Prevalence and predictors of heart failure among patients on maintenance hemodialysis therapy at Muhimbili National Hospital in Tanzania: a cross-sectional study

Background Heart failure among patients on hemodialysis therapy portends poor outcomes. Traditional risk factors like aging, hypertension and diabetes mellitus are relatively common in these patients and may not accurately predict the occurrence of heart failure. Such patients may have other factors that contribute to heart failure. This study aimed to investigate the prevalence and predictors of heart failure among patients on maintenance hemodialysis at Muhimbili National Hospital in Dar es Salaam, Tanzania. Results Among 160 patients on maintenance hemodialysis, 49 (30.6%) were female. The mean age of patients was 52.2 ± 13.3 years. Almost all patients had hypertension and 69 (43.1%) had diabetes mellitus. Heart failure was prevalent in 17 (10.6%) patients. On multivariate analysis, presence of angina, intradialytic hypertension, and anemia were independent predictors of heart failure. Patients with heart failure had significantly higher malnutrition inflammation scores and erythropoietin resistance indexes. Conclusions Heart failure among hemodialysis patients correlates with the presence of angina, intradialytic hypertension, and anemia. Patients with heart failure had a greater degree of malnutrition–inflammation complex, and erythropoietin resistance. Patients with these conditions require a thorough cardiac evaluation and appropriate treatment.

Neutrophil-to-Lymphocyte Ratio and Erythropoietin Resistance among Maintenance Hemodialysis Patients

<b><i>Introduction:</i></b> Neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) are recent prognostic biomarkers associated with inflammation. Increased erythropoiesis resistance index (ERI) may predict the risk of all-cause and cardiovascular mortality in hemodialysis (HD) patients. However, the roles of NLR and PLR in erythropoietin (EPO) responsiveness remain unclear in HD patients. This study aims to investigate the relationship between NLR and PLR and EPO responsiveness in maintenance HD patients. <b><i>Methods:</i></b> A total of 299 HD patients were included in this survey. Laboratory data and demographic details were collected. EPO responsiveness was evaluated by ERI. Pearson correlation analysis and logistic regressions were conducted to evaluate the factors that may be associated with EPO responsiveness. <b><i>Results:</i></b> The EPO responsiveness was positively related to ferritin and negatively related to serum albumin, lymphocytes, and hemoglobin. A multivariate linear regression revealed that only NLR (standardized β = 0.13, <i>p</i> = 0.024) but not PLR (standardized β = 0.107, <i>p</i> = 0.063) was correlated with a higher ERI. <b><i>Conclusion:</i></b> A higher NLR level was shown to be a cheaper method to predict worse EPO responsiveness in HD patients.

Anemia in heart failure: still an unsolved enigma

Background Anemia affects one-third of heart failure patients and is associated with increased morbidity and mortality. Despite being one of the commonest comorbidities associated with heart failure, there is a significant knowledge gap about management of anemia in the setting of heart failure due to conflicting evidence from recent trials. Main body The etiology of anemia in heart failure is multifactorial, with absolute and functional iron deficiency, decreased erythropoietin levels and erythropoietin resistance, inflammatory state and heart failure medications being the important causative factors. Anemia adversely affects the already compromised hemodynamics in heart failure, besides being commonly associated with more comorbidities and more severe disease. Though low hemoglobin levels are associated with poor outcomes, the correction of anemia has not been consistently associated with improved outcomes. Parenteral iron improves the functional capacity in iron deficient heart failure patients, the effects are independent of hemoglobin levels, and also the evidence on hard clinical outcomes is yet to be ascertained. Conclusion Despite all the research, anemia in heart failure remains an enigma. Perhaps, anemia is a marker of severe disease, rather than the cause of poor outcome in these patients. In this review, we discuss the current understanding of anemia in heart failure, its management and the newer therapies being studied.

Relationships among the Dosage of Erythropoiesis-Stimulating Agents, Erythropoietin Resistance Index, and Mortality in Maintenance Hemodialysis Patients

