Ultrafiltration Rate, Residual Kidney Function, and Survival Among Patients Treated With Reduced-Frequency Hemodialysis.

RATIONALE & OBJECTIVE: Patients receiving twice-weekly or less-frequent hemodialysis (HD) may need to undergo higher ultrafiltration rates (UFRs) to maintain acceptable fluid balance. We hypothesized that higher UFRs are associated with faster decline in residual kidney function (RKF) and a higher rate of mortality. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 1,524 patients with kidney failure who initiated maintenance HD at a frequency of twice or less per week for at least 6 consecutive weeks at some time between 2007 and 2011 and for whom baseline data for UFR and renal urea clearance were available. PREDICTOR: Average UFR during the first patient-quarter during less-frequent HD (<6, 6-<10, 10-<13, and≥13mL/h/kg). OUTCOME: Time to all-cause and cardiovascular death, slope of decline in RKF during the first year after initiation of less-frequent HD (with slopes above the median categorized as rapid decline). ANALYTICAL APPROACH: Cox proportional hazards regression for time to death and logistic regression for the analysis of rapid decline in RKF. RESULTS: Among 1,524 patients, higher UFR was associated with higher all-cause mortality; HRs were 1.43 (95% CI, 1.09-1.88), 1.51 (95% CI, 1.08-2.10), and 1.76 (95% CI, 1.23-2.53) for UFR of 6 to<10, 10 to<13, and≥13mL/h/kg, respectively (reference: UFR < 6mL/h/kg). Higher UFR was also associated with higher cardiovascular mortality. Baseline RKF modified the association between UFR and mortality; the association was attenuated among patients with renal urea clearance≥5mL/min/1.73m2. Higher UFR had a graded association with rapid decline in RKF; ORs were 1.73 (95% CI, 1.18-2.55), 1.89 (95% CI, 1.12-3.17), and 2.75 (95% CI, 1.46-5.18) at UFRs of 6 to<10, 10 to<13, and≥13mL/h/kg, respectively (reference: UFR < 6mL/h/kg). LIMITATIONS: Residual confounding from unobserved differences across exposure categories. CONCLUSIONS: Higher UFR was associated with worse outcomes, including shorter survival and more rapid loss of RKF, among patients receiving regular HD treatments at a frequency of twice or less per week.

Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced chronic kidney disease.

In patients with advanced (estimated glomerular filtration rate <25 mL/min/1.73 m2) non-dialysis-dependent chronic kidney disease (CKD) the optimal transition of care to renal replacement therapy (RRT), i.e. dialysis or transplantation, is not known. Mortality and hospitalization risk are extremely high upon transition and in the first months following the transition to dialysis. Major knowledge gaps persist pertaining to differential or individualized transitions across different demographics and clinical measures during the 'prelude' period prior to the transition, particularly in several key areas: (i) the best timing for RRT transition; (ii) the optimal RRT type (dialysis versus transplant), and in the case of dialysis, the best modality (hemodialysis versus peritoneal dialysis), format (in-center versus home), frequency (infrequent versus thrice-weekly versus more frequent) and vascular access preparation; (iii) the post-RRT impact of pre-RRT prelude conditions and events such as blood pressure and glycemic control, acute kidney injury episodes, and management of CKD-specific conditions such as anemia and mineral disorders; and (iv) the impact of the above prelude conditions on end-of-life care and RRT decision-making versus conservative management of CKD. Given the enormous changes occurring in the global CKD healthcare landscape, as well as the high costs of transitioning to dialysis therapy with persistently poor outcomes, there is an urgent need to answer these important questions. This review describes the key concepts and questions related to the emerging field of 'Transition of Care in CKD', systematically defines six main categories of CKD transition, and reviews approaches to data linkage and novel prelude analyses along with clinical applications of these studies.

Renal Replacement Therapy and Incremental Hemodialysis for Veterans with Advanced Chronic Kidney Disease.

