Reassessing the utility of access recirculation and Kt/V for the prediction of arteriovenous fistula failure using online clearance monitoring: the SHUNT STUDY.

BACKGROUND: The arteriovenous fistula (AVF) is prone to thrombosis which can be avoided by use of monitoring and surveillance programmes. Although surveillance imaging techniques have been shown to be more sensitive and specific than clinical monitoring during dialysis, monitoring may have significant advantages in terms of cost and time saving. In this study we evaluate the yield of two monitoring techniques [blood temperature monitoring (BTM) access recirculation (AR) and Kt/V via online-clearance-monitoring (OCM)]. METHODS: In this single-centre prospective observational study, 101 patients were followed-up for one year. The primary outcome measure was a composite of AVF failure. OCM-Kt/V and BTM-AR were recorded at every dialysis session. RESULTS: Of all baseline characteristics only a prior history of percutaneous transluminal angioplasty (PTA) to the AVF conferred a significant change in AVF survival (failure events/100 pt years with prior PTA vs. without = 64.0 vs. 17.3, log-rank p = 0.0014; unadjusted hazard ratio (HR) 3.74 (95% CI 1.56-8.94) p = 0.003). Participants with baseline AR < 10% vs. > 15% had poorer AVF survival (p = 0.0002) and HR for baseline AR 10-15% group vs. AR > 15% group = 4.5 (95% CI 1.55-13.05). There was no combination of change in (Δ) AR, ΔKt/V or its presence over any number of dialysis sessions that provided an acceptable combination of sensitivity and specificity or discrimination for AVF failure. CONCLUSIONS: BTM-AR and OCM-Kt/V are specific but insufficiently sensitive tools for the prediction of AVF failure. BTM-AR and OCM-Kt/V use at every dialysis session appears to add little to the traditional, infrequent use of these evaluations.

The prevalence and potential aetiological factors associated with restless legs syndrome in patients with chronic kidney disease: a cross-sectional study.

BACKGROUND: There is limited understanding of aetiological factors of and treatment options for restless leg syndrome (RLS) in patients with chronic kidney disease (CKD). This study aimed to estimate the prevalence of RLS in CKD patients and identify factors that may contribute to RLS. METHODS: A questionnaire-based cross-sectional study of patients with CKD stage 4 (CKD 4), pre-dialysis stage 5 (CKD-5ND) and haemodialysis-dependent stage 5 (CKD-5D) was conducted. Eligible patients were enrolled from the local dialysis units and renal clinics. The International RLS Study Group rating scale was used to establish the diagnosis of RLS and quantify its severity. RESULTS: 212 patients with CKD 4 (n = 92), CKD-5ND (n = 14) and CKD-5D (n = 106) were included. The overall prevalence of RLS was 32.1%. Women had a significantly higher odds of having RLS despite adjustment for age, diabetes, cardiovascular disease and whether patients were on dialysis (odds ratio 2.8 [95% confidence intervals 1.5-5.2]). In pre-dialysis groups, patients with RLS had significantly higher serum ferritin (323.9 [SD 338.1] vs 177.5 [SD 178.5] µg/L, p = 0.020) compared to non-RLS patients. In dialysis patients (CKD-5D), those with RLS had significantly higher total white cell (8.0 [SD 3.5] vs 6.8 [SD 1.9] × 109/L, p = 0.026) and neutrophil (6.4 [SD 3.9] vs 4.6 [SD1.7] × 109/L, p = 0.002) counts compared to patients without RLS. CONCLUSION: RLS remains a significant problem in patients with CKD and may be related to underlying inflammation. Targeting this pathway may be useful. Prevalence of RLS, diagnosed using validated measures, is higher than previous reports. TRIAL REGISTRATION: N/A (the current study is not a trial).

A mixed-method feasibility study of a novel transitional regime of incremental haemodialysis: study design and protocol.

