Retrospective single center cohort study: effect of intensive home hemodialysis on right ventricular systolic pressure and clinical outcomes.

BACKGROUND: Increased right ventricular systolic pressure (RVSP), a surrogate marker for pulmonary hypertension, is common in patients with end-stage kidney disease. Limited data suggest improvement of RVSP with intensive dialysis, but it is unknown whether these improvements translate to better clinical outcomes. METHODS: We conducted a retrospective single center cohort study at the Toronto General Hospital. All patients who performed intensive home hemodialysis (IHHD) for at least a year between 1999 and 2017, and who had a baseline as well as a follow-up echocardiogram more than a year after IHHD, were included. Patients were categorized into two groups based on the RVSP at follow-up: elevated (≥ 35 mmHg) and normal RVSP. Multivariate and cox regression analyses were done to identify risk factors for elevated RVSP at follow-up and reaching the composite endpoint (death, cardiovascular hospitalization, treatment failure), respectively. RESULTS: One hundred eight patients were included in the study. At baseline, 63% (68/108) of patients had normal RVSP and 37% (40/108) having elevated RVSP. After a follow-up of 4 years, 70% (76/108) patient had normal RVSP while 30% (32/108) had elevated RVSP. 8 (10%) out of the 76 patients with normal RVSP and 15 (47%) out of the 32 patients with elevated RVSP reached the composite endpoint of death, cardiovascular hospitalization or technique failure. In a multivariate analysis, age, diabetes and smoking were not associated with elevated RVSP at follow-up. Elevated RVSP at baseline was not associated with a higher likelihood in reaching the composite endpoint or mortality. CONCLUSION: Mean RVSP did not increase in patients on IHHD over time, and maintenance of normal RVSP was associated with better clinical outcomes.

Kidney Pathology after Hematologic Cell Transplantation-A Single-Center Observation Study of Indication Biopsies and Autopsies.

Hematopoietic cell transplantation (HCT) is an increasingly used treatment for hematologic malignancies as well as for nonmalignant diseases. Kidney impairment remains an important early and late post-transplantation complication. Although numerous histopathological changes have been reported, the pathophysiology remains incompletely understood. Furthermore, correlations between clinical findings and morphological changes have not been well studied. Between 2000 and 2016, 17 recipients of allogeneic (n = 12) or autologous (n = 5) HCT underwent kidney biopsy for either proteinuria or deterioration of kidney function at our center. The most common biopsy findings were therapy-related changes with thrombotic microangiopathy (n = 5), calcineurin inhibitor toxicity (n = 4), and membranous glomerulonephritis (n = 3), representing the majority of cases in this category. In addition, kidney findings from 137 autopsies performed between 1995 and March 2017 were analyzed. The most common changes were acute kidney injury (n = 55), most likely due to the patients' premortal deteriorated state, and thrombotic microangiopathy (n = 14). Several cases demonstrated involvement by either infectious agents (n = 6) or tumors (n = 9). Distinct kidney diseases, such as glomerulonephritis, were rare (3% of cases). Uncommon and yet rarely described diagnoses for this patient cohort were IgG4-related tubulointerstitial nephritis and fibrillary nephritis. This study provides a comprehensive overview of the histomorphological findings in kidney biopsy specimens from HCT recipients. Along with treatment-related complications, one putative correlate of chronic GVHD of the kidney could be documented: membranous glomerulonephritis. In contrast, no morphological correlate of acute GVHD of the kidney was identified. Findings at the time of autopsy varied greatly, spanning a wider range than those of indication biopsies.

Short term sequelae of preeclampsia: a single center cohort study.

BACKGROUND: Data on the prevalence of persistent symptoms in the first year after preeclampsia are limited. Furthermore, possible risk factors for these sequelae are poorly defined. We investigated kidney function, blood pressure, proteinuria and urine sediment in women with preeclampsia 6 months after delivery with secondary analysis for possible associated clinical characteristics. METHODS: From January 2007 to July 2014 all women with preeclampsia and 6-months follow up at the University Hospital Basel were analyzed. Preeclampsia was defined as new onset of hypertension (≥140/90 mmHg) and either proteinuria or signs of end-organ dysfunction. Hypertension was defined as a blood pressure ≥ 140/90 mmHg or the use of antihypertensive medication. Proteinuria was defined as a protein-to-creatinine ratio in a spot urine > 11 mg/mmol. Urine sediment was evaluated by a nephrologist. Secondary analyses were performed to investigate for possible parameters associated with persistent symptoms after preeclampsia. RESULTS: Two hundred two women were included into the analysis. At a mean time of follow up of 172 days (+/- 39.6) after delivery, mean blood pressure was 124/76 mmHg (+/- 14/11, range 116-182/63-110) and the mean serum-creatinine was 61.8 µmol/l (33-105 µmol/l) (normal < 110 µmol/l). Mean estimated glomerular filtration rate using CKD-EPI was 110.7 mml/min/1.73m2 (range 59.7-142.4 mml/min/1.73m2) (normal > 60 mml/min/1.73m2). 20.3% (41/202) had a blood pressure of 140/90 mmHg or higher (mean 143/89 mmHg) or were receiving antihypertensive medication (5.5%, 11/202). Proteinuria was present in 33.1% (66/199) (mean 27.5 mg/mmol). Proteinuria and hypertension was present in 8% (16/199). No active urine sediment (e.g. signs of glomerulonephritis) was observed. Age and gestational diabetes were associated with persistent proteinuria and severe preeclampsia with eGFR decline of ≥ 10 ml/min/1.73m2. CONCLUSION: Hypertension and proteinuria are common after 6 months underlining the importance of close follow up to identify those women who need further care.