Each year approximately 13,000 Veterans transition to maintenance dialysis, mostly in the traditional form of thrice-weekly hemodialysis from the start. Among >6000 dialysis units nationwide, there are currently approximately 70 Veterans Affairs (VA) dialysis centers. Given this number of VA dialysis centers and their limited capacity, only 10% of all incident dialysis Veterans initiate treatment in a VA center. Evidence suggests that, among Veterans, the receipt of care within the VA system is associated with favorable outcomes, potentially because of the enhanced access to healthcare resources. Data from the United States Renal Data System Special Study Center "Transition-of-Care-in-CKD" suggest that Veterans who receive dialysis in a VA unit exhibit greater survival compared with the non-VA centers. Substantial financial expenditures arise from the high volume of outsourced care and higher dialysis reimbursement paid by the VA than by Medicare to outsourced providers. Given the exceedingly high mortality and abrupt decline in residual kidney function (RKF) in the first dialysis year, it is possible that incremental transition to dialysis through an initial twice-weekly hemodialysis regimen might preserve RKF, prolong vascular access longevity, improve patients' quality of life, and be a more patient-centered approach, more consistent with "personalized" dialysis. Broad implementation of incremental dialysis might also result in more Veterans receiving care within a VA dialysis unit. Controlled trials are needed to examine the safety and efficacy of incremental hemodialysis in Veterans and other populations; the administrative and health care as well as provider structure within the VA system would facilitate the performance of such trials.

Concurrence of Serum Creatinine and Albumin With Lower Risk for Death in Twice-Weekly Hemodialysis Patients.

OBJECTIVE: Markers of better nutritional status including both higher levels of serum albumin (as a measure of visceral proteins) and creatinine (as a measure of the muscle mass) are associated with lower mortality in conventional (thrice weekly) hemodialysis patients. However, data for these associations in twice-weekly hemodialysis patients, in whom less frequent hemodialysis may confound nutritional predictors, are lacking. DESIGN AND SUBJECTS: We identified 1,113 twice-weekly and matched 4,448 thrice-weekly hemodialysis patients from a large national dialysis cohort of incident hemodialysis patients over 5 years (2007-2011). Mortality risk, adjusted for potential confounders, was examined across two-by-two combinations of serum creatinine (<6 vs. ≥6 mg/dL) and albumin (<3.5 g/dL vs. ≥3.5 g/dL) for each treatment frequency yielding a total of 8 groups. RESULTS: Patients were aged 70 ± 14 years and included 48% women and 55% diabetics. Using the thrice-weekly hemodialysis patients with creatinine ≥ 6 mg/dL and albumin ≥ 3.5 g/dL as reference, patients with creatinine <6 mg/dL and albumin <3.5 g/dL had a 1.8-fold higher risk of mortality (hazard ratio: 1.75, 95% confidence interval: 1.33-2.30) in twice-weekly and 2.2-fold increased risk of mortality (hazard ratio: 2.21, 95% confidence interval: 1.81-2.70) in thrice-weekly hemodialysis patients, respectively in fully adjusted models adjusted for demographics, comorbidities, and markers of malnutrition and inflammation. A test for interaction showed that there was no significant difference in albumin creatinine mortality associations between twice-weekly and thrice-weekly hemodialysis patients (P-for-interaction = .7667). CONCLUSIONS: Surrogate markers of higher visceral protein and muscle mass combined may confer greatest survival in both twice-weekly and thrice-weekly hemodialysis patients.

Treatment frequency and mortality among incident hemodialysis patients in the United States comparing incremental with standard and more frequent dialysis.

