Changes in Intraocular Pressure During Hemodialysis: A Meta-analysis.

PRCIS: Acetate dialysate causes elevation of intradialytic intraocular pressure (IOP) and contributed to the rise of IOP in the early years of hemodialysis (HD). Glaucoma, narrow-angle, or impaired aqueous outflow is another moderator causing a rise of intradialytic IOP. PURPOSE: Severe IOP elevation during HD has been described in many case reports. However, the results of primary studies are conflicting. This meta-analysis examined the impact of HD on IOP and explored the potential moderators. METHODS: Medline, PubMed, Embase, Web of Science, and Cochrane were systematically searched. Before-after studies reporting the change of IOP during HD were included. Intradialytic IOP changes were calculated based on 4 different definitions: highest-baseline, lowest-baseline, max-baseline, and end-baseline IOP difference. Standardized mean difference (SMD) was pooled using the random-effects model. RESULTS: Fifty-three studies involving 1903 participants and 2845 eyes were included. Overall data pooling showed no significant rise in intradialytic IOP. However, subgroup analysis showed an intradialytic IOP rise before 1986 (SMD: 0.593; 95% confidence interval: 0.169-1.018; max-baseline IOP difference as representative; most studies using acetate dialysate), no change between 1986 and 2005 (using both acetate and bicarbonate), and a decline after 2005 (SMD: -0.222; 95% confidence interval: -0.382 to -0.063; entirely using bicarbonate). Multivariable meta-regression showed only the type of dialysate, but not publication year or other potential factors, as a significant moderator. Glaucoma was found to be another significant moderator independent of the dialysate effect in bivariate meta-regression. CONCLUSIONS: IOP elevation in the early years of HD with the use of acetate dialysate is less of a clinical problem following its substitution with bicarbonate dialysate. However, physicians should still be cautious of potential IOP changes in the HD population with glaucoma.

Multidisciplinary care improves clinical outcome and reduces medical costs for pre-end-stage renal disease in Taiwan.

AIM: Multidisciplinary care (MDC) for patients with chronic kidney disease (CKD) may help to optimize disease care and improve clinical outcomes. Our study aimed to evaluate the effectiveness of pre-end-stage renal disease (ESRD) patients under MDC and usual care in Taiwan. METHOD: In this 3-year retrospective observational study, we recruited 822 ESRD subjects, aged 18 years and older, initiating maintenance dialysis more than 3 months from five cooperating hospitals. The MDC (n = 391) group was cared for by a nephrologists-based team and the usual care group (n = 431) was cared for by sub-specialists or nephrologists alone more than 90 days before dialysis initiation. Patient characteristics, dialysis modality, hospital utilization, hospitalization at dialysis initiation, mortality and medical cost were evaluated. Medical costs were further divided into in-hospital, emergency services and outpatient visits. RESULTS: The MDC group had a better prevalence in peritoneal dialysis (PD) selection, less temporary catheter use, a lower hospitalization rate at dialysis initiation and 15% reduction in the risk of hospitalization (P < 0.05). After adjusting for gender, age and Charlson Comorbidity Index score, there were lower in-hospital and higher outpatient costs in the MDC group during 3 months before dialysis initiation (P < 0.05). In contrast, medical costs (NT$ 146,038 vs 79,022) and hospitalization days (22.4 vs 15.5 days) at dialysis initiation were higher in the usual care group. Estimated medical costs during 3 months before dialysis till dialysis initiation, the MDC group yielded a reduction of NT$ 59,251 for each patient (P < 0.001). Patient mortality was not significantly different. CONCLUSION: Multidisciplinary care intervention for pre-ESRD patients could not only significantly improve the quality of disease care and clinical outcome, but also reduce medical costs.

Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study.

