Pre-transplant Social Adaptability Index and clinical outcomes in renal transplantation: The Swiss Transplant Cohort study.

BACKGROUND: The impact of pre-transplant social determinants of health on post-transplant outcomes remains understudied. In the United States, poor clinical outcomes are associated with underprivileged status, as assessed by the Social Adaptability Index (SAI), a composite score of education, employment status, marital status, household income, and substance abuse. Using data from the Swiss Transplant Cohort Study (STCS), we determined the SAI's predictive value regarding two post-transplant outcomes: all-cause mortality and return to dialysis. METHODS: Between 2012 and 2018, we included adult renal transplant patients (aged ≥ 18 years) with pre-transplant assessment SAI scores, calculated from a STCS Psychosocial Questionnaire. Time to all-cause mortality and return to dialysis were predicted using Cox regression. RESULTS: Of 1238 included patients (mean age: 53.8 ± 13.2 years; 37.9% female; median follow-up time: 4.4 years [IQR: 2.7]), 93 (7.5%) died and 57 (4.6%) returned to dialysis. The SAI's hazard ratio was 0.94 (95%CI: 0.88-1.01; p = .09) for mortality and 0.93 (95%CI: 0.85-1.02; p = .15) for return to dialysis. CONCLUSIONS: In contrast to most published studies on social deprivation, analysis of this Swiss sample detected no significant association between SAI score and mortality or return to dialysis.

The Survival Benefit of "Fistula First, Catheter Last" in Hemodialysis Is Primarily Due to Patient Factors.

Patients needing hemodialysis are advised to have arteriovenous fistulas rather than catheters because of significantly lower mortality rates. However, disparities in fistula placement raise the possibility that patient factors have a role in this apparent mortality benefit. We derived a cohort of 115,425 patients on incident hemodialysis ≥67 years old from the US Renal Data System with linked Medicare claims to identify the first predialysis vascular access placed. We compared mortality outcomes in patients initiating hemodialysis with a fistula placed first, a catheter after a fistula placed first failed, or a catheter placed first (n=90,517; reference group). Of 21,436 patients with a fistula placed first, 9794 initiated hemodialysis with that fistula, and 8230 initiated dialysis with a catheter after failed fistula placement. The fistula group had the lowest mortality over 58 months (hazard ratio, 0.50; 95% confidence interval, 0.48 to 0.52; P<0.001), with mortality rates at 6, 12, and 24 months after initiation of 9%, 17%, and 31%, respectively, compared with 32%, 46%, and 62%, respectively, in the catheter group. However, the group initiating hemodialysis with a catheter after failed fistula placement also had significantly lower mortality rates than the catheter group had over 58 months (hazard ratio, 0.66; 95% confidence interval, 0.64 to 0.68; P<0.001), with mortality rates of 15%, 25%, and 42% at 6, 12, and 24 months, respectively. Thus, patient factors affecting fistula placement, even when patients are hemodialyzed with a catheter instead, may explain at least two thirds of the mortality benefit observed in patients with a fistula.

Second vascular access after failure of the first fistula in the elderly
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BACKGROUND: In patients with failure of an initial arteriovenous fistula (AVF), a subsequent vascular access is needed before hemodialysis (HD) initiation. METHODS: To assess the optimal access strategy after a failed AVF, we linked data from the US Renal Data System with Medicare claims data identifying 21,436 patients ≥ 67 years old who started HD between January 1, 2005, and December 31, 2008, with an AVF placed as their first predialysis access. Of the 10,568 subjects whose AVF failed, 1,796 patients had an AVF placed as a second access predialysis (AVF2 group) and 399 patients had an arteriovenous graft placed as a second access predialysis (AVG2 group). Second access success was defined as HD initiation for the first HD session using this access avoiding need for a catheter. RESULTS: The mean age for AVF2 and AVG2 groups was 75.9 ± 6.0 and 75.9 ± 5.9 years with a significantly greater percentage of men and whites in the AVF2 group and women and blacks in the AVG2 group. Overall, 53% of AVF2 group initiated dialysis using AVF2, and 66% of AVG2 group started dialysis using AVG2 (p < 0.001). The following variables were found to be associated with AVF2 failure: female gender, peripheral vascular disease (PVD), interventional procedures, and the absence of pre-ESRD nephrology care. AVG2 failure was associated with white race, lower body mass index (BMI), and the absence of pre-ESRD (end-stage renal disease) nephrology care. CONCLUSION: Since the success rate to avoid the use of a catheter was significantly higher in the AVG2 group than in the AVF2 group, an AVG may be a preferable choice of second access in certain patients, especially in females, blacks and those with PVD.
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Arteriovenous fistula placement in the elderly: when is the optimal time?

Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD). However, many AVFs fail before starting dialysis. To assess the optimal time for AVF placement in the elderly, we linked data from the US Renal Data System with Medicare claims data to identify 17,511 patients ≥67 years old on incident HD who started dialysis between January 1, 2005, and December 31, 2008, with an AVF placed as the first predialysis access. AVF success was defined as dialysis initiation using the AVF, with time between AVF placement and dialysis start as our primary variable of interest. The mean age was 76.1±6.0 years, and 58.3% of subjects were men. Overall, 54.9% of subjects initiated dialysis using an AVF, and 45.1% of subjects used a catheter or graft. The success rate increased as time from AVF creation to HD initiation increased from 1-3 months (odds ratio [OR], 0.49; 95% confidence interval [95% CI], 0.44 to 0.53) to 3-6 months (OR, 0.93; 95% CI, 0.85 to 1.02) to 6-9 months (OR, 0.99; 95% CI, 0.88 to 1.11) but stabilized after that time. Furthermore, the number of interventional access procedures increased over time starting at 1-3 months, with a mean of 0.64 procedures/patient for AVFs created 6-9 months predialysis compared with 0.72 for AVFs created >12 months predialysis (P<0.001). Although limited by the observational nature of this study, our results suggest that placing an AVF >6-9 months predialysis in the elderly may not associate with a better AVF success rate.

Clinical issues in renal transplantation in the elderly.

Kidney transplantation is the best renal replacement therapy option and is superior to dialysis in elderly end-stage renal disease (ESRD) patients. Furthermore, the outcome of transplantation in the elderly is comparable to younger patients in terms of allograft survival. The exact nature of this phenomenon is not completely clear. As the elderly population continues to grow, it becomes more important to identify specific issues associated with kidney transplantation. In particular, elderly transplant recipients might have a lower chance of acute rejection as their immune systems seem to be less reactive. This might predispose elderly recipients to greater risk of post-transplant infectious complications or malignancies. Furthermore, due to differences in pharmacokinetics, elderly recipients might require lower doses of immunosuppressive medication. As the main cause of graft failure in the elderly is death with a functioning graft and also considering the scarcity of donor organs, it might make sense to recommend transplanting elderly recipients with extended criteria donor kidneys. This approach would balance shorter patient survival compared to younger recipients. In conclusion, old age should not preclude ESRD patients from kidney transplantation. However, specific differences that have to do with immunosuppression and other aspects of managing elderly transplant recipients should be considered.

Short-term responses of the kidney to high altitude in mountain climbers.

In high-altitude climbers, the kidneys play a crucial role in acclimatization and in mountain sickness syndromes [acute mountain sickness (AMS), high-altitude cerebral edema, high-altitude pulmonary edema] through their roles in regulating body fluids, electrolyte and acid-base homeostasis. Here, we discuss renal responses to several high-altitude-related stresses, including changes in systemic volume status, renal plasma flow and clearance, and altered acid-base and electrolyte status. Volume regulation is considered central both to high-altitude adaptation and to maladaptive development of mountain sickness. The rapid and powerful diuretic response to the hypobaric hypoxic stimulus of altitude integrates decreased circulating concentrations of antidiuretic hormone, renin and aldosterone, increased levels of natriuretic hormones, plasma and urinary epinephrine, norepinephrine, endothelin and urinary adrenomedullin, with increased insensible fluid losses and reduced fluid intake. The ventilatory and hormonal responses to hypoxia may predict susceptibility to AMS, also likely influenced by multiple genetic factors. The timing of altitude increases and adaptation also modifies the body's physiologic responses to altitude. While hypovolemia develops as part of the diuretic response to altitude, coincident vascular leak and extravascular fluid accumulation lead to syndromes of high-altitude sickness. Pharmacological interventions, such as diuretics, calcium blockers, steroids, phosphodiesterase inhibitors and ß-agonists, may potentially be helpful in preventing or attenuating these syndromes.