Most patients with end-stage renal disease in the United States are initiated on thrice-weekly hemodialysis (HD) regimens. However, an incremental approach to HD may provide several patient benefits. We tested whether initiation of incremental HD does or does not compromise survival compared with a conventional HD regimen. The survival of 434 incremental, 50,162 conventional, and 160 frequent HD patients were compared using Cox regression analysis after matching for demographic and comorbid factors in a longitudinal national cohort of adult incident HD patients enrolled between January 2007 and December 2011. Sensitivity analysis included adjustment for residual kidney function. After adjustment for residual kidney function, all-cause mortality was not significantly different in the incremental compared with conventional HD group (hazard ratio 0.88, 95% confidence interval 0.72-1.08), but was higher in the frequent compared with the conventional HD group (hazard ratio, 1.56, 95% confidence interval 1.21-2.03). The comorbidity burden modified the association of treatment frequency and mortality, with higher comorbidity associated with higher mortality in the incremental HD group (hazard ratio, 1.77, 95% confidence interval 1.20-2.62) for a Charlson Comorbidity Index of ≥5. Thus, among incident HD patients with low or moderate comorbid disease, survival was similar for patients initiated on an incremental or conventional HD regimen. Clinical trials are needed to examine the safety and effectiveness of incremental HD and the selected patient populations who may benefit from an incremental approach to HDs initiation.

Pain and Kidney Function Decline and Mortality: A Cohort Study of US Veterans.

BACKGROUND: Chronic pain is a common condition in the general population. However, large epidemiologic studies examining the role of pain in the deterioration of kidney function, development of chronic kidney disease, and risk for death are lacking. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: A nationally representative cohort of 2,360,056 US veterans with baseline estimated glomerular filtration rates (eGFRs) ≥ 60mL/min/1.73m(2), followed up from October 2004 to September 2006. PREDICTOR: 4 pain categories were compared: none (score, 0), mild (1-4), moderate (5-6), or severe (≥7). OUTCOMES: eGFR decline (determined by eGFR slope) and combined incident eGFR<60mL/min/1.73m(2) or all-cause death. MEASUREMENTS: We examined the pain management pattern and association of reported pain with (1) rapid eGFR decline and (2) a composite outcome of incident eGFR<60mL/min/1.73m(2) or all-cause death using logistic regression and Cox models adjusted for baseline eGFR, demographics, comorbid conditions, cardiovascular risk factors, and depression. RESULTS: ∼60% of veterans reported pain of any severity during the baseline period. The most commonly prescribed analgesics were opioids. In a dose-response relationship, veterans reporting moderate or severe pain had a higher risk for faster eGFR decline compared with those reporting none (ORs of 1.11 [95% CI, 1.09-1.14] and 1.17 [95% CI, 1.13-1.21] for moderate and severe pain, respectively). In combined analyses, veterans reporting moderate or severe pain both had 30% higher risk of the combined outcome (incident eGFR, 60 mL/min/1.73 m(2) or death) compared with those reporting none (HRs of 1.30 [95% CI, 1.28-1.31] and 1.30 [95% CI, 1.28-1.32] for moderate and severe pain, respectively). LIMITATIONS: Lack of granular data regarding type and location of pain. CONCLUSIONS: We observed a high prevalence of pain and analgesic prescription in the US veteran population with normal eGFRs. Pain was associated with a higher incidence of eGFRs<60mL/min/1.73m(2), faster kidney function decline, and higher mortality.

Examining the robustness of the obesity paradox in maintenance hemodialysis patients: a marginal structural model analysis.