BACKGROUND: Incremental haemodialysis/haemodiafiltration (HD) may help reduce early mortality rates in patients starting HD. This mixed-method feasibility study aims to test the acceptability, tolerance and safety of a novel incremental HD regime, and to study its impact on parameters of patient wellbeing. METHOD: We aim to enrol 20 patients who will commence HD twice-weekly with progressive increases in duration and frequency, achieving conventional treatment times over 15 weeks (incremental group). Participants will be followed-up for 6 months and will undergo regular tests including urine collections, bio-impedance analyses and quality-of-life questionnaires. Semi-structured interviews will be conducted to explore patients' prior expectations from HD, their motivations for participation and experiences of receiving incremental HD. For comparison of safety and indicators of dialysis adequacy, a cohort of 40 matched patients who previously received conventional HD will be constructed from local dialysis records (historical controls). RESULTS: Data will be recorded on the numbers screened and proportions consented and completing the study (primary outcome). Incremental and conventional groups will be compared in terms of differences in blood pressure control, interdialytic weight changes, indicators of dialysis adequacy and differences in adverse and serious adverse events. In analyses restricted to incremental group, measurements of RRF, fluid load and quality-of-life during follow-up will be compared with baseline values. From patient interviews, a narrative description of key themes along with anonymised quotes will be presented. CONCLUSION: Results from this study will address a significant knowledge gap in the prescription HD therapy and inform the development novel future therapy regimens.

The impact of e-alerts on inpatient diagnosis and management of acute kidney injury.

AIMS/BACKGROUND: Electronic alerts can help with the early detection of acute kidney injury in hospitalised patients. Evidence for their role in improving patient care is limited. The authors have completed an audit loop to evaluate the impact of electronic alerts, and an associated acute kidney injury management pathway, on patient care. METHODS: The audits were conducted at a large tertiary care hospital in the UK. Case notes were reviewed for 99 patients over two periods: pre-alert (in 2013; n=55) and post-alert (in 2018; n=44), using the same methodology. Patients for case note reviews were randomly chosen from the list of acute kidney injury alerts generated by the local laboratory information management system. RESULTS: Recognition of acute kidney injury, as documented in the case notes, increased from 15% to 43% between the two periods. Time to first medical review (following electronic alerts) improved by 17 minutes (median 4 hours 4 minutes in 2013 vs 3 hours 47 minutes in 2018). Completion of pre-defined acute kidney injury assessment tasks (review of vital signs, biochemistry and acid-base parameters, evidence of fluid balance assessment, consideration of possible sepsis, and examination or requesting urinalysis) improved in 2018. However, acute kidney injury management tasks (correction of hypovolaemia, addressing or investigating obstruction, medications review, renal referral, requesting of further biochemical tests, addressing possible sepsis) showed very little or no improvement. CONCLUSIONS: The introduction of acute kidney injury electronic alerts and management pathway resulted in improved recognition and initial assessment of patients with acute kidney injury. Further steps are needed to translate this in to improved patient management.

Age, Gender and Diabetes as Risk Factors for Early Mortality in Dialysis Patients: A Systematic Review.

Objective: To study the impact of age, gender, and presence of diabetes (any type) on the risk of early deaths (180-day mortality) in patients starting long-term hemodialysis (HD) therapy.Design: Systematic review of the literature.Setting: Out-patient (non-hospitalized), community-based HD therapy world-wide.Participants: Patients with advanced chronic kidney disease (CKD) starting long-term HD treatment for end-stage renal disease (ESRD).Methods: Medline and EMBASE were searched for studies published between 1/1/1985 and 12/31/2017. Observational studies involving adult subjects commencing HD were included. Data extracted included population characteristics and settings. In addition, patient or treatment related factors studied with reference to their relationship with the risk of early mortality were documented. The Quality in Prognosis Studies tool was used to assess risk of bias in individual studies. Findings were summarized, and a narrative account was drawn.Results: Included were 26 studies (combined population 1,098,769; representing 287,085 person-years of observation for early mortality). There were 17 cohort and 9 case-control studies. Risk of bias was low in 13 and high in a further 13 studies. Patients who died in the early period were older than those who survived. Mortality rates increased with advancing age. Female gender was associated with slightly increased early mortality rates in larger and higher quality studies. The available data showed conflicting results in relation to the association of diabetes and risk of early mortality.Conclusions: This systematic review evaluated the impact of key demographic and co-morbid factors on risk of early mortality in patients starting maintenance HD. The information could help in delivering more tailored prognostic information and planning of future interventions.