Visions in a Crystal Ball: The Future of Peritoneal Dialysis.

BACKGROUND: Peritoneal dialysis (PD) is one of the corner stones of renal replacement therapy and should be strongly considered if preemptive kidney transplantation is not available. SUMMARY: There are several initiatives that may help the growth in the use of PD around the world. First, PD is an underused and valuable option in patients with heart failure and the chronic cardiorenal syndrome, especially in those with frequent hospitalizations despite optimal medical therapy. To identify these patients, an interdisciplinary approach of nephrologists and cardiologists is needed. These patients and other CKD patients with significant residual kidney function may do well with a regimen employing fewer than the usual number of bag exchanges, referred to as "incremental" dialysis. Second, acute kidney injury (AKI) is a worldwide burden with high morbidity and mortality, especially in low income countries. To reach the goal of zero preventable deaths caused by AKI by 2025 endorsed by the International Society of Nephrology, PD is the therapy of choice for treatment in this setting. Third, although dextrose has served well as the osmotic agent in PD solutions, there has been a continuous search for alternative agents. Hyperbranched polyglycerol might be such an osmole. Finally, to obviate the need for production and delivery of bags of PD solution, the development of home-generated dialysate is of interest. Key Message: The future of PD lies not only in accruing experience from the past decades, but also in staying open to other uses.

Ventricular ejection fraction over time in patients on intensive home hemodialysis: A retrospective cohort study.

INTRODUCTION: Intensive hemodialysis has been demonstrated to have several beneficial cardiovascular effects. There is a paucity of studies examining the effect of intensive home hemodialysis (IHHD) on left ventricular ejection fraction (LVEF). METHODS: We conducted a retrospective cohort study at the Toronto General Hospital including all IHHD patients between 1999 and 2017 with baseline and follow-up echocardiograms for at least a year. Patients were categorized according to LVEF at follow-up: patients with normal and patients with abnormal LVEF and/or a decline in LVEF. Normal LVEF was defined as ≥55% and a decline as ≥5% at follow-up compared to baseline Cox regression analyses were performed to ascertain the association between reduced LVEF and reaching the composite endpoint of death, cardiovascular hospitalization, and technique failure, respectively. Multivariate logistic analysis was used to investigate possible risk factors for changes in LVEF. FINDINGS: A total of 154 patients were included in the study. At baseline, 18.8% (29/154) of patients had reduced LVEF. After a mean follow-up of 3.9 years, overall mean LVEF did not change (59.3% [at follow-up] vs. 59.9% [baseline], P = 0.45). Seventeen out of the 130 patients with normal LVEF (13.1%) and nine out of the 24 with abnormal LVEF (37.9%) reached the composite endpoint of death, cardiovascular hospitalization, or technique failure. Reduced LVEF at baseline odds ratio ((OR) 13.26 [95% confidence interval (CI) 4.62-38.05]) as well as coronary heart disease (OR 7.82 [95% CI 1.92-31.82]) were associated with reduced ejection fraction at follow-up. When adjusted for age and diabetes, patients with abnormal LVEF were more likely to reach the composite endpoint hazard ratio ((HR) 3.85, 95% CI 1.70-8.71). We did not identify a risk factor associated with progression or worsening of LVEF. DISCUSSION: Preserved LVEF occurs in most patients on IHHD and is associated with better clinical outcomes. Further studies are needed to identify the mechanism affecting left ventricular function in patients undergoing intensive hemodialysis.

A Single-Center Retrospective Study on the Initiation of Peritoneal Dialysis in Patients With Cardiorenal Syndrome and Subsequent Hospitalizations.

