Patient‐reported cognitive functioning and daily functioning in chronic dialysis patients

Subjective cognitive impairment negatively affects daily functioning, health‐related quality of life, and health care consumption, and is predictive of future cognitive decline in many patient populations. However, no subjective measures of multidimensional cognitive functioning have been evaluated for dialysis patients. Our purposes were to examine (1) the association between patient‐reported (subjective) cognitive functioning and objective cognitive functioning and (2) the relationships between subjective and objective cognitive functioning and everyday functioning of dialysis patients. We used baseline data from an ongoing longitudinal observational study of trajectories in dialysis patients' multidimensional quality of life. One hundred thirty‐five patients completed a telephone‐based neuropsychological battery (Brief Test of Adult Cognition by Telephone, a measure of objective cognitive functioning), a measure of subjective cognitive functioning (Patient's Assessment of Own Functioning Inventory), and measures of everyday functioning (Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL] scales). After controlling for age and education, there was a modest correlation (r = 0.33, P > 0.001) between subjective and objective cognitive functioning. Multivariate logistic regression models showed subjective, but not objective, cognitive functioning was a significant predictor of both ADLs and IADLs. The findings suggest the potential clinical value of subjective measures of cognitive functioning, not to replace objective measures or diagnostic tests, but rather to optimize the meaningfulness of clinical assessment and management.     

Correlates of ADL difficulty in a large hemodialysis cohort

Needing assistance with activities of daily living (ADL) is an early indicator of functional decline and has important implications for individuals' quality of life. However, correlates of need for ADL assistance have received limited attention among patients undergoing maintenance hemodialysis (HD). A multicenter cohort of 742 prevalent HD patients was assessed in 2009–2011 and classified as frail, prefrail and nonfrail by the Fried frailty index (recent unintentional weight loss, reported exhaustion, low grip strength, slow walk speed, low physical activity). Patients reported need for assistance with 4 ADL tasks and identified contributing symptoms/conditions (pain, balance, endurance, weakness, others). Nearly 1 in 5 patients needed assistance with 1 or more ADL. Multivariable analysis showed increased odds for needing ADL assistance among frail (odds ratio [OR] 11.35; 95% confidence interval [CI] 5.50–23.41; P < 0.001) and prefrail (OR 1.93; 95% CI 1.01–3.68; P = 0.046) compared with non‐frail patients. In addition, the odds for needing ADL assistance were lower among blacks compared with whites and were higher among patients with diabetes, lung disease, and stroke. Balance, weakness, and “other” (frequently dialysis‐related) symptoms/conditions were the most frequently named reasons for ADL difficulty. In addition to interventions such as increasing physical activity that might delay or reverse the process of frailty, the immediate symptoms/conditions to which individuals attribute their ADL difficulty may have clinical relevance for developing targeted management and/or treatment approaches.     

Associations of microvascular dysfunction with cardiovascular outcomes: The cardiac,endothelial function and arterial stiffness in ESRD (CERES) cohort

Introduction: Patients with end‐stage renal disease (ESRD) have reduced endothelial function, but whether macro‐ and microvascular endothelial function correlate with baseline risk factors and cardiovascular outcomes in this population is not well understood. Methods: Among 146 participants of the Cardiac, Endothelial Function and Arterial Stiffness in ESRD (CERES) study, we evaluated macro‐ and microvascular endothelial dysfunction as flow‐mediated dilation (FMD) and velocity time integral (VTI), respectively. We examined cross‐sectional correlations of baseline characteristics, inflammatory and cardiac markers with FMD and VTI. We followed participants for the composite outcome of cardiovascular hospitalization or all‐cause death over fourteen months. Cox survival analyses were adjusted for demographics, comorbidities, medications, systolic blood pressure, inflammation, high‐sensitivity troponin T (hs‐TnT), and N‐terminal pro B‐type natriuretic peptide (NT‐proBNP). Findings: Impaired VTI was associated with older age and Black race (P < 0.05), as well as female gender, atherosclerosis, and hemodialysis (as opposed to peritoneal dialysis) (P < 0.2). Myocardial injury, measured as hs‐TnT, inflammatory markers and NT‐proBNP correlated with impaired VTI. In unadjusted analyses, VTI was significantly associated with the composite outcome (HR per SD VTI 0.65 [95%CI 0.45, 0.95]), but FMD was not (HR per SD FMD 0.97 [95%CI 0.69, 1.4]). When VTI was calculated as the ratio of (hyperemic VTI‐baseline VTI)/baseline VTI, its association with the outcome persisted after multivariable adjustment. Discussion: Microvascular function was associated with higher rates of cardiovascular hospitalizations and all‐cause mortality among individuals with ESRD on dialysis. Further research is needed to learn whether novel therapies that target microvascular endothelial function could improve outcomes in this high‐risk population.     

