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.     

Global ESRD Costs Associated with a Short Daily Hemodialysis Program in the United States

In spite of the growing evidence that daily hemodialysis (DHD) improves clinical outcomes and quality of life, the additional dialysis costs are not currently reimbursed in the United States. Nor have there been reports of the effects of DHD on end-stage renal disease (ESRD) global costs, which would help predict the financial impact of DHD on the ESRD program. Since 1996, 22 patients (20 in-center, 2 home) have switched from conventional thrice-weekly dialysis to short, daily dialysis with six treatments per week. Eighteen patients started for medical indications, and four started for nonmedical reasons. Causes of ESRD were the following: diabetes mellitus (6), hypertension (4), glomerulonephritis (6), hereditary (2), and other (4). Mean age was 56 ± 16 years. Patients had an average of 3.3 major comorbidities. Weekly conventional HD dialysis times were divided into six DHD treatments, each 2.0 ± 0.3 hours. Weekly Kt/V remained unchanged. Twenty-two patients were followed on DHD for 220 patient-months: 7 patients died after 1.8 ± 1.3 months, 2 were transplanted at 4.3 ± 3.2 months, and 2 discontinued DHD at 3.6 ± 4.8 months. Eleven patients remain on DHD at 17.4 ± 8.3 months. Actual costs per extra dialysis session are as follows: $14.30 for supplies and $3.20 for labor for setup/cleanup time (15 minutes at $12.80/hour). Annualized DHD savings are based on comparison of doses of epoetin alpha (Epogen) and blood pressure medication at the start and after 12 months of DHD. Hospitalization rates include all enrolled patients, comparing rates for the 12 months prior to DHD with the first year on DHD, or annualized rates for those on DHD less than one year. Cost assumptions are $9/ 1000 U Epogen, $1/blood pressure pill, and $1200/per day of hospitalization. Extra transportation costs were covered by the patients. No increased access problems were observed. For patients on short DHD longer than 12 months, supply and labor costs increased to $2733/patient/year; however, Epogen use was reduced 55%, and blood pressure medications were reduced 40%. For all patients who switched to DHD, hospitalization rates were reduced 24%. This resulted in a net savings of about $4241/patient/ year after 12 months on DHD. Overall ESRD costs were substantially decreased on DHD. These cost savings must be passed on to providers before DHD becomes more widely available.     

Free dialysis in Nepal: Logistical challenges explored

Nepal's Ministry of Health began offering free lifetime hemodialysis (HD) in 2016. There has been a large growth in renal replacement therapy (RRT) services offered in Nepal since 2010, when the last known data on the subject was published. In 2016, 42 HD centers existed (223% increase since 2010) serving 1975 end stage renal disease patients (303% increase since 2010); 36 nephrologists were registered (200% increase since 2010), 12 were trained in transplantation, and 790 transplants had been performed to date. We estimate the incidence of end stage renal disease to be 2900 patients (100 per million population). With an annual cost of approximately US$2300 per dialysis patient, offering free dialysis could potentially cost the government US$6.7 million per year, suggesting that 2.1% of the annual health budget would be allocated to 0.01% of the population. The geographic zone surrounding the capital city, Kathmandu, contains 50% of HD centers, but only 14.5% of Nepal's population. Forty‐eight percent of the population lives within zones without HD service, therefore infrastructure challenges exist in providing equitable access to RRT. The aim of this article is to summarize the current statistics of RRT in Nepal.     