The role of patient portals in enhancing self-care in patients with renal conditions.

Web-based portals enable patients to access their electronic health records, including test results and clinical documents, from anywhere with Internet access. Some portals also serve as a means of two-way communication between patients and healthcare professionals and provide a platform for the recording of patient-entered data such as home blood pressure readings. Such systems are designed to encourage patient participation in the management of their condition, and ultimately to increase patient empowerment and self-management, which are associated with improved clinical outcomes. As an example of portal use in patients with renal conditions, we discuss the PatientView portal, which is offered free of cost to patients under the care of renal physicians in the UK. We present an account of its various features and briefly describe the user experience. Previous studies examining the impact of this portal on patient care have been very positive; it appears to be popular among users and overall levels of satisfaction with the service are high. As the use of patient portals increases, we discuss barriers to the more widespread use of portals. We offer suggestions on how the care of patients with renal conditions can be enhanced in the future by further developing the existing features, learning from experiences of other patient portals and providing better integration of portal use into the current model of care.

Early Mortality Rates After Commencement of Maintenance Hemodialysis: A Systematic Review and Meta-Analysis.

Mortality rates are reported to be high soon after the commencement of maintenance HD for ESRD. Our aim was to estimate early mortality rates (deaths within 180 days of starting therapy), through a systematic review of literature, in this patient population. Medline and EMBASE were searched for publications between 1 January 1985 and 31 December 2017. Observational studies reporting deaths involving adults commencing HD were included. The Quality in Prognosis Studies tool was used to assess risk of bias in studies. Crude mortality rates (expressed in 100 person-years) and age-standardized mortality ratios (SMR) were calculated. Meta-analyses of these rates were conducted for studies with lowest risk of bias (i.e. highest quality). In total, 32 studies were included (combined population: 1 083 264) representing 283 277 person-years of observation; median follow-up: 90 days. Mortality rates ranged between 12.8 and 55.6 per 100 person-years. Cardiovascular causes accounted for the majority of early deaths. Meta-analysis of high-quality studies showed an overall crude mortality rate of 32.6 per 100 person-years (95% CI 32.4-32.8). This equates to 16.3% mortality in first 180 days of starting HD. Six high-quality studies contained sufficient data for calculation of SMR. Meta-analysis of SMRs showed that patients starting HD therapy sustain 8.8 times higher mortality rates compared to the general population. We have combined the results of high-quality studies to produce new estimates of early mortality rates after commencement of HD therapy. This information can help relay more reliable prognostic information to this patient population.

Can incremental haemodialysis reduce early mortality rates in patients starting maintenance haemodialysis?

PURPOSE OF REVIEW: Early mortality rates after the start of maintenance haemodialysis therapy are high. Compared with three-times weekly haemodialysis, incremental haemodialysis is associated with better preservation of residual renal function (RRF) and at least equivalent mid-term to long-term survival. However, there is paucity of data in relation to its use as a means of helping patients through the transitional period, when they first become dialysis dependent. RECENT FINDINGS: Studies of incremental haemodialysis have overlooked early mortality as an outcome measure. This is primarily due to their retrospective design which makes it difficult to link early deaths to the frequency of haemodialysis. New data confirm previous observations associating incremental haemodialysis with favourable outcomes. They also raise the possibility that in selected groups and for short periods, the pursuit of set clearance targets during the early days of dialysis may not necessarily bring additional short-term gains. SUMMARY: We argue that, while simpler ways of estimating RRF are being explored, future trials must consider implementing incremental haemodialysis focusing on practical aspects of care in the transitional period; safety monitoring in such regimes should be undertaken using conventional methods. Such an approach is likely to benefit a larger subset of haemodialysis population.

The Use of Automated Electronic Alerts in Studying Short-Term Outcomes Associated with Community-Acquired Acute Kidney Injury.

