Economic evaluation of peritoneal dialysis and hemodialysis in Thai population with End-stage Kidney Disease.

BACKGROUND: This study aimed to conduct a cost-utility analysis of the "Peritoneal Dialysis (PD)-First" policy in 2008 under a universal health coverage scheme and hemodialysis (HD) in Thai patients with End-stage Kidney Disease (ESKD) using updated real-practice data. METHODS: Markov model was used to evaluate the cost-utility of two modalities, stratified into five age groups based on the first modality taken at 20, 30, 40, 50, and 60 years old from government and societal perspectives. Input parameters related to clinical aspects and cost were obtained from 15 hospitals throughout Thailand and Thai Renal Replacement Therapy databases. Both costs and outcomes were discounted at 3%, adjusted to 2021, and converted to USD (1 USD = 33.57 Thai Baht). One-way analysis and probabilistic sensitivity analysis were performed to assess the uncertainty surrounding model parameters. RESULTS: From the government perspective, compared to PD-first policy, the incremental cost-effectiveness ratio (ICER) was between 19,434 and 23,796 USD per QALY. Conversely, from a societal perspective, the ICER was between 31,913 and 39,912 USD per QALY. Both are higher than the willingness to pay threshold of 4,766 USD per QALY. CONCLUSION: By applying the updated real-practice data, PD-first policy still remains more cost-effective than HD-first policy at the current willingness to pay. However, HD gained more quality-adjusted life years than PD. This information will assist clinicians and policymakers in determining the future direction of dialysis modality selection and kidney replacement therapy reimbursement policies for ESKD patients.

Any heart failure treatments associated with worsening renal function in patients admitted due to acute heart failure?

BACKGROUND: Worsening renal function (WRF) occurs in approximately 25% of acute heart failure patients, and both baseline characteristics and heart failure treatment may increase the risk of WRF. This study aimed to evaluate additional risk factors for WRF in acute heart failure, particularly those related to heart failure treatment. METHODS: This was a retrospective, observational, analytical study. The inclusion criteria were age 18 years or over, hospital admission due to acute heart failure, and having undergone at least two serum creatinine tests during admission. The eligible patients were classified into two groups: WRF and non-WRF. Predictors for WRF (including treatment parameters) were determined using logistic regression analysis. RESULTS: During the study period, there were 301 eligible patients who met the study criteria. Of those, 82 (27.24%) had WRF. There were two independent factors associated with WRF occurrence: baseline diastolic blood pressure and beta blocker treatment, with adjusted odds ratios (95% confidence interval) of 1.060 (1.008, 1.114) and 0.064 (0.006, 0.634), respectively. The Hosmer-Lemeshow Chi square for the final model was 6.11 (p = .634). CONCLUSIONS: After examining several heart failure treatments and baseline factors, we found that beta blocker treatment results improvement in kidney function.

Metabolic Effects of Diet and Exercise in Patients with Moderate to Severe CKD: A Randomized Clinical Trial.

CKD is steadily increasing along with obesity worldwide. Furthermore, obesity is a proinflammatory risk factor for progression of CKD and cardiovascular disease. We tested the hypothesis that implementation of caloric restriction and aerobic exercise is feasible and can improve the proinflammatory metabolic milieu in patients with moderate to severe CKD through a pilot, randomized, 2×2 factorial design trial. Of 122 participants consented, 111 were randomized to receive caloric restriction and aerobic exercise, caloric restriction alone, aerobic exercise alone, or usual care. Of those randomized, 42% were women, 25% were diabetic, and 91% were hypertensive; 104 started intervention, and 92 completed the 4-month study. Primary outcomes were a change from baseline in absolute fat mass, body weight, plasma F2-isoprostane concentrations, and peak oxygen uptake (VO2 peak). Compared with usual care, the combined intervention led to statistically significant decreases in body weight and body fat percentage. Caloric restriction alone also led to significant decreases in these measures, but aerobic exercise alone did not. The combined intervention and each independent intervention also led to significant decreases in F2-isoprostane and IL-6 concentrations. No intervention produced significant changes in VO2 peak, kidney function, or urine albumin-to-creatinine ratio. In conclusion, 4-month dietary calorie restriction and aerobic exercise had significant, albeit clinically modest, benefits on body weight, fat mass, and markers of oxidative stress and inflammatory response in patients with moderate to severe CKD. These results suggest healthy lifestyle interventions as a nonpharmacologic strategy to improve markers of metabolic health in these patients.