Impact of Predialysis Care on Clinical Outcomes

Introduction: A structured predialysis multidisciplinary team program is beneficial in improving quality of life in patients with end‐stage renal disease (ESRD). Educating pre‐ESRD patients about their disease is vital in their care. Patients who can identify signs and symptoms of impending problems can seek help and avoid complications that may lead to hospital admissions. Our dialysis center offers two predialysis classes in a structured format. The first class is for those patients with mild to moderate renal disease, whereas the second class is for those with advanced renal disease who are expected to need dialysis in 3 to 6 months. The patients are followed by a multidisciplinary team once they are enrolled in our chronic kidney disease program. Methods: We retrospectively reviewed all the charts of patients who started dialysis at our center between 1997 and 2000. We identified 68 patients who participated in the predialysis education program and 35 patients who did not because of late referral or refusal to participate. We compared these two groups over a 100‐day period (10 days before initial dialysis and 90 days after), for hospitalizations, emergency room (ER) visits, and dialysis access placement. Patients' comorbid conditions, complications, and length of hospitalizations were extracted from the medical records. Results: The 68 patients who completed the predialysis program had an average age of 60.3 years, a total of 96 hospital days, and 39 ER visits. Average length of hospital stay for these patients was 1.4 days. Three patients (4.4%) required placement of temporary catheters for the initial dialysis. Fifty‐one percent of these patients had diabetes mellitus. The 35 patients of average age of 54.9 years who did not go through the program had 347 total hospital days and 39 ER visits. Average length of hospitalization was 9.9 days. Thirteen patients (37%) required temporary catheters for initial dialysis. This group included 16 patients (45.7%) with diabetes. Conclusion: Patients who participated in a multidisciplinary predialysis education program had fewer complications, ER visits, and hospitalizations. They also had fewer temporary catheter placements, shorter hospital stays, and reduced costs associated with initial dialysis.     

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.     

End‐stage renal disease from hemolytic uremic syndrome in the United States, 1995–2010

Management of hemolytic uremic syndrome (HUS) has evolved rapidly, and optimal treatment strategies are controversial. However, it is unknown whether the burden of end‐stage renal disease (ESRD) from HUS has changed, and outcomes on dialysis in the United States are not well described. We retrospectively examined data for patients initiating maintenance renal replacement therapy (RRT) (n = 1,557,117), 1995–2010, to define standardized incidence ratios (SIRs) and outcomes of ESRD from HUS) (n = 2241). Overall ESRD rates from HUS in 2001–2002 were 0.5 cases/million per year and were higher for patients characterized by age 40–64 years (0.6), ≥65 years (0.7), female sex (0.6), and non‐Hispanic African American race (0.7). Standardized incidence ratios remained unchanged (P ≥ 0.05) between 2001–2002 and 2009–2010 in the overall population. Compared with patients with ESRD from other causes, patients with HUS were more likely to be younger, female, white, and non‐Hispanic. Over 5.4 years of follow‐up, HUS patients differed from matched controls with ESRD from other causes by lower rates of death (8.3 per 100 person‐years in cases vs. 10.4 in controls, P < 0.001), listing for renal transplant (7.6 vs. 8.6 per 100 person‐years, P = 0.04), and undergoing transplant (6.9 vs. 9 per 100 person‐years, P < 0.001). The incidence of ESRD from HUS appears not to have risen substantially in the last decade. However, given that HUS subtypes could not be determined in this study, these findings should be interpreted with caution.     

Comparison of Preventive Care Provided to Dialysis Patients by Nephrologists and to Patients Followed in General Medical Clinics: Compliance with American College of Physicians Guidelines

Most end‐stage renal disease (ESRD) patients do not have primary‐care providers, and preventive medicine often is provided by their nephrologists. Little has been written about their success in providing this care. We studied all patients on dialysis at our hospital and compared their preventive care to a control group followed in the general medical clinic. The general medical group showed higher compliance with Pap smears (89% vs 48%), mammography (87% vs 62%), fecal occult blood testing (75% vs 50%), and pneumococcal vaccination (55% vs 28%). The ESRD group had better compliance with influenza vaccination (70% vs 55%) and lipid profile (100% vs 75%). When the subgroup of patients on hemodialysis (HD) was compared with patients on peritoneal dialysis (PD), it was shown that HD patients were more likely than PD patients to receive preventive care. We also compared diabetes‐specific care. The ESRD group had a higher rate of HbA _1C (100% vs 78%) and lipid monitoring (100% vs 76%), diabetes education (100% vs 84%), and podiatry visits (70% vs 38%). There was no difference in ophthalmologic examination or influenza vaccination. We found that nephrologists provide preventive care to ESRD patients with success approximately equal to primary‐care physicians in our institution, although in different parameters. Ready access to dialysis patients and their blood and unit‐specific policies contribute to compliance that is above national averages. Further improvements can be made by additional preventative measures policies, by physician and patient education, and by monitoring primary‐care compliance in the chart.     

