Evaluation of the effect of clinical characteristics and intensive care treatment methods on the mortality of covid-19 patients aged 80 years and older.

BACKGROUND: Older adults have an increased risk of mortality from Coronavirus disease 2019 (Covid-19). Despite the high number of publications on the topic of Covid-19 pandemic, few studies have focused on the intensive care treatments of Covid-19 patients aged 80 years and older. The goal of our study is to investigate the effect of the intensive care treatments on the mortality of Covid-19 patients aged 80 years and older based on their clinical features, laboratory findings and the intensive care treatments methods. METHODS: The data of 174 patients aged 80 years and older treated from Covid-19 in intensive care unit were assessed retrospectively. The patients were divided into two groups as survivor and non-survivor. The effects of age, gender, length of stay, comorbid diseases, laboratory values, thoracic computed tomography findings, having invasive mechanical ventilation (IMV), high flow nasal cannula (HFNC) and/or non-invasive mechanical ventilation (NIMV), hemodiafiltration (HDF), anti-cytokines and plasma therapy on mortality have been investigated. RESULTS: The mean age and mean values of CRP, PCT, Ferritin, LDH were statistically significantly high in the non-survivor group. The mortality rate of the patients who had IMV was also statistically significantly higher compared to patients who had HFNC and/or NIMV. Albumin level and the rate of treatment with HFNC and/or NIMV were statistically significantly low in non-survivor group compared to the Survivor group. CONCLUSION: ICU treatments may be beneficial for the Covid-19 patients aged 80 years and older. Increased age, high levels of CRP, PCT, ferritin, and having IMV are detected as poor outcome markers.

Determining factors for hemodiafiltration to equal or exceed the performance of expanded hemodialysis.

The aim of the study was to compare expanded hemodialysis (HDx) with hemodiafiltration (HDF) at different infusion flows to identify the main determinants, namely blood flow (Qb), replacement volume, infusion flow (Qi), ultrafiltration flow (Quf ), filtration fraction (FF), and the point at which the effectiveness of HDF equals or exceeds that of HDx. We conducted a prospective, single-center study in 12 patients. Each patient underwent 12 dialysis sessions: six sessions with Qb 350 and six with Qb 400 mL/min; with each Qb, one session was with HDx and five sessions were with FX80 (one in HD, and four with Qi 50, 75, 90/100 mL/min or autosubstitution in postdilution HDF). The reduction ratios (RR) of urea, creatinine, ß2 -microglobulin, myoglobin, prolactin, α1 -microglobulin, α1 -acid glycoprotein, and albumin were compared intraindividually and the global removal score (GRS) was calculated. The mean replacement volume with Qb 350 mL/min was 13.77 ± 0.92 L with Qi 50 mL/min, 20.75 ± 1.17 L with Qi 75, 23.83 ± 1.92 L with Qi 90, and 27.51 ± 2.77 L with autosubstitution. Similar results were obtained with Qb 400 mL/min, and the results were only slightly higher with Qi 100 mL/min or in autosubstitution. The GRS was positively correlated with replacement volume with Qb 350 (R2  = 0.583) and with Qb 400 (R2  = 0.584); with Quf with Qb 350 (R2  = 0.556) and with Qb 400 (R2  = 0.604); and also with FF with Qb 350 (R2  = 0.556) and with Qb 400 mL/min (R2  = 0.603). The minimum convective volume in HDF from which it is possible to overcome the efficacy of HDx was 19.2 L with Qb 350 and 17.6 L with Qb 400 mL/min. The cut-off point of Quf at which HDF exceeded the effectiveness of HDx was 80.6 mL/min with Qb 350 and 74.1 mL/min with Qb 400 mL/min. The cut-off point at which FF in HDF exceeded the effectiveness of the HDx was 23.0% with Qb 350 and 18.6% with Qb 400 mL/min. In conclusion, this study confirms the superiority of postdilution HDF over HDx when replacement volume, convective volume, Quf , or FF exceeds certain values. Increasing the Qb in postdilution HDF manages to increase the convective dose and more easily overcome the HDx.

Global prevalent use, trends and practices in haemodiafiltration.