BACKGROUND: The inverse association between body mass index (BMI) and mortality observed in patients treated with maintenance hemodialysis (MHD), also known as the obesity paradox, may be a result of residual confounding. Marginal structural model (MSM) analysis, a technique that accounts for time-varying confounders, may be more appropriate to investigate this association. We hypothesize that after applying MSM, the inverse association between BMI and mortality in MHD patients is attenuated. METHODS: We examined the associations between BMI and all-cause mortality among 123 624 adult MHD patients treated during 2001-6. We examined baseline and time-varying BMI using Cox proportional hazards models and MSM while considering baseline and time-varying covariates, including demographics, comorbidities and markers of malnutrition and inflammation. RESULTS: The patients included 45% women and 32% African Americans with a mean age of 61(SD 15) years. In all models, BMI showed a linear incremental inverse association with mortality. Compared with the reference (BMI 25 to <27.5 kg/m(2)), a BMI of <18 kg/m(2) was associated with a 3.2-fold higher death risk [hazard ratio (HR) 3.17 (95% CI 3.05-3.29)], and mortality risks declined with increasing BMI with the greatest survival advantage of 31% lower risk [HR 0.69 (95% CI 0.64-0.75)] observed with a BMI of 40 to <45 kg/m(2). CONCLUSIONS: The linear inverse relationship between BMI and mortality is robust across models including MSM analyses that more completely account for time-varying confounders and biases.

Lean Body Mass and Survival in Hemodialysis Patients and the Roles of Race and Ethnicity.

BACKGROUND: Lean body mass (LBM) represents the "fat-free" muscle mass in hemodialysis (HD) patients and is an important nutritional measure. Previous studies have found that both higher LBM and body mass index (BMI) were related to greater survival in HD patients. Additional studies have shown differences in survival across racial-ethnic groups of HD patients. However, the association of LBM and mortality across racial-ethnic subgroups has not been examined. OBJECTIVE: We hypothesize that racial differences in LBM affect the mortality in HD patients. SETTING AND SUBJECTS: Chronic HD patients from a large dialysis organization in the United States. PREDICTORS: Estimated LBM (eLBM), self-identified racial subgroups. MAIN OUTCOME MEASURE: 5-year survival. STUDY DESIGN: We examined the association between baseline eLBM and survival using Cox proportional hazard models adjusted for demographics, comorbidities, and laboratory measures. Associations were examined across subgroups of race-ethnicity (non-Hispanic white, African American, and Hispanic) and BMI. RESULTS: The final cohort included 117,683 HD patients, who were 62 ± 15 (mean ± standard deviation) years old, 43% women and 59% with diabetes mellitus. Higher eLBM was linearly associated with lower mortality. Compared with the reference group (48.4-<50.5 kg), patients with the lowest eLBM (<41.3 kg) had a 1.4-fold higher risk of mortality (hazard ratio: 1.37; 95% confidence interval: 1.30-1.44) in the fully adjusted model. A similar linear association was seen among patients with BMI < 35 kg/m(2) and in non-Hispanic whites and African American subgroups. However, higher eLBM was not associated with improved survival in Hispanic patients or patients with BMI ≥ 35 kg/m(2). LIMITATION: Potential residual confounding. CONCLUSIONS: Higher eLBM is associated with a lower mortality risk in HD patients, especially among non-Hispanic white and African American groups. Hispanic patients do not demonstrate a similar inverse relationship. The association between LBM and mortality among different racial groups of HD patients deserves additional study.

Dietary restrictions in dialysis patients: is there anything left to eat?

A significant number of dietary restrictions are imposed traditionally and uniformly on maintenance dialysis patients, whereas there is very little data to support their benefits. Recent studies indicate that dietary restrictions of phosphorus may lead to worse survival and poorer nutritional status. Restricting dietary potassium may deprive dialysis patients of heart-healthy diets and lead to intake of more atherogenic diets. There is little data about the survival benefits of dietary sodium restriction, and limiting fluid intake may inherently lead to lower protein and calorie consumption, when in fact dialysis patients often need higher protein intake to prevent and correct protein-energy wasting. Restricting dietary carbohydrates in diabetic dialysis patients may not be beneficial in those with burnt-out diabetes. Dietary fat including omega-3 fatty acids may be important caloric sources and should not be restricted. Data to justify other dietary restrictions related to calcium, vitamins, and trace elements are scarce and often contradictory. The restriction of eating during hemodialysis treatment is likely another incorrect practice that may worsen hemodialysis induced hypoglycemia and nutritional derangements. We suggest careful relaxation of most dietary restrictions and adoption of a more balanced and individualized approach, thereby easing some of these overzealous restrictions that have not been proven to offer major advantages to patients and their outcomes and which may in fact worsen patients' quality of life and satisfaction. This manuscript critically reviews the current paradigms and practices of recommended dietary regimens in dialysis patients including those related to dietary protein, carbohydrate, fat, phosphorus, potassium, sodium, and calcium, and discusses the feasibility and implications of adherence to ardent dietary restrictions and future research.

