Socioeconomic Determinants of Peripheral Arterial Disease in Dialysis Patients: A National-Level Analysis.

The incidence of hepatitis B virus (HBV) infection in dialysis populations has declined over recent decades, largely because of improvements in infection control and widespread implementation of HBV vaccination. Regardless, outbreaks of infection continue to occur in dialysis units, and prevalence rates remain unacceptably high. For a variety of reasons, dialysis patients are at increased risk of acquiring HBV. They also demonstrate different disease manifestations compared with healthy individuals and are more likely to progress to chronic carriage. This paper will review the epidemiology, modes of transmission and diagnosis of HBV in this population. Prevention and treatment will be discussed, with a specific focus on strategies to improve vaccination response, new therapeutic options and selection of patients for therapy.

To assess the impact of sociodemographic factors and comorbid conditions on access to renal transplantation for adult US dialysis patients with end-stage renal disease (ESRD). Cohort analytic study. Data on comorbid conditions at onset of ESRD were abstracted from patients' medical records and matched to sociodemographic and ESRD data from the United States Renal Data System database. United States Medicare dialysis population. Random, national sample of ESRD patients starting dialysis in 1986 and 1987 (n = 4118). Time to first renal transplant (living or cadaver donor) since onset of ESRD regressed with two nested Cox proportional hazards models, first against sociodemographic factors alone, and then against sociodemographic factors and comorbid conditions. Cardiovascular diseases are most predictive of who received a transplant; patients with coronary heart disease, congestive heart failure, or left ventricular hypertrophy showed lower transplantation rates relative to patients without the disease (relative rate [RR] = 0.65 to 0.80, P < .05 each). Obese patients and patients with peripheral vascular disease also showed lower transplantation rates (RR = 0.65 to 0.75, P < .05 each). Previously reported sociodemographic effects of lower transplantation rates for older patients, women, nonwhite patients, and lower income patients were confirmed (P < .01). Sociodemographic effects remained essentially unchanged when adjusted for comorbid conditions. These findings indicate that sociodemographics have strong independent effects on access to transplantation that cannot be explained away as "surrogate" effects related to comorbid factors. Furthermore, the results suggest that lower mortality rates for transplant recipients relative to dialysis patients are due, in part, to a healthier case mix among patients receiving transplants.

Introduction: There is lack of information whether waitlisted dialysis patients with peripheral vascular disease (PVD) benefit from kidney transplantation. Methods: We used a cohort of USRDS incident dialysis patients from 2001 to 2007, with follow-up through 2008. Patients with PVD and under the age of 70 were included and divided into three groups; PVD patients on dialysis, waitlisted and PVD patients who received a first transplant (deceased or living). We calculated the mean comorbidity risk score (CRS) to determine differences in health status inpatients on dialysis, waitlist and at transplantation. CRS comprised of history of diabetes mellitus, hypertension, hypercholesterolemia, myocardial infarction, cerebrovascular disease and age greater than 55 years, by assigning a value of 1 to each comorbidity at the time first service. The primary outcome was all cause mortality. Standardized Mortality Ratios (SMR) and hazard ratios of death were calculated for statistical comparisons between the 3 groups. Results: 23,699 incident dialysis patients met inclusion criteria; only 16.7% (n=3964) were waitlisted, of which 8.9 % (n=2121) were transplanted. The annual death rates per 100 patient years was 22.86 in PVD patients on dialysis, 4.98 in waitlisted PVD patients and 4.86 in kidney transplant recipients. There was significant differences in mean co-morbidity risk score (2.38± 0.018 vs. 2.30 ±0.020 p=0.003) but not in adjusted hazard ratio 1.10 (95% CI 0.89-1.33, p=0.41) vs. 1.05 (95% CI 0.79-1.39, p=0.75) between waitlisted and transplanted patients with PVD. Figure 1 shows patient survival in PVD patients.Figure: No Caption available.Conclusions: There was no survival advantage of transplantation compared to remaining on the waitlist in PVD patients.

Establishing guidelines for the appropriate preventive medical care for chronic dialysis patients requires consideration of many factors. These include the population's underlying risk factors and expected survival, the effectiveness of screening procedures in improving the duration and/or quality of life, and the potential for renal transplantation. Although many nephrologists order and direct routine cancer screening in their dialysis patients, recent studies suggest such screening is not cost effective. Cardiovascular disease is the leading cause of death among end-stage renal disease (ESRD) patients and peripheral vascular disease is a leading cause of morbidity among dialysis patients, but even less is known about the cost-effectiveness of screening for peripheral vascular and cardiovascular disease risks in ESRD patients. Despite a recently reported overall standardized cancer incidence of 1.18 in dialysis patients compared with normal populations, the shortened expected survival of dialysis patients argues against routine cancer screening in this population. Dialysis units and nephrologists should focus cancer screening on individual patients and include specific cancer risk as well as expected survival assessments and transplant candidacy in their decisions to screen a patient for cancer. Routine cancer screening of all dialysis patients is not indicated. Additional study of the benefits and cost-effectiveness of screening ESRD patients for cardiovascular and peripheral vascular disease risk factors is needed.