Online haemodiafiltration (HDF) represents today the most advanced and innovative form of renal replacement therapy (RRT). Recent controlled trials tend to prove its superiority over conventional haemodialysis on hard clinical end points provided that the right convective dose was delivered. In this article we report on present prevalent use and epidemiologic trends of HDF worldwide as well as on practice patterns in HDF prescription. In addition we analyze factors that may affect HDF clinical acceptance and more widely its implementation. National and international renal registries provide valuable demographic and epidemiologic information on end stage kidney disease patients on RRT. However, the updating and maintenance of such information system is particularly challenging at a country level and even more so on an international basis. Lag time, incompleteness and/or imprecision of data collection may further hamper precision and validity of data reporting. Fresenius Medical Care (FMC), as a large dialysis care provider operating worldwide, maintains an annually updated database addressing international end stage kidney disease data. Over the last decade, FMC has produced series of precise and reliable reports analyzing RRT trends and practices worldwide. The present overview and analysis is based on our consolidated data from market survey as well as national database registries and databases of recent studies. Online HDF acceptance is growing fast in the two leading regions having approved the method, i.e. Europe and Asia Pacific, with a patient average growth rate of 12 to 24%, being far above the total patient HD growth rate of 6.6%. Today online HDF represents a new paradigm shift in RRT with promising clinical results. Further initiatives (e.g., Kidney Health Initiative, NICE) might provide further push for promoting HDF as a new standard of care in end stage kidney disease patients on a global scale.

Association of Net Ultrafiltration Rate With Mortality Among Critically Ill Adults With Acute Kidney Injury Receiving Continuous Venovenous Hemodiafiltration: A Secondary Analysis of the Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy Trial.

Importance: Net ultrafiltration (NUF) is frequently used to treat fluid overload among critically ill patients, but whether the rate of NUF affects outcomes is unclear. Objective: To examine the association of NUF with survival among critically ill patients with acute kidney injury being treated with continuous venovenous hemodiafiltration. Design, Setting, and Participants: The Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy trial was conducted between December 30, 2005, and November 28, 2008, at 35 intensive care units in Australia and New Zealand among critically ill adults with acute kidney injury who were being treated with continuous venovenous hemodiafiltration. This secondary analysis began in May 2018 and concluded in January 2019. Exposures: Net ultrafiltration rate, defined as the volume of fluid removed per hour adjusted for patient body weight. Main Outcomes and Measures: Risk-adjusted 90-day survival. Results: Of 1434 patients, the median (interquartile range) age was 67.3 (56.9-76.3) years; 924 participants (64.4%) were male; median (interquartile range) Acute Physiology and Chronic Health Evaluation III score was 100 (84-118); and 634 patients (44.2%) died. Using tertiles, 3 groups were defined: high, NUF rate greater than 1.75 mL/kg/h; middle, NUF rate from 1.01 to 1.75 mL/kg/h; and low, NUF rate less than 1.01 mL/kg/h. The high-tertile group compared with the low-tertile group was not associated with death from day 0 to 6. However, death occurred in 51 patients (14.7%) in the high-tertile group vs 30 patients (8.6%) in the low-tertile group from day 7 to 12 (adjusted hazard ratio [aHR], 1.51; 95% CI, 1.13-2.02); 45 patients (15.3%) in the high-tertile group vs 25 patients (7.9%) in the low-tertile group from day 13 to 26 (aHR, 1.52; 95% CI, 1.11-2.07); and 48 patients (19.2%) in the high-tertile group vs 29 patients (9.9%) in the low-tertile group from day 27 to 90 (aHR, 1.66; 95% CI, 1.16-2.39). Every 0.5-mL/kg/h increase in NUF rate was associated with increased mortality (3-6 days: aHR, 1.05; 95% CI, 1.00-1.11; 7-12 days: aHR, 1.08; 95% CI, 1.02-1.15; 13-26 days: aHR, 1.11; 95% CI, 1.04-1.18; 27-90 days: aHR, 1.13; 95% CI, 1.05-1.22). Using longitudinal analyses, increase in NUF rate was associated with lower survival (ß = .056; P < .001). Hypophosphatemia was more frequent among patients in the high-tertile group compared with patients in the middle-tertile group and patients in the low-tertile group (high: 308 of 477 patients at risk [64.6%]; middle: 293 of 472 patients at risk [62.1%]; low: 247 of 466 patients at risk [53.0%]; P < .001). Cardiac arrhythmias requiring treatment occurred among all groups: high, 176 patients (36.8%); middle: 175 patients (36.5%); and low: 147 patients (30.8%) (P = .08). Conclusions and Relevance: Among critically ill patients, NUF rates greater than 1.75 mL/kg/h compared with NUF rates less than 1.01 mL/kg/h were associated with lower survival. Residual confounding may be present from unmeasured risk factors, and randomized clinical trials are required to confirm these findings. Trial Registration: ClinicalTrials.gov identifier: NCT00221013.