<b><i>Background:</i></b> Erythropoiesis-stimulating agents (ESAs) constitute an important treatment option for anemia in hemodialysis (HD) patients. We investigated the relationships among the dosage of ESA, erythropoietin resistance index (ERI) scores, and mortality in Chinese MHD patients. <b><i>Methods:</i></b> This multicenter observational retrospective study included MHD patients from 16 blood purification centers (<i>n</i> = 824) who underwent HD in 2011–2015 and were followed up until December 31, 2016. We collected demographic variables, HD parameters, laboratory values, and ESA dosages. Patients were grouped into quartiles according to ESA dosage to study the effect of ESA dosage on all-cause mortality. The ERI was calculated as follows: ESA (IU/week)/weight (kg)/hemoglobin levels (g/dL). We also compared outcomes among the patients stratified into quartiles according to ERI scores. We used the Cox proportional hazards model to measure the relationships between the ESA dosage, ERI scores, and all-cause mortality. Using propensity score matching, we compared mortality between groups according to ERI scores, classified as either &#x3e; or ≤12.80. <b><i>Results:</i></b> In total, 824 patients were enrolled in the study; 200 (24.3%) all-cause deaths occurred within the observation period. Kaplan-Meier analyses showed that patients administered high dosages of ESAs had significantly worse survival than those administered low dosages of ESAs. A multivariate Cox regression identified that high dosages of ESAs could significantly predict mortality (ESA dosage &#x3e;10,000.0 IU/week, HR = 1.59, 95% confidence intervals (CIs) (1.04, 2.42), and <i>p</i> = 0.031). Our analysis also indicated a significant increase in the risk of mortality in patients with high ERI scores. Propensity score matching-analyses confirmed that ERI &#x3e; 12.80 could significantly predict mortality (HR = 1.56, 95% CI [1.11, 2.18], and <i>p</i> = 0.010). <b><i>Conclusions:</i></b> Our data suggested that ESA dosages &#x3e;10,000.0 IU/week in the first 3 months constitute an independent predictor of all-cause mortality among Chinese MHD patients. A higher degree of resistance to ESA was related to a higher risk of all-cause mortality.

MO901ASSOCIATION OF MALNUTRITION AND INFLAMMATION WITH ERYTHROPOIETIN RESISTANCE INDEX

Background and Aims Erythropoietin Resistance Index (EPORI) has been previously associated with higher risk of mortality and morbidity in hemodialysis (HD) patients (pts). The objectives of this study were to identify which factors, such as the risk of malnutrition, are associated with EPORI and to assess its association with mortality and hospitalization risk. Method Historical cohort study in a group of high-flux HD pts from 25 outpatient HD clinics, starting from a baseline group of 2975 pts. We evaluated EPORI, interdialytic weigh gain (IDWG), Malnutrition Inflammation Score (MIS) and the other parameters at the study baseline. For a better understanding of weight gain patterns, we calculated the average of the IDWG at the day of monthly blood sample collection of the previous 3 months, values &gt;4% were considered high. A MIS&gt;5 indicated nutritional risk. Results We analyzed 2044 pts, 1148 (56%) males, 642 (31%) diabetic, with a mean age 68.4±14.12 years, a mean HD vintage 105±74 months and mean EPORI 7.23±7.51 (U/week/kg)/(g/dL). During a follow-up of 48 months, 719 pts (35%) died and 1291 pts (63%) were hospitalized at least once after baseline assessment, 531 pts and 400 pts were excluded because follow up was not possible and EPORI data was not available, respectively. ROC curve analysis identified different cut-off values for EPORI in relation with all-cause mortality and hospitalizations. Univariable analysis An EPORI&gt;5 was associated with higher MIS (7.06±3.9, vs 6.02±3.48, p&lt;0.001), higher IDWG (3.15±1.23 vs 1.26±1.09, p&lt;0.001), lower Hematocrit (Htc) (33.26±3.17 vs 33.69±2.61, p&lt;0.001), higher C-Reactive Protein (CRP) 14.94±24.45 vs 10.4±18.9, p&lt;0.001), female gender (57% vs 48%, p&lt;0.001), death (58% vs 49%, p&lt;0.001) and hospitalization (55% vs 47%, p&lt;0.001). When analyzing with Kaplan-Meier estimator using log-rank test to compare survival curves, mortality and hospitalizations were increased in all sub-groups with higher values for EPORI (cut-offs of 5 to 8) when compared, respectively, with lower EPORI values. Multivariable analysis The predictors of EPORI were MIS&gt;5 (OR 1.564, p&lt;0.001), IDWG (OR 1.234, p&lt; 0.001), CRP (OR 1.010, p&lt;0.001) and Htc (OR 0.948, p&lt;0.001). In similar models, adjusting for MIS&gt;5 (p&lt;0.001), gender (p&lt;0.001), age (p&lt;0.001), CRP (p&lt;0.001) and dialysis vintage (p&lt;0.001), different EPORI cut-off values were associated with higher risk of mortality and hospitalizations. Conclusion In the modern hemodialysis era, higher EPORI cut-off values were associated with a progressive higher risk of mortality and of hospitalization. The modification of the EPORI predictors that are susceptible to improvement, such as the nutritional and inflammation status, may contribute for a better prognosis in this population.