Independence of older adults in performing instrumental activities of daily living (IADLs) and the relation of this performance to visual abilities

A questionnaire study was undertaken of more than 2800 elderly people aged 60 years and over and living at home, to investigate the relationship between their performance of some instrumental activities of daily living (IADLs) and their visual abilities. The IADL measured the ability of elderly participants to pick up coins, manage monthly financial matters, use the telephone and take medication as recommended. Visual abilities were assessed by means of each subject's answers to questions relating to resolution, focus, adaptation to bright or to dim lighting, dynamic acuity, distance perception and colour vision. The types of visual functions that, together with age and gender, contribute to determining the level of independence in the performance of IADL activities were identified using logistic regression analysis. The results indicated that elderly participants who had problems with either distance perception or yellowish vision also tended to have difficulties in picking up coins, using the telephone and taking medication as recommended. In addition, problems with adaptation and dynamic acuity were associated with difficulty in managing monthly financial matters. From an analysis of all subjects, distance perception was the significant factor that determined whether an elderly subject could pick up coins or use a telephone unaided. Yellowish vision was also significantly associated with a need for assistance or with an inability to manage monthly financial matters, use the telephone or take medication as recommended.     

Measures of blood pressure and cognition in dialysis patients

There are few reports on the relationship of blood pressure with cognitive function in maintenance dialysis patients. The Cognition and Dialysis Study is an ongoing investigation of cognitive function and its risk factors in six Boston area hemodialysis units. In this analysis, we evaluated the relationship between different domains of cognitive function with systolic and diastolic blood pressure, pulse pressure, and intradialytic changes in systolic blood pressure, using univariate and multivariable linear regression models adjusted for age, sex, race, education, and primary cause of end‐stage renal disease. Among 314 participants, mean age was 63 years; 47% were female, 22% were African American, and 48% had diabetes. The mean (SD) of systolic blood pressure, diastolic blood pressure, pulse pressure, and intradialytic change in systolic blood pressure were 141 (21), 73 (12), 68 (15), and ?10 (24) mmHg, respectively. In univariate analyses, the performance on cognitive tests primarily assessing executive function and processing speeds was worse among participants with lower diastolic blood pressure and higher pulse pressure. These relationships were not statistically significant, however, in multivariable analyses. There was no association between cognitive function and systolic blood pressure or intradialytic change in systolic blood pressure in either univariate or multivariable analyses. We found no association between different measures of blood pressure and cognitive function in cross‐sectional analysis. Longitudinal studies are needed to confirm these results.     

Revisiting Autonomic Dysfunction in End-Stage Renal Disease Patients

Background: Autonomic dysfunction is frequent in end‐stage renal disease (ESRD) patients, but both the relative involvement of the parasympathetic and sympathetic branches and the role of antihypertensive drugs in this setting are still controversial. The present study addressed these issues employing a battery of standard noninvasive cardiovascular autonomic tests. Methods: Sympathetic (S) function was evaluated by responses of both systolic blood pressure (BP) to passive tilting and diastolic BP to handgrip; parasympathetic (P) function, through the respiratory sinus arrhythmia test and the heart rate response to the 4‐s unloaded exercise test. Additional tests influenced by both branches of the autonomic system (P + S) were accomplished by the assessment of heart rate response to the Valsalva maneuver, handgrip, and tilting. Results: Studied subjects belonged to one of the three groups: ESRD patients not requiring BP medications (n = 11; 8 men, 3 women); ESRD patients receiving antihypertensive therapy (n = 36; 21 men, 15 women); and apparently healthy controls (n = 15; 10 men, 5 women). When the variables grouped according to the branch of the autonomic nervous system predominantly probed were analyzed, only the frequency of impaired sympathetic autonomic responses was higher in ESRD patients not receiving BP drugs compared to controls (55 vs. 23%, P = 0.040). In contrast, when ESRD patients receiving BP drugs were compared to controls, the differences became significant in S, P, and P + S tests (46 vs. 23%, P = 0.045; 22 vs. 3%, P = 0.020; and 34 vs. 13%, P = 0.010, respectively). With the criterion of more than one positive finding in any of the variables examined for diagnosing autonomic dysfunction, the prevalence of autonomic dysfunction was 20% in controls, 64% in ESRD patients not receiving BP drugs (P = 0.005 vs. controls), and 67% in ESRD patients receiving BP drugs (P = 0.043 vs. controls). Conclusions: ESRD continues to be associated with a high prevalence of autonomic dysfunction. ESRD patients receiving BP drugs were found to have detectable impairment in the entire autonomic system in contrast to those not receiving BP drugs in whom inadequate responses were restricted to the sympathetic branch.     