Glycemic load is associated with oxidative stress among prevalent maintenance hemodialysis patients.

BACKGROUND: High glycemic index (GI) and glycemic load (GL) are associated with increased levels of oxidative stress and systemic inflammation in the general population. Maintenance hemodialysis (MHD) patients are known to have excessive oxidative stress burden and inflammation. In this study, we examined the relationship between dietary GI or GL and markers of oxidative stress or inflammation among prevalent MHD patients. METHODS: A registered dietitian obtained GI, GL and other dietary data from 58 MHD patients. Two separate 24-h diet recalls (a hemodialysis day and a non-hemodialysis day) were analyzed using the Nutrition Data System for Research (NDS-R) software. Plasma or serum concentrations of F2-isoprostanes, high sensitivity C-reactive protein (hsCRP), leptin and adiponectin (ADPN) were measured in fasting state. Fat mass was measured by dual-energy X-ray absorptiometry (DEXA). Cross-sectional associations between GI, GL and markers of interest were examined by multiple regression analysis with adjustment for potential covariates. RESULTS: Mean (±SD) age, body mass index (BMI) and total trunk fat were 47 ± 12 years, 29.5 ± 6.8 kg/m(2) and 16.4 ± 8.8 kg, respectively. Dietary GI was associated with trunk fat (r = -0.182, P = 0.05) but not with F2-isoprostanes and hsCRP. In contrast, GL was significantly associated with F2-isoprostanes (P = 0.002), in unadjusted analysis, which remained in adjusted analyses, adjusting for age and sex (P = 0.005), and after adjusting for BMI, trunk fat and waist/hip ratio (P = 0.004). Addition of leptin or ADPN did not alter the significance of the association. GL also correlated with hsCRP (P = 0.03), but this association was modified by BMI and trunk fat. CONCLUSIONS: Dietary GL is significantly associated with markers of oxidative stress and inflammation among prevalent MHD patients, independent of the body composition and adipocytokines. These data indicate the importance of the contents of dietary nutrient intake composition and its potential role in determining the metabolic disturbances in MHD patients.

Disease duration and herpes zoster infection related to neutropenia in patients with systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is an autoimmune disease involving several organs. Neutropenia in patients with SLE may be a factor associated with infection leading to higher morbidity and mortality. There are several inconsistent predictors of neutropenia in patients with SLE. The present study is a retrospective, analytical study, which aimed to identify other predictors of neutropenia in patients with SLE. Patients with SLE who had been regularly followed up for ≥1 year were included in this study. Clinical factors, including history of disease, comorbidities, previous infection, laboratory results and treatment, were collected. The primary analyzed indicator was the occurrence of neutropenia. Factors associated with neutropenia were calculated by multivariate logistic regression analysis. A total of 84 patients met the study criteria. Of those 84 patients, 36 (42.86%) developed neutropenia. There were seven factors placed in the predictive model for neutropenia. Two factors were independently associated with the presence of neutropenia: Disease duration and herpes zoster infection. The first factor was negatively related with neutropenia with an adjusted odds ratio of 0.70 (95% confidence interval, 0.54, 0.92), whereas herpes zoster infection was an independent risk factor for neutropenia with an adjusted odds ratio of 8.46 (95% confidence interval, 1.30, 54.80). In conclusion, the present study revealed that short duration of disease and herpes zoster infection are predictors of neutropenia in patients with SLE.