BACKGROUND: Inotropic dependence and diuretic resistance in patients with cardiorenal syndrome (CRS) lead to frequent hospitalizations and are associated with high mortality. Starting peritoneal dialysis (PD) acutely (within 2 weeks of a heart failure hospitalization) offers effective volume removal without hemodynamic compromise in this population. There is little data on this approach in the North American literature. OBJECTIVE: To determine whether volume-overloaded patients with CRS on maximal doses of diuretic therapy had reduced hospitalization for heart failure following PD initiation. DESIGN: Retrospective cohort study. SETTING: Academic hospital network (University Health Network, Toronto, Ontario). PATIENTS: Patients with CRS receiving a bedside catheter and starting PD within 2 weeks of insertion at the University Health Network from January 1, 2013, to December 31, 2018. METHODS AND MEASUREMENTS: Data for heart failure-related hospitalizations and length of stay 6 months before and after PD initiation were collected. Patients who died, switched to hemodialysis, or were transferred to another facility within 6 months of starting PD were excluded from the analysis. RESULTS: We identified 31 patients with CRS who had a bedside PD catheter inserted. The average age of patients was 66.0 ± 13.0 years. There were 7 (22.6%) deaths and 4 (12.9%) transfers to other programs or hemodialysis within 6 months of catheter insertion. After exclusion, we analyzed hospitalization and length of stay data for 20 patients. The hospitalization rate 6 months before PD initiation was 6.9 admissions per 1000 patient-days. This decreased to 2.5 admissions per 1000 patient-days after PD initiation. In addition, there was also a significant reduction in the average length of stay per hospitalization (24.1-3.9 days; P = .001). LIMITATIONS: Our study did not assess the severity of heart failure symptoms using a standardized functional classification system. We did not assess quality of life and illness intrusiveness scores before and after starting dialysis, nor did we capture non-heart-failure-related hospitalizations or external admissions at other hospital sites. We limited eligibility to clinically stable patients with no prior major abdominal surgical history in a single Canadian PD program using bedside ultrasound approach for catheter insertions by experienced nephrologists and included a small number of patients. CONCLUSIONS: Volume-overloaded patients with CRS receiving maximal diuretic therapy have lower hospitalization rates and shorter stays after initiation of PD. The development of a bedside PD catheter insertion program and close collaboration between nephrology and cardiology services may facilitate acute start dialysis in this population.

CONTEXTE: La dépendance inotrope et la résistance aux diurétiques entraînent de fréquentes hospitalisations et sont associées à une mortalité élevée chez les patients atteints du syndrome cardio-rénal (SCR). Dans cette population, l'amorce de la dialyse péritonéale (DP) en temps opportun, soit dans les deux semaines suivant une hospitalisation pour insuffisance cardiaque, permet d'éliminer efficacement la surcharge liquidienne sans compromettre l'hémodynamie. On trouve toutefois peu de données sur cette approche dans la littérature nord-américaine. OBJECTIF: Déterminer si les patients atteints du SCR et présentant une surcharge volémique qui reçoivent une dose maximale de diurétiques sont hospitalisés moins souvent pour insuffisance cardiaque après l'amorce de la DP. TYPE D'ÉTUDE: Une étude de cohorte rétrospective. CADRE: Un réseau de centres hospitaliers universitaires (University Health Network) de Toronto (Ontario). SUJETS: Des patients atteints du SCR, hospitalisés au University Health Network entre le 1er janvier 2013 et le 31 décembre 2018, à qui on avait installé un cathéter de DP au chevet et qui avaient amorcé un traitement de dialyse dans les deux semaines suivant l'insertion. MÉTHODOLOGIE: On a recueilli les données sur les hospitalisations pour insuffisance cardiaque et la durée des séjours dans les six mois avant et après l'initiation de la PD. Les patients décédés, passés à l'hémodialyse ou ayant été transférés vers un autre centre dans les six mois suivant l'amorce de la PD ont été exclus de l'analyse. RÉSULTATS: Nous avons identifié 31 patients atteints du SCR, âgés en moyenne de 66,0 ±13,0 ans, à qui un cathéter de DP avait été installé au chevet. Dans les six mois suivant l'insertion du cathéter, sept patients (22,6 %) sont décédés et quatre (12,9 %) ont été transférés dans un autre centre ou sont passés à l'hémodialyse. À la suite de ces exclusions, l'analyse a porté sur les hospitalisations et les durées de séjour de 20 patients. Le taux d'hospitalisation dans les six mois précédant l'initiation de la DP s'établissait à 6,9 admissions par 1 000 jours-patient; un taux qui est passé à 2,5 admissions par 1 000 jours-patient une fois la DP amorcée. On a également observé une réduction significative de la durée moyenne du séjour, celle-ci étant passée de 24,1 à 3,9 jours (p=0,001). LIMITES: La gravité des symptômes de l'insuffisance cardiaque n'a pas été évaluée à l'aide d'un système de classification fonctionnel normalisé. Les scores de la qualité de vie et du caractère intrusif de la maladie n'ont pas été évalués avant et après l'amorce de la dialyse. Les données des hospitalisations non liées à l'insuffisance cardiaque et des admissions externes dans d'autres sites n'ont pas été colligées. L'admissibilité a été limitée aux patients cliniquement stables et sans antécédent de chirurgie abdominale majeure. Les participants provenaient d'un seul programme canadien de DP où la méthode d'insertion du cathéter utilise une approche par ultrasons pratiquée par un néphrologue expérimenté. Enfin, l'étude porte sur un faible échantillon de sujets. CONCLUSION: Les patients atteints du SCR et présentant une surcharge volémique qui reçoivent une dose maximale de diurétiques ont été moins souvent hospitalisés à la suite de l'amorce de la DP. Le développement d'un programme d'insertion du cathéter de DP au chevet du patient et une collaboration étroite entre les services de cardiologie et de néphrologie pourraient faciliter l'amorce rapide de la dialyse dans cette population.

