Patient Survival Between Hemodialysis and Peritoneal Dialysis Among End-Stage Renal Disease Patients Secondary to Myeloperoxidase-ANCA-Associated Vasculitis

BackgroundA significant proportion of anti-neutrophil cytoplasmic antibody (ANCA) associated glomerulonephritis eventually progresses to end-stage renal disease (ESRD) thus requiring long-term dialysis. There is no consensus about which dialysis modality is more recommended for those patients with associated vasculitis (AAV-ESRD). The primary objective of this study was to compare patient survival in patients with AAV-ESRD treated with hemodialysis (HD) or peritoneal dialysis (PD).MethodsThis double-center retrospective cohort study included dialysis-dependent patients who were treated with HD or PD. Clinical data were collected under standard format. The Birmingham vasculitis activity score (BVAS) was used to evaluate disease activity at diagnosis and organ damage was assessed using the vasculitis damage index (VDI) at dialysis initiation.ResultsIn total, 85 patients were included: 64 with hemodialysis and 21 with peritoneal dialysis. The patients with AAV-PD were much younger than the AAV-HD patients (48 vs. 62, P < 0.01) and more were female (76.2 vs. 51.6%, P = 0.05). The laboratory data were almost similar. The comorbidities, VDI score, and immuno-suppressive therapy at dialysis initiation were almost no statistical difference. Patient survival rates between HD and PD at 1 year were 65.3 vs. 90% (P = 0.062), 3 year were 59.6 vs. 90% (P < 0.001), and 5 years were 59.6 vs. 67.5% (P = 0.569). The overall survival was no significant difference between the two groups (P = 0.086) and the dialysis modality (HD or PD) was not shown to be an independent predictor for all-cause death (hazard ratio (HR) 0.73; 95% confidence interval (CI) 0.31–1.7; P = 0.473). Cardio-cerebrovascular events were the main cause of death among AAV-HD patients while infection in patients with AAV-PD.ConclusionThese results provide real-world data that the use of either hemodialysis or peritoneal dialysis modality does not affect patient survival for patients with AAV-ESRD who need long-term dialysis.

Comparison of Outcomes among Chronic Kidney Disease V Patients with COVID-19 at the National Kidney and Transplant Institute: A Retrospective Cohort Study

Background. There is very little published data on outcomes of COVID-19 among chronic kidney disease (CKD) patients. We compared the outcomes of COVID-19 in a tertiary care renal hospital among CKD V patients on hemodialysis (HD), peritoneal dialysis (PD), and dialysis initiation, in terms of duration of hospitalization, in-patient mortality, and 30-day mortality. Methods. A total of 436 CKD V patients, on either HD, PD, or dialysis initiation, with COVID-19 who were admitted at the National Kidney and Transplant Institute (NKTI) from March 13, 2020, to August 31, 2020, were included. Kaplan–Meier survival analysis was performed. Comparison of probability of mortality by group was performed using Log-Rank test. p values ≤0.05 were considered statistically significant. Results. Among 436 CKD V patients, 298 (68%) were on HD, 103 (24%) were on PD, and 35 (8%) required dialysis initiation. Overall in-hospital mortality was 34%; 38% were on HD, 20% on PD, and 37% on dialysis initiation. Total 30-day mortality was 27%; 32% were on HD, 26% on PD, and 16% on dialysis initiation. Median follow-up was 24 days. Among the 137 deaths recorded, total median time to death was 10 days; 8.5 days, 15.5 days, and 9 days for HD, PD, and dialysis initiation groups, respectively. Probability of mortality was significantly higher in HD patients versus PD patients ( p < 0.00001 ) and in the dialysis initiation group compared to PD patients ( p = 0.0234 ). Mortality probability, however, was not significantly different in HD patients versus the dialysis initiation group ( p = 0.63 ). Conclusion. Among CKD V patients diagnosed with COVID-19 at the NKTI, those on HD and on dialysis initiation had significantly higher in-hospital and 30-day mortality, compared to patients on PD.