Factors associated with preventive behaviors for COVID-19 infection among healthcare workers by a health behavior model.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a pandemic disease. There are limited data on predictors of good preventive behaviors among healthcare workers. This study aimed to evaluate if any factors were predictors of good preventive behaviors in healthcare workers under the theory of health behavior model. METHODS: This was a cross-sectional study in healthcare workers who were willing to participate in the study. Participants were requested to fill out a self-administered questionnaire that comprised health behavior model and preventive behaviors from COVID-19 infection. Factors associated with preventive behavior, an outcome, were analyzed by multivariate linear regression analysis. RESULTS: There were 273 healthcare workers who participated in this study. The average (SD) age and working duration of participants was 38.9 (12.1) and 11.4 (9.8) years. The preventive behavior category had an average score of 87.6% (70.3/80). After adjusted, knowledge and perception of personal preventability were independently associated with preventive behaviors. The adjusted coefficients of both factors were-0.911 (p 0.009) and 0.477 (p < 0.001). CONCLUSIONS: Specific knowledge and perception of personal ability questions were associated with preventive behaviors for COVID-19 infection. To improve personal preventive behaviors in healthcare workers, these factors should be emphasized.

The association of glycated hemoglobin with mortality and ESKD among persons with diabetes and chronic kidney disease.

CONTEXT: Diabetic kidney disease (DKD) is the leading cause of end stage kidney disease (ESKD) and is associated with a considerably shortened lifespan. While glucose-lowering therapy targeting glycated hemoglobin (HbA1c) <7% is proven to reduce the risk of developing DKD, its effects on complications of DKD are unclear. OBJECTIVE: We examined the associations of HbA1c with risks of progression to ESKD and death within a clinic-based study of CKD. We hypothesized that higher HbA1c concentrations would be associated with increased risks of ESKD and death. DESIGN AND SETTING: We studied 618 participants from the Seattle Kidney Study (mean eGFR 42 ml/min), 308 of whom had diabetes, and tested associations of baseline HbA1c with time to a composite outcome of initiation of renal replacement therapy or death. RESULTS: During a median follow-up of 4.2 years, there were 343 instances of the composite outcome (11.5 per 100 person-years). Among participants with diabetes, in both crude and adjusted analyses, higher HbA1c levels (examined continuously or categorically) were not associated with the risk of the composite outcome (HR (95% CI): 0.99 (0.88, 1.10) per 1% additional HbA1c, p = 0.79). HbA1c was not associated with ESKD or mortality when the outcomes were examined separately, nor when stratified between insulin users and non-users. CONCLUSION: In a referred population of established DKD, higher HbA1c was not associated with higher risk of ESKD or death. These data support current recommendations to be conservative with glycemic control among patients with advanced diabetes complications, such as CKD.

Close Monitoring of eGFR Should Be Performed in HIV-Infected Patients Aged over 37 Years.

Chronic kidney disease (CKD) has been shown to be a poor prognostic factor in HIV patients. This study aimed to identify risk factors in HIV-infected patients with early decline in renal function or an estimated glomerular filtration rate (eGFR) less than 90 mL/min/1.73 m2. The study was retrospectively conducted at Panyananthaphikkhu Chonprathan Medical Center, Thailand. The inclusion criteria were HIV-infected adult patients who were treated at the hospital's HIV clinic and whose eGFR levels at the first visit had been evaluated. Eligible patients were categorized according to their eGFR level being lesser or greater than 90 mL/min/1.73 m2. Multivariate logistic analysis was performed to evaluate the association of risk factors with an eGFR of less than 90 mL/min/1.73 m2. There were 301 HIV-infected patients included in the study. Of those, 89 patients (29.57%) had an eGFR of less than 90 mL/min/1.73 m2. Age was the only significant risk factor associated with an eGFR of less than 90 mL/min/1.73 m2 with an adjusted odds ratio of 1.072 (95% confidence interval: 1.015-1.132). Age of over 37 years predicted an eGFR of less than 90 mL/min/1.73 m2 as a risk factor in HIV-infected patients, with a sensitivity of 80.9% and specificity of 34.91%. Age was independently associated with eGFRs of less than 90 mL/min/1.73 m2 in HIV-infected patients. Close monitoring of eGFR should be performed in HIV-infected patients aged over 37 years.