Clinical outcomes of hemodialysis patients in a public-private partnership care framework in Italy: a retrospective cohort study.

BACKGROUND: Innovative care models such as public-private partnerships (PPPs) may help meet the challenge of providing cost-effective high-quality care for the steadily growing and complex chronic kidney disease population since they combine the expertise and efficiency of a specialized dialysis provider with the population care approach of a public entity. We report the five-years main clinical outcomes of a population of patients treated on hemodialysis within a PPP-care model in Italy. METHODS: This descriptive retrospective cohort study consisted of all consecutive hemodialysis patients treated in the NephroCare-operated Nephrology and Dialysis unit of the Seriate Hospital in 2012-2016, which exercises a PPP-care model. Clinical and treatment information was obtained from the European Clinical Database. Hospitalization outcomes and cumulative all-cause mortality incidences that accounted for competing risks were calculated. RESULTS: We included 401 hemodialysis patients (197 prevalent and 204 incident patients) in our study. The mean cohort age and age-adjusted Charlson Comorbidity Index were 67.0 years and 6.7, respectively. Patients were treated with online high-volume hemodiafiltration or high-flux hemodialysis. Parameters of treatment efficiency were above the recommended targets throughout the study period. Patients in the PPP experienced benefits in terms of hospitalization (average number of hospital admissions/patient-year: 0.79 and 1.13 for prevalent and incident patients, respectively; average length of hospitalization: 8.9 days for both groups) and had low cumulative all-cause mortality rates (12 months: 10.6 and 7.8%, 5 years: 42.0 and 35.9%, for prevalent and incident patients, respectively). CONCLUSIONS: Results of our descriptive study suggest that hemodialysis patients treated within a PPP-care model framework received care complying with recommended treatment targets and may benefit in terms of hospitalization and mortality outcomes.

Outcomes and practice patterns with hemodiafiltration in Shanghai: a longitudinal cohort study.

BACKGROUND: Globally, there is increased clinical interest and uptake of hemodiafiltration (HDF) for increased removal of uremic toxins. To date, there has been no epidemiological analysis of HDF in China. We present HDF practice patterns and associated mortality risk in Shanghai. METHODS: This is an observational, prospectively collected, retrospective analysis of 9351 Chinese patients initiating hemodialysis in Shanghai from 2007 to 2014. The primary exposure was hemodialysis sub-modality at inception, classified into hemodiafiltration (HDF) and hemodialysis (HD), with adjustment for concommitant hemoperfusion. The primary outcome was patient mortality. We used Cox proportional hazards regression and Fine and Gray's proportional subhazards regression, with multiple imputation of missing co-variates by the chained equation method, adjusting for demographic and clinical variables. RESULTS: Overall, patients in the cohort were younger, with a more males, and with a lower body mass index when compared to corresponding non-Asian cohorts. Mortality rate was low although it doubled over the period of observation. HDF utilization increased from 7% of patients in 2007 to 42% of patients in 2014. The majority of patients received HDF once a week. The adjusted hazard ratio of death (95% confidence intervals) for HDF versus HD was 0.85 (0.71-1.03), and corresponding sub-hazard ratio 0.86 (0.71-1.03). There was strong effect modification by age. In those aged 40-60 years, the hazard ratio (95% confidence intervals) was 0.65 (0.45-0.94), and sub-hazard ratio also 0.65 (0.45-0.95). CONCLUSIONS: Our study has certain limitations resulting from the limited number of co-variates available for modelling, missing data for some co-variates, and the lack of verification of data against source documentation. Notwithstanding, there is evidence of clinical benefit from HDF in China, and potential to improve patient outcomes through the greater removal of middle and larger uremic solutes.

Intraocular Pressure Changes During Hemodialysis or Hemodiafiltration in End-Stage Renal Disease Patients.

