Patient perspectives on peritoneal dialysis (PD) and the PD catheter: Strategies and Solutions.

INTRODUCTION: Peritoneal dialysis (PD) catheter complications reduce quality of life and increase risks for hospitalizations, for unplanned transitions to haemodialysis and for death. Patient PD catheter management is crucial for safe, sustained PD. Patient perspectives on strategies for living with PD and using a PD catheter may inform efforts to reduce PD catheter complications, increase individual patient PD modality persistence, and thus increase overall home dialysis prevalence. METHODS: We interviewed 32 adult PD patients in Nashville, Tennessee. Qualitative analyses included (1) isolation of themes, (2) development of a coding system and (3) creation of a conceptual framework using an inductive-deductive approach. RESULTS: Challenges identified by patients as important included drain pain, difficulty eating and sleeping, and fear of peritonitis. Coping strategies included repositioning while draining, adjusting eating patterns, and development of PD patient and helper knowledge and confidence, especially at home after initial training. Patients described a trial-and-error iterative process of trying multiple strategies with input from multiple sources, which led to individualised solutions. CONCLUSIONS: The trial-and-error process may be crucial for maintaining PD. Individual patient success with PD may be promoted by creating expectations during training that a solution may require multiple attempts, and by a reimbursement policy that supports robust nursing support for safe progression through the trial-and-error process, particularly in the first few months for incident patients. Interventions to support patient motivation and optimal coping behaviour may also support an increase in PD modality duration for individual patients, and thus increase overall PD prevalence.

A Cross-sectional Study of Fixed and Growth Mindset in Adult Peritoneal Dialysis Patients.

Increasing home dialysis prevalence is an international priority. Many patients start peritoneal dialysis, then transition to hemodialysis after complications. New strategies are needed to support modality persistence. Health mindset refers to individual belief about capacity to change to improve health. Mindset was measured in a cross-section of 101 adult peritoneal dialysis patients from April 2019 to June 2020. The Health Mindset Scale was administered to characterize the continuum of fixed vs. growth mindset with respect to health. Health literacy and health self-efficacy were also assessed. Participants were 43% female, 32% African American, and 42% diabetic. Health mindset scores were skewed toward growth (range 3-18), with average (SD) 12.83 (4.2). Growth mindset was strongly associated with health self-efficacy. Adults receiving peritoneal dialysis report health mindset variation. Growth mindset and health self-efficacy correlation suggests measurement of similar constructs, demonstrating convergent validity. The Health Mindset Scale may identify individuals who could benefit from targeted interventions to improve mindset, and foster peritoneal dialysis modality persistence.

Psychological Adaptation to Serious Illness: A Qualitative Study of Culturally Diverse Patients With Advanced Chronic Kidney Disease.

CONTEXT: Psychological distress is associated with adverse health outcomes in serious illness and magnified among patients of low socioeconomic status. Aspects of one's culture, such as religion and spirituality, can influence these patients' coping response to distress. Advanced chronic kidney disease (CKD) is a serious illness that disproportionately affects patients of low socioeconomic status, but a theory-based understanding of this group's lived experience of CKD is lacking. OBJECTIVES: We explored the cognitions, emotions, and coping behaviors of patients with CKD with emphasis on those of low socioeconomic status. We further inquired into any influences of religion or spirituality. METHODS: We interviewed 50 English-speaking or Spanish-speaking adults with advanced CKD from three medical centers in Nashville, Tennessee. Analyses occurred with isolation of themes; development of a coding system; and creation of a conceptual framework using an inductive-deductive approach. RESULTS: Median age was 65 years; median annual income was $17,500 per year; and 48% of participants had not progressed beyond high school. Key beliefs (awareness of mortality and lack of control) influenced patients' emotions (existential distress in the form of death anxiety, prognostic uncertainty, and hopelessness) and coping behaviors (acceptance, avoidance, emotion regulation via spirituality, and seeking socialsupport via a religious community). CONCLUSION: Individuals with advanced CKD and low socioeconomic status lack control over disease progression, experience death anxiety and existential distress, and emphasize spirituality to cope. Our study identifies novel components for a psychotherapeutic intervention for patients with advanced CKD at high risk for adverse health outcomes.