Inflammation as a cause of malnutrition, atherosclerotic cardiovascular disease, and poor outcome in hemodialysis patients

Cardiovascular disease (CVD) remains the major cause of morbidity and mortality in end‐stage renal disease (ESRD) patients treated by hemodialysis (HD). Although traditional risk factors are common in dialysis patients, they may not alone be sufficient to account for the unacceptable high prevalence of CVD in this patient group. Recent evidence demonstrates that chronic inflammation, a nontraditional risk factor that is commonly observed in HD patients, may cause malnutrition and progressive atherosclerotic CVD by several pathogenetic mechanisms. The cause(s) of inflammation in HD patients is multifactorial and includes both dialysis‐related (such as graft and fistula infections, bioincompatibility, impure dialysate, and back‐filtration) and dialysis‐unrelated factors. Although inflammation may reflect underlying CVD, an acute‐phase reaction may also be a direct cause of vascular injury. Available data suggest that proinflammatory cytokines play a central role in the genesis of both malnutrition and CVD in ESRD. Thus, it could be speculated that suppression of the vicious cycle of malnutrition, inflammation, and atherosclerosis (MIA syndrome) would improve survival in dialysis patients. As there is not yet any recognized, or even proposed, targeted treatment for ESRD patients with chronic inflammation; it would be of considerable interest to study the long‐term effect of various anti‐inflammatory treatment strategies on nutritional and cardiovascular status as well as outcome in these patients.     

Relationship of Hypoalbuminemia to Multiple Clinical Factors in Hemodialysis Patients

Research shows that low albumin is correlated with higher morbidity and mortality in the dialysis population. The reasons for this are multi‐factorial and may be related to inadequate protein intake, infection and sepsis, inadequate dialysis, or catabolism of uremia. USRDS data show that ESRD Network 16 tends to have lower albumins compared to other ESRD Networks. Objective: To evaluate albumin status of HD patients at Puget Sound Kidney Centers, Everett, WA (ESRD Network 16) and identify potential factors that may put patients at risk of hypoalbuminemia. Methods: Clinical and biochemical data were collected for 3 months on 221 HD patients. Data included serum albumin (bromcresol purple), calcium, phosphorus, CO₂, Hct, % saturation, ferritin, PTH, BUN, Kt/V, URR, nPCR, hours of HD treatment, interdialytic fluid weight gains, DW changes, incidence of infection and hospitalization, catheter use for dialysis access, presence of diabetes and other co‐morbidities, dialyzer reuse, social/psychological status, and use of nutrition supplements. All biochemical data were collected after the longest interdialytic period and analyzed at the same reference laboratory. Data were averaged for each patient for the 3 months and correlations between parameters were determined using Chi‐square analysis. Results: 25% of all patients had albumins <3.2 g/dL (reference range for normal population 3.5–5.0 g/dL). Patients with lower albumins were significantly more likely to have DM (p < 0.02), use catheters for HD access (p < 0.001), had infections during the previous month (p < 0.001), been hospitalized during the previous month (p < 0.002), have co‐morbid issues (p < 0.001), and use nutrition supplements (p < 0.002). No other factors were significantly correlated with lower albumin. Conclusion: Factors other than nutrition seem to be related to hypoalbuminemia. This study has prompted improved protocols for catheter care and use, infection control, and early intervention for nutrition supplement use. Increased screening and monitoring at‐risk patients (those with diabetes and other co‐morbid conditions) has resulted in improved patient care.     

Acute hemodialysis complications in end‐stage renal disease patients: The burden and implications for the under‐resourced Sub‐Saharan African health systems

Little is known about the challenges of routine renal replacement therapy in Sub‐Saharan Africa. We investigated the fatal and nonfatal acute hemodialysis (HD) complications in patients with end‐stage renal disease (ESRD) in two main dialysis centers in Cameroon. 1000 consecutive HD sessions incurred over a 4‐month period by 129 patients (96 men, 74%) with ESRD, receiving two weekly HD sessions of 4 hours each, were considered. Personal and clinical profiles before, during, and within 24 hours after HD sessions were used to diagnose complications. Participants were aged 7 to 80 years (mean 46 years). In all, 452 acute complications were recorded in 411 (41%) of the 1000 HD sessions. Of the 11 types of complications, hypotension (25%), muscular cramps (22%), hypertensive crisis (14%), pruritus (10%), and fever (7%) were the most frequent. Three hundred and six complications (67.7%) occurred during understaffed nighttime. The vascular access was the main bleeding site with 64%. Being diabetic and ultrafiltration rate >1000 mL/h were associated with hypotension and muscle cramps. The shorter duration in dialysis was associated with the risk of bleeding and the disequilibrium syndrome while longer duration was associated with muscle cramps. Four deaths (three from bleeding and one from disequilibrium syndrome) occurred, all during nighttime. Nearly half of dialysis sessions in these settings are associated with acute complications, some of which are fatal. Those complications occurred mostly during understaffed periods. Urgent strategies are needed to quickly solve the human capital crisis in the health care sector.     