BACKGROUND/AIMS: The use of electronic alerts (e-alerts) may increase the detection rate of acute kidney injury (AKI) since they are sensitive to small changes in serum creatinine. Our aim was to follow-up a cohort of patients presenting to hospital from the community with AKI (community-acquired AKI [c-AKI]), detected through the use of e-alerts, and describe their short-term outcomes regardless of whether they were subsequently admitted to hospital. METHODS: Blood samples for all hospital attenders from the community either to the Accidents and Emergency department or one of the acute care areas of the hospital during a 6-month period (November 1, 2013-April 30, 2014) were screened for presence of c-AKI using a locally developed e-alerts system based on Kidney Disease: Improving Global Outcomes criteria. Follow-up data were obtained for a period of 3 months. RESULTS: A total of 1,277 c-AKI episodes were identified in 1,185 patients (incidence 579 per 100,000 persons). Episodes that lead to hospitalization (n = 1,096 [86%]) were associated with a median length of hospital stay of 6.6 days; a graded increase in duration of stay was noted with increasing severity of AKI. Acute dialysis was needed during 21 (1.6%) episodes. For mortality rates, only the first AKI episode was considered. There were 298 deaths within 30 days of diagnosis irrespective of admissions status (30-day mortality rate: 25%). CONCLUSIONS: Using e-alerts in acute care settings to detect c-AKI is novel and may be used to stage and follow-up AKI using existing diagnostic criteria. c-AKI is relatively common and leads to significant mortality.

The Impact of Lowering Haemoglobin Targets on Patterns of Erythropoiesis-Stimulating Agent Use in Patients on Haemodialysis.

BACKGROUND/AIMS: Haemoglobin (Hb) targets have been reduced in patients receiving haemodialysis (HD). We have investigated the impact of new guidance on current practices and costs. METHODS: Anaemia management in all patients undergoing thrice-weekly HD was retrospectively reviewed. Hb targets were compared against Kidney Disease: Improving Global Outcomes 2012 recommendations. The impact of new guidance was assessed by comparing anaemia parameters pre- and post-guideline publication. RESULTS: Two hundred and ninety two patients, with a mean age of 64 years were included. The Hb target range was achieved in 44% patients and was above target in 51%. In a sub-group of 230 patients, the mean Hb did not differ during Q4-2011 and Q4-2012. A reduction in erythropoiesis-stimulating agent (ESA) use was observed. ESA efficiency (Hb/ESA) increased in the later period (6.08 vs. 6.41 g/l/µg) and was associated with a 3% cost reduction. CONCLUSION: Introduction of guidelines lowering Hb targets in HD patients led to more efficient ESA usage and cost-savings. Anaemia treatment, however, remains unnecessarily aggressive in some patients. Further reductions in Hb and ESA dose are achievable.

Barriers to patient participation in a self-management and education website Renal PatientView: A questionnaire-based study of inactive users.

OBJECTIVES: The Renal PatientView (RPV) website is an information and education tool aimed at increasing patient involvement in their care. We have conducted this study to elucidate why some users remain inactive on RPV despite initially signing up for the service. METHODS: Patients at a teaching hospital in United Kingdom, who originally signed up for RPV but are no longer active (no logins during previous 6 months), were sent paper questionnaires. Responses were collected for up to 6 months. RESULTS: Of the 190 questionnaires, 69 (39%) were returned partially or fully completed. Majority of respondents could access computer (94%) and internet (91%) from home. Reasons for inactivity among survey respondents included: loss of login credentials (45%), perception that it did not add anything to existing care (37%), being too busy (13%) and anxiety of viewing results from home (10%). Thirty-seven respondents provided free-text comments. Thematic analysis of these reinforced above findings and also indicated that despite infrequent use, some patients valued RPV availability. Patients made very little reference to using sections of the website other than test results. CONCLUSIONS: Patients find RPV a valuable resource. It is, however, mainly seen as a portal to check blood test results; other sections of the website aimed at promoting self-management remain underutilized. Several local and central level changes, such as a robust system of user accounts handling, improved promotion, and emphasis on further development of self-management sections of RPV may help improve participation.