Fistula first is not always the best strategy for the elderly.

Whether placing a fistula first is the superior predialysis approach among octogenarians is unknown. We analyzed data from a cohort of 115,425 incident hemodialysis patients ≥67 years old derived from the US Renal Data System with linked Medicare claims, which allowed us to identify the first predialysis vascular access placed rather than the first access used. We used proportional hazard models to evaluate all-cause mortality outcomes based on first vascular access placed, considering the fistula group as the reference. In the study population, 21,436 patients had fistulas as the first predialysis access placed, 3472 had grafts, and 90,517 had catheters. Those patients with a catheter as the first predialysis access placed had significantly inferior survival compared with those patients with a fistula (HR=1.77; 95% CI=1.73 to 1.81; P<0.001). However, we did not detect a significant mortality difference between those patients with a graft as the first access placed and those patients with a fistula (HR=1.05; 95% CI=1.00 to 1.11; P=0.06). Analyzing mortality stratified by age groups, grafts as the first predialysis access placed had inferior mortality outcomes compared with fistulas for the 67 to ≤79-years age group (HR=1.10; 95% CI=1.02 to 1.17; P=0.007), but differences between these groups were not statistically significant for the 80 to ≤89- and the >90-years age groups. In conclusion, fistula first does not seem to be clearly superior to graft placement first in the elderly, because each strategy associates with similar mortality outcomes in octogenarians and nonagenarians.

The role of disparities and socioeconomic factors in access to kidney transplantation and its outcome.

BACKGROUND: Research focused on identifying vulnerable populations and revealing specific risk factors for barriers along the pathway from ESRD to kidney transplantation has been mostly descriptive and the causes of existing disparities remain unclear. However, several socio-economic factors that are associated with the access to and the outcome of the kidney transplantation have been identified. SUMMARY: While the presence of racial, gender, and geographic disparities is noted, we were interested mostly to describe potential socio-economic factors associated with and possibly responsible for the presence of such disparities. In this review we focused on five factors: education level, employment status, income, presence of substance addiction or abuse, and marital status. We describe the new method to quantify patients' socio-economic status and identify the group of high risk in terms of the transplant outcome, easily calculated social adaptability index, previously associated with clinical outcome in several patient populations including those with kidney transplant. At the end, based on literature analyzed we offer potential interventions that potentially can be used in order to reduce the degree of disparities. CONCLUSION: Based on review of literature socio-economic factors are associated with and possibly responsible for healthcare disparities. Social adaptability index allows quantifying the degree of socio-economic status and identifying the group of high risk for inferior transplant outcome.

Renal transplantation in the setting of early steroid withdrawal: a comparison of rabbit antithymocyte globulin induction dosing in two eras.

