Prevalence of arterial stiffness and associated factors in Thai hemodialysis patients: A multicenter cross-sectional study.

BACKGROUND: Hemodialysis (HD) patients have higher risks of cardiovascular morbidity and mortality compared to the general population. Cardio-femoral pulse wave velocity (cfPWV) is associated with cardiovascular morbidity and mortality in HD patients. This study aimed to evaluate the prevalence and associated factors of arterial stiffness in Thai HD patients. MATERIALS AND METHODS: This cross-sectional multicenter study was conducted at 4 HD centers in Bangkok, Thailand. cfPWV and peripheral blood pressure were assessed using SphygmoCor XCEL Model EM4C (AtCor medical Inc., Sydney, Australia). Significant arterial stiffness was defined by cfPWV > 10 m/s. Univariate and multivariable regression models were used to identify factors associated with arterial stiffness. RESULTS: 144 HD patients were assessed for arterial stiffness by cfPWV measurement. The mean age of the patients was 57.8 ± 12.8 years, with 50% male and a mean dialysis vintage of 7.6 years. The mean cfPWV was 11.7 ± 3.0 m/s. The prevalence of increased arterial stiffness was 73.6%. Multivariable analysis showed that older age, hypertension, lower HD adequacy, and higher fasting plasma glucose were independently associated with arterial stiffness. CONCLUSION: There was a high prevalence of arterial stiffness among HD patients. Some modifiable factors found to be independently associated, including dialysis adequacy and glycemic control, should be further investigated to identify approaches to retard vascular stiffness.

Effect of Menaquinone-7 Supplementation on Arterial Stiffness in Chronic Hemodialysis Patients: A Multicenter Randomized Controlled Trial.

BACKGROUND: There is a very high prevalence of subclinical vitamin K deficiency in patients requiring hemodialysis (HD), and this problem is associated with vascular calcification and arterial stiffness. Vitamin K2 (MK-7) supplementation can improve vitamin K status in HD patients. However, the benefits of vitamin K supplementation on arterial stiffness have still not been established. The present study was conducted to evaluate the efficacy of menaquinone-7 (MK-7) supplementation on arterial stiffness in chronic HD patients. METHODS: This open-label multicenter randomized clinical trial was conducted in 96 HD patients who had arterial stiffness, defined by high carotid femoral pulse wave velocity (cfPWV ≥ 10 m/s). The patients were randomly assigned to receive oral MK-7 (375 mcg once daily) for 24 weeks (n = 50) or standard care (control group; n = 46). The change in cfPWV was the primary outcome. RESULTS: Baseline parameters were comparable between the two groups. There was no significant difference in the change in cPWV at 24 weeks between the MK-7 group and standard care [-6.0% (-20.2, 2.3) vs. -6.8% (-19.0, 7.3), p = 0.24]. However, we found that MK-7 significantly decreased cPWV in patients with diabetes [-10.0% (-15.9, -0.8) vs. 3.8% (-5.8, 11.6), p = 0.008]. In addition, the MK-7 group had a lower rate of arterial stiffness progression, compared to controls (30.2% vs. 39.5%, p = 0.37), especially in diabetes patients (21.4% vs. 72.7%, p = 0.01). No serious adverse events were observed during the 24 weeks. CONCLUSION: Vitamin K supplements provided a beneficial impact in lowering the rate of arterial stiffness progression in chronic hemodialysis patients with diabetes. Possible benefits on cardiovascular outcomes require further investigation.

The role of once-weekly online hemodiafiltration with low protein diet for initiation of renal replacement therapy: A case series.

Incremental hemodialysis (HD) has become an exciting approach according to the recognition of the importance of preserving residual kidney function (RKF). However, not all incident HD patients are suitable for this approach, particularly once-weekly HD. This is the first study which reported the effectiveness of once-weekly online-hemodiafiltration (OL-HDF) plus low protein diet (LPD) in incident HD patients. All stage 5 CKD patients who had chosen HD as their treatment modality at the HD center of King Chulalongkorn Memorial Hospital, Bangkok, Thailand, with RKF ⩾ 3 mL/min calculated by renal clearance of urea and urine output ⩾ 800 mL/day, started the treatment with once-weekly OL-HDF. Dietitians advised patients to consume LPD (0.6-0.8 g/kg/day) on non-dialysis days and a regular protein diet on the dialysis day (1.2 g/kg/day). Eleven incident HD patients were enrolled in the study. The mean RKF and urine volume at baseline were 4.56 ± 2.21 mL/min and 2,019.54 ± 743.73 mL/day, respectively. After 6 and 12 months of follow-up, the mean RKF of the patients who remained in the once-weekly OL-HDF protocol were 3.82 ± 1.68 mL/min and 3.28 ± 0.95 mL/min, respectively. The median duration of once-weekly OL-HDF before transitioning to twice- or thrice-weekly OL-HDF was 7 months (3-24 months). The most common indication for stepping prescription was too low RKF. We reported that dialysis initiation in the university-based center with once-weekly OL-HDF in carefully selected incident HD patients combined with LPD under serial monitoring is practical. Further studies on the clinical benefits of once-weekly OL-HDF are still required.

