Geriatric Nutritional Risk Index and First-Year Mortality in Incident Hemodialysis Patients.

OBJECTIVE: The Geriatric Nutritional Risk Index is a simple nutritional screening method, and this study aimed to investigate the association between the initial Geriatric Nutritional Risk Index and all-cause mortality in incident patients in the first year after the initiation of hemodialysis. MATERIALS AND METHODS: This study is a retrospective cohort study and used the Korean Renal Data System database. Patients who were eligible for Geriatric Nutritional Risk Index assessment and underwent hemodialysis from January 2016 to December 2019 were included. The primary outcome was all-cause mortality, and outcome evaluation was performed in December 2020. A Cox proportional hazard model was used to analyze the association between the Geriatric Nutritional Risk Index and mortality. RESULTS: A total of 10,545 patients were included, and the mean age was 63.9 ± 3.7 years. The patients were divided into four groups by the quartile of the Geriatric Nutritional Risk Index with a mean value of 96.2 ± 8.2. During the study period, 545 (5.2%) deaths occurred. The surviving patients had higher Geriatric Nutritional Risk Index values than ones who died in the first year of hemodialysis initiation (96.6 ± 7.5 vs. 88.2 ± 9.3, p < 0.001). Quartile 1 (Geriatric Nutritional Risk Index < 91.8) showed a significantly increased risk of all-cause (Hazard Ratio: 2.56; 95% Confidence Interval: 2.13-3.09; p < 0.001) and cardiovascular mortality (Hazard Ratio: 22.29; 95% Confidence Interval: 1.71- 3.08; p < 0.001) at the first year in comparison with Quartile 4 (Geriatric Nutritional Risk Index ≥ 101.3). In areas under the receiver-operating characteristic curves of all-cause mortality, the Geriatric Nutritional Risk Index model improved predictive values, compared to the baseline model. The area with the Geriatric Nutritional Risk Index model was significantly higher than the one with a model including albumin or body mass index (p < 0.001). CONCLUSIONS: These findings suggest that a low Geriatric Nutritional Risk Index (<91.8) is associated with first-year all-cause and cardiovascular mortality in patients who start hemodialysis and may be a useful and reproducible tool for assessing prognoses in this population.

Remaining life expectancy of Korean hemodialysis patients: how much longer can they live?

Background: Hemodialysis (HD) patients have a higher mortality rate compared to the general population. However, no study has investigated life expectancy in Korean HD patients so far. Therefore, this study aimed to calculate the remaining life expectancy among Korean maintenance HD patients and compare it to those of the general population as well as HD patients from other countries. Methods: Baseline data were retrieved from HD quality assessment data from 2015. Among the patients over 30 years old who were alive at the beginning of 2016 (20,304 males and 14,264 females), a total of 22,078 (12,621 males and 9,457 females) were still alive at the end of 2021 while 12,490 (7,683 males and 4,807 females) were deceased during 6 years of follow-up. We used the life table method to calculate the expected remaining years of life in 2-year increments. Results: The remaining life expectancies for 60-year-old patients were 11.64 years for males and 14.64 years for females. The average remaining lifetimes of the HD population were only about half of the general population. Diabetic patients demonstrated shorter life expectancy compared to patients with hypertension or glomerulonephritis. The remaining life expectancy of Korean HD patients was similar to that of Japanese and was almost double that of HD patients in Western countries such as Europe and the United States. Conclusion: The HD population shows shorter life expectancy compared to the general population. Longitudinal analysis should be warranted to analyze the effect of advanced dialysis technology on improved survival rates among the HD population.

Effectiveness of regdanvimab on mortality in COVID-19 infected patients on hemodialysis.