The alternate forms reliability of the new tasks added to the Assessment of Motor and Process Skills

The purpose of this study was to evaluate the alternate forms reliability of new tasks vs. old tasks of the Assessment of Motor and Process Skills (AMPS). The participants in this study were 44 persons taken from the AMPS database who had completed two old tasks and two new tasks within a 4-day period. Paired t tests revealed no significant difference between the means of ADL ability measures based on the performance of new vs. old tasks. The Pearson product moment correlations between the ADL ability measures based on the performance of new vs. old tasks was r =.92, p <.001 for motor ability measures and r =.77, p <.001 for process ability measures. We found that 100% of the ADL motor ability measures had standardized differences less than 2.00 (p <.05) and 97% of the ADL process ability measures had standardized differences less than 2.00 (p <.05). Considered together, the results support good alternate forms reliability of the ADL motor and ADL process ability measures. This study supported the finding that the 20 newly calibrated IADL and PADL tasks can be used reliably in clinical practice. When the AMPS is used to evaluate change, we can have 80 to 93% confidence that paired ability measures that change by more than +0.5 logits are the result of actual changes in ability.     

Sex differences in vascular dysfunction and cardiovascular outcomes: The cardiac,endothelial function,and arterial stiffness in ESRD (CERES) study

Introduction: Recent studies suggest that women with end‐stage renal disease (ESRD) may have higher rates of mortality than men, but it is unknown whether sex differences in vascular function explain this disparity. The cardiac, endothelial function, and arterial stiffness in ESRD (CERES) study is an ongoing, prospective observational study designed to investigate vascular function, myocardial injury, and cardiovascular outcomes in ESRD. Methods: Among 200 CERES participants (34% women), we evaluated arterial wave reflections as augmentation index normalized to a heart rate of 75 (AIx75), arterial stiffness as pulse wave velocity, and macro‐ and microvascular endothelial dysfunction as flow‐mediated dilation and velocity time integral (VTI). Over a median of 14 months, participants were followed for the composite outcome of cardiovascular hospitalization or all‐cause death. Findings : Women had higher arterial wave reflection (Mean, SD AIx75 30% ± 9% for women vs. 21% ± 10% for men; P < 0.001) and worse microvascular function (VTI 55 ± 30 cm for women vs. 70 ± 27 cm for men; P = 0.007). After multivariable adjustment, female sex remained associated with a 0.5‐SD higher AIx75 (95% CI [0.01, 0.9]) and 0.3‐SD lower VTI (95%CI [0.1, 0.7]). Women experienced higher adjusted rates of the composite outcome (HR 2.5; 95%CI [1.1, 5.6]; P = 0.03), and further adjustment for arterial wave reflection attenuated this risk. Discussion: Vascular dysfunction may partly explain the association of female sex with higher cardiovascular risk and mortality in patients with ESRD. Further studies are needed to explore whether sex differences in vascular function predict long‐term outcomes, and whether hormonal or inflammatory factors explain these associations.     