BACKGROUND: Modern immunosuppression and rabbit antithymocyte globulin (rATG) have facilitated the success of early steroid withdrawal (ESW) protocols. Little data exist on optimal rATG dosing in ESW protocols. METHODS: Rejection at 12 months in era 1 (four doses of rATG, 1.25 mg/kg) vs. era 2 (three doses of rATG, 1.25 mg/kg) was the primary endpoint. Secondary endpoints included patient and graft survival, renal function and infectious complications. Factors associated with rejection at 1 year were identified. RESULTS: 199 patients received rATG induction and ESW: 102 in era 1 and 97 in era 2. Compared to era 1, era 2 was not associated with worse outcomes, including rejection, renal function, infection or graft survival. Rejection at 1 year and uncensored graft survival differed between the dosing groups. Rejection rates were significantly higher in the <4 mg/kg group compared to the 4-5.9-mg/kg and the ≥6-mg/kg groups, whereas uncensored graft survival was the lowest in the ≥6-mg/kg group. Factors associated with rejection at 12 months included: rATG dose received of 4-5.9 versus <4 mg/kg (OR 0.20, 95% CI 0.036-0.85, p = 0.026); recipient age (per year, OR 0.94, 95% CI 0.89-1.0, p = 0.038); panel reactive antibody 10-79.9 versus <10% (OR 5.4, 95% CI 1.2-25, p = 0.030) and rATG dose held (OR 4.0, 95% CI 1.0-15, p = 0.049). CONCLUSIONS: A comparison of rATG dosing based on era did not result in a significant difference in rejection, renal function, infection or graft survival. However, when evaluating the study population based on actual dose received there were notable differences in both rejection rates and uncensored graft survival.

The role of initial hemodialysis vascular access in the outcome of subsequent kidney transplantation.

The role of initial hemodialysis vascular access in the subsequent kidney transplant outcome is unclear. Study population was derived from the United States Renal Data System and included adult patients with end-stage renal disease who started HD 1/1/2005-9/1/2009 and subsequently received at least one kidney transplant. Primary outcome variables were death-censored graft loss and all-cause recipient mortality. Among the study population (n = 17 157), 12 428 (72.4%) patients were initiated on HD with a catheter, 4090 (23.8%) patients with an arterio-venous fistula (AVF), and 639 (13.7%) patients with an arterio-venous graft (AVG). The rate of death-censored kidney allograft loss in AVF and AVG groups was not significantly different from the catheter group (HR, 0.82; p = 0.07 and HR, 0.68; p = 0.13, respectively). All-cause mortality of patients initiated on HD with AVG (HR, 0.761; p = 0.21) was not significantly different compared to those with catheters. However, all-cause mortality in the AVF group was lower compared to patients initiated on HD with catheters (HR, 0.65; p = 0.001). AVF used at the initiation of HD was associated with lower rate of all-cause mortality after kidney transplantation compared to the catheter. The type of initial vascular access for hemodialysis was not associated with kidney allograft survival.

Social adaptability index predicts kidney transplant outcome: a single-center retrospective analysis.

BACKGROUND: Social adaptability index (SAI) is the composite index of socioeconomic status based upon employment status, education level, marital status, substance abuse and income. It has been used in the past to define populations at higher risk for inferior clinical outcomes. The objective of this retrospective study was to evaluate the association of the SAI with renal transplant outcome. METHODS: We used data from the clinical database at the Beth Israel Deaconess Medical Center Transplant Institute, supplemented with data from United Network for Organ Sharing for the years 2001-09. The association between SAI and graft loss and recipient mortality in renal transplant recipients was studied using Cox model in the entire study population as well as in the subgroups based on age, race, sex and diabetes status. RESULTS: We analyzed 533 end-stage renal disease patients (mean age at transplant 50.8 ± 11.8 years, 52.2% diabetics, 58.9% males, 71.1% White). Higher SAI on a continuous scale was associated with decreased risk of graft loss [hazard ratio (HR) 0.89, P < 0.05, per 1 point increment in the SAI] and decreased risk of recipient mortality (HR 0.84, P < 0.01, per 1 point increment in the SAI). Higher SAI was also significantly associated with decreased risk for graft loss/recipient mortality in some study subgroups (age 41-65 years, males, non-diabetics). CONCLUSIONS: SAI has an association with graft and recipient survival in renal transplant recipients. It can be helpful in identifying patients at higher risk for inferior transplant outcome as a target population for potential intervention.

Access to renal transplantation in the diabetic population-effect of comorbidities and body mass index.