BACKGROUND: Although several therapeutic agents have been evaluated for the treatment of coronavirus disease 2019 (COVID-19), there are lack of effective and proven treatments for end-stage renal disease (ESRD). The present study aims to evaluate the effectiveness of regdanvimab on mortality in COVID-19-infected patients on hemodialysis (HD). METHODS: We conducted an observational retrospective study in 230 COVID-19-infected patients on HD, of whom 77 (33.5%) were administered regdanvimab alone or in combination with dexamethasone or remdesivir during hospitalization (regdanvimab group) and 153 patients (66.5%) were not (no regdanvimab group). The primary outcome was in-hospital mortality. We compared mortality rates according to the use of regdanvimab and investigated the factors associated with mortality. RESULTS: Fifty-nine deaths occurred during hospitalization, 49 in the no regdanvimab group (32.0%) and 10 in the regdanvimab group (13.0%), and the mortality rate was significantly higher in the no regdanvimab group than that in the regdanvimab group (p = 0.001). Multivariate Cox regression analysis showed that malignancy (p = 0.001), SPO2 of <95% at admission (p = 0.003), and administration of antibiotics and regdanvimab (p = 0.007 and p = 0.002, respectively) were significantly associated factors with mortality. CONCLUSION: Regdanvimab administration is beneficial in improving prognosis in hospitalized COVID-19 patients on HD. Considering the vulnerability to infection and high mortality of ESRD patients, regdanvimab may be considered as a therapeutic option in COVID-19 patients on HD.

Adaptive Nutrition Intervention Stabilizes Serum Phosphorus Levels in Hemodialysis Patients: A Multicenter Decentralized Clinical Trial Using Real-World Data.

OBJECTIVE: This study aims to evaluate the effect of an adaptive nutritional and educational intervention for patients on hemodialysis (HD) in a routine care setting, using real-world data from electronic health records. METHODS: Decentralized clinical trial of seven HD facilities recruited patients who have been on HD for over 3 months (N = 153) for an 8-week adaptive intervention protocol. Patients were divided into four groups: (1) control (2) education intervention (3) meal intervention (4) education and meal interventions. Educational contents were digitally delivered via mobile phones and premade meals tailored on laboratory findings were home-delivered. Changes in serum electrolytes and malnutrition inflammation score (MIS) were analyzed. RESULTS: Meal intervention statistically significantly stabilized serum phosphorus level (ß = -0.81 mg/dL, 95% confidence interval = [-1.40, -0.22]) at week 8, with increased likelihood of being within target serum value range (odds ratio = 1.21, 95% confidence interval = [1.04, 1.40]). Meal group showed better nutritional status (MIS = 3.65) than the education group (MIS = 5.10) at week 8 (adjusted p < .05). No significant changes were observed in serum potassium level, depression, and self-efficacy. CONCLUSION: It was demonstrated that an adaptive meal intervention in a real-world care setting may benefit serum phosphorus control and nutritional status of patients on HD, without negative effect on depression levels or self-efficacy. More work is needed to develop an effective educational intervention.

Geriatric Nutritional Risk Index as a Prognostic Factor for Renal Progression in Patients with Type 2 Diabetes Mellitus.

The aim of this study was to evaluate whether the geriatric nutritional risk index (GNRI) is associated with chronic kidney disease (CKD) progression in patients with type 2 diabetes mellitus (DM). In total, 1100 patients with type 2 DM with a follow-up duration > 1 year were included in this longitudinal study. The risk of CKD progression was assessed according to GNRI quartiles. Patients in the lowest GNRI quartile exhibited a significantly lower estimated glomerular filtration rate (eGFR), compared with those in quartile four. Moreover, these patients had poorer glycemic control and lower hemoglobin levels, body mass index, and albumin levels. Additionally, they exhibited a greater annual decline in eGFR. Multivariate logistic regression analysis showed that old age (>60 years), baseline eGFR, the presence of proteinuria, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and low GNRI were significantly associated with CKD progression. GNRI may serve as a valuable predictive tool for identifying the risk of adverse renal outcomes in patients with type 2 DM. It may potentially serve as a more feasible measure for assessing the nutritional status of these patients, as well as for predicting their clinical outcomes.

Regular laboratory testing and patient survival among patients undergoing maintenance hemodialysis: a Korean nationwide cohort study.

