Early as compared to late initiation of twice-weekly hemodialysis and short-term survival among end-stage renal disease patients.

INTRODUCTION: The impact of timing of hemodialysis (HD) for end-stage renal disease (ESRD) patients treated with twice-weekly HD remains unclear. We aimed to determine the effects of late initiation of HD on short-term mortality and hospitalization. METHODS: A multicenter cohort study was conducted in 11 HD centers in Northeastern Thailand (HEmodialysis Network of the NorthEastern Thailand study group). We recruited adult ESRD patients who were treated with twice-weekly HD for more than 3 months and had data on eGFR at HD initiation. Clinical and laboratory values at the time of recruitment were recorded. Late and early (eGFR at start <5 and >5 ml/min/1.73 m2 ) initiations were defined. Outcomes were disease-related death (excluding any accidental deaths) and first hospitalization. Data analysis was performed by multivariable cox-regression analysis. FINDINGS: A total of 407 patients who had data on eGFR at HD initiation (303 in late group and 104 in early group) were included for analysis. There were 56.8% male with a mean age of 55 years. During the 15.1 months of follow-up, there were 27 (6.6%) disease-related deaths. The 1-year survival rate was similar among late and early initiation groups. The incidence density of first hospitalization in the late group was significantly lower than those in the early group (HR adjusted, 0.63; 95% CI, 0.40-0.99, p = 0.047). Among 303 patients who were in the late start group, patients with diabetes had a higher mortality rate (HR, 3.49; 95% CI, 1.40-8.70, p = 0.007) when compared to non-diabetic patients. DISCUSSION: Early initiation of HD at eGFR >5 ml/min/1.73 m2 had no short-term survival benefit compared to the late group in ESRD patients treated with twice-weekly HD for at least 3 months in a resource-limited setting. A survival benefit from an early start of HD was found among diabetic patients.

Dialysis dose and risk factors for death among ESRD patients treated with twice-weekly hemodialysis: a prospective cohort study.

BACKGROUND/AIMS: We aimed to define the dosing and risk factors for death in patients undergoing twice-weekly hemodialysis. METHODS: A prospective multi-center cohort study was conducted with one-year observation. Patients treated with twice- or thrice-weekly hemodialysis were identified. Death and first admission were the outcomes. spKt/V was a factor of interest. RESULTS: We enrolled 504 twice-weekly and 169 thrice-weekly hemodialysis patients. The mean weekly values of spKt/V in the two groups were 3.4 and 5.1. The one-year survival rate and times to hospitalization were similar in both groups. The hazard ratios for death in higher spKt/V quartile was not associated with lower mortality, p = 0.70. The four significant predictors for death were serum albumin, HR = 2.6, current smoking, HR = 19.3, age, HR = 1.1, and the Index of Coexistent Disease [ICED], HR = 1.9. CONCLUSION: The effect of spKt/V on short-term mortality was not obvious in twice-weekly dialysis patients. Attention should be paid to patients who smoke, have hypoalbuminemia, are elderly, or have a high ICED.

The effects of peritoneal dialysis catheter insertion using paramedian versus midline approach on CAPD patients.

OBJECTIVE: Types of peritoneal dialysis (PD) catheter design and catheter insertion techniques have been shown to affect catheter-associated infection, catheter survival, as well as, overall patient survival. Thus far, there have been no studies demonstrating a difference in long term outcome between two insertion techniques used for PD placement, including midline and paramedian incisions. The present study was conducted to compare clinical outcomes among CAPD patients who had bedside PD catheter insertion through midline incision vs. paramedian incision in terms of early post-operative complications and long term outcomes. MATERIAL AND METHOD: This is a retrospective study. All CAPD patients who received treatments at Maharat Nakhonratchasima Hospital during the year 2008-2010 were included in the present study. Age, sex, co-morbid diseases, laboratory results obtained prior to dialysis, early post-operative complications, and late post-operative complications were documented. RESULTS: A total of 392 patients were identified. Of these, 43 patients were excluded due to incomplete medical records. The remaining 349 cases were collected for analysis, 90 cases having paramedian incision and 259 cases having midline incision. The average age was 51.7 years old, and 52% were male. The baseline characteristics and patient parameters were similar in both approaches. The paramedian group was found to have lesser early post-operative complications (7.78%) when compared to the midline group (18.82%) (p = 0.02). Moreover, the long term outcomes were shown to be greater in paramedian approach when compared to the midline group in terms of PD catheter survival (985.5 vs. 698.1 days, p = 0.048) and overall patient survival (915.4 vs. 700.6 days, p = 0.01). However, there was no significant difference in peritonitis-free survival (848.7 vs. 824.3 days, p = 0.93). CONCLUSION: Comparing PD catheter insertion using paramedian incision with midline incision, paramedian incision was associated with less early post operative complications, more prolonged PD catheter survival and better overall patient survival. Therefore, paramedian incision should be recommended as the preferred method for PD catheter insertion.