BACKGROUND: In this study, we hypothesized that higher level of comorbidity and greater body mass index (BMI) may mediate the association between diabetes and access to transplantation. METHODS: We used data from the United States Renal Data System (01/01/2000-24/09/2007; n = 619,151). We analyzed two outcomes using Cox model: (i) time to being placed on the waiting list or transplantation without being listed and (ii) time to transplantation after being listed. Two primary Cox models were developed based on different levels of adjustment. RESULTS: In Cox models adjusted for a priori defined potential confounders, history of diabetes was associated with reduced transplant access (compared with non-diabetic population) - both for wait-listing/transplant without being listed (hazard ratio, HR = 0.80, p < 0.001) and for transplant after being listed (HR = 0.72, p < 0.001). In Cox models adjusted for BMI and comorbidity index along with the potential confounders, history of diabetes was associated with shorter time to wait-listing or transplantation without being listed (HR = 1.07, p < 0.001), and there was no significant difference in time to transplantation after being listed (HR = 1.01, p = 0.42). CONCLUSION: We demonstrated that higher level of comorbidity and greater BMI mediate the association between diabetes and reduced access to transplantation.

Effect of education on racial disparities in access to kidney transplantation.

Higher education level might result in reduced disparities in access to renal transplantation. We analyzed two outcomes: (i) being placed on the waiting list or transplanted without listing and (ii) transplantation in patients who were placed on the waiting list. We identified 3224 adult patients with end-stage renal disease (ESRD) in United States Renal Data System with education information available (mean age of ESRD onset of 57.1 ± 16.2 yr old, 54.3% men, 64.2% white, and 50.4% diabetics). Compared to whites, fewer African Americans graduated from college (10% vs. 16.7%) and a higher percentage never graduated from the high school (38.6% vs. 30.8%). African American race was associated with reduced access to transplantation (hazard ratio [HR] 0.70, p < 0.001 for wait-listing/transplantation without listing; HR 0.58, p < 0.001 for transplantation after listing). African American patients were less likely to be wait-listed/transplanted in the three less-educated groups: HR 0.67 (p = 0.005) for those never completed high school, HR 0.76 (p = 0.02) for high school graduates, and HR 0.65 (p = 0.003) for those with partial college education. However, the difference lost statistical significance in those who completed college education (HR 0.75, p = 0.1). In conclusion, in comparing white and African American candidates, racial disparities in access to kidney transplantation do exist. However, they might be alleviated in highly educated individuals.

Education is associated with reduction in racial disparities in kidney transplant outcome.

In this study, we hypothesized that higher level of education might be associated with reduced racial disparities in renal transplantation outcomes. We used data from the United States Renal Data System (September 1, 1990-September 1, 2007) (n=79,223) and analyzed two outcomes, graft loss and recipient mortality, using Cox models. Compared with whites, African Americans had increased risk of graft failure (HR, 1.48; p<0.001) and recipient mortality (HR, 1.06; p=0.004). Compared with recipients who graduated from college, all other education groups had inferior graft survival. Specifically, compared with college-graduated individuals, African Americans who never finished high school had the highest risk of graft failure (HR, 1.45; p<0.001), followed by high school graduates (HR, 1.27; p<0.001) and those with some college education (HR, 1.18; p<0.001). A similar trend was observed in whites. In African Americans (compared with whites), the highest risk of graft failure was associated with individuals who did not complete high school (HR, 1.96; p<0.001) followed by high school graduates (HR, 1.47; p<0.001), individuals with some college education (HR, 1.45; p<0.001), and college graduates (HR, 1.39; p<0.001). A similar trend was observed with recipient mortality. In sum, higher education was associated with reduced racial disparities in graft and recipient survival.

Social Adaptability Index: application and outcomes in a dialysis population.