Routine laboratory tests are regularly performed in patients undergoing maintenance hemodialysis (HD) to detect anemia, chronic kidney disease-mineral bone disorders, and cardiovascular disease. More frequent laboratory tests may be associated with better outcomes. However, there is little evidence supporting a specific monitoring interval. This study evaluated the impact of regular laboratory testing on mortality in Korean patients undergoing maintenance HD. We used HD quality assessments, and National Health Insurance Service claims data from October to December 2015. In HD quality assessment, 22 tests are recommended every 1-6 months. A total of 34,950 patients were divided into two groups based on the regularity of laboratory testing. A Cox proportional hazards model was used to assess the effects of regular laboratory tests on patient mortality during a mean follow-up duration of 53.7 months. The proportion of patients with and without regular laboratory testing was 85.6% (n = 29,914) and 14.4% (n = 5036), respectively. Patients who underwent regular laboratory testing had a longer dialysis duration, lower serum phosphorus levels and diastolic blood pressure, and higher hemoglobin and single-pool Kt/V levels than those who did not. After adjusting for demographic and clinical parameters, regular laboratory testing independently reduced mortality risk (hazard ratio, 0.90; 95% confidence interval 0.85-0.95; P < 0.001). Regular laboratory testing was associated with a decreased mortality risk among patients undergoing HD. Management of end-stage kidney disease-related complications based on laboratory tests can improve survival.

Baseline characteristics of the Korean genetic cohort of inherited cystic kidney disease.

BACKGROUND: Identifying genetic mutations in individuals with inherited cystic kidney disease is necessary for precise treatment. We aimed to elucidate the genetic characteristics of cystic kidney disease in the Korean population. METHODS: We conducted a 3-year prospective, multicenter cohort study at eight hospitals from May 2019 to May 2022. Patients with more than three renal cysts were enrolled and classified into two categories, typical autosomal dominant polycystic kidney disease (ADPKD) and atypical PKD. We identified the clinical characteristics and performed a genetic analysis using a targeted gene panel. RESULTS: A total of 725 adult patients were included in the study, of which 560 (77.2%) were diagnosed with typical ADPKD and 165 (22.8%) had atypical PKD. Among the typical ADPKD cases, the Mayo imaging classification was as follows: 1A (55, 9.9%), 1B (149, 26.6%), 1C (198, 35.8%), 1D (90, 16.3%), and 1E (61, 11.0%). The atypical PKD cases were classified as bilateral cystic with bilateral atrophic (31, 37.3%), lopsided (27, 32.5%), unilateral (nine, 10.8%), segmental (eight, 9.6%), bilateral cystic with unilateral atrophic (seven, 8.4%), and asymmetric (one, 1.2%). Pathogenic variants were found in 64.3% of the patients using the ciliopathy-related targeted gene panel. The typical ADPKD group demonstrated a higher discovery rate (62.3%) than the atypical PKD group (41.8%). CONCLUSION: We present a nationwide genetic cohort's baseline clinical and genetic characteristics for Korean cystic kidney disease.

The Geriatric Nutritional Risk Index Is an Optimal Evaluation Parameter for Predicting Mortality in Adult All Ages Hemodialysis Patients: A Korean Population-Based Study.

The Geriatric Nutritional Risk Index (GNRI) is a nutritional screening tool used for predicting mortality in patients undergoing hemodialysis (HD). This study investigated the cutoff values for the GNRI for predicting mortality in HD patients using Korean HD quality assessment data from 2015. To identify the optimal GNRI cutoff value, we used Harrell's C-index with multivariate Cox regression models. The highest value of C-index was identified as the cutoff value of GNRI for all-cause mortality in this population. In total, 34,933 patients were included; 90.8 of GNRI was the highest value of C-index, and it was used as a cutoff value to predict mortality; 3311 patients (9.5%) had GNRI values < 90.8, and there were 12,499 deaths during the study period. The mean follow-up period was 53.7 months. The crude mortality rates in patients with GNRI values < 90.8 and ≥ 90.8 were 160.4/1000 and 73.2/1000 person-years respectively. In the fully adjusted Cox model, patients with a GNRI < 90.8 had a 1.78 times higher risk of mortality than those with a GNRI ≥ 90.8. These findings suggest that the optimal GNRI cutoff value is 90.8 for predicting mortality in maintenance HD patients.

Factors Associated With the Development and Severity of Polycystic Liver in Patients With Autosomal Dominant Polycystic Kidney Disease.