Pruritus in hemodialysis patients: Results from the Japanese Dialysis Outcomes and Practice Patterns Study (JDOPPS)

Pruritus affects many patients undergoing hemodialysis (HD). In this study, pruritus and its relationship to morbidity, quality of life (QoL), sleep quality, and patient laboratory measures were analyzed in a large sample of Japanese patients undergoing HD. Severity of patient‐reported pruritus symptoms experienced during a 4‐week period was collected from 6480 Japanese patients undergoing HD in three phases of the Dialysis Outcomes and Practice Patterns Study (DOPPS; 1996–2008; 60–65 study facilities/phase). Adjusted linear and logistic regressions were used to identify associations of pruritus with treatment parameters and QoL outcomes. Adjusted Cox regressions examined the influence of pruritus severity on mortality. Moderate to extreme pruritus was experienced by 44% of prevalent patients undergoing HD in the Japanese Dialysis Outcomes and Practice Patterns Study. Many patient characteristics were significantly associated with pruritus, but this did not explain the large differences in pruritus among facilities (20–70%). Pruritus was slightly less common in patients starting HD than in patients on dialysis >1 year. Patients with moderate to extreme pruritus were more likely to feel drained (adjusted odds ratio = 2.2–5.8, P < 0.0001), have poor sleep quality (adjusted odds ratio = 1.9–3.7, P < 0.0001), and have QoL mental and physical composite scores 2.3–6.7 points lower (P < 0.0001) than patients with no/mild pruritus. Pruritus in patients undergoing HD was associated with a 23% higher mortality risk (P = 0.09). The many poor outcomes associated with pruritus underscore the need for better therapeutic agents to provide relief for the 40–50% of prevalent patients undergoing HD substantially affected by pruritus. Pruritus in new patients with end‐stage renal disease likely results from uremia or pre‐existing conditions (not HD per se), indicating the need to understand development of pruritus before end‐stage renal disease.     

Health-related qualıty of lıfe, sleep qualıty, and depressıon in peritoneal dialysis and hemodıalysıs patıents

Health-related quality of life (HRQoL) and sleep quality (SQ) were impaired in patients with end-stage renal disease (ESRD). The impairment of both HRQoL and SQ and being in a depressive mood were found to be associated with increased morbidity and mortality in dialysis patients. We aimed to investigate the association between SQ, HRQoL, and depression, and to define independent predictors of SQ and depression in peritoneal dialysis (PD) and hemodialysis (HD) patients. Ninety HD patients (41 females, 49 males with mean age 50 ± 15.7 years) and 64 PD patients (27 females, 37 males with mean age 52.4 ± 15.3 years) receiving renal replacement therapy for at least 3 months were screened for the assessment of SQ, HRQoL, and depression in this cross-sectional study. A modified postsleep inventory, Short Form of Medical Outcomes Study (SF-36) and Beck depression inventory (BDI) were applied to all patients for evaluating SQ, HRQoL, and depression, respectively. HD and PD patients had similar total SQ scores. Physical and mental component scale of HRQoL were found to be significantly higher in HD patients (p < 0.001). PD patients were found to be much more in depressive mood when compared with HD patients (p < 0.001). Independent predictors of depression in patients were mental component scale of HRQoL, gender (being female), and dialysis modality (being PD patient). Physical component scale was also found to be an independent predictor of SQ. This study showed that despite similar SQ scores between two groups, HD patients had better HRQoL and less depression than PD patients.     

