Patients were pooled into one group for further analyses. Decline in GFR correlated significantly with decreasing HRQOL over time. HRQOL was stable over time, with a slight nonsignificant tendency toward improved HRQOL. The largest HRQOL‐differences (positive values equal improved HRQOL) observed during the 12 month study period were (mean[95% confidence interval]): Burden of kidney disease:6.4[?2.2;15.0], Role limitations‐physical:12.7[?2.1;27.5], and Role limitations‐emotional:9.7[?5.2;24.6]. Comorbidity, especially diabetes, hospital admissions, female gender, and age were strongly associated with lower HRQOL in cross sectional analysis. Discussion: Preservation of residual renal function seems to be important for HRQOL. In newly started HD patients, HRQOL showed little change after 12 months. HRQOL was negatively affected by comorbidity, especially diabetes, hospital admissions, female gender, and age.     

Predialysis volume overload and patient‐reported sleep duration and quality in patients receiving hemodialysis

Introduction: Previous studies of patients with end‐stage renal disease have examined the role of fluid shifts on apnea‐hypopnea episodes, but the association between volume overload and patient‐reported sleep quality or duration has not been well‐established. Methods: We studied the association between predialysis bioimpedance spectroscopy‐derived volume estimates and self‐reported sleep quality and duration in 638 patients in the United States Renal Data System ACTIVE/ADIPOSE study receiving hemodialysis from 2009 to 2011. We used questionnaires to assess self‐reported sleep duration and quality. We used relative hydration status (fluid overload/extracellular water; FO/ECW) as the primary predictor and examined associations with hours of sleep duration using linear regression. We used multivariable ordinal logistic regression to determine the association between categories of relative hydration status (normal hydration [FO/ECW < 6.8%], mild overhydration [FO/ECW 6.8%–15%], and hyperhydration [FO/ECW > 15%]) and four levels of difficulty with falling asleep, waking, and returning to sleep. Findings: Higher relative hydration status was associated with fewer hours of sleep (?0.31 hours per 10%, 95% confidence interval (CI) ?0.49 to ?0.13). Compared to the normal hydration group, there was a statistically significant association between higher relative hydration status category and more frequent nighttime waking (OR: mild overhydration 1.92 [95% CI 1.23–2.99], hyperhydration 1.87 [95% CI 1.16–2.99]), a trend toward more difficulty returning to sleep (OR: mild overhydration 1.46 [95% CI 0.94–2.27], hyperhydration 1.52 [95% CI 0.95–2.43]), and no association between relative hydration category and difficulty falling asleep. Discussion: Hydration status was associated with self‐reported sleep duration in patients on dialysis. Future studies should prospectively examine the effects of optimizing fluid status on sleep duration and quality.     

Cardiac troponin-I and its prognostic significance in a dialysis population

Background: The objective was to study the prevalence and specificity of elevated levels of cardiac troponin‐I (cT‐I) in patients on maintenance hemodialysis in relation to creatine kinase (CK), the CK‐MB fraction, and the ratio CK‐MB of total CK and to assess its significance for the long‐term prognosis in these patients, compared to other parameters known to influence the outcome. Methods: Predialysis blood samples were taken from 93 asymptomatic hemodialysis patients for cT‐I, total CK, the CK‐MB fraction, and the ratio of CK‐MB to total CK. cT‐I was measured by a microparticle enzyme immunoassay. The patients were followed for 1 year, after which baseline levels of cT‐I and age, duration of dialysis, and the presence of diabetes mellitus and ischemic heart disease were correlated by linear regression analysis with the outcome parameter all‐cause mortality. Results: None of the patients had a cT‐I level higher than the manufacturer's indicated cutoff point of 2.0 ng/mL for myocardial infarction, indicating a specificity of 100%. Nine of the 93 patients (9.7%) had detectable cT‐I levels (>0.0 ng/mL). Twelve patients died within 1 year, among which 4 had baseline cT‐I levels above 0 ng/mL. From the study variables, an elevated baseline cT‐I was found to be the only factor that significantly correlated with the outcome all‐cause mortality (p = 0.029). Conclusions: cT‐I has a high specificity for the diagnosis of myocardial infarction in dialysis patients. Despite the relatively low number of positive test results, cT‐I was found to be significantly correlated with the outcome all‐cause mortality at 1 year.     

Prognostic factors for chronic neck pain in persons with minor or moderate injuries in traffic accidents

Prognostic factors for chronic neck pain were identified in a prospective Norwegian insurance cohort comprising 636 persons with minor or moderate traffic injuries. One questionnaire was used at baseline and another at 3 years post-injury. Daily severe or very severe neck pain at three years follow up was defined as chronic neck pain. Eight significant independent prognostic factors for chronic neck pain were identified: (1) rear-end or frontal and rear-end collision, odds ratio (OR): 4.10 (95% confidence interval (CI): 1.72-10.82); (2) neck and/or shoulder pain before the accident, OR: 2.38 (95% CI: 1.07-5.37); (3) post-accident (a) memory and concentration problems, OR: 4.62 (95% CI: 1.99-11.20), (b) bodily tension, OR: 3.43 (95% CI: 1.49-8.42), (c) difficulties to climb stairs, OR: 5.03 (95% CI: 1.77-14.95), (d) difficulties to bend forward, OR: 4.85 (95% CI: 2.06-11.79), (e) difficulties to do heavy labour, OR: 3.70 (95% CI: 1.24-11.64); (4) beliefs in future work disability, OR: 2.64 (95% CI: 1.11-6.48). The results indicate that development of chronic neck pain is influenced by pre-accident neck and/or shoulder pain, the impact of the collision, as well as post-accident symptoms, perceived impaired function and pessimism for the future ability to work.     