Barriers to home dialysis: Unraveling the tapestry of policy.

Home dialysis use as a treatment for end-stage kidney disease varies locally, nationally, and internationally. There is a call to action in the United States to significantly increase access and uptake of home dialysis as the preferred dialysis treatment option. Although most do not object to patient choice in modality selection, the reality is that there are multilevel barriers both obvious and subtle that interfere with expanding home dialysis access. Financial barriers and how payment is structured continue to be key drivers, although new models of care are emerging that include for the first time incentives rather than penalties regarding home dialysis. Resources to support implementation include expert personnel requiring educational training. Policies requiring training curriculum content that is not only specified within nephrology but also for these multidisciplinary providers requisite for successful home dialysis to ensure professional expertise is ready and available, and also to cultivate champions of home modality within the broader nephrology community. Perhaps most importantly, innovation through expanded investment in research is necessary to advance practices, elevate quality, and improve outcomes. Policy in a variety of sectors at local, regional, national, and international levels has the potential to drastically drive expansion and increasing success of home dialysis.

Quantifying the risk of insertion-related peritoneal dialysis catheter complications following laparoscopic placement: Results from the North American PD Catheter Registry.

BACKGROUND: Peritoneal dialysis (PD) is a more cost-effective therapy to treat kidney failure than in-center hemodialysis, but successful therapy requires a functioning PD catheter that causes minimal complications. In 2015, the North American Chapter of the International Society for Peritoneal Dialysis established the North American PD Catheter Registry to improve practices and patient outcomes following PD catheter insertion. AIMS: The objective of this study is to propose a methodology for defining insertion-related complications that lead to significant adverse events and report the risk of these complications among patients undergoing laparoscopic PD catheter insertion. METHODS: Patients undergoing laparoscopic PD catheter insertion were enrolled at 14 participating centers in Canada and the United States and followed using a Web-based registry. Insertion-related complications were defined as flow restriction, exit-site leak, or abdominal pain at any point during follow-up. We also included infections or bleeding within 30 days of insertion, and any immediate postoperative complications. Adverse events were categorized as PD never starting or termination of PD therapy, delay in the start of PD therapy or interruption of PD therapy, an emergency department visit or hospitalization, or need for invasive procedures. Cause-specific cumulative incidence functions were used to estimate risk. RESULTS: Five hundred patients underwent laparoscopic PD catheter insertion between 10 November 2015 and 24 July 2018. The cumulative risk of insertion-related complications 6 months from the date of insertion that led to an adverse event was 24%. The risk of flow restriction, exit-site leak, and pain at 6 months was 10.2%, 5.7%, and 5.3%, respectively. PD was never started or terminated in 6.4% of patients due to an insertion-related complication. Leaks and flow restrictions were most likely to delay or interrupt PD therapy. Flow restrictions were the primary cause of invasive procedures. Fifty percent of the complications occurred before the start of PD therapy. CONCLUSIONS: Insertion-related complications leading to significant adverse events following laparoscopic placement of PD catheters are common. Many complications occur before the start of PD. Insertion-related complications are an important area of focus for future research and quality improvement efforts.

Incorporating patient-reported outcomes (PROs) into dialysis policy: Current initiatives, challenges, and opportunities.

Governments at national and state levels regulate dialysis care in the United States to ensure safe practices, and continually elevate the quality of care. An objective of these regulatory policies is the independent evaluation of dialysis unit outcomes by patients, caregivers, and the community to facilitate choices as well as to advance equal access to high quality dialysis care. These polices recognized decades ago that it was fundamental to include the patient perspective in the assessment and evaluation of dialysis care quality by requiring both individual and aggregate patient reported outcomes (PROs). Although there is support for integrating the patient perspective, concerns persist about the implementation of these polices including selection of PRO measures, administration timing and reach, as well as interpretation of results including benchmarking to permit comparisons across organizations. The experience from the early adoption of PROs into dialysis policies in conjunction with advances in electronic health records, personal data capture and monitoring, and analytics is poised to address these concerns. The dialysis community has the opportunity to lead the way in innovation related to PRO implementation not only in kidney disease care, but also for other healthcare conditions or contexts such as oncology, surgical, and acute care.