The aim of this study was to evaluate the intraocular pressure during hemodialysis and hemodiafiltration. Fifteen patients were enrolled (seven treated with hemodialysis therapy and eight with hemodiafiltration). The intraocular pressure was measured before and after dialysis and every 30 min during dialysis. Before dialysis, both groups had similar dialysis prescription, blood pressure, and biochemical parameters. At the end of dialysis, potassium, and osmolarity decreased in both groups, while systolic blood pressure and sodium decreased in the hemodialysis group, and glucose decreased in the hemodiafiltration group. Mean intraocular pressure was similar between groups at all measured times and had no significant changes during hemodialysis. During minute 120 of hemodiafiltration, mean intraocular pressure in the left eye decreased significantly compared to minute 90. This suggests a high intra-individual variability of intraocular pressure during both types of dialysis, which could be relevant particularly among those with the risk of glaucoma.

Comparison of hemodialysis with medium cut-off dialyzer and on-line hemodiafiltration on the removal of small and middle-sized molecules
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BACKGROUND: Recent data suggest that the use of medium cut-off (MCO) dialyzers in hemodialysis (HD) promotes greater clearance and reduction ratio (RR) for myoglobin and other large-sized molecules than on-line hemodiafiltration (ol-HDF), but its effects on ß2-microglobulin are not clear. We compared RR and clearances of small and middle-sized molecules between high-flux ol-HDF and MCO (Theranova) dialyzer in HD (MCO-HD) as well as nutritional parameters. MATERIALS AND METHODS: We retrospectively analyzed 10 patients treated first with ol-HDF who were thereafter switched to MCO-HD over a 1-year period. Three dialysis sessions in each 6-month period were examined. We calculated RR and clearance of small and middle-sized molecules. RESULTS: There was no significant difference between ol-HDF and MCO-HD for median serum albumin and prealbumin level, mean KT/V, mean urea and creatinine RR, mean ß2-microglobulin (81 ± 5 vs. 81 ± 6%, p = 0.72) and myoglobin (60 ± 9% vs. 61 ± 7%, p = 0.59), RR or clearances. CONCLUSION: The use of MCO (Theranova) dialyzer in HD produces similar removal of urea, creatinine, ß2-microglobulin and myoglobin as does ol-HDF, with good tolerance profile and without modification of nutritional status.
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Peritoneal Water Transport Characteristics of Diabetic Patients Undergoing Peritoneal Dialysis: A Longitudinal Study.

BACKGROUND: Volume overload is frequent in diabetics undergoing peritoneal dialysis (PD), and may play a significant role in the excess mortality observed in these patients. The characteristics of peritoneal water transport in this population have not been studied sufficiently. METHOD: Following a prospective, single-center design we made cross-sectional and longitudinal comparisons of peritoneal water transport in 2 relatively large samples of diabetic and nondiabetic PD patients. We used 3.86/4.25% glucose-based peritoneal equilibration tests (PET) with complete drainage at 60 min, for these purposes. MAIN RESULTS: We scrutinized 59 diabetic and 120 nondiabetic PD patients. Both samples showed relatively similar characteristics, although diabetics were significantly more overhydrated than nondiabetics. The baseline PET disclosed lower ultrafiltration (mean 439 mL diabetics vs. 532 mL nondiabetics, p = 0.033) and sodium removal (41 vs. 53 mM, p = 0.014) rates in diabetics. One hundred and nine patients (36 diabetics) underwent a second PET after 12 months, and 45 (14 diabetics) underwent a third one after 24 months. Longitudinal analyses disclosed an essential stability of water transport in both groups, although nondiabetic patients showed a trend where an increase in free water transport (p = 0.033) was observed, which was not the case in diabetics. CONCLUSIONS: Diabetic patients undergoing PD present lower capacities of ultrafiltration and sodium removal than their nondiabetic counterparts. Longitudinal analyses disclose an essential stability of water transport capacities, both in diabetics and nondiabetics. The clinical significance of these differences deserves further analysis.

Modulation of Myostatin/Hepatocyte Growth Factor Balance by Different Hemodialysis Modalities.