Tracing all patients who received insured dialysis treatment in Japan and the present situation of their number of deaths

Background The survival rate of chronic dialysis patients in Japan remains the highest worldwide, so there is value in presenting Japan’s situation internationally. We examined whether aggregate figures on dialysis patients in the National Database of Health Insurance Claims and Special Health Checkups of Japan (NDB), which contains data on insured procedures of approximately 100 million Japanese residents, complement corresponding figures in the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR). Methods Subjects were patients with medical fee points for dialysis recorded in the NDB during 2014–2018. We analyzed annual numbers of dialysis cases, newly initiated dialysis cases– and deaths. Results Compared with the JRDR, the NDB had about 6–7% fewer dialysis cases but a similar number of newly initiated dialysis cases. In the NDB, the number of deaths was about 6–10% lower, and the number of hemodialysis cases was lower, while that of peritoneal dialysis cases was higher. The cumulative survival rate at dialysis initiation was approximately 6 percentage points lower in the NDB than in the JRDR, indicating that some patients die at dialysis initiation. Cumulative survival rate by age group was roughly the same between the NDB and JRDR in both sexes. Conclusion The use of the NDB enabled us to aggregate data of dialysis patients. With the definition of dialysis patients used in this study, analyses of concomitant medications, comorbidities, surgeries, and therapies will become possible, which will be useful in many future studies.

Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study

Objective To identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease. Design Nationwide observational cohort study. Setting National Swedish Renal Registry of patients referred to nephrologists. Participants Patients had a baseline eGFR between 10 and 20 mL/min/1.73 m 2 and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017. Main outcome measures The strict design criteria of a clinical trial were mimicked by using the cloning, censoring, and weighting method to eliminate immortal time bias, lead time bias, and survivor bias. A dynamic marginal structural model was used to estimate adjusted hazard ratios and absolute risks for five year all cause mortality and major adverse cardiovascular events (composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) for 15 dialysis initiation strategies with eGFR values between 4 and 19 mL/min/1.73 m 2 in increments of 1 mL/min/1.73 m 2 . An eGFR between 6 and 7 mL/min/1.73 m 2 (eGFR 6-7 ) was taken as the reference. Results Among 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m 2 ), 3822 started dialysis, 4160 died, and 2446 had a major adverse cardiovascular event. A parabolic relation was observed for mortality, with the lowest risk for eGFR 15-16 . Compared with dialysis initiation at eGFR 6-7 , initiation at eGFR 15-16 was associated with a 5.1% (95% confidence interval 2.5% to 6.9%) lower absolute five year mortality risk and 2.9% (0.2% to 5.5%) lower risk of a major adverse cardiovascular event, corresponding to hazard ratios of 0.89 (95% confidence interval 0.87 to 0.92) and 0.94 (0.91 to 0.98), respectively. This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up. However, dialysis would need to be started four years earlier. When emulating the intended strategies of the Initiating Dialysis Early and Late (IDEAL) trial (eGFR 10-14 v eGFR 5-7 ) and the achieved eGFRs in IDEAL (eGFR 7-10 v eGFR 5-7 ), hazard ratios for all cause mortality were 0.96 (0.94 to 0.99) and 0.97 (0.94 to 1.00), respectively, which are congruent with the findings of the randomised IDEAL trial. Conclusions Very early initiation of dialysis was associated with a modest reduction in mortality and cardiovascular events. For most patients, such a reduction may not outweigh the burden of a substantially longer period spent on dialysis.