FGF‐23 and cognitive performance in hemodialysis patients

Although cognitive impairment is common in hemodialysis patients, the etiology of and risk factors for its development remain unclear. Fibroblast growth factor 23 (FGF‐23) levels are elevated in hemodialysis patients and are associated with increased mortality and left ventricular hypertrophy. Despite FGF‐23 being found within the brain, there are no prior studies assessing whether FGF‐23 levels are associated with cognitive performance. We measured FGF‐23 in 263 prevalent hemodialysis patients in whom comprehensive neurocognitive testing was also performed. The cross‐sectional association between patient characteristics and FGF‐23 levels was assessed. Principal factor analysis was used to derive two factors from cognitive test scores, representing memory and executive function, which carried a mean of 0 and a standard deviation of 1. Multivariable linear regression adjusting for age, sex, education status, and other relevant covariates was used to explore the relationship between FGF‐23 and each factor. Mean age was 63 years, 46% were women and 22% were African American. The median FGF‐23 level was 3098 RU/mL. Younger age, lower prevalence of diabetes, longer dialysis vintage, and higher calcium and phosphorus were independently associated with higher FGF‐23 levels. Higher FGF‐23 was independently associated with a lower memory score (per doubling of FGF‐23, β = ?0.08 SD [95% confidence interval, CI: ?0.16, ?0.01]) and highest quartile vs. lowest quartile (β = ?0.42 SD [?0.82, ?0.02]). There was no definite association of FGF 23 with executive function when examined as a continuous variable (β = ?0.03 SD [?0.10, 0.04]); however, there was a trend in the quartile analysis (β = ?0.28 SD [?0.63, 0.07], P = 0.13, for 4th quartile vs. 1st quartile). FGF‐23 was associated with worse performance on a composite memory score, including after adjustment for measures of mineral metabolism. High FGF‐23 levels in hemodialysis patients may contribute to cognitive impairment.     

Thyroid function in end stage renal disease and effects of frequent hemodialysis

Introduction: End‐stage renal disease (ESRD) is associated with perturbations in thyroid hormone concentrations and an increased prevalence of hypothyroidism. Few studies have examined the effects of hemodialysis dose or frequency on endogenous thyroid function. Methods: Within the Frequent Hemodialysis Network (FHN) trials, we examined the prevalence of hypothyroidism in patients with ESRD. Among those with endogenous thyroid function (without overt hyper/hypothyroidism or thyroid hormone supplementation), we examined the association of thyroid hormone concentration with multiple parameters of self‐reported health status, and physical and cognitive performance, and the effects of hemodialysis frequency on serum thyroid stimulating hormone (TSH), free thyroxine (FT4), and free tri‐iodothyronine (FT3) levels. Conventional thrice‐weekly hemodialysis was compared to in‐center (6 d/wk) hemodialysis (Daily Trial) and Nocturnal (6 nights/wk) home hemodialysis (Nocturnal Trial) over 12 months. Findings: Among 226 FHN Trial participants, the prevalence of hypothyroidism was 11% based on thyroid hormone treatment and/or serum TSH ≥8 mIU/mL. Among the remaining 195 participants (147 Daily, 48 Nocturnal) with endogenous thyroid function, TSH concentrations were modestly (directly) correlated with age (r = 0.16, P = 0.03) but not dialysis vintage. Circulating thyroid hormone levels were not associated with parameters of health status or physical and cognitive performance. Furthermore, frequent in‐center and nocturnal hemodialysis did not significantly change (baseline to month 12) TSH, FT4, or FT3 concentrations in patients with endogenous thyroid function. Discussion: Among patients receiving hemodialysis without overt hyper/hypothyroidism or thyroid hormone treatment, thyroid indices were not associated with multiple measures of health status and were not significantly altered with increased dialysis frequency.     

The long‐term effects of arteriovenous fistula creation on the development of pulmonary hypertension in hemodialysis patients

The aim of this prospective study was to evaluate long‐term effects of arteriovenous fistula (AVF) on the development of pulmonary arterial hypertension (PAH) and the relationship between blood flow rate of AVF and pulmonary artery pressure (PAP) in the patients with end‐stage renal disease (ESRD). This prospective study was performed in 20 patients with ESRD. Before an AVF was surgically created for hemodialysis, the patients were evaluated by echocardiography. Then, an AVF was surgically created in all patients. After mean 23.50 ± 2.25 months, the second evaluation was performed by echocardiography. Also, the blood flow rate of AVF was measured at the second echocardiographic evaluation. Pulmonary arterial hypertension was defined as a systolic PAP above 35 mmHg at rest. Mean age of 20 patients with ESRD was 55.05 ± 13.64 years; 11 of 20 patients were males. Pulmonary arterial hypertension was detected in 6 (30%) patients before AVF creation and in 4 (20%) patients after AVF creation. Systolic PAP value was meaningfully lower after AVF creation than before AVF creation (29.95 ± 10.26 mmHg vs. 35.35 ± 7.86 mmHg, respectively, P: 0.047). However, there was no significant difference between 2 time periods in terms of presence of PAH (P>0.05). Pulmonary artery pressure did not correlate with blood flow rate of AVF and duration after AVF creation (P>0.05). In hemodialysis patients, a surgically created AVF has no significant effect on the development of PAH within a long‐term period. Similarly, blood flow rate of AVF also did not affect remarkably systolic PAP within the long‐term period.     