Pyogenic liver abscess in end‐stage renal disease patients: A nationwide longitudinal study

End‐stage renal disease (ESRD) patients are more prone to infectious disease because of their immunocompromised status. However, the association between pyogenic liver abscess (PLA) and ESRD remains not clear. The aim of our study is to evaluate the incidence, risk factors, and outcomes of PLA in ESRD patients. We recruited all incident ESRD patients from the Taiwan National Health Insurance database from 1998 to 2006. The incidence rate of PLA in ESRD patients was compared with that of a randomly selected non‐ESRD control group matched for age, sex gender, Charlson comorbidity score, diabetes mellitus, and cirrhosis. Among the 57,761 incident dialysis patients, there were 538 cases of PLA. The incidence rate of PLA was 18.20 per 10,000 person‐years in the ESRD cohort and 6.34 per 10,000 person‐years in matched control cohort. The rate of PLA was significantly higher in the ESRD cohort (hazard ratio 3.63, 95% confidence interval 2.83–4.65, P < 0.001). The mortality rates of PLA were higher in the ESRD cohort than those in matched control cohort. Diabetes mellitus was an independent risk factor for mortality of PLA. Compared with non‐ESRD patients, ESRD patients have a higher risk of PLA and poorer outcomes.     

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.     

Spontaneous perirenal hemorrhage in hemodialysis patient treated with selective embolization: A case series and review of the literature

Introduction: Spontaneous perirenal hemorrhage (SPH) or Wunderlich syndrome, is a rare but potentially life‐threatening condition. It is characterized by an unexpected bleeding in the kidneys and usually presents as an abdominal pain. Angiography and more recently selective renal arterial embolization are emerging as effective modalities for the diagnosis and treatment of SPH. In this article, we report a total of three cases of SPH in hemodialysis (HD) patients. Methods: This is the experience of diagnosis and treatment of SPH in HD patients. Findings: All three were female, between 37 and 54 years of age and were undergoing HD for end stage renal disease (ESRD). Two of patients presented with left flank or abdominal pain after termination of HD therapy, while the third patient presented with left abdominal pain during the dialysis session. All patients received anti‐coagulation therapy for HD, but no abnormal levels of coagulation index were found. These patients were diagnosed using CT and two of them were diagnosed with acquired cystic kidney disease (ACKD). Selective renal arterial embolization was performed in the case of active bleeding. Discussion: We are aware that HD patients have elevated risk of bleeding related complications, additionally the presence of an acute abdominal pain increases the suspicion of SPH as a possible cause. ACKD can be considered one of the possible risk factors for SPH in long‐term HD patients. Interventional treatment for kidney injury is useful and safe for active bleeding in most cases.     

Impact of advanced dialysis technology on the prevalence of dialysis‐related amyloidosis in long‐term maintenance dialysis patients

Dialysis‐related amyloidosis (DRA) is a unique type of amyloidosis (beta‐2 microglobulin) predominantly in end‐stage renal disease. Its clinical manifestations add to increased morbidity and reduced quality of life. There seems to be a relative risk reduction in DRA manifestations when hemodialysis (HD) patients are treated with advanced HD technology, but changes of the course of DRA are uncertain. The aim of our investigation was to evaluate the prevalence and severity of carpal tunnel syndrome (CTS) in long‐term dialysis patients receiving either conventional or high‐flux, online‐produced ultrapure dialysis fluid. The cross‐sectional study included 147 HD patients (at least 10 years). The definitive diagnosis of CTS was made histologically or by the coexistence of CTS with other radiological DRA manifestations (bone cysts, arthropathies). The two HD patient groups did not differ significantly in age at start of HD, gender, major co‐morbid diseases, anuria, and dialysis vintage. The conventional HD group had significantly higher circulating beta‐2 microglobulin and C‐reactive protein (CRP) levels. The prevalence of DRA was 68% for the conventional HD group and 28% for the advanced HD group. Duration of dialysis treatment was the only significant risk factor for the development of clinical DRA manifestations in both study groups, but CTS, bone cysts, or arthropathies occurred significantly earlier in conventional HD patients. The prevalence and severity of DRA have decreased with advances in dialysis technology during the last two decades, although its occurrence is simply delayed.     