The ratio of measured to estimated glomerular filtration rate may be a marker of early mortality and dialysis requirement

Background It has been suggested that, in patients with CKD stage 5, measured GFR (mGFR), defined as the mean of urea and creatinine clearance, as measured by a 24-h urine collection, is a better measure of renal function than estimated GFR (eGFR), based on the CKD-EPI formula. This could be due to reduced muscle mass in this group. Its use is recommended in the ERBP guidelines. Unplanned dialysis initiation (DI) is associated with increased morbidity, mortality, and reduced modality choice and is generally considered undesirable. We hypothesized that the ratio mGFR/eGFR (M/E) aids prediction of death and DI. Methods All 24-h measurements of urea and creatinine excretion were extracted from the clinical biochemistry databases in Zealand. Data concerning renal diagnosis, comorbidity, biochemistry, medical treatment, mortality and date of DI, were extracted from patient notes, the National Patient Registry and the Danish Nephrology Registry. Patients were included if their eGFR was < 30 ml/min/1.73m2. The last available value for each patient was included. Follow-up was 12 months. Results One thousand two hundred sixty-five patients were included. M/E was median 0.91 ± 0.43. It was highly correlated to previous determinations. It was negatively correlated to eGFR, comorbidity, high age and female sex. It was positively related to albumin and negatively to C-reactive protein. M/E was higher in patients treated with ACE inhibitors and diuretics but no other treatment groups. On a multivariate analysis, M/E was negatively correlated with mortality and combined mortality/DI, but not DI. A post hoc analysis showed a negative correlation to DI at 3 months. For patients with an eGFR 10–15 ml/min/1.73m2, combined mortality and DI at 3 months was for low M/E (< 0.75) 36%, medium (0.75–1.25) 20%, high (> 1.25) 8%. A low M/E predicted increased need for unplanned DI. A supplementary analysis in 519 patients where body surface area values were available, allowing BSA-corrected M/E to be analyzed, revealed similar results. Conclusion A low mGFR/eGFR ratio is associated with comorbidity, malnutrition, and inflammation. It is a marker of early DI, mortality, and unplanned dialysis initiation, independently of eGFR, age and comorbidity. Particular attention paid to patients with a low M/E may lower the incidence of unplanned dialysis requirement.

Morbidity and Mortality Associated with Hemodialysis Versus Peritoneal Dialysis in Patients with End Stage Renal Disease Caused By Sickle Cell Disease