BACKGROUND: Factors related to the development and severity of polycystic liver disease (PLD) have not been well established. We aimed to evaluate the genetic and epidemiologic risk factors of PLD in patients with autosomal dominant polycystic kidney disease (ADPKD). METHODS: Adult patients with inherited cystic kidney disease were enrolled from May 2019 to May 2021. Demographic, clinical, and laboratory data were collected at the initial study visit. The severity of PLD was graded based on the height-adjusted total liver volume: < 1,000 mL/m (Gr1), 1,000-1,800 mL/m (Gr2), and > 1,800 mL/m (Gr3). Targeted exome sequencing was done by a gene panel including 89 ciliopathy-related genes. We searched out the relative factors to the presence and the severity of PLD using logistic regression analysis. RESULTS: Of 602 patients with typical ADPKD, 461 (76.6%) patients had PLD. The patients with PLD showed female predominance and a higher frequency of other ADPKD-related complications. The genetic variants with truncating mutation of PKD1 (PKD1-protein-truncating [PT]) or PKD2 commonly affected the development and severity of PLD. An older age, female sex, and higher kidney volume with Mayo classification 1C-1E was significantly associated with the development of PLD, but not with the severity of PLD. On the other hand, higher body mass index, lower hemoglobin, and higher alkaline phosphatase (ALP) were the significant risk factors of severe PLD (≥ Gr2). CONCLUSION: Hepatic involvement in ADPKD could be related to kidney manifestations and genetic variants including PKD1-PT or PKD2. Monitoring hemoglobin and ALP and evaluating the genetic variants might help predict severe PLD. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0005580.

Mortality and Risk Factors in Very Elderly Patients Who Start Hemodialysis: Korean Renal Data System, 2016-2020.

INTRODUCTION: The number of elderly patients with end-stage renal disease (ESRD) is increasing worldwide. However, decision-making about elderly patients with ESRD remains complex because of the lack of studies, especially in very elderly patients (≥75 years). We examined the characteristics of very elderly patients starting hemodialysis (HD) and the associated mortality and prognostic factors. METHODS: Data were analyzed retrospectively using a nationwide cohort registry, the Korean Renal Data System. Patients who started HD between January 2016 and December 2020 were included and divided into three groups according to age at HD initiation (<65, 65-74, and ≥75 years). The primary outcome was all-cause mortality during the study period. Risk factors for mortality were analyzed using Cox proportional hazard models. RESULTS: In total, 22,024 incident patients were included with 10,006, 5,668, and 6,350 in each group (<65, 65-74, and ≥75 years, respectively). Among the very elderly group, women had a higher cumulative survival rate than men. The survival rate was lower in patients with vascular access via a catheter than in those with an arteriovenous fistula or graft. Very elderly patients with more comorbid diseases had a significantly lower survival rate than those with fewer comorbidities. In the multivariate Cox models, old age, cancer presence, catheter use, low body mass index, low Kt/V, low albumin concentration, and capable status of partial self-care were associated with high risk of mortality. CONCLUSION: Preparation of an arteriovenous fistula or graft when starting HD should be considered in very elderly patients with fewer comorbid diseases.

Dialysis specialist care and patient survival in hemodialysis facilities: a Korean nationwide cohort study.

BACKGROUND: It is important for the dialysis specialist to provide essential and safe care to hemodialysis (HD) patients. However, little is known about the actual effect of dialysis specialist care on the survival of HD patients. We therefore investigated the influence of dialysis specialist care on patient mortality in a nationwide Korean dialysis cohort. METHODS: We used an HD quality assessment and National Health Insurance Service claims data from October to December 2015. A total of 34,408 patients were divided into two groups according to the proportion of dialysis specialists in their HD unit, as follows: 0%, no dialysis specialist care group, and ≥50%, dialysis specialist care group. We analyzed the mortality risk of these groups using the Cox proportional hazards model after matching propensity scores. RESULTS: After propensity score matching, 18,344 patients were enrolled. The ratio of patients from the groups with and without dialysis specialist care was 86.7% to 13.3%. The dialysis specialist care group showed a shorter dialysis vintage, higher levels of hemoglobin, higher single-pool Kt/V values, lower levels of phosphorus, and lower systolic and diastolic blood pressures than the no dialysis specialist care group. After adjusting demographic and clinical parameters, the absence of dialysis specialist care was a significant independent risk factor for all-cause mortality (hazard ratio, 1.10; 95% confidence interval, 1.03-1.18; p = 0.004). CONCLUSION: Dialysis specialist care is an important determinant of overall patient survival among HD patients. Appropriate care given by dialysis specialists may improve clinical outcomes of patients undergoing HD.