Livedoid Dermatitis Treated With Nifedipine.

Intravenous injection of buprenorphine as a cause of livedoid dermatitis is a recently described phenomenon. This report reviews the brief literature of this finding, and presents a case of livedoid dermatitis of both heels following injection more than one day prior, and thesuccessful treatment with nifedipine monotherapy.

Catheter Insertion and Perioperative Practices Within the ISPD North American Research Consortium.

UNLABELLED: ♦ BACKGROUND: In general, efforts to standardize care based on group consensus practice guidelines have resulted in lower morbidity and mortality. Although there are published guidelines regarding insertion and perioperative management of peritoneal dialysis (PD) catheters, variation in practice patterns between centers may exist. The objective of this study is to understand variation in PD catheter insertion practices in preparation for conducting future studies. ♦ METHODS: An electronic survey was developed by the research committee of the International Society for Peritoneal Dialysis - North American Research Consortium (ISPD-NARC) to be completed by physicians and nurses involved in PD programs across North America. It consisted of 45 questions related to 1) organizational characteristics; 2) PD catheter insertion practices; 3) current quality-improvement initiatives; and 4) interest in participation in PD studies. Invitation to participate in the survey was given to nephrologists and nurses in centers across Canada and the United States (US) identified by participation in the inaugural meeting of the ISPD-NARC. Descriptive statistics were applied to analyze the data. ♦ RESULTS: Fifty-one ISPD-NARC sites were identified (45% in Canada and 55% in the US) of which 42 responded (82%). Center size varied significantly, with prevalent PD population ranging from 6 - 300 (median: 60) and incident PD patients in the year prior to survey administration ranging from 3 - 180 (median: 20). The majority of centers placed fewer than 19 PD catheters/year, with a range of 0 - 50. Availability of insertion techniques varied significantly, with 83% of centers employing more than 1 insertion technique. Seventy-one percent performed laparoscopic insertion with advanced techniques (omentectomy, omentopexy, and lysis of adhesions), 62% of sites performed open surgical dissection, 10% performed blind insertion via trocar, and 29% performed blind placement with the Seldinger technique. Use of double-cuff catheters was nearly universal, with a near even distribution of catheters with pre-formed bend versus straight inter-cuff segments. There was also variation in the choice of perioperative antibiotics and perioperative flushing practices. Although 86% of centers had quality-improvement initiatives, there was little consensus as to appropriate targets. ♦ CONCLUSIONS: There is marked variability in PD catheter insertion techniques and perioperative management. Large multicenter studies are needed to determine associations between these practices and catheter and patient outcomes. This research could inform future trials and guidelines and improve practice. The ISPD-NARC is a network of PD units that has been formed to conduct multicenter studies in PD.

Phosphate binder pill burden, patient-reported non-adherence, and mineral bone disorder markers: Findings from the DOPPS.

Because of multiple comorbidities, hemodialysis (HD) patients are prescribed many oral medications, including phosphate binders (PBs), often resulting in a high "pill burden." Using data from the international Dialysis Outcomes and Practice Patterns Study (DOPPS), we assessed associations between PB pill burden, patient-reported PB non-adherence, and levels of serum phosphorus (SPhos) and parathyroid hormone (PTH) using standard regression analyses. The study included data collected from 5262 HD patients from dialysis units participating in the DOPPS in 12 countries. PB prescription ranged from a mean of 7.4 pills per day in the United States to 3.9 pills per day in France. About half of the patients were prescribed at least 6 PB pills per day, and 13% were prescribed at least 12 PB pills per day. Overall, the proportion of patients who reported skipping PBs at least once in the past month was 45% overall, ranging from 33% in Belgium to 57% in the United States. There was a trend toward greater PB non-adherence and a higher number of prescribed PB pills per day. Non-adherence to PB prescription was associated with high SPhos (>5.5 mg/dL) and PTH (>600 pg/mL). Adherence to PB is a challenge for many HD patients and may be related to the number of PB pills prescribed. Prescription of a simplified PB regimen could improve patient adherence and perhaps improve SPhos and PTH levels.

Two cases of successful pregnancy in patients with Gitelman's syndrome.

