Risk factors associated with mortality among patients on maintenance hemodialysis: The Thailand Renal Replacement Therapy registry.

INTRODUCTION: End-stage kidney disease (ESKD) has been increasing in prevalence across the world, including Thailand, and patients with ESKD on hemodialysis have a high mortality risk. METHODS: A retrospective cohort study was performed across 855 hemodialysis centers in the Thailand Renal Replacement Therapy registry. The database and mortality data were analyzed. RESULTS: A total of 58 952 patients were included. The survival rates at 1, 3, and 5 years were 93.5%, 69.7%, and 41.2%, respectively. On multivariate analysis, factors such as aging, permanent catheter or arteriovenous graft, twice-weekly hemodialysis, low levels of urea reduction ratio, normalized protein catabolic rate, hemoglobin, transferrin saturation, serum albumin, LDL-cholesterol, intact-parathyroid hormone, uric acid, sodium, phosphate, and bicarbonate were significantly related to death. CONCLUSION: Mortality is high in ESKD patients on hemodialysis. Age, type of vascular access, twice-weekly hemodialysis, inadequate dialysis, low protein intake, anemia, abnormal electrolytes, and bone mineral disorders are associated with all-cause mortality.

Effect of intradialytic weight resistance training exercise in sarcopenic hemodialysis patients: A randomized controlled trial.

BACKGROUND: Sarcopenia has a high prevalence in end-stage kidney disease (ESKD). However, there is limited evidence of resistance exercise in these patients. OBJECTIVE: The study investigated the effects of resistance exercise on muscle mass, strength, and physical functioning. METHOD: Fifty-three patients were randomly assigned to resistance training exercise (n = 26) and standard exercise (n = 27) groups. All of the patients were diagnosed with sarcopenia by the Asian Working Group for Sarcopenia 2019 criteria. RESULTS: After 12 weeks, an improvement in leg muscle strength was significantly greater in the resistant exercise group compared with standard exercise (12.19 vs. 2.83 kg, p < 0.001). Appendicular skeletal muscle mass had a mean difference (1.01 vs. 1.02 kg/m2 , p = 0.96). Physical performance status had a mean difference (-2.3 vs. -18 s, p = 0.42). There were no serious adverse events. CONCLUSION: Over a 12-week follow-up, resistance exercise improved muscle strength in sarcopenic ESKD patients. Muscle mass and physical performance showed no significant change, but there is still a trend demonstrating to improve.

The effect of prescribing vitamin D analogues and serum vitamin D status on both contracting COVID-19 and clinical outcomes in kidney dialysis patients'.

AIMS: Vitamin D plays a role in innate immune system activation, and deficiency increases susceptibility to respiratory infections and disease severity including COVID-19. We determined whether vitamin D levels and medications were associated with contracting COVID-19, and disease severity defined by hospitalisation and dialysis patient mortality. METHODS: We reviewed serum vitamin D levels, and prescription of cholecalciferol and alfacalcidol along with corresponding medical records of adult dialysis patients from a United Kingdom tertiary centre between March 2020 and May 2021. COVID-19 infection was determined by polymerase chain reaction (PCR) results. RESULTS: 362 (35%) of 1035 dialysis patients tested PCR positive for COVID-19. COVID-19 positive patients had lower native median vitamin D (65 (39-95) versus 74 (40.5-101) nmol/L (p = .009) despite greater prescription of cholecalciferol (median 20 000 (20000-20 000) versus 20 000 (0-20 000) IU/week), p < .001, but lower prescription of alfacalcidol 0 (0-3.0) versus 2.0 (0.-5.0) ug/week, p < .001. On multivariate logistic regression COVID-19 infection was associated with haemodialysis versus peritoneal dialysis (p < .001), cholecalciferol dose (p < .001) and negatively with alfacalcidol (p < .001). However, serum vitamin D levels and alfacalcidol dosages were not significantly different for those requiring hospitalisation compared to those managed at home, although those who died were prescribed lower alfacalcidol dosages. CONCLUSION: Dialysis patients who contracted COVID-19 had lower levels of native vitamin D prior to COVID-19 and were prescribed lower dosages of alfacalcidol. However, there was no association between vitamin D status and disease severity. This retrospective observational analysis supports a potential role for vitamin D and susceptibility to COVID-19 infection in dialysis patients.

