Facility size and mortality in hospital-based and freestanding haemodialysis units: A nationwide retrospective cohort study.

AIM: Existing studies on the association between haemodialysis facility size/volume and patient survival are mostly limited to freestanding dialysis units in the United States. This study in Taiwan explored the facility size - mortality association in both hospital-based and freestanding haemodialysis (HD) units. METHODS: In this nationwide population-based retrospective cohort study, we used the Taiwan National Health Insurance Research Database to include patients who began maintenance (HD) between 2008 and 2012. Facility size was categorized according to the number of stations in the HD unit. The 5 years mortality rate was analyzed using a frailty model for Cox regression. The patients in hospital-based and freestanding HD units were examined separately. RESULTS: Among the 39 506 patients, 24 597 (62.3%) and 14 909 (37.7%) patients received HD in hospital-based and freestanding facilities, respectively. After the 4th month of dialysis initiation, the 5 years survival rates of patients in hospital-based and freestanding HD units were 50.7% and 52.3%, respectively. When patient and other facility characteristics were adjusted, patients in the smallest facility category (1-15 stations) showed the highest mortality risk (hazard ratio, 1.36; 95% confidence interval, 1.11-1.67) among all the patients treated in hospital-based units. The patients treated in freestanding units with 1-15, 16-30 and 31-45 stations showed 31%, 33% and 36%, respectively, higher mortality risks than those of patients treated in units with more than 45 stations. CONCLUSION: A small facility size was associated with an increased mortality risk in HD patients, and the threshold size was higher in freestanding units.

A patient with hemodialysis-related hyperammonemic encephalopathy: a delayed presentation of congenital arterioportal fistulas.

We present a 32-year-old woman who developed hyperammonemic encephalopathy during hemodialysis. She was rather well before 2009 when receiving peritoneal dialysis due to chronic interstitial nephritis. Due to a refractory peritonitis, the treatment was shifted to hemodialysis in January 2009. About 1 year later, she was found with consciousness disturbance during hemodialysis then admitted to the hospital because of hyperammonemia (165 µg/dl). During hospitalization, the patient's abdominal Doppler sonography showed a hepatofugal flow in the portal trunk while the hepatic artery angiography demonstrated multiple intrahepatic arterioportal fistulas. Her general condition was improved after the treatment of lactulose and hepatic artery embolization. With the occurrence of arterioportal fistulas induced portal hypertension, we speculated that the portal-systemic shunt was enhanced during hemodialysis because of venous hypotension which then resulted in the transient hyperammonemia. To the best of our knowledge, this is the first patient who developed hemodialysis- related hyperammonemic encephalopathy due to multiple arterioportal fistulas.

Peritoneal dialysis as compared with hemodialysis is associated with higher overhydration but non-inferior blood pressure control and heart function.

BACKGROUND/AIMS: Fluid overload is an important factor causing cardiovascular complications in dialysis patients. We compared fluid status, blood pressure (BP) and heart function between peritoneal dialysis (PD) patients and hemodialysis (HD) patients. METHODS: We recruited 94 PD and 75 HD patients in our hospital. Fluid status was assessed by bioimpedance spectroscopy. Home BP was recorded. Use of antihypertensives was retrieved by chart review. In each group, 39 patients received echocardiographic examinations. RESULTS: PD patients' fluid status was similar to that of predialysis HD patients. PD patients had lower systolic BP. E/E' and left ventricular mass index (LVMI) showed no significant intergroup difference. In multiple linear regression analyses, overhydration (OH)/extracellular water ratio >0.15 was associated with higher systolic BP, E/E' and LVMI. CONCLUSIONS: While PD was associated with higher OH but non-inferior BP control and heart function, OH was indeed related to poor BP control, diastolic dysfunction and left ventricular hypertrophy.

Creatinine clearance rate and nerve conduction velocity are effective in objectively assessing oxaliplatin-neuropathy in patients with colorectal carcinoma.

BACKGROUND/AIMS: To evaluate the efficacy of using creatinine clearance rate (CCr) and nerve conduction velocity (NCV) study in objectively assessing oxaliplatin-induced neuropathy, a study was performed. METHODOLOGY: Sixty-eight patients with unresectable metastatic colorectal carcinoma were enrolled. FOLFOX-4 regimen was administrated as first-line chemotherapy. Patients were divided into CCr-impaired (60-80mL/min) and CCr-fair (>80mL/min) groups before treatment. NCV was examined accordingly, and the correlations of CCr and NCV with oxaliplatin-induced neuropathy were analyzed. RESULTS: An excellent correlation was identified in impaired CCr and the severity of neurological symptoms (p<0.01). Nine (47.3%) CCr-impaired patients developed severe (grade 3 or 4) neuropathy and only 5 (10.2%) CCr-fair patients developed grade 3/4 neuropathy. A good correlation was found in NCV abnormalities and the severity of neuropathy, too (p<0.01). Thirteen (33.3%) patients with impaired NCV developed grade 3/4 neuropathy but only one (3.4%) patient with normal NCV had grade 3/4 neuropathy. However, there remained 26 (66.7%) NCV-impaired patients who had no or only mild neurological symptoms. CONCLUSIONS: These data suggest that CCr and NCV correlate well with the severity of neurological symptoms in colorectal cancer patients treated with oxaliplatin-based chemotherapy. The additions of CCr and NCV, to a precise physical examination, are helpful in objectively assessing oxaliplatin-induced neuropathy.

Impact of time-varying center volume on technique failure and mortality in peritoneal dialysis.

BACKGROUND: Most studies on volume-outcome association used the number of patients at a particular period as the independent variable. However, peritoneal dialysis (PD) is a chronic treatment, and center volume usually changes over a patient's treatment period. Accordingly, this study used the time-varying center volume to explore the volume-outcome association in PD. METHODS: We conducted a nationwide population-based retrospective cohort study, which included patients who began chronic PD between 2001 and 2010. The risk factors of 5-year technique failure and mortality were analyzed using cause-specific and subdistribution hazard models, respectively. The annual number of patients initiating PD in each patient's treatment center was modeled as a time-varying variable with four categories. RESULTS: We included 9071 patients who started PD in 100 centers where the number of incident patients ranged from 1 to 107 patients per year (median, 25; interquartile range, 13-42). The estimated 5-year patient and technique survival rates were 64.7% and 66.6%, respectively. Being treated in centers in the largest volume category (the number of incident PD patients ≥43 per year) was associated with significantly lower cause-specific and cumulative hazards for technique failure. No association was found between facility volume and hazards of mortality. CONCLUSIONS: Receiving PD in high-volume facilities was associated with a lower risk in technique failure. No association was found between facility volume and mortality risk.