Trabecular bone score in patients with chronic kidney disease.

Patients with chronic kidney disease have high risk of osteoporotic fractures. Lower trabecular bone score (TBS) was associated with poorer kidney function and higher fracture risk when kidney function was normal. Addition of TBS to The Fracture Risk Assessment Tool with bone mineral density did not improve fracture risk prediction. INTRODUCTION: We sought to determine whether trabecular bone score (TBS) either independently or adjusted for The Fracture Risk Assessment Tool (FRAX) could predict risk of major osteoporotic fractures (MOFs) in a large population-based sample of patients with all stages of chronic kidney disease (CKD). METHODS: We used population-based administrative databases to identify patients above age 20 years who had dual-energy X-ray absorptiometry (DXA) scan and serum creatinine measured within 1 year, during the years 2005 to 2010. Patients were excluded if they were on dialysis or had a functioning renal transplant. We stratified patients by estimated glomerular filtration rate (eGFR). We collected femoral neck bone mineral density (BMD), lumbar spine TBS, incident major osteoporotic fractures (MOF) and hip fractures, and other clinical characteristics. RESULTS: Among 8289 patients, there were 6224 (75.1%) with eGFR ≥ 60 mL/min/1.73 m2, 1624 (19.6%) with eGFR 30-60 mL/min/1.73 m2, and 441 (5.3%) with eGFR < 30 mL/min/1.73 m2. There were 593 patients (7.2%) with MOFs and 163 (2.0%) with hip fractures. Lower TBS score was associated with increased risk of MOF and hip fractures across all eGFR strata in unadjusted Cox proportional hazards models but after adjusting for FRAX with BMD, lower TBS was only statistically significant for MOF prediction for eGFR ≥ 60 mL/min/1.73 m2. CONCLUSION: Lower TBS scores were associated with lower eGFR and increased fracture risk in patients with eGFR ≥ 60 mL/min/1.73 m2. However, the addition of TBS to the FRAX score with BMD did not significantly improve fracture risk prediction in patients with CKD.

Sodium thiosulfate-based treatment in calcific uremic arteriolopathy: a consecutive case series.

BACKGROUND: Calcific uremic arteriolopathy (CUA) is a rare complication in end stage renal disease with high mortality. Numerous case reports and one case series of 3 patients report the benefit of sodium thiosulfate (STS) for treatment of CUA. The purpose of this evaluation was to examine the response to a STS-based treatment approach in patients with CUA with 1 year follow up. METHODS: A retrospective case series of 6 consecutive patients from Manitoba, Canada who met predefined diagnostic criteria for CUA and received STS between 2006 and 2008 were included. STS responders were defined as improvement in at least one of the following three parameters: pain severity, wound size and diagnostic imaging/radiography. Mortality, STS dose, duration, adverse events and cost were also collected. RESULTS: Four patients were classified as responders. The 2 responders who survived at 1 year of follow-up demonstrated an improvement in all 3 parameters examined including an improvement in their follow-up diagnostic imaging results within the first 4 - 6 weeks of STS treatment. At 1 year of follow-up, 3 patients died. CONCLUSION: Using an STS-based multifaceted treatment approach for CUA, 4 patients responded but 3 of 6 patients died within 1 year. Further larger prospective studies are needed to delineate STS responders from non-responders.

The evaluation of a successful home hemodialysis program: establishing a prospective framework for quality.

A mounting body of clinical data and purported quality of life benefits has been primarily responsible for a renewed interest in programs providing longer more frequent home hemodialysis. As novel forms of home hemodialysis (HHD) like nocturnal (nightly) home hemodialysis (NHD) move from strictly the academic "experimental" arenas to potentially the preferred renal replacement modality for patients, it will be necessary for programs to plan and evaluate standardized metrics for program quality. This will be essential for smaller, less experienced centers to gauge their outcomes against larger, more established programs. Driven by market forces primarily in the United States, conventional hemodialysis programs have begun to explore optimal strategies for reporting quality of care in their respective dialysis centers. Extrapolating this to home hemodialysis modalities the question remains which criteria do we use as measures of quality? The evidence is limited to small, observational studies and one small randomized controlled trial. Extrapolating existing quality indices from conventional hemodialysis seems reasonable however may miss many of the true clinically significant advantages of HHD as a modality. Although definitive evidence does not yet exist for intensive home hemodialysis strategies, clearly clinicians, payers and patients are convinced enough of this approach for programs to justify the expansion of these modalities. We have laid the groundwork for the CANadian Slow Long nightly ExtEnded dialysis Programs (CAN-SLEEP), a multicenter cohort aimed to investigate the clinical and programmatic outcomes of NHD. This will allow for the assessment of numerous outcomes on a global scale for this state-of-the art dialysis modality in the form of a multidimensional programmatic evaluation.

The economics of home nocturnal hemodialysis: how should we cost the benefits?

Home nocturnal hemodialysis (HNHD) has been established as a safe and effective way to provide dialysis for patients who require renal replacement therapy. Non-randomized studies have shown that patients switched to HNHD have improvements in blood pressure, left ventricular mass and quality of life. At present, there are no RCTs or long-term observational studies demonstrating a clear reduction in cardiovascular events or mortality. Several HNHD centers have published articles documenting the costs of this modality as compared to conventional HD. Some of these studies have found HNHD to provide significant cost savings, while others have found the two modalities to be relatively equivalent in terms of costs. In this paper, we review the results of these costing studies and illustrate some of the limitations associated with these studies including the lack of randomization, inconsistent reporting of HNHD start-up costs, potential patient selection biases and limited follow-up. On balance, it appears premature to conclude that HNHD is cost-saving in comparison to conventional hemodialysis. However, two ongoing randomized trials, which are collecting resource use information, will help to answer this question. Once these data are available, a formal economic evaluation should be done to determine the impact of HNHD on both clinical outcomes and costs. This information will assist decision-makers in determining whether to make HNHD more widely available.