MO1055JUDICIOUS DIALYSIS DISCONTINUATION IN CHRONIC KIDNEY DISEASE: LENDING MORE TIME TO ECONOMICALLY BURDENED PATIENTS IN DEVELOPING COUNTRY

Background and Aims Chronic kidney disease (CKD) is important public health problem owing to its high prevalence, morbidity, mortality and socio-economic burden. Patients with end stage kidney disease need to be on kidney replacement therapy which significantly impacts livelihood. Annual average cost of treatment for patients on dialysis is reported to be USD 3151 in developing country like India. It’s quiet high given per capita income of USD 1670 Method One hundred fifty one CKD Stage 5D patients from Punjab and Rajasthan states, North India were studied in this cross-sectional study. Patients initiated on dialysis within 3 months or protein energy wasting (as per criteria proposed by ISRNM) were excluded. Asymptomatic willing patients, clinically stable for at least 3 months and with pre-dialysis serum Creatinine <6mg/dl, serum potassium <5mg/dl were given a trial for dialysis discontinuation after informed written consent. Biochemical and hemodynamic parameters were measured weekly for 4 weeks and later once monthly. Patients who developed uremic features or rapid rise in serum creatinine were restarted on dialysis. Results Fourteen (9.27%) asymptomatic patients with well controlled blood pressure were discontinued from dialysis. Out of them, thirteen patients were on hemodialysis and one on peritoneal dialysis. Twelve (85.71%) out of them were presumed chronic interstitial nephritis while two (14.28%) were autosomal dominant polycystic kidney disease. Mean age of patients was 52.5 years (SD ±18.14 years). Most patients (11/14) were on three or more anti-hypertensive. Mean dialysis vintage was 8.14 months (range 4-16 months). Most patients were non-compliant to dialysis (Mean frequency once in seven days). Two patients were on once in two week dialysis schedule. Mean 24 hour urine output (calculated over 1 week) was 1500ml. Mean baseline serum creatinine was 4.4 mg/dl (SD ±1.06 mg/dl). Mean pre-dialysis serum potassium was 4.5 mg/dl (SD ±0.42 mg/dl). Post-discontinuation serum creatinine levels has been outlined in figure 1. Mean distance of dialysis centre from residence was 83.43 Km (range 1-240 km). One patient need to be restarted on dialysis at fourth week of dialysis discontinuation. Rest patients remained symptom-free and tolerated well. Conclusion CKD Stage5D patients should be regularly screened for residual renal function. Recovery of renal function could be seen in some (<10%) cases. Dialysis discontinuation in these cases would decrease their financial and stress burden. However, these cases should be monitored closely and followed-up regularly

Concomitant Use of Gabapentinoids with Opioids Is Associated with Increased Mortality and Morbidity among Dialysis Patients

Background: The opioid epidemic is a public health emergency and appropriate medication prescription for pain remains challenging. Physicians have increasingly prescribed gabapentinoids for pain despite limited evidence supporting their use. We determined the prevalence of concomitant gabapentinoid and opioid prescriptions and evaluated their associations with outcomes among dialysis patients. Methods: We used the United States Renal Data System to identify patients treated with dialysis with Part A, B, and D coverage for all of 2010. Patients were grouped into 4 categories of drugs exposure status in 2010: (1) no prescriptions of either an opioid or gabapentinoid, (2) ≥1 prescription of an opioid and no prescriptions of gabapentinoids, (3) no prescriptions of an opioid and ≥1 prescription of gabapenbtinoids, (4) ≥1 prescription of both an opioid and gabapentinoid. Outcomes included 2-year all-cause death, dialysis discontinuation, and hospitalizations assessed in 2011 and 2012. Results: The study population included 153,758 dialysis patients. Concomitant prescription of an opioid and gabapentin (15%) was more common than concomitant prescription of an opioid and pregabalin (4%). In adjusted analyses, concomitant prescription of an opioid and gabapentin compared to no prescription of either was associated with increased risk of death (hazard ratio [HR] 1.16, 95% CI 1.12–1.19), dialysis discontinuation (HR 1.14, 95% CI 1.03–1.27), and hospitalization (HR 1.33, 95% CI 1.31–1.36). Concomitant prescription of an opioid and pregabalin compared to no prescription of either was associated with increased mortality (HR 1.22, 95% CI 1.16–1.28) and hospitalization (HR 1.37, 95% CI 1.33–1.41), but not dialysis discontinuation (HR 1.13, 95% CI 0.95–1.35). Prescription of opioids and gabepentinoids compared to only being prescribed opioids was associated with higher risk of hospitalizations, but not mortality, or dialysis discontinuation. Conclusions: Concomitant prescription of opioids and gabapentinoids among US dialysis patients is common, and both drugs have independent effects on outcomes. Future research should prospectively investigate the potential harms of such drugs and identify safer alternatives for treatment of pain in end-stage renal disease patients.

Racial/Ethnic Differences in Dialysis Discontinuation and Survival after Hospitalization for Serious Conditions among Patients on Maintenance Dialysis

BackgroundRacial and ethnic minorities on dialysis survive longer than whites, and are less likely to discontinue dialysis. Both differences have been attributed by some clinicians to better health among minorities on dialysis.MethodsTo test if racial and ethnic differences in dialysis discontinuation reflected better health, we conducted a retrospective cohort study of survival and dialysis discontinuation among patients on maintenance dialysis in the US Renal Data System after hospitalization for either stroke (n=60,734), lung cancer (n=4100), dementia (n=40,084), or failure to thrive (n=42,950) between 2003 and 2014. We examined the frequency of discontinuation of dialysis and used simulations to estimate survival in minorities relative to whites if minorities had the same pattern of dialysis discontinuation as whites.ResultsBlacks, Hispanics, and Asians had substantially lower frequencies of dialysis discontinuation than whites in each hospitalization cohort. Observed risks of mortality were also lower for blacks, Hispanics, and Asians. In simulations that assigned discontinuation patterns similar to those found among whites across racial and ethnic groups, differences in survival were markedly attenuated and hazard ratios approached 1.0. Survival and dialysis discontinuation frequencies among American Indians and Alaska Natives were close to those of whites.ConclusionsRacial and ethnic differences in dialysis discontinuation were present among patients hospitalized with similar health events. Among these patients, survival differences between racial and ethnic minorities and whites were largely attributable to differences in the frequency of discontinuation of dialysis.

Conservative management for patients with chronic kidney disease refusing dialysis

ABSTRACT Estimates suggest that 20-30% of the deaths of patients with chronic kidney disease with indication to undergo dialysis occur after refusal to continue dialysis, discontinuation of dialysis or inability to offer dialysis on account of local conditions. Contributing factors include aging, increased comorbidity associated with chronic kidney disease, and socioeconomic status. In several occasions nephrologists will intervene, but at times general practitioners or family physicians are on their own. Knowledge of the main etiologies of chronic kidney disease and the metabolic alterations and symptoms associated to end-stage renal disease is an important element in providing patients with good palliative care. This review aimed to familiarize members of multidisciplinary care teams with the metabolic alterations and symptoms arising from chronic kidney disease treated clinically without the aid of dialysis.