Are adverse events in newly trained home dialysis patients related to learning styles? A single-centre retrospective study from Toronto, Canada.

OBJECTIVES: Home haemodialysis (HD) and peritoneal dialysis (PD) have seen growth in utilisation around the globe over the last few years. However, home dialysis, with its attendant technical complexity and risk of adverse events continues to pose challenges for wider adoption. We examined whether differences in patients' learning styles are associated with differing risk of adverse events in both home HD and PD patients. DESIGN: Retrospective cohort study. SETTING: Tertiary care hospital in Toronto, Ontario, Canada. PARTICIPANTS: One hundred and eighteen prevalent adult (≥18 years) home dialysis patients (40 PD and 78 home HD) were enrolled. Patients on home dialysis for less than 6 months or receiving home nursing assistance for dialysis were excluded from the study. INTERVENTIONS: Enrolled patients completed (VARK) Visual, Aural, Reading-writing and Kinesthetic questionnaires to determine learning styles. PRIMARY AND SECONDARY OUTCOME MEASURES: Home HD and PD adverse events were identified within 6 months of completing home dialysis training. Event rates were then stratified and compared according to learning styles. RESULTS: Thirty patients had a total of 53 adverse events. We used logistic regression analysis to determine unadjusted and adjusted ORs for a single adverse event. Non-visual learners were 4.35 times more likely to have an adverse event (p=0.001). After adjusting for age, gender, dialysis modality, training duration, dialysis vintage, prior renal replacement therapy, visual impairment, education and literacy, an adverse event was still four times more likely among non-visual learners compared to visual learners (p=0.008). A subgroup analysis of home HD patients showed adverse events were more likely among non-visual learners (OR 11.1; p=0.003), whereas PD patients showed a trend for more adverse events in non-visual learners (OR: 1.60; p=0.694). CONCLUSIONS: Different learning styles in home dialysis patients exist. Visual learning styles are associated with fewer adverse events in home dialysis patients within the first 6 months of completing training. Individualisation of home dialysis training by learning style is warranted.

The need for outpatient back-up for home hemodialysis patients: Implications for resource utilization.

INTRODUCTION: The provision of sufficient support contributes to home hemodialysis (HHD) technique survival. The need for back-up treatment in incident and prevalent patients on HHD has not been well described previously, and is important from both technique survival and resource allocation. We aimed to quantify the amount of back-up treatment given to patients in our HHD unit, and hypothesized that the provision of back-up HD facilitated technique survival. METHODS: This was a retrospective, single-center cohort study quantifying the provision of back-up HD between January and December 2018. Electronic and paper medical records were accessed for data collection. FINDINGS: One hundred and nineteen patients dialyzed independently at home during the study period (96 patient years of HHD). Seventy-eight (66%) patients required a total of 292 back-up HD sessions in the HHD unit, representing an average of three back-up HD runs per patient year of HHD. Fifty-three percent of back-up HD runs were required for vascular access related issues. The most common clinical issue requiring assessment and back-up HD was extracellular fluid volume management. An equal proportion (95%) of those that utilized back-up HD and those that did not utilize back-up HD maintained a positive disposition (transplant or ongoing HHD) in relation to technique survival in the short term. CONCLUSIONS: From a resource viewpoint, this program of approximately 100 HHD patients required the availability of one to two staffed HD stations each weekday for back-up HD. The provision of back-up HD was not a harbinger of HHD discontinuation.

Correction of pulmonary hypertension with intensive hemodialysis: A case report.

Pulmonary hypertension (PH) defined as a mean pulmonary arterial pressure ≥25 mmHg is a common complication in hemodialysis occurring in up to 58% of patients. PH is classified according to its etiology. We report in a patient with severe PH of mixed etiology (connective tissue disease and left-sided heart failure) who improved after initiation of intensive home hemodialysis. We postulated that the use of a frequent mode of hemodialysis may ameliorate PH via enhanced volume control. Thereby, an intensive hemodialysis schedule may be preferred renal replacement modality in this patient population.