Background. In this study we investigated the relevance of myostatin and Hepatocyte Growth Factor (HGF) in patients undergoing hemodialysis HD and the influence of different HD modalities on their levels. Methods. We performed a prospective crossover study in which HD patients were randomized to undergo 3-month treatment periods with bicarbonate hemodialysis (BHD) followed by online hemodiafiltration (HDF). Clinical data, laboratory parameters, and myostatin and HGF serum levels were collected and compared. Results. Ten patients and six controls (C) were evaluated. In any experimental condition myostatin and HGF levels were higher in HD than in C. At enrollment and after BHD there were not significant correlations, whereas at the end of the HDF treatment period myostatin and HGF were inversely correlated (r -0.65, p < 0.05), myostatin serum levels inversely correlated with transferrin (r -0.73, p < 0.05), and HGF levels that resulted positively correlated with BMI (r 0.67, p < 0.05). Moving from BHD to HDF, clinical and laboratory parameters were unchanged, as well as serum HGF, whereas myostatin levels significantly decreased (6.3 ± 4.1 versus 4.3 ± 3.1 ng/ml, p < 0.05). Conclusions. Modulation of myostatin levels and myostatin/HGF balance by the use of different HD modalities might represent a novel approach to the prevention and treatment of HD-related muscle wasting syndrome.

Current practice in continuous renal replacement therapy: An epidemiological multicenter study. / Manejo actual de las terapias continuas de reemplazo renal: Estudio epidemiológico multicéntrico.

OBJECTIVE: The aim of the study is to ascertain the most relevant aspects of the current management of renal replacement therapy (RRT) in critically ill patients, and to analyze renal function recovery and mortality in patients undergoing RRT. METHODS: A non-interventional three-month observational study was made in 2012, with a follow-up period of 90 days, in 21 centers in Catalonia (Spain). Demographic information, severity scores and clinical data were obtained, as well as RRT parameters. INCLUSION CRITERIA: patients aged ≥ 16 years admitted to Intensive Care Units (ICUs) and subjected to RRT. RESULTS: A total of 261 critically ill patients were recruited, of which 35% had renal dysfunction prior to admission. The main reason for starting RRT was oliguria; the most widely used RRT modality was hemodiafiltration; and the median prescribed dose at baseline was 35mL/kg/h. The median time of RRT onset from ICU admission was one day. The mortality rate at 30 and 90 days was 46% and 54%, respectively, and was associated to greater severity scores and a later onset of RRT. At discharge, 85% of the survivors had recovered renal function. CONCLUSIONS: Current practice in RRT in Catalonia abides with the current clinical practice guidelines. Mortality related to RRT is associated to later onset of such therapy. The renal function recovery rate at hospital discharge was 85% among the patients subjected to RRT.

Peritoneal Dialysis Registry With 2013 Survey Report.

Since 2009, the peritoneal dialysis (PD) registry has been carried out as part of the annual nationwide survey conducted by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy with the cooperation of the Japanese Society for Peritoneal Dialysis. In this study, the current status of PD patients is reported on the basis of the results of the survey conducted at the end of 2013. The subjects were PD patients who lived in Japan and participated in the 2013 survey. Descriptive analysis was performed for various items including the current status of the combined use of PD and another dialysis method such as hemodialysis (HD) or hemodiafiltration (HDF), the method of exchanging dialysate, the use of an automated peritoneal dialysis (APD) machine, and the incidences of peritonitis and catheter exit-site infection. From the results of the facility survey in 2013, the number of PD patients was 9392, a decrease of 122 from that in 2012. Among the entire dialysis patient population, 3.0% were PD patients, a decrease of 0.1%. Among the studied patients, 292 had a peritoneal catheter and underwent peritoneal lavage, 174 were started on PD in 2013 but introduced to other blood purification methods in 2013, and 1920 underwent both PD and another dialysis method such as HD or HDF. The percentage of patients who underwent PD and another dialysis method increased with the number of years on PD: <1 year, 3.5%; 1 to < 2 years, 8.4%; 2 to < 4 years, 15.3%; 4 to < 6 years, 27.1%; 6 to < 8 years, 39.3%; 8 to < 10 years, 47.1%; and ≥ 10 years, 57.5%. The percentage of PD patients for whom the dialysate was completely manually exchanged was 31.6%, whereas the percentages of PD patients who used a bag-exchange device based on ultraviolet-light irradiation and that based on thermal sterile joint systems were 52.1 and 14.9%, respectively. The mean incidence of peritonitis was 0.22 per patient per year (once per 54.5 patients per month). The mean incidence of catheter exit-site infection was 0.34 per patient per year (once per 35.3 patients per month).