BACKGROUND: Previous studies have demonstrated that multidisciplinary pre-dialysis education and team care may slow the decline in renal function for chronic kidney disease (CKD). Our study compared clinical outcomes of CKD patients between multidisciplinary care (MDC) and usual care in Taiwan. METHODS: In this 3-year prospective cohort study from 2008 to 2010, we recruited 1056 CKD subjects, aged 20-80 years, from five hospitals, who received either MDC or usual care, had an estimated glomerular filtration rate (eGFR) <60 mL/min, were matched one to one with the propensity score including gender, age, eGFR and co-morbidity diseases. The MDC team was under-cared based on NKF K/DOQI clinical practice guidelines and the Taiwanese pre-end-stage renal disease (ESRD) care program. The incidence of progression to ESRD (initiation of dialysis) and mortality was compared between two groups. We also monitored blood pressure control, the rate of renal function decline, lipid profile, hematocrit and mineral bone disease control. RESULTS: Participants were prone to be male (64.8%) with a mean age of 65.1 years and 33.1 months of mean follow-up. The MDC group had higher prescription rates of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), phosphate binder, vitamin D3, uric acid lower agents and erythropoietin-stimulating therapy and better control in secondary hyperparathyroidism. The decline of renal function in advanced stage CKD IV and V was also slower in the MDC group (-5.1 versus -7.3 mL/min, P = 0.01). The use of temporary dialysis catheter was higher in the usual care group, and CKD patients under MDC intervention exhibited a greater willingness to choose peritoneal dialysis modality. A Cox regression revealed that the MDC group was associated with a 40% reduction in the risk of hospitalization due to infection, and a 51% reduction in patient mortality, but a 68% increase in the risk of initiation dialysis when compared with the usual care group. CONCLUSIONS: MDC patients were found to have more effective medication prescription according to K/DOQI guidelines and slower renal function declines in advanced/late-stage CKD. After MDC intervention, CKD patients had a better survival rate and were more likely to initiate renal replacement therapy (RRT) instead of mortality.

Effect of soya protein on serum lipid profile and lipoprotein concentrations in patients undergoing hypercholesterolaemic haemodialysis.

Clinical trials have shown that soya protein reduces the concentrations of some atherogenic lipids in subjects with normal renal function. The present study examined the effects of soya protein on serum lipid concentrations and lipoprotein metabolism in patients on hypercholesterolaemic haemodialysis. Twenty-six hypercholesterolaemic (total cholesterol > or =6.21 mmol/l) patients on haemodialysis were studied in a randomized, double-blind, placebo-controlled clinical trial. After a 4-week run-in phase, the subjects were randomly assigned to two groups. Isolated soya protein or milk protein 30 g was consumed daily as a beverage at breakfast or post-dialysis for 12 weeks. Soya protein substitution resulted in significant reductions in total cholesterol (17.2 (sd 8.9 )%), LDL-cholesterol (15.3 (sd 12.5 )%), apo B (14.6 (sd 12.1 )%) and insulin (23.8 (sd 18.7) %) concentrations. There were no significant changes in HDL-cholesterol or apo A-I. These results indicate that replacing part of the daily protein intake with soya protein has a beneficial effect on atherogenic lipids and favourably affects lipoprotein metabolism in hypercholesterolaemic patients undergoing haemodialysis.

Variable effects of soy protein on plasma lipids in hyperlipidemic and normolipidemic hemodialysis patients.

BACKGROUND: Hyperlipidemic factors contribute to the high cardiovascular risk in hemodialysis patients. Soy protein has decreased some atherogenic lipid concentrations in subjects with normal renal function. This study evaluates the effect of soy protein on serum lipid profiles in hyperlipidemic and normolipidemic hemodialysis patients. METHODS: Nineteen hyperlipidemic and 18 normolipidemic hemodialysis patients were enrolled in a randomized, double-blind, placebo-controlled, clinical trial. After a 4-week run-in phase, subjects in each category were randomly assigned to 2 groups. Thirty grams of isolated soy protein or milk protein was consumed daily as a beverage at breakfast or postdialysis for 12 weeks. RESULTS: In hyperlipidemic subjects, soy protein intake significantly decreased total cholesterol levels by 18.6% (95% confidence interval [CI], -11.4 to -25.8; P = 0.04), triglyceride levels by 43.1% (95% CI, -34.0 to -52.2; P = 0.02), non-high-density lipoprotein cholesterol levels by 23.6% (95% CI, -14.7 to -32.5; P < 0.01), apolipoprotein B levels by 15.4% (95% CI, -5.4 to -25.4; P = 0.01), and insulin levels by 49.8% (95% CI, -23.3 to -66.1; P < 0.01). Low-density lipoprotein cholesterol concentration was decreased significantly (-25.8%; 95% CI, -8.3 to -42.7; P = 0.01), and high-density lipoprotein cholesterol level was increased significantly (17%; 95% CI, 2 to 32.0; P = 0.03), but there was no significant difference compared with the milk protein group (-5.5% +/- 16.9% and 7.0% +/- 11.8%, respectively). There were no significant changes in serum lipid and lipoprotein concentrations in normolipidemic subjects. CONCLUSION: These results indicate soy protein substitution has lipid-lowering effects in hyperlipidemic hemodialysis patients. However, soy protein intake had little effect on plasma lipid levels in normolipidemic hemodialysis patients.