Hepatitis C virus infection in patients with end‐stage renal disease

Chronic hepatitis C virus (HCV) infection is a major global health problem affecting 3–5 million people in the United States and over 100 million worldwide. Chronic HCV infection, which can lead to cirrhosis and hepatocellular carcinoma, also results in numerous other complications, including impairment of renal function. Because HCV is most often transmitted via parenteral exposure to blood or blood products, patients with end‐stage renal disease (ESRD) treated with hemodialysis are at particular risk for infection. Historically, the medications available to treat HCV infection in these patients had significant side effects and were not particularly effective in generating a sustained virologic response. Since 2011, a number of direct‐acting antiviral therapies have emerged that can lead to virological cure in the vast majority of patients, with low pill burden and few side effects. Here, we describe the biology and pathophysiology of HCV infection, and summarize current information on new therapies, with a particular focus on their application in patients with chronic kidney disease including ESRD.     

Cerebral microbleeds and cognitive decline in a hemodialysis patient: Case report and review of literature

Cerebral microbleeds (CMBs) are small hemosiderin deposits indicative of prior cerebral microscopic hemorrhage and previously thought to be clinically silent. Recent population‐based cross‐sectional studies and prospective longitudinal cohort studies have revealed association between CMB and cognitive dysfunction. In the general population, CMBs are associated with age, hypertension, and cerebral amyloid angiopathy. In the chronic kidney disease (CKD) population, diminished estimated glomerular filtration rate has been found to be an independent risk factor for CMB, raising the possibility that a uremic milieu may predispose to microbleeds. In the end‐stage renal disease (ESRD) population on hemodialysis, the incidence of microbleeds is significantly higher compared with a control group without history of CKD or stroke. We present an ESRD patient on chronic hemodialysis with a history of gradual cognitive decline and progressive CMBs. Through this case and literature review, we illustrate the need to develop detection and prediction models to treat this frequent development in ESRD patients.     

Depressive symptom severity,contributing factors,and self‐management among chronic dialysis patients

Despite the high prevalence of depressive symptoms in patients receiving chronic dialysis, there has been inadequate attention to patient‐related barriers to management of depressive symptoms, such as factors identified by these patients as contributing to their symptoms, and how they responded to the symptoms. Participants (N = 210) in an ongoing longitudinal observational study of multidimensional quality of life in patients receiving chronic dialysis completed a battery of measures monthly for 12 months. For each patient at each measurement point, an event report was generated if he or she scored outside of the normal range on the depressive symptom scale (Center for Epidemiologic Studies Depression Scale‐Short Form [CESD‐SF] ≥10) or expressed suicidal ideation. Of the 210 participants, 100 (47.6%) had a CESD‐SF score ≥10 at least once resulting in 290 event reports. Of these 100 participants, 15 (15%) had also reported suicidal ideation in addition to having depressive symptoms. The most frequently stated contributing factors included “managing comorbid conditions and complications” (56 event reports, 19.3%), “being on dialysis” (50, 17.2%), “family or other personal issues” (37, 12.8%), and “financial difficulties” (31, 10.7%). On 11 event reports (3.8%) participants had been unaware of their depressive symptoms. On 119 event reports (41%) participants reported that they discussed these symptoms with their dialysis care providers or primary care providers, while on 171 event reports (59%) symptoms were not discussed with their health‐care providers. The prevalence of depressive symptoms is high and many patients lack knowledge about effective self‐management strategies.     