Toxinas unidas a proteínas: valor añadido en su eliminación con altos volúmenes convectivos / Protein-bound toxins: added value in their removal with high convective volumes

La enfermedad renal crónica tiene mayor riesgo de eventos cardiovasculares. En los últimos años, han ido adquiriendo mayor importancia las toxinas unidas a proteínas, que han sido asociadas a mayor morbimortalidad y que se caracterizan por la dificultad para su depuración en diálisis. El objetivo de este estudio es valorar la influencia de altos volúmenes convectivos en HDF-OL posdilucional sobre la eliminación de medianas moléculas, pequeñas moléculas y moléculas unidas a proteínas. Material y métodos: Se realizaron 40 sesiones de HDF-OL posdilucional en 13 pacientes y se midió el porcentaje de reducción de toxinas de distinto peso molecular y entre ellas, moléculas unidas a proteínas como el p-cresyl sulfato, indoxyl sulfato y homocisteína. Resultados: El volumen convectivo total fue de 28,3(5,1) litros con un rango entre 16,3 y 38,0 litros. La reducción media de moléculas unidas a proteínas fue de 44,4 (15,7) % para el p-cresyl sulfato, de 48,7(14,1) % para el indoxyl sulfato y de 58,6(8,8) % para la homocisteína. Además, se encontró una relación directa y estadísticamente significativa entre el porcentaje de reducción de las tres moléculas con el volumen de sustitución y con el Kt/V. Conclusión: Altos volúmenes convectivos totales en HDF-OL en posdilución se asocian a una mayor eliminación de toxinas urémicas unidas a proteínas (AU)

Chronic kidney disease is associated with an increased risk of cardiovascular events. In recent years, protein-bound toxins have become more important due to their association with increased morbidity and mortality, characterised by inadequate clearance during dialysis. The purpose of this study is to assess the influence of high convective volumes on postdilution online haemodiafiltration (OL-HDF) on the removal of medium-sized molecules, small molecules and protein-bound molecules. Material and methods: In forty postdilutional OL-HDF sessions, the reduction rates of toxins of different molecular weights were measured in 13 patients, including protein-bound molecules such as p-cresyl sulphate, indoxyl sulphate and homocysteine. Results: Total convective volume was 28.3 (5.1) litres (range 16.3-38.0 litres). Mean reduction rate of protein-bound molecules was 44.4% (15.7%), 48.7% (14.1%) and 58.6% (8.8%) for p-cresyl sulphate, indoxyl sulphate and homocysteine, respectively. Moreover, a statistically significant direct association was found between the reduction rates of all three molecules, the replacement volume and the Kt/V. Conclusion: High convective volumes during postdilution OL-HDF are associated with increased removal of protein-bound uraemic toxins (AU)

Renal Replacement Therapy in Slovenia: Excerpts From 2013 Data.

This report provides a summary of the 2013 Slovenian renal replacement therapy (RRT) data, obtained from 24 renal centers: 23 dialysis and one transplant center, referring from 31 December 2013, with 100% response rate to individual patient questionnaires. Slovenia had a population of 2 061 085 on 1 January 2014. The total number of patients treated by RRT was 2077, i.e. 1008.3 per million of population (pmp); 1349 (65%) were treated by hemodialysis, 52 (2.5%) by peritoneal dialysis, and 676 (32.5%) had a functioning kidney graft. A total of 260 incident patients, 126.2 pmp (at day one), started RRT, their median age was 69 years, 59.8% were men,. 58.5% of hemodialysis patients were treated with on-line hemodiafiltration. Vascular access was arteriovenous fistula in 79%, polytetrafluoroethylene graft in 8%, and catheter in 13% of patients, mean blood flow 276 ± 41 mL/min, 5.5% dialyzed in a single-needle mode. The crude death rate was 11.4% in all RRT patients (incident patients day 1 included, 15.9% in hemodialysis, 12.3% in peritoneal dialysis, 2.1% in transplant recipients). 60 kidney transplantations were performed in 2013, from deceased donors.

Ultrafiltration Rates and the Quality Incentive Program: Proposed Measure Definitions and Their Potential Dialysis Facility Implications.