Gitelman's syndrome (GS) is a distal convoluted tubule (DCT) defect clinically characterized by hypokalemic metabolic alkalosis. Pregnancy in women with GS often results in severe hypomagnesemia and hypokalemia. We report two cases of successful pregnancies, after previous fetal loss, in patients with GS managed with aggressive oral and intravenous electrolyte repletion. These cases illustrate increased potassium and magnesium requirements over the course of the pregnancies and are notable due to the high doses of electrolytes required. They also demonstrate the possibility of successful pregnancy outcomes with frequent laboratory monitoring and aggressive titration of electrolyte replacement either orally or intravenously to maintain appropriate serum levels necessary to provide a suitable environment for fetal development.

Factors associated with growth and blood pressure patterns in children with sickle cell anemia: Silent Cerebral Infarct Multi-Center Clinical Trial cohort.

Individuals with sickle cell anemia (SCA) exhibit delayed growth trajectories and lower blood pressure (BP) measurements than individuals without SCA. We evaluated factors associated with height, weight, and BP and established reference growth curves and BP tables using data from the Silent Cerebral Infarct Multi-Center Clinical (SIT) Trial (NCT00072761). Quantile regression models were used to determine the percentiles of growth and BP measurements. Multivariable quantile regression was used to test associations of baseline variables with height, weight, and BP measurements. Height and weight measurements were collected from a total of 949 participants with median age of 10.5 years [Interquartile range (IQR) 8.2-12.9] and median follow-up time of 3.2 years (IQR 1.8-4.7, range 0-12.9). Serial BP measurements were collected from a total of 944 and 943 participants, respectively, with median age of 10.6 years (IQR = 8.3-12.9 years), and median follow-up time of 3.3 years (IQR = 1.7-4.8). Multivariable quantile regression analysis revealed that higher hemoglobin measurements at baseline were associated with greater height (P < 0.001), weight (P = 0.000), systolic BP (P < 0.001), and diastolic BP (P = 0.003) measurements. We now provide new reference values for height, weight, and BP measurements that are now readily available for medical management.

Association of dialysate bicarbonate concentration with mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS).

BACKGROUND: Most hemodialysis patients worldwide are treated with bicarbonate dialysis using sodium bicarbonate as the base. Few studies have assessed outcomes of patients treated with different dialysate bicarbonate levels, and the optimal concentration remains uncertain. STUDY DESIGN: The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international prospective cohort study. SETTING & PARTICIPANTS: This study included 17,031 patients receiving thrice-weekly in-center hemodialysis from 11 DOPPS countries (2002-2011). PREDICTOR: Dialysate bicarbonate concentration. OUTCOMES: All-cause and cause-specific mortality and first hospitalization, using Cox regression to estimate the effects of dialysate bicarbonate concentration, adjusting for potential confounders. MEASUREMENTS: Demographics, comorbid conditions, laboratory values, and prescriptions were abstracted from medical records. RESULTS: Mean dialysate bicarbonate concentration was 35.5 ± 2.7 (SD) mEq/L, ranging from 32.2 ± 2.3 mEq/L in Germany to 37.0 ± 2.6 mEq/L in the United States. Prescription of high dialysate bicarbonate concentration (≥38 mEq/L) was most common in the United States (45% of patients). Approximately 50% of DOPPS facilities used a single dialysate bicarbonate concentration. 3,913 patients (23%) died during follow-up. Dialysate bicarbonate concentration was associated positively with mortality (adjusted HR, 1.08 per 4 mEq/L higher [95% CI, 1.01-1.15]; HR for dialysate bicarbonate ≥38 vs 33-37 mEq/L, 1.07 [95% CI, 0.97-1.19]). Results were consistent across levels of pre-dialysis session serum bicarbonate and between facilities that used a single dialysate bicarbonate concentration and those that prescribed different concentrations to individual patients. The association of dialysis bicarbonate concentration with mortality was stronger in patients with longer dialysis vintage. LIMITATIONS: Due to the observational nature of the present study, we cannot rule out that the reported associations may be biased by unmeasured confounders. CONCLUSIONS: High dialysate bicarbonate concentrations, especially prolonged exposure, may contribute to adverse outcomes, likely through the development of postdialysis metabolic alkalosis. Additional studies are warranted to identify the optimal dialysate bicarbonate concentration.