An ADL measure for spinal cord injury

Occupational therapists do not have a comprehensive, objective method for measuring how persons with tetraplegia perform activities of daily living (ADL) in their homes and communities, because SCI ADL performance is usually determined in rehabilitation. The ADL Habits Survey (ADLHS) is designed specifically to address this knowledge gap by surveying performance on relevant and meaningful activities in homes and communities. After a comprehensive task analysis and pilot development, 30 activities were selected that emphasize a broad range of hand and wrist, reaching, and grasping movements in compound activities. A sample of 49 persons with cervical spinal cord injuries responded to items. The sample was predominantly male, median age was 41 years, and ASIA motor classification levels ranged from C2 through C8/T1 with majority concentration in C4, C5, or C6 (68%). Each participant report was rated by an occupational therapist using a seven category rating scale, and the item by participant response matrix (30 X 49) was analyzed with a Rasch model for rating scales. Results showed excellent participant separation (>4) and very high reliability (>.95), and both item and participant fit values were adequate (STANDARDIZED INFIT less than absolute value of 3). With only two exceptions, all participants fit the Rasch rating scale model, and only one item "Light housekeeping" presented significant fit issues. Principal Components Analysis an analysis of item residuals did not reveal serious threats to unidimensionality. A between group fit comparison of participants with more versus less movement found invariant item calibrations, and ANOVA of participant measures found statistically significant differences across ASIA motor classification levels. These ADLHS results offer occupational therapists a new method for measuring ADL that is potentially more sensitive to functional changes in tetraplegia than most instruments in common use. Accommodation of step disorder with a three category rating scale did not diminish measurement properties.     

The neuroprotective effect of a traditional herbal (kyung‐ok‐ko) on transient middle cerebral artery occlusion‐Induced ischemic rat brain

Kyung‐ok‐ko (KOK) has been used for the treatment of central nervous system disorders such as amnesia, dementia, and cerebral ischemia. However, the effects of KOK on transient ischemic‐induced neuronal damage are still unclear. We examined whether KOK improves functional recovery and has a neuroprotective effect on infarction volume after transient middle cerebral artery occlusion (MCAO). KOK (50, 100, and 200 mg/kg) was administered orally following reperfusion and twice per day for 14 days post‐MCAO. Infarction volume was measured using 2% 2‐3‐5 triphenylterazolium (TTC) staining at 14 days post‐MCAO and alteration in regional cerebral blood flow (rCBF) after KOK treatment was monitored. Functional improvement was evaluated using adhesive removal and treadmill tests at 1, 7, and 14 days post‐MCAO. Also, apoptotic cell death was assessed by terminal deoxynucleotidyl‐transferase mediated d‐UTP‐biotin nick end (TUNEL) in the peri‐infarction region. The protein level of inflammatory cytokines such as tumor necrosis factor‐α (TNF‐α), interleukin‐1α (IL‐1α), and interleukin‐1β (IL‐1β) was measured in the ischemic core, ischemic border zone, and contralateral hemisphere regions. The KOK‐treated group showed both reduced infarction volume and behavior tests demonstrated a significant improvement as compared to the control. Also, in the KOK‐treated group, rCBF was recovered to near normal levels. The apoptotic cells were significantly decreased as compared with the control group in the ischemic peri‐infarction area. Furthermore, the level of TNF‐α, IL‐1β, and IL‐1α was decreased. These results suggest that KOK may improve functional outcome by inhibiting inflammatory cytokines (TNF‐α, IL‐1β, and IL‐1α) in neuronal injury such as ischemic stroke.     

High prevalence of subclinical hypothyroidism and nodular thyroid disease in patients on hemodialysis

Chronic kidney disease has been known to affect thyroid hormone metabolism. Low serum levels of T3 and T4 are the most remarkable laboratorial findings. A high incidence of goiter and nodules on thyroid ultrasonography has been reported in patients with end‐stage renal disease (ESRD). Our objective is to evaluate the prevalence of laboratorial and morphologic alterations in the thyroid gland in a cohort of patients with ESRD on hemodialysis (HD). Sixty‐one patients with ESRD on HD were selected and compared with 43 healthy subjects matched by age, gender, and weight. Patients were submitted to thyroid ultrasonography. T3, free T4 (FT4), thyroid‐stimulating hormone, antithyroglobulin, and antithyroperoxidase antibodies were measured. The mean age of patients with ESRD was 47.4 ± 12.3 and 61% were women. ESRD was mainly caused by hypertensive nephrosclerosis and diabetic nephropathy. Mean thyroid volume, as determined by ultrasonography, was similar in both groups. Patients with ESRD had more hypoechoic nodules when compared with the control group (24.1% vs. 7.9%, P = 0.056). Mean serum FT4 and T3 levels were significantly lower in patients with ESRD, and subclinical hypothyroidism was more prevalent in patients with ESRD (21.82% vs. 7.14% control group, P = 0.04). Titers of antithyroid antibodies were similar in both groups. ESRD was associated with a higher prevalence of subclinical hypothyroidism and lower levels of T3 and FT4. Almost a quarter of patients showed thyroid nodules >10 mm. Periodic ultrasound evaluation and assessment of thyroid function are recommended in patients with ESRD on HD.     