BACKGROUND AND OBJECTIVES: Rapid ultrafiltration rates are associated with adverse outcomes among patients on hemodialysis. The Centers for Medicare and Medicaid Services is considering an ultrafiltration rate quality measure for the ESRD Quality Incentive Program. Two measure developers proposed ultrafiltration rate measures with different selection criteria and specifications. We aimed to compare the proposed ultrafiltration rate measures and quantify dialysis facility operational burden if treatment times were extended to lower ultrafiltration rates. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data were taken from the 2012 database of a large dialysis organization. Analyses of the Centers for Medicare and Medicaid Services measure considered 148,950 patients on hemodialysis, and analyses of the Kidney Care Quality Alliance measure considered 151,937 patients. We described monthly patient and facility ultrafiltration rates and examined differences in patient characteristics across ultrafiltration rate thresholds and differences in facilities across ultrafiltration rate measure scores. We computed the additional treatment time required to lower ultrafiltration rates <13 ml/h per kilogram. RESULTS: Ultrafiltration rates peaked in winter and nadired in summer. Patients with higher ultrafiltration rates were younger; more likely to be women, nonblack, Hispanic, and lighter in weight; and more likely to have histories of heart failure compared with patients with lower ultrafiltration rates. Facilities had, on average, 20.8%±10.3% (July) to 22.8%±10.6% (February) of patients with ultrafiltration rates >13 ml/h per kilogram by the Centers for Medicare and Medicaid Services monthly measure. Facilities had, on average, 15.8%±8.2% of patients with ultrafiltration rates ≥13 ml/h per kilogram by the Kidney Care Quality Alliance annual measure. Larger facilities (>100 patients) would require, on average, 33 additional treatment hours per week to lower all facility ultrafiltration rates <13 ml/h per kilogram when total treatment time is capped at 4 hours. CONCLUSIONS: Ultrafiltration rates vary seasonally and across clinical subgroups. Extension of treatment time as a strategy to lower ultrafiltration rates may pose facility operational challenges. Prospective studies of ultrafiltration rate threshold implementation are needed.

Present Status of Renal Replacement Therapy in Asian Countries.

BACKGROUND: Asia is a huge and populous continent with diverse economies where the status of renal replacement therapy varies among different countries. SUMMARY: The penetration of dialysis is poor among low income countries like India and China. A lack of trained nephrologists and limited numbers of dialysis facilities plague South Asian countries. Most of the hemodialysis centers are in the private sector; the few centers that are government-run or run by charitable organizations cannot meet growing needs. China has shown that twice-a-week hemodialysis can be feasible in female patients with small build. Peritoneal dialysis (PD) has less penetration among the developing countries than the developed countries in Asia. Novel schemes in India including the 'once-in-a-lifetime payment' scheme and an insurance scheme for peritonitis are attracting more patients to PD. New biocompatible PD solutions and home care facilities have brought down the peritonitis rates. The PD-first policy in Thailand alongside the domestic manufacture of PD fluids has decreased the cost of PD there. Iran has shown drastic changes in its PD policy (from 0 to 1,150 recruitments in 5 years) in spite of its high transplantation rate. Home hemodialysis is practiced in mostly affluent countries like Japan, where again it accounts for only 0.1% of all hemodialysis. KEY MESSAGES: Developing countries should have more budgetary allocation for chronic ailments such as chronic kidney disease that can be utilized for training programs and establishing dialysis units, and thus meet the growing demands for renal replacement therapy. PD should be encouraged and adopted as first modality of renal replacement therapy considering its ease and economy.

Clinical Expectation of Online Hemodiafiltration: A Japanese Perspective.

Many pieces of evidence of online hemodiafiltration (HDF) have been reported, and the clinical advantage of postdilution online HDF with sufficient substitution is now established. After the approval of online HDF in 2012, the number of online HDF patients has been dramatically increasing in Japan and reached 10% of the total dialysis population at the end of 2013. One of the marked characteristics of Japanese online HDF is a widespread use of predilution treatment and, in 2013, 90.8% of online HDFs were carried out with the predilution mode. The main reason for the wide use of predilution online HDF results from the low blood flow rate in Japan, by which it is difficult to substitute a sufficient volume during the limited treatment time. Other reasons to choose the predilution mode include the reduction of albumin loss and the suppression of membrane fouling during treatment. Contrary to postdilution treatment, adequate clinical evidence has not been reported for predilution online HDF to provide a better outcome of the patients. A further clinical trial is expected to elucidate the clinical advantages over conventional hemodialysis for predilution online HDF.

Continuous Veno-Venous Hemodiafiltration and Plasma Exchange in Infantile Acute Liver Failure.