BACKGROUND: Patient groups associated with disparities in health care are usually defined on the basis of race, gender or geographic location. Social Adaptability Index (SAI), calculated based on education, marital status, income, employment and substance abuse, has been strongly associated with clinical outcome in other patient populations and may be used to identify individuals at risk. We used data from the United States Renal Data System to evaluate the role of SAI in survival of patients on dialysis. METHODS: We used Cox model analyses to study the association between SAI and patient survival in patients with ESRD on dialysis, as well as in the subgroups based on age, race, sex, comorbidites and diabetic status. RESULTS: We analyzed 3396 patients (age of ESRD onset 56.9 ± 16.1 years, 54.2% males, 64.2% white, 30.3% African-American). Mean SAI of the entire population was 7.1 ± 2.5 (range 0-12 points). SAI was higher in whites (7.4 ± 2.4) than in African-Americans (6.5 ± 2.5) (analysis of variance, P <0.001) and greater in men (7.4 ± 2.4) than in women (6.7 ± 2.5) (t-test, P <0.001). In a Cox model adjusted for potential confounders, SAI was associated with decreased mortality [hazards ratio of 0.97 (95% confidence interval 0.95-0.99), P = 0.006]. Subgroup analysis demonstrated an association of SAI with survival in most of the subgroups. Potential limitations of the study include reverse causality, possible misclassification and retrospective design. CONCLUSION: We demonstrated that SAI is significantly associated with mortality in dialysis patients. SAI could be used to identify individuals at risk for inferior clinical outcomes.

Social Adaptability Index predicts access to kidney transplantation.

Identifying the group of subjects prone to disparities in access to kidney transplantation is important for developing potential interventions. Data from the United States Renal Data System (January 1, 1990-September 1, 2007; n = 3407) were used to study association between the Social Adaptability Index (SAI; based upon employment, marital status, education, income, and substance abuse) and outcomes (time to being placed on the waiting list and time to being transplanted once listed). Patients were 56.9 ± 16.1 yr old, 54.2% men, 64.2% white, and 50.4% had diabetes. SAI was higher in whites (7.4 ± 2.4) than African Americans (6.5 ± 2.6) [ANOVA, p < 0.001] and greater in men (7.4 ± 2.4) than in women (6.7 ± 2.5) [T-test, p < 0.001]. In multivariate model, greater SAI (range 0-12) was associated with increased likelihood of being placed on the waiting list (hazard ratio [HR] 1.19 [95% CI 1.15-1.23] per each point of increase in SAI, p < 0.001) and greater likelihood of receiving a transplant once listed (HR of 1.06 [95% CI 1.03-1.09] per point of increase in SAI, p < 0.001). Similar trends were observed in most of the subgroups (based upon race, sex, diabetic status, age, comorbidities, and donor type). SAI is associated with access to renal transplantation in patients with end-stage renal disease; it may be used to indentify individuals at risk of healthcare disparities.

Factors associated with nonadherence to medication in kidney transplant recipients.

Nonadherence in kidney transplant recipients was evaluated in this report using a questionnaire with five binary questions and one question on a continuous scale. Study participants at the University of Utah Transplant Program (n = 199) were 43.0 ± 14.2 years old; 67% were males, and 81% were White. Two questions that produced heterogeneous outcome were analyzed: 'Do you ever forget to take your medication?' (79% no, 21% yes) and 'Have you ever taken your medications late?' (67% no, 33% yes). Responses to these questions correlated (χ² 65.2, p < 0.001; correlation coefficient 0.57, p < 0.001). We performed a logistic regression analysis to identify factors associated with the combined outcome of forgetting/not taking medications altogether or taking medications off schedule. Higher comorbidity index [odds ratio (OR) 2.19, p < 0.001], living (compared to deceased) donor (OR 2.81, p = 0.005) and full-time employment were associated with forgetting medications or taking them late (OR 3.12, p = 0.01). Recipient age tended to be associated with lower risk of nonadherence, but did not reach statistical significance (OR 0.98 per year of age, p = 0.13). Education level, smoking status, recipient race, dialysis modality, number of medications and the time since first kidney transplantation were not associated with the outcome. In conclusion, renal transplant recipients with greater comorbidity, receiving kidney from a living donor and with full-time employment reported lower levels of medication adherence.

Association between social adaptability index and survival of patients with chronic kidney disease.