Cardioprotection in the ESRD Population: How Do We Get There?

Cardiovascular mortality for end‐stage renal disease (ESRD) patients is about 30 times the risk in the general population. About 30% of ESRD patients have hyperlipidemia. The 1998 National Kidney Foundation Task Force on Cardiovascular Disease recommends implementation of effective measures to prevent and treat cardiovascular disease in this population. Our intent was to evaluate the extent of use of cardioprotective drugs in ESRD patients through a quality improvement project. Twenty‐eight dialysis facilities throughout Ohio volunteered for this project. Data regarding use of angiotensin‐converting enzyme inhibitors (ACE‐I) and angiotensin receptor blockers (ARB) in heart failure, beta‐blockers in myocardial infarction (MI), aspirin in coronary artery disease, and 3‐hydroxy‐3‐methylglutaryl coenzyme A (HMG‐CoA) reductase inhibitors (statins) were collected using chart abstraction for the period March through May 2000. The results were compared to Ohio hospital discharges from July through September 2000. This latter population was comprised of non‐‐ESRD patients. Dialysis facilities were visited and interviews were conducted with staff members. Information was gathered regarding facility infrastructure, quality improvement process, and existing protocols. 27% of ESRD patients with a history of heart failure were on ACE‐I, compared to 75.7% of non‐ESRD patients. 34.8% of ESRD patients with a previous MI were taking beta‐blockers, compared with 68.0% of non‐ESRD patients with a prior MI. Aspirin use in ESRD patients with a previous MI was 52.8%, compared to 88% in non‐ESRD patients with a prior MI. 17.3% of ESRD patients were on statins. Hyperlipidemia is found in 30% to 50% of ESRD patients. The use of cardioprotective drugs in the Medicare ESRD patient is lower than in the Medicare non‐dialysis counterpart. Reasons for this are related to fragmentation of health care arising from communication and infrastructure issues. Until these issues are addressed and resolved, efforts at initiation of cardioprotective strategies will be slowed.     

Outcomes of patients with end‐stage renal disease (ESRD) under chronic hemodialysis requiring continuous renal replacement therapy (CRRT) and patients without ESRD in acute kidney injury requiring CRRT: A single‐center study

In most continuous renal replacement therapy (CRRT) studies, end‐stage renal disease (ESRD) patients were excluded and the outcomes of patients with ESRD treated with chronic hemodialysis (HD) were unknown. The purposes of this study were to (1) evaluate short‐term patient survival and (2) compare the survival of conventional HD patients needing CRRT with the survival of non‐ ESRD patients in acute kidney injury (AKI) requiring CRRT. We evaluated adults (>18 years) requiring CRRT who were treated in the intensive care unit (ICU) at Kosin University Gospel Hospital from January 1, 2009 to December 31, 2010. A total of 100 (24 ESRD, 76 non‐ESRD) patients underwent CRRT during the study period. Patients were divided into two major groups: patients with ESRD requiring chronic dialysis and patients without ESRD (non‐ESRD) with AKI. We compared the survival of conventional HD patients requiring CRRT with the survival of non‐ ESRD patients in AKI requiring CRRT. For non‐ESRD patients, the 90‐day survival rate was 41.6%. For ESRD patients, the 90‐day survival rate was 55.3%. Multivariate Cox proportional hazards analyses demonstrated that conventional HD was not a significant predictor of mortality (hazard ratio [HR]: 0.334, 95% confidence interval [CI]: 0.063–1.763, P = 0.196), after adjustment for age, gender, presence of sepsis, APACHE score, use of vasoactive drugs, number of organ failures, ultrafiltration rate, and arterial pH. The survival rates of non‐ESRD and ESRD patients requiring CRRT did not differ; ESRD with conventional HD patients may be not a significant predictor of mortality.