ACUTE KIDNEY INJURY
Liver Transplant Outcomes Worsen with AKI
Journal of Intensive Care Medicine. doi.org/10.1177/0885066618790558
Both prior to and following liver transplant, the development of acute kidney injury (AKI) in the setting of liver disease is a significant event. AKI may be the cause of worse outcomes or may merely be associated with worse outcomes; the occurrence of renal failure affects prognosis as well as diagnosis and therapeutics. According to Jeffrey DallaVolpe, MD, MPH, and colleagues, there are some etiologies that are correctable, including hypovolemia, nephrotoxic medications, and acute tubular necrosis. In the period following liver transplantation, AKI is associated with graft failure and overall worse outcomes.
“Prompt recognition, workup, and intervention can significantly impact outcomes and survival both before and after liver transplant,” the researchers said.
CHRONIC KIDNEY DISEASE
Estimating Glomerular Filtration Rate: Beyond Creatinine and Cystatin C
Current Opinion in Nephrology and Hypertension. doi:10.1097/MNH.0000000000000444
Reduced glomerular filtration rate (GFR) is associated with increased risk for numerous adverse outcomes. Equations used to estimate GFR use serum concentrations of creatinine and cystatin C to facilitate the assessment of kidney function. However, according to Dominik Steubl, MD, and Lesley A. Inker, MD, MS, current equations are less than optimal in some clinical settings. The researchers prepared a review that focused on approaches to improve the estimation of GFR.
In populations where creatinine or cystatin C measurements are inaccurate, low molecular weight proteins such as b-trace-protein and b-2 microglobulin, as well as newly discovered metabolites, have shown promise as filtration markers. Drs. Steubl and Inker hypothesized that the combination of multiple novel markers, either alone or in combination with creatinine, cystatin C, or demographics, may improve estimation of GFR.
They added, “Current GFR estimating equations are an essential part of routine clinical practice but have limitations. The use of multiple markers combined in a single equation appears to be the most promising approach. Future research is required to validate proposed equations in diverse populations.”
Survival Improved with Dialysis Initiation at Higher Levels of Kidney Function
Journal of the American Society of Nephrology. 2018;29(8):2169-2177
Patient selection and optimal timing of initiation of dialysis among older adults with chronic kidney disease are not well defined. Manjula Kurella Tamura, MD, and colleagues conducted a study to examine the association between dialysis versus medical management and survival at varying ages and levels of kidney function.
Data from a nationally representative 20% sample of US veterans with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 between 2005 and 2010 were utilized for the analysis; follow-up continued through 2012. The study population included 73,349 individuals. An extended Cox model was used to determine associations among the time-varying exposures, age, and provision of dialysis with survival.
Over a mean follow-up of 3.4 years, 15.5% of patients initiated dialysis and 52% died. There was variation by age in the eGFR at which dialysis, compared with medical management, was associated with lower mortality (P<.001). For those aged <65, 65-74, 85-84, and ≥85 years, dialysis was associated with lower mortality for those with eGFR not exceeding 6-to <9, <6, 9 to <12, and 9 to <12 mL/min/1.73 m2, respectively.
There was an association between dialysis initiation at eGFR <6 mL/min/1.73 m2 and a higher median life expectancy of 26, 25, and 19 months for patients aged 65, 75, and 85 years, respectively. When dialysis was initiated at eGFR 9-<12 mL/min/1.73 m2, the estimated difference in median life expectancy was <1 year in this patient population.
“Provision of dialysis at higher levels of kidney function may extend survival for some older patients,” the researchers said.
Use of Phosphate-Binders Lowers Risk of Infection-Related Mortality
Scientific Reports. doi:10.1038/s41598-018-29757-0
Treatment with phosphate binders in patients on hemodialysis allows for increased protein intake, thus helping patients maintain good nutritional status. The risk of infection-related death is increased in patients with protein-energy-malnutrition. There are few data available on the association between phosphate binder use and the relative risks of infection-related death.
Shunsuke Yamada, MD, PhD, and colleagues conducted an analysis of data from 2925 patients registered to the Q-Cohort Study. During the 4-year follow-up period, 106 patients died of infection-related causes and 492 patients died of any cause. The incidence of infection-related death was significantly lower in patients with phosphate-binder use compared with those without phosphate-binder use (hazard ratio for infection-related mortality, 0.63; 95% confidence interval, 0.40-0.99). Following application of four different propensity score-based analyses, the results remained significant. Use of phosphate-binders was also associated with lower risk of all-cause mortality.