Changes in extracellular water and left ventricular mass in peritoneal dialysis patients.

BACKGROUND: Increasing number of peritoneal dialysis (PD) patients are reported to have increased left ventricular hypertrophy (LVH), a major risk factor for cardiovascular mortality. We wished to determine which factors were most associated with changes in left ventricular mass index (LVMI). METHODS: We reviewed patient and treatment factors in prevalent PD patients with repeat echocardiograms 18 to 24 months apart, with corresponding bioimpedance measurements of extracellular water (ECW) and serum N-terminal pro-brain natriuretic peptide (NT-proBNP). RESULTS: We studied 60 patients (34 males, 35 with diabetes) who were treated with PD for a median of 14 months (2.5-26.3 months). All but one had LVH; on repeat echocardiography, there was no overall change in LVMI (106 [84-127] g/m2 vs. 108 [91-122] g/m2) despite a loss of residual renal function. Left ventricular mass increased in 34 (56.7%), and the percent change in LVMI was associated with percent change in NT-proBNP (r = 0.51, p = 0.017) and ECW/height (r = 0.32, p = 0.029), but not with ECW/total body water or changes in systolic or mean arterial pressure, urine output, 24-hour PD ultrafiltration, or net sodium balance. Only ECW/height remained independently associated with the percent change in LVMI in a multivariable model (odds ratio, 1.25; 95% confidence interval, 1.08-1.36; p = 0.007). CONCLUSION: In this observational longitudinal report, a reduction in ECW/height was associated with regression of LVMI, whereas an increased ECW/height was associated with increased LVMI. As there was no corresponding association with systolic or mean arterial pressure, then volume expansion would appear to be a more significant factor in determining LVH than blood pressure.

Peritoneal sodium removal compared to glucose absorption in peritoneal dialysis patients treated by continuous ambulatory peritoneal dialysis and automated peritoneal dialysis with and without a daytime exchange.

Sodium removal in peritoneal dialysis (PD) depends on convective clearance, typically generated by a glucose gradient, but this can result in glucose absorption. We wished to determine which factors determine peritoneal sodium losses to glucose absorption (PD Na/Gluc). Peritoneal sodium losses and glucose absorption were calculated from measured 24-h collections of PD effluent, in patients attending for assessment of peritoneal membrane function. Five hundred and fifty eight patients; 317 (56.8%) males, mean age 56.1 ± 16.0 years, were studied, 281 treated by automated peritoneal dialysis (APD) with a daytime exchange (50.4%); 179 (32.1%) by APD and 98 (17.6%) by continuous ambulatory peritoneal dialysis (CAPD). All patients used glucose containing dialysates, with 352 (63.1%) using icodextrin and 210 (37.6%) hypertonic (22.7 g/L glucose) dialysates. The ratio of PD Na/Gluc was 0.14 (0.02-0.29). Patients using icodextrin had a higher ratio (0.16 (0.03-0.32) versus 0.11 (-0.02-0.26), P < .001), as did those using 22.7 g/L glucose versus 13.6 g/L (0.16 (0.06-0.32) versus 0.13 (-0.01-0.19), P < .01), and CAPD versus APD (0.18 (0.05-0.36) versus 0.11 (0.0-0.27), P < .05), respectively. A multivariable model showed that 24-h ultrafiltration (odds ratio [OR] 7.6 (95% confidence interval [3.9-14.8]), P < .001 was associated with increased PD Na/Gluc, whereas APD (OR 0.19 (0.06-0.62), P < .01 and increased extracellular water to total body water (OR 0.001 [0-0.08], P = .03) were associated with lower ratios. Twenty four-hour peritoneal ultrafiltration was strongly associated with PD Na/Gluc, whereas patients treated with APD cyclers without a daytime icodextrin exchange and those with an increased extracellular water to total body water had lower peritoneal sodium losses but with greater peritoneal glucose absorption.

Does Pulse Wave Velocity Increase Over Time in Hemodialysis Patients?