Comparison of outcomes of chronic kidney disease based on etiology: a prospective cohort study from KNOW-CKD.

The causes of chronic kidney disease (CKD) affects its outcomes. However, the relative risks for adverse outcomes according to specific causes of CKD is not well established. In a prospective cohort study from KNOW-CKD, a cohort was analyzed using overlap propensity score weighting methods. Patients were grouped into four categories according to the cause of CKD: glomerulonephritis (GN), diabetic nephropathy (DN), hypertensive nephropathy (HTN), or polycystic kidney disease (PKD). From a total of 2070 patients, the hazard ratio of kidney failure, the composite of cardiovascular disease (CVD) and mortality, and the slope of the estimated glomerular filtration rate (eGFR) decline according to the cause of CKD were compared between causative groups in a pairwise manner. There were 565 cases of kidney failure and 259 cases of composite CVD and death over 6.0 years of follow-up. Patients with PKD had a significantly increased risk for kidney failure compared to those with GN [Hazard ratio (HR) 1.82], HTN (HR 2.23), and DN (HR 1.73). For the composite outcome of CVD and death, the DN group had increased risks compared to the GN (HR 2.07), and HTN (HR 1.73) groups but not to the PKD group. The adjusted annual eGFR change for the DN and PKD groups were - 3.07 and - 3.37 mL/min/1.73 m2 per year, respectively, and all of these values were significantly different than those of the GN and HTN groups (- 2.16 and - 1.42 mL/min/1.73 m2 per year, respectively). In summary, the risk of kidney disease progression was relatively higher in patients with PKD compared to other causes of CKD. However, the composite of CVD and death was relatively higher in patients with DN-related CKD than in those with GN- and HTN-related CKD.

Nutritional Status is Associated With Preserved Kidney Function in Patients With Autosomal Dominant Polycystic Kidney Disease.

OBJECTIVE: Malnutrition is a common complication in autosomal dominant polycystic kidney disease (ADPKD). We examined whether nutritional status is associated with the preservation of kidney function, using a cohort of typical ADPKD. METHODS: We enrolled ambulatory ADPKD patients in 9 tertiary medical centers in Korea from May 2019 to December 2021. We excluded patients who were aged less than 18 years, who had known end-stage kidney disease at the time of enrollment, who had a diagnosis of atypical ADPKD, and who were Tolvaptan users. The primary outcome was an estimated glomerular filtration rate (eGFR) decline >3 mL/min/1.73 m2, based on nutritional status assessed by subjective global assessment (SGA). We also evaluated an eGFR decline >1 mL/min/1.73 m2, an increase in urine protein-creatinine ratio (UPCR) > 0, and an increase in UPCR >0.3 as secondary outcomes, based on SGA after the 1-year follow-up. A logistic regression (LR) model was used to calculate the odds ratio (OR) for the primary outcome. Because there were differences in several baseline variables, such as Mayo classification, serum hemoglobin, serum creatinine, and UPCR between SGA groups, we matched propensity scores. RESULTS: In total, 805 patients were prospectively enrolled. Among them, 236 patients who had 1-year follow-up data and typical imaging findings were analyzed to evaluate the effect of nutritional status on kidney function. SGA was used to assess the nutritional status. The mean age was 45.0 ± 13.3 years, and 49.6% of the patients were female. The mean eGFR was 81.9 mL/min/1.73 m2. Among the 236 patients, 91 (38.6%) experienced a 1-year eGFR decline >3 mL/min/1.73 m2. When a multivariable LR was applied, SGA 3-6 was identified as a significant factor related to a 1-year eGFR decline >3 mL/min/1.73 m2 (adjusted OR = 1.22 [1.04-1.43]; P = .017). Despite matching propensity scores, the 1-year eGFR decline >3 mL/min/1.73 m2 was still higher in the SGA 3-6 group regardless of proteinuria. CONCLUSION: Good nutritional status is associated with better-preserved kidney function in non-obese typical ADPKD patients who do not take Tolvaptan.

Evaluating the Safety and effectivenesS in adult KorEaN patients treated with Tolvaptan for management of autosomal domInAnt poLycystic kidney disease (ESSENTIAL): short-term outcomes during the titration period.