Ten-Year Survival of End-Stage Renal Disease Patients Treated with High-Efficiency Online Hemodiafiltration: A Cohort Study of a Center in South East Asia.

BACKGROUND: Recently, in the first hemodiafiltration (HDF) experience report from South East Asia (SEA), we reported a 3-year prospective study demonstrating the various short-term benefits of high-efficiency online HDF (OL-HDF) over high-flux hemodialysis (HD). Very few long-term survival reports of high-efficiency OL-HDF are available and the data are heterogeneous and incomplete. OBJECTIVES: The present historical cohort study was conducted to determine the long-term survival and outcome of high-efficiency OL-HDF-treated patients. METHODS: Sixty-six high-efficiency OL-HDF treated patients at a center in SEA were included in the study. The prescription included blood and dialysis fluid flow rates of 400 and 800 mL/min, respectively. The post- or pre-dilution substitution fluid of 100 or 200 mL/min, respectively, was prescribed. RESULTS: Of 66 HDF patients, whose age was 57.4 ± 14.0 years, there were 38 (58%) females. The majority of comorbidity was diabetes (36%). There were 33 (50%) incident HDF cases that were prescribed OL-HDF at the dialysis initiation and 33 (50%) prevalent HDF cases that were switched from HD to OL-HDF. The 1-, 3-, 5-, and 10-year survival rate were 95.1, 83.4, 77.7, and 61.8% respectively. The mean survival time was 8.99 ± 0.64 years. There were 15 transplantations and 15 deaths during this study periods. The 2 major causes of death were cardiovascular (33.3%) and infectious diseases (20%). Serum ferritin was the only parameter that correlated with mortality (HR 1.004, p = 0.005). There was comparable survival between incident and prevalent HDF cases. The survival after transplantation of a sub-group of patients who received kidney transplantation (KT) was not different from that of the overall HDF patients (p = 0.93). CONCLUSIONS: High-efficiency OL-HDF could provide an excellent long-term survival nearly comparable to the KT sub-group.

Long-term efficacy of pre- and post-dilution online hemodiafiltration with dialyzer reuse.

OBJECTIVE: Growing evidence has demonstrated the potential survival benefit of online hemodiafiltration (HDF) over conventional hemodialysis (HD). Previous studies regarding online HDF utilized single-use dialyzer The present study was conducted to compare the long-term clinical parameters between pre- and post-dilution online HDF with the reuse dialyzer MATERIAL AND METHOD: This 2-year historical cohort study was conducted in 20 chronic hemodialysis patients who had undergone thrice-a-week pre-dilution online HDF for at least one year. The patients were switched to post-dilution online HDF for another year. Reuse dialyzers were utilized in both methods. RESULTS: No pyrogenic reactions had been detected throughout the 2-year study period. The C-reactive protein (CRP) and nutritional parameters were in good normal ranges. The normalization of protein equivalent of nitrogen appearance (nPNA) was significantly higher during the post-dilution period (1.25 +/- 0.22 vs. 1.11 +/- 0.14 g/kg/d, p < 0.01). Regarding adequacy of hemodialysis, the post-dilution online HDF showed significantly better Kt/V than the pre-dilution mode (2.46 +/- 0.35 vs. 2.35 +/- 0.35, p < 0.05) whereas the predialysis beta2-microglobulin levels were not different (23.43 +/- 5.35 vs. 23.73 +/- 5.55 mg/L, NS). The numbers of reuse were comparable (17.3 +/- 2.6 vs. 16.4 +/- 2.7, NS). CONCLUSION: Utilizing reuse dialyzer in online HDF could provide efficacy, safety, cost saving, and environmental benefit. The post-dilution technique yielded the better adequacy and nutritional status without causing the limitation in the reuse number and would be the standard mode-of-choice for online HDEF

Exfoliated mesothelial cell and CA-125 in automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) patients.