OBJECTIVES: Arterial stiffness, measured by pulse wave velocity (PWV), is reported to be increased in hemodialysis (HD) patients and increases cardiovascular mortality. Previous studies have reported an association between extracellular water (ECW) and PWV. We wished to review whether PWV increases over time and whether this is associated with ECW. METHODS: We reviewed repeat aortic PWV measurements using an oscillograph method along with corresponding ECW measured by multifrequency bioimpedance in HD patients a minimum of 5 years apart. RESULTS: Twenty-four patients (16 [66.7%] male and 11 [45.8%] diabetic, mean age 61.7 ± 15.2 years) had PWV and ECW initially measured after 46 (26-124) months of HD and then after 112 (97-202) months. Overall, there was no change in PWV or ECW (9.4 ± 2.2 vs. 8.1 ± 2.5 cm/s; 14.7 ± 2.5 vs. 15.2 ± 2.9 L, respectively), whereas the ECW/total body water ratio increased (0.399 ± 0.015 vs. 0.408 ± 0.021, p < 0.05). We found no association between changes in PWV and ECW (r = -0.05, p = 0.84), whereas there was an association with the change in peri-dialytic systolic blood pressure (SBP) (r = 0.59, p = 0.007). CONCLUSION: In our small observational study, there was no overall change in PWV, after 5 years of HD, with PWV increasing in 50% and falling in 50%. Changes in PWV were not associated with changes in ECW but were associated with changes in peri-dialytic SBP. Our study demonstrates that PWV does not increase in all HD patients with time, and interventional studies are required to determine whether targeted blood pressure control reduces PWV in HD patients.

Comparison of skin autofluorescence, a marker of tissue advanced glycation end-products in the fistula and non-fistula arms of patients treated by hemodialysis.

Advanced glycosylation end-products (AGEs) are reported to be a risk factor for cardiovascular mortality in hemodialysis (HD) patients. As serum AGEs can change with dialysis, measurement of AGEs deposited in the skin by autofluorescence (SAF) is now a recognized method of measuring AGEs. An arteriovenous fistula (AVF) is the preferred way to access blood in HD patients, and as the creation of an AVF changes blood flow distribution in the arm, we wished to determine whether this affected SAF deposition in the skin. SAF was measured using the AGE reader, which directs ultraviolet light at an intensity range of 300-420 nm (peak 370 nm) in the arms of HD patients dialyzing with an AVF. We measured SAF in 267 patients, 60.3% male, 46.1% diabetic, median duration of dialysis 34.7 (15.1-64.2) months with AVF. The median SAF was lower in the AVF arm (median 3.4 (2.9-4.2) vs. 3.7 (3.2-4.5) AU, P < .001), and for the 160 patients with an upper arm AVF (3.5 (2.9-4.3) vs. 3.8 (3.2-4.5) AU, P < .001), but not for the 107 patients dialyzing with a forearm AVF ((3.4 (2.8-4.2) vs. 3.6 (3.0-4.5) AU, P = .085). Blood flow was greater for upper arm AVF compared to forearm AVFs (1190 (770-1960) vs. (930 (653-1250) mL/min, P = .007), but there was no association between blood flow and SAF (P > .05). AVF alters blood flow in the arm, and we found that SAF measurements were lower in the arm with AVF. We suggest that SAF measurements are made in the non-AVF arm.

Differences in predicting glucose absorption from peritoneal dialysate compared to measured absorption in peritoneal dialysis patients treated by continuous ambulatory peritoneal dialysis and ambulatory peritoneal dialysis cyclers.