Comparison of the Seldinger technique and surgical technique in Tenckhoff catheter insertion in CAPD patients: a single center experience.

OBJECTIVE: To compare clinical outcomes of catheter placement between surgical technique and Seldinger technique, including catheter survival and early post-operative complications. MATERIAL AND METHOD: This retrospective study was conducted in Maharaj Nakhon Si Thammarat Hospital, a tertiary-center hospital in southern part of Thailand. Three-year data, during October 2007-2010, were retrieved from medical records and hospital database. Early post-operative complications, including major bleeding, peritoneal leakage, and peritonitis rate, and long-term outcome were assessed. RESULTS: One hundred forty-nine and 56 out of 205 patients were inserted Tenckhoff catheter by surgical technique and Seldinger technique, accordingly. The average age was 49.8 years old. Sixty percent of them were male. Neither of early postoperative complication and long-term outcome was found to have significant difference. However, patients with surgical technique received more topical antibiotic [15 (10.0%) vs. 0 (0%), p = 0.014] and trended to have more episode of early postoperative peritonitis [15 (10.1%) vs. 3 (5.4%)p = 0.288]. CONCLUSION: Although Seldinger technique is more feasible for practical nephrologists and less time consumption; the success, early post-operative complications, and long term outcome are comparable with surgical technique. The surgeons or nephrologists who perform catheter placement should be aware of catheter-related infection, especially in the first few weeks.

Abnormalities in bone mineral density and bone histology in thalassemia.

UNLABELLED: This study demonstrated that there was extensive iron staining on trabecular surface and marked reduction in trabecular bone volume without significant alteration in bone formation and bone resorption rates as well as significant reduction in bone mineral density in 18 thalassemic patients. Serum IGF-I was reduced and may modulate the reduction of bone mass. INTRODUCTION: Bone histomorphometric studies in thalassemia to show alterations in bone histology and their relationship to biochemical parameters are very limited. Therefore, this study was systematically conducted to determine the alterations in thalassemia patients. METHODS: Serum biochemical parameters, trans-iliac crest bone biopsy, and determination of bone mineral density of femur and lumbar spine were done in 18 thalassemic patients (10 females and 8 males). RESULTS: Serum osteocalcin, carboxy terminal teleopeptide fragment of type I collagen, and parathyroid hormone levels were within normal limits, but serum 25(OH) vitamin D (19.3 +/- 1.6 ng/ml) and 1,25(OH)2 vitamin D (33.77 +/- 1.51 pg/ml) levels were decreased. Serum insulin-like growth factor I (IGF-I; 145.2 +/- 20 ng/ml) was suppressed, whereas serum ferritin (1366.6 +/- 253.9 ng/ml) was markedly elevated. Reduced bone mineral density was found in all studied areas. Trabecular bone volume was significantly decreased (16.65 +/- 1.12%), whereas bone formation rate, eroded surface, and other bone histomorphometric parameters were within normal limits. The trabecular bone volume varied significantly with bone mineral density of total femur (r = 0.48, p = 0.04). There was an extensive stainable iron surface on the mineral front (9-60%). Significant correlation between serum IGF-I, serum ferritin, stainable iron surface, and bone mineral density, lumbar spine, and total femur were found. Serum IGF-I correlated with trabecular bone volume (r = 0.6, p = 0.03), inversely with both serum ferritin level (r = -0.6, p < 0.01), and inversely with stainable iron surface (r = -0.53, p = 0.02). Multiple regression analysis demonstrated that IGF-I was the only independent variable that determined bone mineral density of lumbar spine and total femur. CONCLUSION: Low bone mineral density and reduced trabecular bone volume with extensive iron deposition are the predominant findings in thalassemic patients. There was no evidence of increased bone resorption or mineralization defect. A reduction in circulatory IGF-I may modulate the reduction of bone mass.