Hemodialysis patient preference for type of vascular access: variation and predictors across countries in the DOPPS.

PURPOSE: Catheters are associated with worse clinical outcomes than fistulas and grafts in hemodialysis (HD) patients. One potential modifier of patient vascular access (VA) use is patient preference for a particular VA type. The purpose of this study is to identify predictors of patient VA preference that could be used to improve patient care. METHODS: This study uses a cross-sectional sample of data from the Dialysis Outcomes and Practice Patterns Study (DOPPS 3, 2005-09), that includes 3815 HD patients from 224 facilities in 12 countries. Using multivariable models we measured associations between patient demographic and clinical characteristics, previous catheter use and patient preference for a catheter. RESULTS: Patient preference for a catheter varied across countries, ranging from 1% of HD patients in Japan and 18% in the United States, to 42% to 44% in Belgium and Canada. Preference for a catheter was positively associated with age (adjusted odds ratio per 10 years=1.14; 95% CI=1.02-1.26), female sex (OR 1.49; 95% CI=1.15-1.93), and former (OR=2.61; 95% CI=1.66-4.12) or current catheter use (OR=60.3; 95% CI=36.5-99.8); catheter preference was inversely associated with time on dialysis (OR per three years=0.90; 95% CI=0.82-0.97). CONCLUSIONS: Considerable variation in patient VA preference was observed across countries, suggesting that patient VA preference may be influenced by sociocultural factors and thus could be modifiable. Catheter preference was greatest among current and former catheter users, suggesting that one way to influence patient VA preference may be to avoid catheter use whenever possible.

Preemptive renal transplant candidate survival, access to care, and renal function at listing.

BACKGROUND: Preemptive transplantation is associated with better survival and transplant outcomes than transplantation after dialysis has been started. The purpose of this study is to examine associations between candidate characteristics, likelihood of preemptive transplant, candidate survival and renal function (RF) at the time of listing. METHODS: We looked at 57 677 solitary renal transplant candidates from the Scientific Registry of Transplant Recipients database listed prior to dialysis from 2000 to 2009. Using multivariable models, we measured associations between candidate characteristics, likelihood of preemptive transplantation, candidate survival and RF at listing. RESULTS: Candidates with higher RF at listing were more likely to be male, Caucasian, diabetic, be a prior transplant recipient and have more education. Higher RF at listing was strongly associated with greater likelihood of receipt of preemptive transplant [adjusted odds ratio = 1.45, 95% confidence interval (CI) 1.38-1.51] and conferred a significant survival advantage [adjusted hazards ratio = 0.84, 95% CI 0.79-0.89, per 5 mL/min/1.73 m(2)]. CONCLUSIONS: Patient characteristics associated with higher RF at listing suggest differences in access to care. Given that higher RF at the time of listing was also significantly associated with greater likelihood of preemptive transplantation and better survival prior to transplantation, our results suggest that listing at higher levels of RF may improve transplant candidate outcomes.

Physical exercise among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS): correlates and associated outcomes.

BACKGROUND: Levels of physical exercise among haemodialysis patients are low. Increased physical activity in this population has been associated with improved health-related quality of life (HRQoL) and survival. However, results of previous studies may not be applicable to the haemodialysis population as a whole. The present study provides the first description of international patterns of exercise frequency and its association with exercise programmes and clinical outcomes among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS). METHODS: Data from a cross section of 20,920 DOPPS participants in 12 countries between 1996 and 2004 were analysed. Regular exercise was defined as exercise frequency equal to or more than once/week based on patient self-report. Linear mixed models and logistic regression assessed associations of exercise frequency with HRQoL and other psychosocial variables. Mortality risk was calculated in Cox proportional hazard models using patient-level (patient self-reported exercise frequency) and facility-level (the dialysis facility percentage of regular exercisers) predictors. RESULTS: Regular exercise frequency varied widely across countries and across dialysis facilities within a country. Overall, 47.4% of participants were categorized as regular exercisers. The odds of regular exercise was 38% higher for patients from facilities offering exercise programmes (adjusted odds ratio = 1.38 [95% confidence interval: 1.03-1.84]; P = 0.03). Regular exercisers had higher HRQoL, physical functioning and sleep quality scores; reported fewer limitations in physical activities; and were less bothered by bodily pain or lack of appetite (P

Atrial fibrillation in hemodialysis patients: clinical features and associations with anticoagulant therapy.