BACKGROUND AND AIMS: Glucose-containing peritoneal dialysates are used to generate an osmotic gradient for the convective removal of water and sodium. Predictive equations were developed to estimate glucose absorption without having to formally measure changes in dialysate glucose. In view of the changes in peritoneal dialysis prescriptions over time, we compared predicted and measured glucose absorption. SUBJECTS/METHODS: We measured peritoneal glucose losses when peritoneal dialysis patients attended their first assessment of peritoneal membrane function, and compared this to glucose exposure and Kidney Disease Outcomes Quality Initiative, Grodstein and Bodnar predictive equations. RESULTS: We studied 689 patients; 329 (56.9%) males, 53 (37.1%) diabetics, with mean age 57.1 ± 16.2 years, with 186 treated by automated peritoneal dialysis cyclers and 377 by automated peritoneal dialysis with a daytime icodextrin exchange and 126 by continuous ambulatory peritoneal dialysis. Using Bland -Altman analysis, all equations demonstrated systematic bias overestimating glucose absorption with increasing glucose absorption. For continuous ambulatory peritoneal dialysis patients, the Kidney Disease Outcomes Quality Initiative formula underestimated glucose absorption (bias 188 (-39 to 437) mmol/day, as did Grodstein (bias 37.9 (-105 to 29) mmol/day, whereas mean bias for Bodnar was -29 (-130 to 180)). There was systematic overestimation for all equations for both automated peritoneal dialysis with and without a daytime exchange, with increasing bias with greater glucose absorption. CONCLUSION: Although formally measuring peritoneal glucose absorption is time consuming and requires patient co-operation, current predictive equations overestimate glucose absorption and do not provide accurate estimations of glucose absorption particularly for automated peritoneal dialysis patients.

Novel Tubular Biomarkers Predict Renal Progression in Type 2 Diabetes Mellitus: A Prospective Cohort Study.

Background. Tubulointerstitial injury is both a key feature of diabetic nephropathy and an important predictor of renal dysfunction. Novel tubular biomarkers related to renal injury in diabetic nephropathy could improve risk stratification and prediction. Methods. A total of 303 type 2 diabetic patients were followed up. The baseline urine values of cystatin-C to creatinine ratio (UCCR), angiotensinogen to creatinine ratio (UANG), NGAL to creatinine ratio (UNGAL), and KIM-1 to creatinine ratio (UKIM-1) were measured. The primary outcome was a decline in estimated GFR of ≥25% yearly from baseline. Results. Urine tubular biomarkers of UCCR, UANG, UNGAL, and UKIM-1 were significantly higher according to the degree of albuminuria and all were significantly higher among patients with rapid decline in estimated GFR of ≥25% yearly from baseline. All biomarkers predicted primary outcomes with ROC for UCCR of 0.72; 95% CI 0.64-0.79, for UANG of 0.71; 95% CI 0.63-0.79, for UNGAL of 0.64; 95% CI 0.56-0.72, and for UKIM-1 of 0.71; 95% CI 0.63-0.79. Using multivariate Cox regression analysis, the number of patients with rapid renal progression was higher among those in the upper quartiles of all biomarkers than in those in the lower quartiles. Conclusions. Type 2 diabetic patients with high levels of urine tubular biomarkers had a more rapid decline in renal function.

Performance of the estimated glomerular filtration rate creatinine and cystatin C based equations in Thai patients with chronic glomerulonephritis.

BACKGROUND: Glomerular filtration rate (GFR) is considered the indicator of overall kidney function, and therefore, its assessment has become an important clinical tool in the daily care of chronic glomerulonephritis (CGN) patients. Currently, practical guidelines recommend using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations to assess GFR in CKD patients. METHODS: A cross-sectional study was performed in CGN patients. Standard GFR was measured using 24-hour urine creatinine clearance. GFR was estimated using the Cockcroft-Gault, Modification of Diet in Renal Disease, CKD-EPI equation based creatinine, cystatin C, and combined creatinine and cystatin C. The performance of GFR estimation equations were examined using bias, precision and accuracy and agreement between standard GFR and estimated GFR by calculating Cohen's k. RESULTS: A total of 125 patients (74 male, 59.2%) with mean age 56.1±18.1 years were included. Mean standard GFR was 51.6±32.2 mL/min per 1.73 m(2). A significant correlation was found between standard GFR and all estimated GFRs (r=0.573 to 0.660, P<0.001). CKD-EPI-creatinine-cystatin C equation had the smallest absolute bias and the significantly highest accuracy, although it was not significantly different from CKD-EPI-cystatin C equation (P=0.523). CKD-EPI-creatinine-cystatin C equation had the highest accuracy to classify CKD staging (Cohen's k=0.345), but it underestimated GFR in 32% and overestimated GFR in 18% of the CGN patients. CONCLUSION: CKD-EPI-creatinine-cystatin C equation estimated GFR with little bias, and the highest accuracy among CGN patients. This equation gave a better estimate of GFR than the equation based on serum creatinine.