BACKGROUND: While individual socioeconomic factors have been associated with clinical outcome, a composite index has not been developed. In this project, we tested the hypothesis that Social Adaptability Index (SAI) based on employment, education, income, marital status and substance abuse is associated with survival in chronic kidney disease (CKD) patients. METHODS: This is a retrospective cohort study of patients with CKD stage 2 or greater. We used the Third National Health and Nutrition Examination Survey (NHANES III) cohort data between 1988 and 1994 including those 18 years or older. Our primary variable of interest is SAI. Each component of SAI (employment status, education, marital status, and substance abuse) has been graded on the scale of 0-3, income has been graded on the scale 0-1. Age, sex, race, diabetes, co-morbidity index, body mass index (BMI), geographic location, haemoglobin, serum creatinine, serum albumin, serum cholesterol and Hba1c were used as covariates in multivariate analysis. The outcome of the study is patient's mortality. The time to death was calculated as time between the first interview by NHANES and death. RESULTS: We analysed 13 400 subjects with mean age of 50.6 ± 20-53.6% males, 44.4% white, 29.7% African American and 22.1% Mexican American-with 8.5% having diabetes, with an average number of co-morbid conditions of 2.7 ± 1.1. Lower SAI is associated with greater stage of CKD. Higher SAI was associated with decreased mortality [hazard ratio (HR) 0.88, P < 0.001, 95% confidence interval (CI) 0.86-0.89]. When SAI quintiles were analysed, we demonstrated a 'dose-dependent' association between SAI and survival. Subgroup analysis showed that this association of SAI and survival was present in all studied subgroups. The limitations of the study include retrospective design, potential misreporting and misclassification, and reverse causality. CONCLUSION: We demonstrated that SAI has a strong and clinically significant association with mortality in CKD patients.

Characteristics of elderly patients with diabetes and end-stage renal disease.

Because of a combination of demographic and social factors, such as the aging of the population in general, increased incidence of diabetes, and more liberal criteria for renal replacement therapy initiation, the proportion of the end-stage renal disease (ESRD) patients with diabetes who are considered elderly is currently the fastest growing segment of incident ESRD population. Despite the fast growth of this group, it is poorly characterized in current literature. In this review, we attempt to summarize the data available to date regarding demographic composition, outcomes, choice of renal replacement therapy, and other management issues including renal transplantation. There is significant evidence that the elderly diabetic patients might differ from the general dialysis population regarding renal replacement modality, vascular access for dialysis, and that guidelines addressing chronic kidney disease (CKD) issues such as nutrition and blood pressure may need modification in this ESRD subgroup. At the same time, other areas such as anemia and bone mineral metabolism have not been adequately studied. Lastly, despite lower rates of kidney transplantation in this population, it confers significant survival advantages, similar to that seen in younger populations. As the fastest growing group in the incident ESRD population, these patients have issues related to clinical management, which represent very important areas for future research.

Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study.

We estimated the survival and hospitalization among frequent hemodialysis users in comparison to those patients undergoing thrice-weekly conventional hemodialysis. All patients had similar characteristics and medical histories. In this cohort study of frequent hemodialysis users and propensity score-matched controls, the collaborating clinicians identified 94 patients who used nocturnal hermodialysis (NHD) and 43 patients who used short-duration daily hemodialysis (SDHD) for a minimum of 60 days. Ten propensity score-matched control patients for each NHD and SDHD patient were identified from the United States Renal Data System database. Primary outcomes were risk for all-cause mortality and risk for the composite outcome of mortality or major morbid event (acute myocardial infarction or stroke) estimated using Cox proportional hazards models. Risks for all-cause, cardiovascular-related, infection-related, and vascular access-related hospital admissions were also studied. Nocturnal hemodialysis was associated with significant reductions in mortality risk and risk for mortality or major morbid event when compared to conventional hemodialysis. There was a reduced but non-significant risk of death for patients using SDHD compared to controls. All-cause and specific hospitalizations did not differ significantly between NHD and SDHD patients and their matched control cohorts. Our study suggests that NHD may improve patient survival.