OBJECTIVE: Automated peritoneal dialysis (APD) becomes the first option for peritoneal dialysis, nowadays overtaking continuous ambulatory peritoneal dialysis (CAPD) in many countries. The comparison of peritoneal membrane alteration in CAPD and APD is inconclusive. The authors therefore compared the peritoneal membrane changes in patients undergoing CAPD and APD. MATERIAL AND METHOD: In naive end stage renal disease patients, the choice of PD modes (CAPD or APD) was dependent on the patient's decision. Thirty-six CAPD and 25APD patients with a total of 287 patient-months were compared. The peritoneal mass parameter, exfoliated mesothelial cell (MTC) and dialysate CA-125, as well as modified peritoneal equilibrium test (mPET) with 4.25% dextrose solution was simultaneously evaluated at 1 and 6 month follow-up. RESULTS: Although the peritoneal function (as measured by D/P creatinine, D/D0 glucose, sodium dipping, and dialysate protein loss), adequacy, serum albumin, nutritional status, and residual renal function showed no significant differences between groups at 1 and 6 months, CA-125 but not MTC was higher in APD compared with CAPD at the first month of PD beginning. Due to the single time-point measurement limitation, the authors compared the peritoneal mass parameter differences between 1 and 6 month. During 6-month follow-up, CA-125 decreased 30 +/- 5% vs. 7 +/- 5% and MTC decreased 5 +/- 12% vs. 40 +/- 11% in APD and CAPD, respectively. The higher CA-125 reduction in APD and greater changes of MTC in CAPD suggested that there was less viable mesothelial cell in APD compared with CAPD. CONCLUSION: The authors observed that both APD and CAPD damaged peritoneum. However, there might be higher peritoneal injury in APD patients. The proper randomization study in longer follow-up period is mandatory to confirm this observation.

Nationwide peritoneal dialysis nurse training in Thailand: 3-year experience.

Peritoneal dialysis (PD) center is not possible to operate if there is no availability of dedicated PD nurse. Generally, the nurse has to play many roles, including educator coordinator, and sometimes leader. As professionalism, the PD nurses need to have both theoretical and practical skills. With the tremendous leap of PD population after the launch of "PD First" policy in Thailand, the shortage of skillful PD nurse is concerned. Hence, the nationwide PD nurse training course was established with the collaborations of many organizations and institutes. Until now, 3 generations of 225 PD nurses are the productions of the course. This number represents 80 percent of PD nurses distributed throughout the whole nation. The survey operated in the year 2010 demonstrated that the output of the course was acceptable in terms of quality since most of the trained PD nurses had a confidence in taking care of PD patients. The quality of patient care is good as indicated by KPIs.

The status of, and obstacles to, continuous ambulatory peritoneal dialysis in Thailand.

The prevalence of dialysis in Thailand is 282 per million population, and utilization of peritoneal dialysis (PD) is only 4.6% of the utilization of hemodialysis (HD). The causes of low PD utilization include a relatively higher cost of PD care, especially from the patient's perspective; less incentive for PD care on the part of health care providers and hospitals; fewer continuing medical and nursing education programs in PD; unavailability of certified PD nurses; lack of confidence in the quality of PD care; fewer offers of PD as a renal replacement therapy option during pre-dialysis counseling; fear of peritonitis on the part of the patient, and also fear of burdening family members; a less stringent government policy regarding the "PD first" strategy. To increase PD utilization. mandatory strategies are lower PD cost, make all PD equipment reimbursable, launch a stringent "PD first" policy, provide incentives to health care providers and hospitals, and improve the quality of PD care.

Experience with prevention programs in Thailand.

BACKGROUND: Thailand is a developing country with a population of 62 million. It is estimated to have 1.6 million stage 3 or higher chronic kidney disease (CKD) patients. With limited funding for dialysis support, prevention of renal disease progression is mandatory and urgently needed. METHODS: The Nephrology Society of Thailand has conducted a survey among Thai nephrologists. The data were analyzed, and a multidisciplinary team approach was introduced to make patients more informed about CKD and more compliant with dietary prescription. RESULTS: The survey showed that the majority of Thai nephrologists know about CKD guidelines. They regularly employed several modes of drug therapy and appropriate target of blood pressure control. However, only 38% and 5% of nephrologists used multidisciplinary team approach and knew how to calculate dietary protein intake, respectively, in CKD patients. To facilitate dietary counseling and care team approach, we invented several dietary record forms (in Thai), Thai food exchange list, 7-day low-protein Thai food menu, and several patient education guidebooks. We also set 1-day lecture tour courses for physicians, nurses, and dietitians in various parts of the country. At our own institute, we followed 17 CKD patients for 4 years: the creatinine clearance (CCr) and glomerular filtration rate (GFR) were 37.5 +/- 5.5 and 24.4 +/- 4.3 mL/min, respectively, at the beginning, and were 35.7 +/- 4.5 and 25.0 +/- 3.5 mL/min, respectively, 4 years thereafter. The rates of Ccr and GFR decline were -0.5 +/- 0.9 mL/min/year and 0.2 +/- 0.6 mL/min/year, respectively. CONCLUSION: A combination of appropriate drug and dietary therapy by employing a multidisciplinary team approach can effectively delay renal disease progression.