Background: Atherosclerosis is a major problem in end-stage renal disease (ESRD) patients treated by hemodialysis and the prevalence of carotid artery disease is much higher in this group than in the general population. Repeated exposure to cytokine-inducing material, derived from dialysate, may induce a chronic inflammatory state, that could contribute to the atherosclerotic process. Endotoxin is mainly cleared from plasma by the sCD14, the soluble form of the endotoxin receptor CD14. The levels of sCD14 are associated with a polymorphism, –159 C/T, of the CD14 gene. Methods and Results: We determined the genotype for the –159 C/T polymorphism in 158 haemodialysis patients and 168 healthy controls. In patients we investigated the association between the CD14 polymorphism and carotid artery disease. With a prospective follow-up study we assessed whether the CD14 polymorphism shows any relationship with cardiovascular mortality. The polymorphic frequency was comparable between patients and controls. In patients, we found a significant difference in the prevalence of carotid artery disease between groups divided by genotype: CC 87.0%, CT 71.7%, TT 48.9% (p = 0.0093). In dialysis patients with hypertension the CC polymorphism was associated with an increased cardiovascular mortality. Conclusions: These results demonstrate an association between the –159 C/T polymorphism of the CD14 gene and carotid artery disease in dialysis patients. We hypothesize that the low plasma clearance of endotoxin associated with the CC genotype facilitates the atherogenic action of endotoxin-derived cytokines in haemodialysis patients.

BackgroundIn March, 2007, a black box warning was issued by the Food and Drug Administration (FDA) to use the lowest possible erythropoiesis-stimulating agents (ESA) doses for treatment of anemia associated with renal disease. The goal is to determine if a change in ESA use was observed following the warning among US dialysis patients.MethodsESA therapy was examined from September 2004 through August 2009 (thirty months before and after the FDA black box warning) among adult Medicare hemodialysis patients. An interrupted time series model assessed the impact of the warnings.ResultsThe FDA black box warning did not appear to influence ESA prescribing among the overall dialysis population. However, significant declines in ESA therapy after the FDA warnings were observed for selected populations. Patients with a hematocrit ≥36% had a declining month-to-month trend before (−164 units/week, p = <0.0001) and after the warnings (−80 units/week, p = .001), and a large drop in ESA level immediately after the black box (−4,744 units/week, p = <.0001). Not-for-profit facilities had a declining month-to-month trend before the warnings (−90 units/week, p = .009) and a large drop in ESA dose immediately afterwards (−2,487 units/week, p = 0.015). In contrast, for-profit facilities did not have a significant change in ESA prescribing.ConclusionsESA therapy had been both profitable for providers and controversial regarding benefits for nearly two decades. The extent to which a FDA black box warning highlighting important safety concerns influenced use of ESA therapy among nephrologists and dialysis providers was unknown. Our study found no evidence of changes in ESA prescribing for the overall dialysis population resulting from a FDA black box warning.

Prevalence of cardiovascular disease in chronic renal failure Cardiovascular disease is now the leading cause of mortality among patients with chronic renal failure in Europe, the United States, and other developed countries. Approximately 60% of deaths among US dialysis patients can be attributed collectively to myocardial infarction, cardiac arrest, stroke, and ‘other cardiac causes’ (Table 1.1). Some international variation may exist, although qualitatively similar patterns have been reported in Europe.At all ages, the absolute mortality rates among dialysis patients are substantially higher than in the general population (Fig. 1.1).

Dialysis Discontinuation: Quo Vadis?

Osteogenic differentiation and calcification of human aortic smooth muscle cells is induced by the RCN2/STAT3/miR-155-5p feedback loop

Malnutrition is Associated with Increased Morbidity and Death in Dialysis Patients Undergoing Endovascular Therapy for Peripheral Artery Disease

Background: Kidney transplantation (KT) has been shown to enhance the quality of life, be more cost-effective, and reduce mortality in dialysis patients. We aimed to study the impact of pre-existing diabetes mellitus (DM) and peripheral arterial disease (PAD) on cardiovascular outcomes and mortality after kidney transplantation (KT). Materials and methods: A secondary USRDS (United States Renal Data System) analysis was performed from 2006 to 2017 in adult patients who underwent KT. The primary outcome was 3-year all-cause mortality, and secondary outcomes were myocardial infarction (MI), cerebrovascular accident, gangrene/limb ischemia, and graft failure. Adjusted hazard ratios were computed, and multivariate analysis was conducted. All p-values were 2-sided, and a value of <0.05 was deemed to be statistically significant. Statistical analyses were performed using the SAS 9.4 software. Results: A total of 51,009 patients with kidney transplants met the study inclusion/ exclusion criterion. Patients with both DM and PAD had the highest risk of mortality (15.3%, aHR 1.8, 1.6-2.0), followed by patients with PAD without DM (14.1%, aHR 1.6, 1.4-1.9), DM without PAD (9.9%, aHR 1.4, 1.3-2.6), and those without either DM or PAD (5.5%). MI was also higher in patients with DM and PAD (7.3%, aHR 1.8, 1.5-2.2), followed by DM alone (4.6%, aHR 1.58, 1.4-1.7), PAD alone (4.3%, aHR 1.14, 0.8-1.6), and no diabetes nor PAD (2.2%). Conclusions: In patients undergoing KT, those with pre-existing DM and/ or PAD have a significantly higher all-cause mortality and risk of MI.

Predialysis Nephrologist Care and Access to Kidney Transplantation in the United States

Human papillomavirus (HPV) causes the majority of cervical, anal/rectal, and oropharyngeal cancers in women. End-stage renal disease (ESRD) is also associated with an increased risk of malignancy, but the incidence...

A cross-sectional study of the prevalence and clinical correlates of congestive heart failure among incident US dialysis patients

Use of the Medical Differential Diagnosis to Achieve Optimal End-Stage Renal Disease Outcomes