BACKGROUND: Tolvaptan reduces height-adjusted total kidney volume (htTKV) and renal function decline in autosomal dominant polycystic kidney disease (ADPKD). This study was aimed at investigating the efficacy and safety of tolvaptan in Korean patients with ADPKD during the titration period. METHODS: This study is a multicenter, single-arm, open-label phase 4 study. We enrolled 108 patients with ADPKD (age, 19-50 years) with an estimated glomerular filtration rate (eGFR) of >30 mL/min/1.73 m2 and factors defined as indicative of rapid disease progression. After tolvaptan titration, we evaluated efficacy and side effects and assessed factors associated with the effects. RESULTS: After titration for 4 weeks, eGFR and htTKV decreased by 6.4 ± 7.9 mL/min/1.73 m2 and 16 ± 45 mL/m, respectively. No serious adverse drug reactions were observed during the titration period. The greatest eGFR decline was observed in the first week, with a starting tolvaptan dose of 45 mg. Multivariate linear regression for htTKV decline showed that the greater the change in urine osmolality (Uosm), the greater the decrease in htTKV (ß, 0.436; p = 0.009) in the 1D group stratified by the Mayo Clinic image classification. Higher baseline eGFR was related to a higher htTKV reduction rate in the 1E group (ß, -0.642; p = 0.009). CONCLUSION: We observed short-term effects and safety during the tolvaptan titration period. The decline of htTKV can be predicted as a short-term effect of tolvaptan by observing Uosm changes from baseline to end of titration in 1D and baseline eGFR in 1E groups.

Impact of needle type on substitution volume during online hemodiafiltration: plastic cannulae versus metal needles.

BACKGROUND: Plastic cannulae have attracted increasing interest as an alternative to traditional metal needles with the aim of reducing cannulation-related complications. We investigated whether the substitution volumes during hemodiafiltration differ using these two types of needles in dialysis patients. METHODS: An intervention study involving 26 hemodialysis patients was conducted in Korea between March and September in 2021. Patients first received online hemodiafiltration using traditional metal needles, and thereafter plastic cannulae were used in a stepwise protocol. Repeated-measures design and linear mixed-effect models were used to compare substitution volumes between the two needle types with the same inner diameter. RESULTS: The mean patient age was 62.7 years, and their mean dialysis vintage was 95.2 months. Most patients (92.3%) had an arteriovenous fistula as the vascular access. The substitution volume increased as blood flow and needle size increased for both plastic cannulae and metal needles. The substitution volume was significantly higher with 17-gauge (G) plastic cannulae than with 16-G metal needles at blood flow rates of 280, 300, and 330 mL/min. Similar results were obtained for 15-G metal needles and 16-G plastic cannulae at a blood flow rate of 330 mL/min. However, the patient ratings of pain on a visual analogue scale were higher for plastic cannulae. CONCLUSION: Higher substitution volumes were obtained at the same prescribed blood flow rate with plastic cannulae than with metal needles during online hemodiafiltration. Plastic cannulae are an option for achieving high-volume hemodiafiltration for patients with low blood flow rates.

Hemodialysis facility star rating affects mortality in chronic hemodialysis patients: a longitudinal observational cohort study.

BACKGROUND: Many countries have their own hemodialysis (HD) quality assurance programs and star rating systems for HD facilities. However, the effects of HD quality assurance programs on patient mortality are not well understood. Therefore, in the present study, the effects of the Korean HD facility star rating on patient mortality in maintenance HD patients were evaluated. METHODS: This longitudinal, observational cohort study included 35,271 patients receiving HD treatment from 741 facilities. The fivestar ratings of HD facilities were determined based on HD quality assessment data from 2015, which includes 12 quality measures in structural, procedural, and outcome domains. The patients were grouped into high (three to five stars) and low (one or two stars) groups based on HD facility star rating. Cox proportional hazards model was used to evaluate the effects of star rating on patient mortality during the mean follow-up duration of 3 years. RESULTS: The patient ratio between high and low HD facility star rating groups was 82.0% vs. 18.0%. The patients in the low star rating group showed lower single-pool Kt/V and higher calcium and phosphorus levels compared with subjects in the high star rating group. After adjusting for sociodemographic and clinical parameters, the HD facility star rating independently increased the mortality risk (hazard ratio, 1.11; 95% confidence interval, 1.04-1.18; p = 0.002). CONCLUSION: The HD facilities with low star rating showed higher patient mortality.