Erythropoietin Resistance Index and the Affecting Factors in Children with Peritoneal Dialysis

<b><i>Background:</i></b> Erythropoiesis-stimulating agents (ESAs) are used to treat anemia in CKD. Erythropoietin resistance index (ERI) is a useful tool used to evaluate the response to ESAs. In this study, we aimed to evaluate the causes of high ERI in children undergoing peritoneal dialysis (PD). <b><i>Method:</i></b> Patients who had been on PD for at least 1 year were included in this retrospective study. Demographic characteristics, residual kidney function (RKF), adequacy of dialysis, peritoneal glucose exposure, the number and reason for hospitalization, and medications were recorded. Anemia and laboratory parameters that may affect anemia were noted by taking the average of laboratory values in the last follow-up year (time-averaged). The weekly ESA dose was proportioned to the annual average hemoglobin value and body weight to calculate the ERI in terms of U/kg/week/g/dL. <b><i>Results:</i></b> A total of 100 patients were included in the study. The mean ESA dose and ERI value were 119.8 ± 66.22 U/kg/week and 13.01 ± 7.52 U/kg/week/g/dL, respectively. It was determined that the patients &#x3c;5 years of age have very high ERI value, and these patients need 2 times more ESA than those &#x3e;10 years of age. Absence of RKF, large number of hospitalization, and ACEI use were also found to affect the ERI value negatively. <b><i>Conclusion:</i></b> We demonstrate that the most important factor affecting ERI value is young age. We also reveal that absence of RKF, large number of hospitalization, and ACEI use are also important variables affecting the ERI value.

Assessment of Platelet/ Lymphocyte Ratio as a Predictor of Erythropoietin Resistance in Hemodialysis Patients

Background: Platelet / lymphocyte ratio has recently been investigated in different clinical conditions associated with hemodialysis and its association with other diseases has been assessed. The purpose of the study was to assess platelet lymphocyte ratio as a predictor of erythropoietin resistance in hemodialysis patients. Methods: The study population consisted of 60 hemodialysis patients, who were subdivided into two groups according to the response to erythropoietin stimulating agents (ESAs) .treatment. Group 1 included 30 patients treated with ESAs with good response to it and group 2 included 30 patients treated with ESAs but with resistance to it. The platelet/ lymphocyte ratio was calculated for each patient and compared between both groups. Results: Platelet lymphocyte ratio of group 2 was significantly higher compared to that of group 1 (P=0.001). Conclusion: PLR is a useful parameter to predict erythropoietin resistance in hemodialysis patients.

Using a generic definition of cachexia in patients with kidney disease receiving haemodialysis: a longitudinal (pilot) study

Background Research indicates that cachexia is common among persons with chronic illnesses and is associated with increased morbidity and mortality. However, there continues to be an absence of a uniformed disease-specific definition for cachexia in chronic kidney disease (CKD) patient populations. Objective The primary objective was to identify cachexia in patients receiving haemodialysis (HD) using a generic definition and then follow up on these patients for 12 months. Method This was a longitudinal study of adult chronic HD patients attending two hospital HD units in the UK. Multiple measures relevant to cachexia, including body mass index (BMI), muscle mass [mid-upper arm muscle circumference (MUAMC)], handgrip strength (HGS), fatigue [Functional Assessment of Chronic Illness Therapy (FACIT)], appetite [Functional Assessment of Anorexia/Cachexia Therapy (FAACT)] and biomarkers [C-reactive protein (CRP), serum albumin, haemoglobin and erythropoietin resistance index (ERI)] were recorded. Baseline analysis included group differences analysed using an independent t-test, dichotomized values using the χ2 test and prevalence were reported using the Statistical Package for the Social Sciences 24 (IBM, Armonk, NY, USA). Longitudinal analysis was conducted using repeated measures analysis. Results A total of 106 patients (30 females and 76 males) were recruited with a mean age of 67.2 years [standard deviation (SD) 13.18] and dialysis vintage of 4.92 years (SD 6.12). At baseline, 17 patients were identified as cachectic, having had reported weight loss (e.g. &gt;5% for &gt;6 months) or BMI &lt;20 kg/m2 and three or more clinical characteristics of cachexia. Seventy patients were available for analysis at 12 months (11 cachectic versus 59 not cachectic). The FAACT and urea reduction ratio statistically distinguished cachectic patients (P = 0.001). However, measures of weight, BMI, MUAMC, HGS, CRP, ERI and FACIT tended to worsen in cachectic patients. Conclusion Globally, cachexia is a severe but frequently underrecognized problem. This is the first study to apply the defined characteristics of cachexia to a representative sample of patients receiving HD. Further, more extensive studies are required to establish a phenotype of cachexia in advanced CKD.