OBJECTIVES: The purpose of the current study was to assess our multidisciplinary approach consisting of early application of neurology-oriented intensive care, aggressive artificial liver support and liver transplantation at the appropriate time for infants with acute liver failure. DESIGN: Retrospective cohort study. SETTING: A tertiary pediatric medical center in Japan. PATIENTS: Seventeen infants younger than 12 months with acute liver failure who subsequently underwent liver transplantation between February 2006 and June 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The patients varied from 1 to 11 months, with a median of 6 months. The median body weight was 8.0 kg (range, 2.7-10 kg). With respect to the encephalopathy grading before liver transplantation, four cases were categorized as grade II, seven cases were categorized as grade III, and five cases were categorized as grade IV. Continuous veno-venous hemodiafiltration and plasma exchange were applied to all the infants until liver transplantation. Bilirubin, ammonia, prothrombin time/international normalized ratio and creatinine decreased significantly after continuous veno-venous hemodiafiltration + plasma exchange (p < 0.001). The median value of catecholamine index changed from 10 to 0 (range, 0-20.6). Notably, among the 16 infants who underwent electroencephalography assessment, five did not show slow waves throughout their stay, and one who did so before treatment ceased to show any after treatment. The all patients underwent living-donor liver transplantation and were subsequently discharged from the PICU. The overall survival rate was 88% (15/17) with a median follow-up period of 28 months (range, 2-64 mo). Regarding the neurological outcomes of the survivors, 73% (11/15) had no neurological morbidities and 20% (3/15) had mild disabilities. CONCLUSIONS: Our multidisciplinary approach for infants with acute liver failure achieved favorable outcomes. Further investigations are needed to examine the efficacy of the artificial liver support.

[Renal replacement therapy in Intensive Care Units in Catalonia (Spain)]. / Utilización de las terapias de depuración extracorpórea en los Servicios de Medicina Intensiva de Cataluña (España).

OBJECTIVE: To assess the indications, settings and techniques used in renal replacement therapy (RRT) in Intensive Care Units (ICUs). STUDY DESIGN: A prospective, multicenter observational study was carried out. SETTING: Intensive Care Units. PATIENTS: All patients admitted to ICUs during the two-month study period in 2011 who required RRT. INTERVENTIONS: None. VARIABLES OF INTEREST: Patient demographic characteristics, baseline clinical data, RRT technique and materials used. RESULTS: Thirty-three patients were analyzed. RRT was started within the first 24hours after ICU admission in 17 of the 33 patients (52%). At the start of RRT, 18% of the patients (n=6) presented grade R on the RIFLE acute kidney injury (AKI) scale. The most common disorder associated with AKI was multiple organ dysfunction syndrome (64%; n=21). At the start of RRT, most patients (76%; n=25) presented hemodynamic instability, while the remaining 24% (n=8) were considered hemodynamically stable. The most common RRT technique in hemodynamically stable patients was continuous renal replacement therapy (CRRT) (63%; n=5). CRRT was the technique of choice in all 25 of the hemodynamically unstable patients (100%). Anticoagulation was used in 55% (n=18) of the patients. In most cases (61%, n=20), RRT was administered through the right femoral vein. In 84% (n=28) of the patients, the ultrafiltration effluent flow rate was ≤ 35ml/kg/h. CONCLUSIONS: The ICU physicians in this study followed current RRT guidelines. CRRT was preferred over intermittent renal replacement therapy, regardless of patient hemodynamic status.

DNA methylation: hemodialysis versus hemodiafiltration.

Aberrant DNA methylation is an emerging characteristic of chronic kidney disease including dialysis patients. It appears to be associated to inflammation. We compared the global DNA methylation status in 10 control subjects compared to 80 dialysis patients (N = 40 on-line hemodiafiltration, N = 40 high-flux hemodialysis) in relation to the dialysis technique and inflammation. Whole blood DNA methylation was assessed with a 5-mc DNA enzyme linked immunosorbent assay Kit. Global DNA methylation was higher in hemodialysis (HD) compared to on-line hemodiafiltration (HDF) patients (0.045 vs. 0.039; P < 0.0001) and controls (0.045 vs. 0.0284; P = 0.0002 for HD; 0.039 vs. 0.0284; P = 0.0254 for on-line HDF). To study the influence of the dialysis technique on DNA methylation we divided dialysis patients according to the median value of 5-mC. DNA methylation was highest in inflamed patients on hemodialysis. The dialysis technique was the only independent predictor of global DNA methylation in dialysis patients. On-line HDF could be associated with a favorable DNA methylation profile.