Blood Access Outcomes Associated with Short Daily Hemodialysis

With the growing number of reports that daily hemodialysis (DHD) improves clinical outcomes and quality of life, there has been increased interest in the effects of more frequent venipunctures on blood accesses. Since 1996, we have converted 30 patients (27 in‐center, 3 home) from conventional 3/week dialysis to short, daily, 6/week dialysis (sDHD). Twenty‐five patients started for medical indications. End‐stage renal disease (ESRD) causes were diabetes mellitus (in 7), hypertension (6), glomerulonephritis (8), hereditary nephritis (2), and other (7). Mean (±SD) age was 57 ± 16 years. Patients had an average of 3.8 major comorbidities in addition to ESRD. Thirty patients were followed on sDHD for 388 patient‐months: 9 patients died after 4.2 ± 6.7 months, 3 were transplanted at 5.4 ± 2.2 months, and 3 were disenrolled at 9.3 ± 10.5 months. Fifteen patients remain on sDHD at 20.4 ± 14.1 months. Access problems for the 12 months prior to sDHD were compared to those that occurred while the patient was on sDHD. Problems were tracked by access type. There were 40 different accesses in 30 patients with a cumulative 28.07 access‐years pre‐DHD; 24 of these accesses were artificial bridge grafts (ABG) of either polytetrafluoroethylene or bovine material. There were 27 access problems pre‐DHD, or 0.962 problems per access‐year. On sDHD these same 30 patients had 41 accesses for 34.44 access‐years; 23 of these were ABGs. There were 31 access problems or 0.900 problems per access‐year. There were no significant differences in access problems comparing pre‐DHD with on‐sDHD, either in aggregate or when analyzed by access type. After 39 months of observation, there does not appear to be an increase in blood access problems when patients are converted from conventional dialysis to sDHD.     

Challenges of providing maintenance hemodialysis in a resource poor country: Experience from a single teaching hospital in Lagos,Southwest Nigeria

Providing maintenance hemodialysis is associated with high costs and poor outcomes. In Nigeria, more than 90% of the population lives below the poverty line, and patients with end‐stage renal disease (ESRD) pay out‐of‐pocket for maintenance hemodialysis. To highlight the challenges of providing maintenance hemodialysis for patients with ESRD in Nigeria, we reviewed records of all patients who joined the maintenance hemodialysis program of our dialysis unit over a 21‐month period. Information regarding frequency of hemodialysis, types of vascular access for dialysis, mode of anemia treatment and frequency of blood transfusion received were retrieved. One hundred and twenty patients joined the maintenance hemodialysis program of our unit during the period under review. Seventy‐two (60%) were males and the mean age of the study population was 47 + 14 years. The mean hemoglobin concentration at commencement of dialysis was 7.3 g/dL + 1.6 g/dL. The initial vascular access was femoral vein cannulation in all the patients. A total of 73.5% of the patients required blood transfusion at some point with 33% receiving five or more pints of blood. Only 3.3% of the patients had thrice weekly dialysis, 21.7% dialyzed twice weekly, 23.3% once weekly, 16.7% once in two weeks, 2.5% once in three weeks and 11.7% once monthly. At the time of review, 8.3% of the patients had died while 38.3% were lost to follow‐up. Majority of patients with ESRD on maintenance hemodialysis in our unit were poorly prepared for dialysis, were under‐dialyzed, and were frequently transfused with blood with resultant poor outcomes.     

Late acceleration of glomerular filtration rate decline is a risk for hemodialysis catheter use in patients with established nephrology chronic kidney disease care

Chronic kidney disease (CKD) patients with established nephrology care have a high rate of tunneled dialysis catheters (TDC) as first vascular access when transitioning to hemodialysis (HD). We sought to identify factors associated with this problem. Patients who started HD and had prior CKD care within our renal clinic were categorized according to access type at incident HD. Clinical factors, all estimated glomerular filtration rates (eGFR), renal clinic attendance records, hospital admissions in the 6 months preceding HD start, and patient participation in predialysis education course were analyzed. Three hundred thirty‐eight patients initiated HD, 107 received pre‐HD CKD care within our clinics. Seventy patients started with a TDC. All groups started HD at similar eGFR values. The trajectory of eGFR decline in the 6 months prior to HD start was significantly more rapid in the TDC group. Patients in the TDC group had more acute health events in the prior 6 months. Multivariate modeling showed that failure to attend a predialysis education course and having a more rapid rate of eGFR decline in the 6 months prior to dialysis initiation were both associated with TDC use. Patients with CKD nephrology care who initiated HD with a TDC as first vascular access had a more rapid rate of decline in eGFR in the months preceding dialysis start and were less likely to have attended our predialysis education course. This appears to correspond with the observed increased number of emergency and hospital visits in the 6 months prior to end‐stage renal disease.