Using data from the international Dialysis Outcomes and Practice Patterns Study (DOPPS), we determined incidence, prevalence, and outcomes among hemodialysis patients with atrial fibrillation. Cox proportional hazards models, to identify associations with newly diagnosed atrial fibrillation and clinical outcomes, were stratified by country and study phase and adjusted for descriptive characteristics and comorbidities. Of 17,513 randomly sampled patients, 2188 had preexisting atrial fibrillation, with wide variation in prevalence across countries. Advanced age, non-black race, higher facility mean dialysate calcium, prosthetic heart valves, and valvular heart disease were associated with higher risk of new atrial fibrillation. Atrial fibrillation at study enrollment was positively associated with all-cause mortality and stroke. The CHADS2 score identified approximately equal-size groups of hemodialysis patients with atrial fibrillation with low (less than 2) and higher risk (more than 4) for subsequent strokes on a per 100 patient-year basis. Among patients with atrial fibrillation, warfarin use was associated with a significantly higher stroke risk, particularly in those over 75 years of age. Our study shows that atrial fibrillation is common and associated with elevated risk of adverse clinical outcomes, and this risk is even higher among elderly patients prescribed warfarin. The effectiveness and safety of warfarin in hemodialysis patients require additional investigation.

Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS).

Mortality risk among hemodialysis (HD) patients may be highest soon after initiation of HD. A period of elevated mortality risk was identified among US incident HD patients, and which patient characteristics predict death during this period and throughout the first year was examined using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS; 1996 through 2004). A retrospective cohort study design was used to identify mortality risk factors. All patient information was collected at enrollment. Life-table analyses and discrete logistic regression were used to identify a period of elevated mortality risk. Cox regression was used to estimate adjusted hazard ratios (HR) measuring associations between patient characteristics and mortality and to examine whether these associations changed during the first year of HD. Among 4802 incident patients, risk for death was elevated during the first 120 d compared with 121 to 365 d (27.5 versus 21.9 deaths per 100 person-years; P = 0.002). Cause-specific mortality rates were higher in the first 120 d than in the subsequent 121 to 365 d for nearly all causes, with the greatest difference being for cardiovascular-related deaths. In addition, 20% of all deaths in the first 120 d occurred subsequent to withdrawal from dialysis. Most covariates were found to have consistent effects during the first year of HD: Older age, catheter vascular access, albumin <3.5, phosphorus <3.5, cancer, and congestive heart failure all were associated with elevated mortality. Pre-ESRD nephrology care was associated with a significantly lower risk for death before 120 d (HR 0.65; 95% confidence interval 0.51 to 0.83) but not in the subsequent 121- to 365-d period (HR 1.03; 95% confidence interval 0.83 to 1.27). This care was related to approximately 50% lower rates of both cardiac deaths and withdrawal from dialysis during the first 120 d. Mortality risk was highest in the first 120 d after HD initiation. Inadequate predialysis nephrology care was strongly associated with mortality during this period, highlighting the potential benefits of contact with a nephrologist at least 1 mo before HD initiation.

Diuretic use, residual renal function, and mortality among hemodialysis patients in the Dialysis Outcomes and Practice Pattern Study (DOPPS).