Administration of IL-1ra improves adiponectin levels in chronic hemodialysis patients.

BACKGROUND: Adiponectin, an adipose tissue derived hormone, is known to have insulin-sensitizing, anti-inflammatory, and anti-atherogenic properties in the general population. Adiponectin secretion is suppressed by systemic inflammation, a highly prevalent condition in maintenance hemodialysis (MHD) patients. We evaluated whether short-term administration of interleukin 1 receptor antagonist (IL-1ra) improves adiponectin levels and insulin sensitivity in MHD patients. METHODS: Ad hoc analysis was performed on a pilot randomized placebo-controlled trial of the administration of IL-1ra in chronically inflamed MHD patients. Twenty-two patients were randomly assigned to receive 100 mg of IL-1ra or placebo (1:1) for 4 weeks, and 14 completed the trial. ANCOVA was used to compare percent change from baseline to 4 weeks. The primary outcome was percent change in adiponectin and the secondary outcomes were changes in leptin, homeostatic model assessment of insulin resistance (HOMA-IR) and the leptin-to-adiponectin ratio (LAR). RESULTS: Patients' mean age was 49 ± 13 years, and 71 % were males. At baseline, the median values for adiponectin, leptin, LAR and HOMA-IR were 11.5 µg/ml [interquartile range (IQR) 9, 28.5], 17.8 ng/ml (3.9, 50.0), 2.20 (0.13, 3.98), and 2.8 (2.0, 3.6), respectively. IL-1ra administration resulted in a mean percent increase in serum adiponectin of 22 % vs. 14 % decrease in the placebo arm (p = 0.003). Leptin, LAR or HOMA-IR levels did not change in either arm. CONCLUSIONS: Short-term administration of IL-1ra significantly increased adiponectin levels among prevalent MHD patients. The intervention did not impact insulin sensitivity parameters. Studies of longer duration and larger sample size are needed to further evaluate the potential effect of anti-inflammatory interventions on metabolic markers and insulin sensitivity in MHD patients.

Safety and immunogenicity of a 2009 influenza A (H1N1) vaccine in hemodialysis patients.

A worldwide vaccination campaign against the 2009 pandemic influenza A (H1N1) virus was launched among high-risk subjects, including hemodialysis patients. The long-term immunogenicity of an influenza vaccine has not been investigated in hemodialysis patients. This study aimed to (1) assess the long-term immunogenicity of a monovalent non-adjuvanted influenza A (H1N1) vaccine in hemodialysis patients and (2) determine the safety of this vaccine. We conducted a prospective cohort study of 44 hemodialysis patients and 149 healthy controls in 2010. All of the participants received a single dose of the monovalent non-adjuvanted 2009 influenza A (H1N1) vaccine. The level of antibodies was measured at baseline and at 4 and 24 weeks post-vaccination using a hemagglutination inhibition assay. The outcomes were the percentages of participants who achieved seroconversion and seroprotection (titer ≥ 1:40) 4 and 24 weeks after vaccination. At 4 weeks post-vaccination, seroconversion was observed in 17 (38.6%) of the hemodialysis patients and 94 (63.1%) of the controls (P=0.056), and protective titers were obtained in 22 (50%) of the hemodialysis patients and 100 (67.1%) of the controls (P=0.426). At 24 weeks post-vaccination, immunogenicity decreased in both the hemodialysis patients and the controls, but there were no significant differences between the hemodialysis patients and the controls in the seroconversion rate (27.3% versus 36.9%, P=0.526) or the seroprotection rate (38.6% versus 48.3%, P=0.996). No differences in adverse events were observed between the hemodialysis patients and the controls. In summary, the 2009 influenza A (H1N1) vaccine elicits a similar immune response in both hemodialysis patients and healthy controls, but immunity declines 24 weeks after vaccination in both groups. Hemodialysis patients should at least be vaccinated annually against the influenza virus.