Practical Issues in the Management of Polycystic Kidney Disease: Blood Pressure and Water Balance.

Autosomal dominant polycystic kidney disease is the most common hereditary renal disease affecting more than 13 million people worldwide. Renal function deteriorates as the cysts in both kidneys increase in number and size, which eventually results in end-stage kidney failure. Until recently, conservative management for chronic kidney disease such as blood pressure control, low sodium diet, adequate water intake, and weight control were known for the only treatment of polycystic kidney disease. However, the introduction of disease-modifying drug has led to the new paradigm shift in the management of polycystic kidney disease. Tolvaptan, the vasopressin V2 receptor antagonist, has been introduced to the patients with large kidneys since it can inhibit cyclic adenosine monophosphate, attenuates cyst growth, and delays renal failure. This article reviews the two important practical issues in the management of polycystic kidney disease: blood pressure and water balance. Firstly, the article will review the pathogenesis of high blood pressure in polycystic kidney disease and will demonstrate the current up-to-date management plan for blood pressure control. Secondly, this article will explain the mechanism of Tolvaptan on the treatment of polycystic kidney disease and its possible adverse effect on water and sodium balance.

The change in Geriatric Nutritional Risk Index is associated with mortality in patients who start hemodialysis: Korean Renal Data Registry, 2016-2018.

Malnutrition is common in patients undergoing hemodialysis (HD) and is associated with mortality. This study aimed to investigate the association between changes in nutrition status measured by the Geriatric Nutritional Risk Index (GNRI) and all-cause mortality in patients who started HD. A nationwide retrospective cohort study was conducted based on the Korean Renal Data System database. Patients who started HD from January 2016 to December 2018, and were eligible for GNRI and GNRI trend were included. GNRI trend was a longitudinal change of GNRI, assessed by random slope in a mixed-effect model. Positive and negative random slopes in each patient were assigned to positive and negative GNRI trends. A total of 2313 patients were included and median follow-up period was 3.1 (2.6-3.7) years. GNRI values decreased over time (estimate - 1.212, 95% confidence interval (CI) - 1.116-0.692) and positive GNRI trend was associated with survival benefit (hazard ratio 0.55, 95% CI 0.36-0.84) after multivariate adjustment. These findings show that serial GNRI assessment, besides GNRI, is a useful prognostic factor for mortality in patients who start HD.

Serum creatinine to cystatin C ratio and clinical outcomes in adults with non-dialysis chronic kidney disease.

Background: Studies have suggested that the serum creatinine/cystatin C (Cr/CysC) ratio is a surrogate marker for muscle wasting is associated with adverse outcomes in several disease conditions. To clarify the utility of the Cr/CysC ratio as a prognostic marker in chronic kidney disease (CKD) we evaluated the association between the Cr/CysC ratio clinical outcomes in patients with non-dialysis CKD. Methods: This prospective observational cohort study included 1,966 participants of the KoreaN cohort study Outcomes in patients With CKD (KNOW-CKD). We evaluated associated factors with the serum Cr/CysC ratio and association between the serum Cr/CysC ratio and composite outcomes of all-cause death and cardiovascular events (CVEs). Results: The mean age was 54 ± 12 (SD) years and 61% were men. The mean serum Cr/CysC ratio was 10.97 ± 1.94 in men and 9.10 ± 1.77 in women. The Cr/CysC ratio correlated positively with urinary creatinine excretion, a marker of muscle mass. In the fully adjusted Cox proportional hazard model, the Cr/CysC ratio was associated with the occurrence of adverse outcomes through a median follow-up of 5.9 years [hazard ratio (HR) = 0.92, 95% confidence interval (CI) = 0.85-0.99 for the composite outcomes, HR = 0.87, 95% CI, 0.78 - 0.97 for all-cause death, and HR = 0.93; 95% CI, 0.84-1.04 for CVEs]. In subgroup analyses, there were interactions of the Cr/CysC ratio with age and sex for risk of the clinical outcomes, but not eGFR group. Conclusion: A higher Cr/CysC ratio is associated with a lower risk of the composite outcomes, especially all-cause mortality, even after adjusting for eGFR. These suggest that the Cr/CysC ratio is a useful prognostic marker in CKD.