Background: End stage renal disease (ESRD) is a common complication of sickle cell disease (SCD), contributing to 14% mortality. Most patients with ESRD are managed with dialysis. The relative risk of mortality in hemodialysis (HD) versus peritoneal dialysis (PD) may be influenced by the primary cause of ESRD (Vonesh et al, 2004). The purpose of this study is to compare patients with ESRD primarily caused by SCD (SCD-ESRD) to non-SCD-ESRD controls and to evaluate the association of dialysis type with mortality and hospitalization in SCD-ESRD patients. Methods: This was a retrospective study of SCD-ESRD patients newly initiated on dialysis in the United States Renal Data System between January 1, 2006 and December 31, 2013. SCD-ESRD patients were identified by ICD-9 codes. A sample of 5% of African Americans with incident ESRD caused by conditions other than SCD (non-SCD-ESRD cohort) initiated within the same timeframe were randomly selected as controls. Patient demographics, comorbidities, and dialysis type were compared between SCD and controls. Patient demographics, clinical characteristics, and outcomes were compared between HD and PD patients in the SCD-ESRD cohort. Chi-square, t-test, and Wilcoxon rank sum tests were used for comparative analysis. Survival times were estimated by Kaplan Meier curve and compared using log rank test. Results: 768 SCD-ESRD and 12,402 non-SCD-ESRD patients were included in analysis. SCD-ESRD patients started dialysis at a younger age (44±12.9 vs 58.6±15.4 years; p&lt;0.001), were more likely to be unemployed (44% vs 29.7%; p&lt;0.001) and have Medicaid insurance (55% vs 33%; p&lt;0.001). Most common comorbidities in SCD-ESRD patients were hypertension (71%) and congestive heart failure (26%) and in controls were hypertension (89.3%) and diabetes (61.3%). SCD-ESRD patients had twice the odds of being initiated on PD compared to controls (11.3% vs 5.7%, OR 2.11, p&lt;0.001). Demographics, comorbidities, laboratory values, access to nephrology care prior to dialysis initiation, survival, hospitalization, and kidney transplantation of HD and PD patients in the SCD-ESRD cohort are shown in Table 1. Kaplan Meier survival plot is shown in Figure 1. PD patients were more likely to be female, have full time employment and employer insurance, be students, have lower glomerular filtration rate, and have congestive heart failure as a comorbidity. They were also 1.6 and 1.9 times more likely to have been seen by a nephrologist and received erythropoietin prior to dialysis initiation respectively (p&lt;0.001). PD patients had significantly better survival rates at year 1 (88.5% vs 75.9%, p=0.01). Survival rates were still higher in PD patients at years 3 and 5 although not statistically significant. HD and PD patients were hospitalized equally within a year of dialysis initiation however, HD patients had more intensive care unit (ICU) stays (p=0.003) and ~1.5 times the number of hospitalizations per person. More PD patients had been informed about (90.8% vs 80.47%, p=0.019) and listed for (42.5% vs 19.1%, p&lt;0.001) transplant although no patients in this study had undergone a kidney transplant within the 5 year follow up. Discussion: SCD-ESRD patients in this study were more likely to be started on PD compared to non-SCD-ESRD patients. This could be explained by the younger age of SCD-ESRD patients as younger individuals are more likely to be started on PD in the general ESRD literature. SCD-ESRD patients started on PD had better survival and hospitalization outcomes particularly within the first year of dialysis initiation when mortality and morbidity is known to be high in ESRD. These results suggest a survival benefit of PD over HD in SCD-ESRD patients. This could perhaps be explained by decreased likelihood of vaso-occlusive events due to less fluid shifts and thus hematocrit fluctuations in the PD group (Boyle et al, 2016). A limitation of our study is that we do not have data on the possibility of individuals switching dialysis modalities (crossovers) over the course of follow up that could bias survival rates in either direction. A next step would be to look at the same outcomes in individuals who switch. Moreover, a prospective observational study or randomized control trial could further evaluate differential survival rates in HD versus PD initiation in SCD and inform guidelines in SCD-ESRD care. Acknowledgement: Support was provided to MKS by the Minority Resident Hematology Award Program. Figure 1 Figure 1. Disclosures Achebe: Pharmacosmos: Membership on an entity's Board of Directors or advisory committees; Fulcrum Therapeutics: Consultancy; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees.

Disease Activity and Adverse Events in Patients with ANCA-Associated Vasculitides Undergoing Long-Term Dialysis

Background and objectivesKidney impairment of ANCA-associated vasculitides can lead to kidney failure. Patients with kidney failure may suffer from vasculitis relapses but are also at high risk of infections and cardiovascular events, which questions the maintenance of immunosuppressive therapy.Design, setting, participants, & measurementsPatients with ANCA-associated vasculitides initiating long-term dialysis between 2008 and 2012 in France registered in the national Renal Epidemiology and Information Network registry and paired with the National Health System database were included. We analyzed the proportion of patients in remission off immunosuppression over time and overall and event-free survival on dialysis (considering transplantation as a competing risk). We compared the incidence of vasculitis relapses, serious infections, cardiovascular events, and cancers before and after dialysis initiation.ResultsIn total, 229 patients were included: 142 with granulomatous polyangiitis and 87 with microscopic polyangiitis. Mean follow-up after dialysis initiation was 4.6±2.7 years; 82 patients received a kidney transplant. The proportion of patients in remission off immunosuppression increased from 23% at dialysis initiation to 62% after 5 years. Overall survival rates on dialysis were 86%, 69%, and 62% at 1, 3, and 5 years, respectively. Main causes of death were infections (35%) and cardiovascular events (26%) but not vasculitis flares (6%). The incidence of vasculitis relapses decreased from 57 to seven episodes per 100 person-years before and after dialysis initiation (P=0.05). Overall, during follow-up, 45% of patients experienced a serious infection and 45% had a cardiovascular event, whereas 13% experienced a vasculitis relapse.ConclusionsThe proportion of patients with ANCA-associated vasculitis in remission off immunosuppression increases with time spent on dialysis. In this cohort, patients were far less likely to relapse from their vasculitis than to display serious infectious or cardiovascular events.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_11_08_CJN03190321.mp3

Peritoneal dialysis vs. hemodialysis: The choice of modality of dialysis may drastically affect the quality of life of patients initiating dialysis

A clinical decision report using Jung HY, Jeon Y, Park Y, et al. Better Quality of Life of Peritoneal Dialysis compared to Hemodialysis over a Two-year Period after Dialysis Initiation. Sci Rep. Jul 16 2019;9(1):10266. https://doi.org/10.1038/s41598-019-46744-1 for a young patient initiating dialysis.