Association of low vitamin D levels with metabolic syndrome in hemodialysis patients

Low vitamin D levels have been linked to metabolic syndrome in the general population. In the present study, the relationship between inadequate serum concentrations of vitamin D and metabolic syndrome in patients with end‐stage renal disease undergoing hemodialysis was explored. In a cross‐sectional setting, 145 patients undergoing maintenance hemodialysis were enrolled. Metabolic syndrome was defined using the International Diabetes Federation criteria. Serum concentration of 25(OH) vitamin D was determined by a commercially available enzyme immunosorbent assay method. The prevalence of metabolic syndrome was 53.1%. The prevalence rate of severe vitamin D deficiency (<5 ng/mL) was 3.4%, mild vitamin D deficiency (5–15 ng/mL) 31.0%, vitamin D insufficiency (16–30 ng/mL) 36.6%, and vitamin D sufficiency (>30 ng/mL) 29.0%. With the increasing number of metabolic abnormalities, vitamin D levels significantly decreased (P for trend = 0.028). Among the components of metabolic syndrome, vitamin D deficiency was significantly associated with central obesity (odds ratio [OR], 95% confident interval [CI] = 2.80, 1.11–7.04, P = 0.028). A positive, but nonsignificant association between vitamin D deficiency and raised fasting plasma glucose was noted (OR, 95% CI = 2.40, 0.94–6.11, P = 0.067). Both vitamin D deficiency and insufficiency were significantly associated with an increased likelihood of having metabolic syndrome (P < 0.05). In a final model controlling for age, sex, and parathyroid hormone levels, vitamin D deficiency increased the odds of having metabolic syndrome by more than threefold (OR, 95% CI = 3.26, 1.30–8.20, P = 0.012). Low levels of vitamin D are frequent among hemodialysis patients and are associated with the metabolic syndrome.     

Incidence of hepatitis C virus infection in patients on hemodialysis: A systematic review and meta‐analysis

Hepatitis C virus infection is a perennial concern for hemodialysis units because the prevalence of hepatitis C is significantly higher there than in the general population. Through a systematic review and meta‐analysis, we aim to assess the incidence rate of hepatitis C virus infection in hemodialysis units and explore its potential risk factors. Five electronic databases were used to search articles from 1990 to 2012, including PubMed, Embase, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang. A random‐effects analysis was used to estimate the overall incidence rate of hepatitis C virus infection. A subgroup analysis and meta‐regression analysis were conducted to explore factors associated with heterogeneity between studies. Twenty‐two eligible articles were found, including 23 incidence rate estimates. The overall incidence rate of hepatitis C virus infection was 1.47 per 100 patient‐years (95% confidence interval [CI] 1.14 to 1.80). In the subgroup analysis, the pooled incidence rate was 4.44 (CI 2.65, 6.23) per 100 patient‐years in the developing world and 0.99 (CI 0.66, 1.29) per 100 patient‐years in the developed world. [Correction added on 2 November 2012, after first online publication: Pooled incidence rate in the developed world has been changed.] In addition, in hemodialysis units with higher prevalence, the incidence rate of hepatitis C virus infection also tended to be higher. Meta‐regression analysis showed that the country's development level and initial HCV prevalence combined could explain 67.91% of the observed heterogeneity. The incidence rate of hepatitis C virus infection among patients on hemodialysis was significantly high. Efforts should be taken to control hepatitis C virus infection in hemodialysis units, especially in developing countries.     

Determinants of training and technique failure in home hemodialysis

Home hemodialysis (HHD) has clinical and economic advantages compared with in‐center conventional hemodialysis. Many health systems wish to broaden the population to which this modality can be successfully offered. However, determinants of successful HHD training and technique survival are unknown. We hypothesize that both medical and social factors play a role when patients fail to successfully adopt HHD. We examined characteristics of consecutive patients who initiated training for HHD between 2003 and 2011. Patients were classified as “failure” if they failed to complete HHD training or experienced technique failure (TF) within the first year of treatment. Remaining patients were classified as “success.” One hundred seventy‐seven patients initiated HHD training. In the “failure” group (n = 32), 24 did not finish training and 8 had TF. In the “success” group (n = 145), 65 (45%) patients remained on NHD, 49 (34%) discontinued HHD because of renal transplantation and 21 (14%) because of death, while only 10 (7%) eventually transferred to another dialysis modality. In a multivariable logistic regression analysis, the strongest predictors of “failure” were end‐stage renal disease because of diabetes (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.4–10.3, P = 0.008) and use of rental housing (OR 3.1, 95% CI 1.3–6.0, P = 0.01). Both medical and social factors are associated with failure to adopt HHD. Enhanced supports or a customized education strategy for these vulnerable patients should be considered.