The relationship between ultraviolet light exposure and mortality in dialysis patients.

BACKGROUND: Emerging data suggest that reduced exposure to ultraviolet (UV) radiation is associated with increased mortality in the general population. To date, the association between UV exposure and mortality in dialysis patients has not been examined. METHODS: We examined the association between UV index, a proxy of UV exposure, and all-cause mortality among 47,286 US dialysis patients (entry period 2001-2006, with follow-up through 2009) from a large national dialysis organization using multivariable Cox regression. The UV index was ascertained by linking individual patients' residential zip codes to National Oceanic and Atmospheric Administration data, and was categorized as low (0-<3), moderate (3-<5), moderate-high (5-<6), high (6-<7), and very-high (≥7). In secondary analyses, we examined the UV index-mortality association within subgroups of age (<65 vs. ≥65 years old), sex, and race (white vs. non-white). RESULTS: The study population's mean ± SD age was 60 ± 16 and included 46% women and 56% diabetics. Compared to patients residing in moderate-high UV index regions, those residing in high and very-high UV index regions had a lower mortality risk: adjusted HRs 0.84 (95% CI) 0.81-0.88 and 0.83 (95% CI) 0.75-0.91, respectively. A similar inverse association between UV index and mortality was observed across all subgroups, although there was more pronounced reduction in mortality among whites vs. non-whites. CONCLUSION: These data suggest that dialysis patients residing in higher UV index regions have lower all-cause mortality compared to those living in moderate-high UV regions. Further studies are needed to determine the mechanisms underlying the UV index-mortality association.

Bleeding complications of native kidney biopsy: a systematic review and meta-analysis.

BACKGROUND: Kidney biopsy provides important information for nephrologists, but the risk of complications has not been systematically described. STUDY DESIGN: Meta-analysis of randomized controlled trials and prospective or retrospective observational studies. SETTING & POPULATION: Adults undergoing native kidney biopsy in an inpatient or outpatient setting. SELECTION CRITERIA FOR STUDIES: MEDLINE indexed studies from January 1980 through June 2011; sample size of 50 or more. INTERVENTION: Native kidney biopsy with automated biopsy device and real-time ultrasonographic guidance. OUTCOMES: Macroscopic hematuria and erythrocyte transfusion rates and factors associated with these outcomes. RESULTS: 34 studies of 9,474 biopsies met inclusion criteria. The rate of macroscopic hematuria was 3.5% (95% CI, 2.2%-5.1%), and erythrocyte transfusion was 0.9% (95% CI, 0.4%-1.5%). Significantly higher rates of transfusion were seen with the following: 14-gauge compared with smaller needles (2.1% vs 0.5%; P = 0.009), studies with mean serum creatinine level ≥2.0 mg/dL (2.1% vs 0.4%; P = 0.02), ≥50% women (1.9% vs 0.6%; P = 0.03), and ≥10% of biopsies for acute kidney injury (1.1% vs 0.04%; P < 0.001). Higher transfusion rates also were observed in studies with a mean age of 40 years or older (1.0% vs 0.2%; P = 0.2) and mean systolic blood pressure ≥130 mm Hg (1.4% vs 0.1%; P = 0.09). Similar relationships were noted for the macroscopic hematuria rate with the same predictors, but none was statistically significant. LIMITATIONS: Publication bias, few randomized controlled trials, and missing data. CONCLUSIONS: Native kidney biopsy using automated biopsy devices and real-time ultrasonography is associated with a relatively small risk of macroscopic hematuria and erythrocyte transfusion requirement. Using smaller gauge needles may lower complication rates. Patient selection may affect outcome because studies with higher serum creatinine levels, more women, and higher rates of acute kidney injury had higher complication rates. Future studies should further evaluate risk factors for complications.