BACKGROUND: Information about residual renal function (RRF) and outcomes associated with practices of diuretic use in patients with end-stage renal disease is not available worldwide. METHODS: Diuretic use was investigated in 16,420 hemodialysis patients from the Dialysis Outcomes and Practice Patterns Study, a prospective observational study of hemodialysis patients selected from nationally representative facilities on 3 continents. Logistic regressions were used to investigate associations between diuretic use and patient characteristics. Outcomes of interdialytic weight gain, increased serum potassium and phosphorus levels, and odds of retaining RRF after 1 year were investigated. Cox regression was used to analyze the association between mortality and diuretic use. RESULTS: Facility diuretic use varied substantially from 0% to 83.9% of patients. Diuretic use decreased sharply after the start of dialysis therapy. Loop diuretic use ranged from 9.2% in the United States to 21.3% in Europe, whereas use within 90 days of starting dialysis therapy ranged from 25.0% in the United States to 47.6% in Japan. Diuretic use was associated with lower interdialytic weight gain and lower odds of hyperkalemia (potassium > 6.0 mmol/L). Patients with RRF on diuretic therapy had almost twice the odds of retaining RRF after 1 year in the study versus patients not on diuretic therapy. Patients administered diuretics had a 7% lower all-cause mortality risk (P = 0.12) and 14% lower cardiac-specific mortality risk (P = 0.03) versus patients not administered diuretics. CONCLUSION: Variation exists in facility practices of diuretic use. In patients with RRF, there may be benefit associated with continuing diuretic use rather than automatically discontinuing diuretic therapy at dialysis initiation.

Factors associated with "do not resuscitate" orders and rates of withdrawal from hemodialysis in the international DOPPS.

BACKGROUND: Worldwide statistics on practice patterns regarding "do not resuscitate" (DNR) orders and patient withdrawal from hemodialysis have not been uniformly collected or analyzed. METHODS: Using data concerning adult hemodialysis patients randomly selected from 308 representative dialysis facilities in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States participating in the Dialysis Outcomes and Practice Patterns Study, DNR orders were tabulated at study entry from a prevalent cross-section of patients (N = 8615), using multivariate logistic regression to investigate characteristics associated with DNR status, Cox models to identify risk factors for withdrawal from hemodialysis, and scores from the mental component summary (MCS) and physical component summary (PCS) of the SF-36 to assess health-related quality of life. RESULTS: The United States had the highest prevalence of DNR orders (7.5%) and rate of withdrawal from hemodialysis (3.5 per 100 patient-years). Significant and independent associations with higher odds ratio (OR) of DNR were observed for older age (OR 1.16 per 10 years higher, P = 0.03) and nursing home residence (OR 2.34, P = 0.003), and with higher relative risk (RR) of withdrawal from dialysis (RR 2.38, P < 0.001). Patients who withdrew from hemodialysis died within a mean of 7.8 days and a median of 6.0 days. CONCLUSION: The higher prevalence of DNR and rate of withdrawal from hemodialysis in the United States are consistent with its greater legal and cultural emphasis on patient autonomy. By showing characteristics associated with these outcomes, this study contributes to our understanding of why hemodialysis patients request DNR or withdraw from treatment.

Dialysis Outcomes and Practice Patterns Study (DOPPS) data on medications in hemodialysis patients.

BACKGROUND: Medications affect many measures of hemodialysis patients' well-being. METHODS: The Dialysis Outcomes and Practice Patterns Study (DOPPS) has evaluated the use of hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins), analgesics, antidepressants, and multivitamins. Additionally, DOPPS has reported on the associations between vascular access outcomes and related medications. RESULTS: Prescription of statins varied widely across countries, with the highest use in the United States. Patients prescribed statins had lower risk of cardiac and noncardiac causes of mortality than those who were not prescribed statins. DOPPS data also show that statins are underprescribed relative to recent Kidney Disease Outcomes Quality Initiative guidelines. No guidelines have been established for analgesic use, but high pain levels self-reported by hemodialysis patients suggest opportunities for improved pain management strategies. Guidelines for analgesic use in dialysis patients may help balance improved quality of life against potential side effects of analgesics. Medical and patient questionnaires show that depression in hemodialysis patients is common, frequently underdiagnosed, usually untreated, and associated with increased rates of mortality and hospitalization. Calcium channel blockers were associated with improved primary graft patency, aspirin with improved secondary graft patency, and angiotensin-converting enzyme inhibitors with improved secondary fistula patency. All 3 medications were associated with significantly decreased relative risk for access failure. There is large country variation in multivitamin use, with significantly higher use in the United States compared with Europe and Japan. Patients taking multivitamins had lower mortality risk than patients not taking multivitamins. CONCLUSION: DOPPS findings on medications indicate that prospective trials are needed before guidelines can be developed for appropriate medication use in these different therapeutic categories.