A massive natural disaster, the Great East Japan Earthquake, and the incidence of dialysis due to end-stage kidney disease

Background Disaster-related stress can increase blood pressure and the incidence of cardiovascular diseases. However, the role of massive disasters in the development of end-stage kidney disease (ESKD) remains unknown. We investigated the incidence and different causes of dialysis initiation in patients with chronic kidney disease in a city affected by the Great East Japan Earthquake. Methods This was a single-center, retrospective observational study. All patients who initiated or were treated with dialysis at Kesennuma City Hospital between 2007 and 2020 were enrolled. The year of dialysis initiation was retrospectively determined based on the initiation date. The causative renal diseases that led to the need for dialysis initiation were divided into four groups: diabetic nephropathy, hypertensive renal disease, glomerulonephritis, and others. Results Age at dialysis initiation differed significantly among the four groups (p = 0.0262). There was a significant difference in the numbers of the four groups before and after the Great East Japan Earthquake (p = 0.0193). The age of hypertensive renal disease patients was significantly higher than those of patients with diabetic nephropathy (p = 0.0070) and glomerulonephritis (p = 0.0386) after the disaster. The increasing number of dialysis initiations after the Great East Japan Earthquake appeared to be associated with changes in hypertensive renal diseases; the number peaked after 10 years. Conclusions There was an increase in the number of dialysis initiations, especially caused by hypertensive renal diseases, for up to 10 years after the Great East Japan Earthquake. Graphic abstract

Changes in Treatment of Patients with Incident End-Stage Kidney Disease During the Novel Coronavirus Disease 2019 Pandemic

Background: The COVID-19 pandemic caused major disruptions to care for patients with advanced CKD. Methods: We investigated the incidence of documented ESKD, ESKD treatment modalities, changes in eGFR at dialysis initiation, and use of incident central venous catheters (CVCs) by epidemiologic week during the first half of 2020 compared to 2017-2019 historical trends, using Centers for Medicare & Medicaid Services data. We used Poisson and logistic regression for analyses of incidence and binary outcomes, respectively. Results: Incidence of documented ESKD dropped dramatically in 2020 compared with the expected incidence, particularly during epidemiologic weeks 15-18 (April; incidence rate ratio [IRR] 0.75, 95% CI 0.73-0.78). The decrease was most pronounced for individuals aged ≥75 years (IRR 0.69, 0.66-0.73). Preemptive kidney transplantation decreased markedly during weeks 15-18 (IRR 0.56, 0.46-0.67). Mean eGFR at dialysis initiation decreased by 0.33 mL/min/1.73 m2 in weeks 19-22; non-Hispanic Black patients exhibited the largest decrease, at 0.61 mL/min/1.73 m2. The odds of initiating dialysis with eGFR <10 ml/min/1.73 m2 were highest during weeks 19-22 (May; OR 1.14, 1.05-1.17), corresponding to an absolute increase of 2.9%. The odds of initiating peritoneal dialysis (versus hemodialysis) were 24% higher (OR 1.24, 1.14-1.34) in weeks 11-14, an absolute increase of 2.3%. Initiation with a CVC increased by 3.3% (OR 1.30, 1.20-1.41). Conclusions: During the first wave of the COVID-19 pandemic, the number of patients starting treatment for ESKD fell to a level not observed since 2011. Changes in documented ESKD incidence and other aspects of ESKD-related care may reflect differential access to care early in the pandemic.