A 90-year-old man with hyperphosphatemia.

Hyperphosphatemia is a common condition in patients with decreased kidney function, and without treatment, it can lead to a variety of clinical consequences. However, the presence of hyperphosphatemia in patients with normal kidney function may be true or spurious. We present a case of pseudohyperphosphatemia in a patient with monoclonal gammopathy. An increased paraprotein level can lead to colorimetric interference of the assay of phosphate measurement and result in spurious hyperphosphatemia. The epidemiologic and clinical characteristics of paraprotein-associated pseudohyperphosphatemia also are reviewed here. Ultrafiltration of paraproteins or deproteinization can help correct the measuring error. Patients with spurious hyperphosphatemia should not be treated with phosphate binders. Clinicians treating patients with monoclonal gammopathy should be aware of this relatively common clinical phenomenon and avoid inappropriate treatment of spurious hyperphosphatemia.

Effect of intra-dialytic, low-intensity strength training on functional capacity in adult haemodialysis patients: a randomized pilot trial.

BACKGROUND: Kidney failure is associated with muscle wasting and physical impairment. Moderate- to high-intensity strength training improves physical performance, nutritional status and quality of life in people with chronic kidney disease and in dialysis patients. However, the effect of low-intensity strength training has not been well documented, thus representing the objective of this pilot study. METHODS: Fifty participants (mean +/- SD, age 69 +/- 13 years) receiving long-term haemodialysis (3.7 +/- 4.2 years) were randomized to intra-dialytic low-intensity strength training or stretching (attention-control) exercises twice weekly for a total of 48 exercise sessions. The primary study outcome was physical performance assessed by the Short Physical Performance Battery score (SPPB) after 36 sessions, if available, or carried forward from 24 sessions. Secondary outcomes included lower body strength, body composition and quality of life. Measurements were obtained at baseline and at completion of 24 (mid), 36 (post) and 48 (final) exercise sessions. RESULTS: Baseline median (IQR) SPPB score was 6.0 (5.0), with 57% of the participants having SPPB scores below 7. Exercise adherence was 89 +/- 15%. The primary outcome could be computed in 44 participants. SPPB improved in the strength training group compared to the attention-control group [21.1% (43.1%) vs. 0.2% (38.4%), respectively, P = 0.03]. Similarly, strength training participants exhibited significant improvements from baseline compared to the control group in knee extensor strength, leisure-time physical activity and self-reported physical function and activities of daily living (ADL) disability; all P < 0.02. Adverse events were common but not related to study participation. CONCLUSIONS: Intra-dialytic, low-intensity progressive strength training was safe and effective among maintenance dialysis patients. Further studies are needed to establish the generalizability of this strength training program in dialysis patients.

Hemodynamic and Laboratory Changes during Incremental Transition from Twice to Thrice-Weekly Hemodialysis.

OBJECTIVE: Incremental hemodialysis (HD) is a strategy utilized to gradually intensify dialysis among patients with incident end-stage renal disease. However, there are scarce data about which patients' clinic status changes by increasing treatment frequency. METHODS: We retrospectively examined statistically de-identified data from 569 patients who successfully transitioned from twice- to thrice-weekly HD (2007-2011) and compared the differences in monthly-averaged values of hemodynamic and laboratory indices during the 3 months before and after the transition with the values at 1 month prior to transition serving as the reference. RESULTS: At 3 months after transitioning from twice- to thrice-weekly HD, ultrafiltration volume decreased by 0.5 (95% CI 0.3-0.6) L/session among 189 patients (33%) with weekly interdialytic weight gain (IDWG) ≥5.4 kg/week, and increased by 0.4 (95% CI 0.3-0.5) L/session among 186 patients (33%) with weekly IDWG <3.3 kg/week. Weekly IDWG consistently increased after the transition irrespective of baseline values (1.7 [95% CI 1.5-1.9] kg/week). Pre-HD systolic blood pressure (SBP) decreased by 12 (95% CI 9-14) mm Hg among 177 patients (31%) with baseline pre-HD SBP ≥160 mm Hg, which coincided with a decreasing trend in post-HD body weight (1.3 [95% CI 0.8-1.7] kg). DISCUSSION: In conclusion, patients who increased HD frequency from twice to thrice weekly treatment experienced increased weekly IDWG and better pre-HD SBP control with lower post-HD body weight.

Plant-Dominant Low-Protein Diet for Conservative Management of Chronic Kidney Disease.

Chronic kidney disease (CKD) affects >10% of the adult population. Each year, approximately 120,000 Americans develop end-stage kidney disease and initiate dialysis, which is costly and associated with functional impairments, worse health-related quality of life, and high early-mortality rates, exceeding 20% in the first year. Recent declarations by the World Kidney Day and the U.S. Government Executive Order seek to implement strategies that reduce the burden of kidney failure by slowing CKD progression and controlling uremia without dialysis. Pragmatic dietary interventions may have a role in improving CKD outcomes and preventing or delaying dialysis initiation. Evidence suggests that a patient-centered plant-dominant low-protein diet (PLADO) of 0.6­0.8 g/kg/day composed of >50% plant-based sources, administered by dietitians trained in non-dialysis CKD care, is promising and consistent with the precision nutrition. The scientific premise of the PLADO stems from the observations that high protein diets with high meat intake not only result in higher cardiovascular disease risk but also higher CKD incidence and faster CKD progression due to increased intraglomerular pressure and glomerular hyperfiltration. Meat intake increases production of nitrogenous end-products, worsens uremia, and may increase the risk of constipation with resulting hyperkalemia from the typical low fiber intake. A plant-dominant, fiber-rich, low-protein diet may lead to favorable alterations in the gut microbiome, which can modulate uremic toxin generation and slow CKD progression, along with reducing cardiovascular risk. PLADO is a heart-healthy, safe, flexible, and feasible diet that could be the centerpiece of a conservative and preservative CKD-management strategy that challenges the prevailing dialysis-centered paradigm.

Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure.

BACKGROUND: Heart failure (HF) is one of the leading causes of morbidity and mortality among Americans. Despite increased interest in end-of-life care, the implications of do-not-resuscitate (DNR) orders in acutely ill patients with HF remain unclear. The goals of this observational study were to describe the use of DNR orders and their impact on treatment approaches in residents of a large New England metropolitan area hospitalized with acute heart failure. METHODS: Use of HF performance measures, including assessment of left ventricular function, use of angiotensin receptor blocking agents, anticoagulation, smoking cessation counseling, and use of nonpharmacologic strategies, was examined through review of the medical records of 4,537 metropolitan Worcester (MA) residents admitted to 11 central Massachusetts hospitals with acute HF in 1995 and 2000 according to the presence of DNR orders. RESULTS: Patients with DNR orders were less likely to have had their left ventricular function assessed (31% vs 43%) as well as receive renin-angiotensin system blockade (49% vs 57%), anticoagulation (65% vs 78%), or nonpharmacologic interventions (87% vs 92%) as compared to patients without DNR orders. Patients with DNR orders were significantly less likely to have received any quality assurance measure for acute HF (adjusted hazard ratio 0.63, 95% confidence interval 0.40-0.99) than patients without DNR orders. CONCLUSIONS: The use of quality assurance measures in acute HF is markedly lower in patients with DNR orders. The implications of DNR orders need to be further clarified in the treatment of patients with acute HF.