According to the researchers, “Further studies including randomized controlled clinical trials and observation studies analyzed by an instrumental variable model will provide more robust evidences for the associations observed in our study.”
Burnt-Out Diabetes Phenomenon in Patients on Peritoneal Dialysis
Diabetes Research and Clinical Practice. doi.org/10.1016/j.diabres.2018.07.026
A phenomenon known as burnt-out diabetes is defined as spontaneous improvement in glycemic control, resulting in normal levels of hemoglobin A1c (HbA1c). It is thought that glycated albumin may be a better indicator of glycemic control than HbA1c in hemodialysis patients; this has not been studied in patients receiving peritoneal dialysis.
Masanori Abe, MD, PhD, and colleagues conducted a study involving patients on peritoneal dialysis with available data on HbA1c level and antidiabetes therapy. The study had two cohorts: (1) those with HbA1c measurements alone and (2) subsequently those with both HbA1c and glycated albumin measurements. The burnt-out diabetes phenomenon was assessed in both cohorts.
There were 1296 patients in the HbA1c cohort; when burnt-out diabetes was defined as HbA1c <6.0% without treatment, it was found in 269 patients (20.8%). When 413 patients were added subsequently to the second cohort, burnt-out diabetes was found in 73 patients (17.7%). When burnt-out diabetes was defined as HbA1c <6.0% and glycated albumin <16.0% without treatment, burnt-out diabetes was observed in 45 patients (10.9%).
In summary the researchers said, “Although the burnt-out diabetes phenomenon was present in 17.7% of patients with diabetes on peritoneal dialysis based on HbA1c, the rate was significantly decreased to 10.9% when taking glycated albumin into account.”
Vitamin D Lowers Risk of Infection in Dialysis Patients
Nephrology Dialysis Transplantation. doi.org/10.1093.ndt/gfy216
Patients with end-stage renal disease (ESRD) receiving maintenance dialysis are at increased risk for infections, some of which can be fatal. There have been conflicting results from recent studies examining the association between infection and vitamin D status or use of vitamin D; data on the association in patients undergoing long-term dialysis are limited.
Guobin Su, MD, and colleagues conducted a systematic review and meta-analysis on vitamin D deficiency and treatment versus the risk of infection in that patient population. PubMed, Web of Science, Cochrane Library, Embase, and three Chinese databases were searched from inception until December 2017.
Search criteria were for interventional controlled trials (randomized and non-randomized), cohort studies, and case-control studies on levels of serum 25-hydroxyvitamin D (25[OH]D), or use of vitamin D (supplemental nutritional vitamin D or vitamin D receptor activator [VDRA]) and infection in long-term dialysis patients. Infection included any infection, infection-required hospitalization, infection-related death, or composite. The meta-analysis examined the relative risk (RR) of infection and level of 25(OH)D or use of vitamin D.
The search revealed 2440 reports. Of those, 17 studies met inclusion criteria; all 17 were of moderate quality. Six cohort studies examined serum concentrations of 25(OH)D and 11 (2 randomized controlled trials and nine observational studies) assessed the use of vitamin D.
In individuals with high or normal levels of 25(OH)D, the risk of composite infection was 39% lower compared with those with low levels (RR, 0.61; 95% confidence interval [CI], 0.41-0.89). The pooled adjusted risk for composite infection was 41% lower in those who used vitamin D compared with those who did not use vitamin D (RR, 0.59; 95% CI, 0.43-0.81).
In conclusion, the researchers said, “High or normal serum levels of 25(OH)D and the use of vitamin D, particularly VDRA, were each associated with a lower risk of composite infection in long-term dialysis patients.”
END-STAGE RENAL DISEASE
Prevalence and Incidence of ESRD-D among Immigrants in Canada
Journal of the American Society of Nephrology. 2018;29(7):1948-1959
Jeffrey Perl, MD, and colleagues recently conducted a study to estimate the prevalence and incidence of end-stage renal disease requiring maintenance dialysis (ESRD-D) among immigrants in Ontario, Canada. Using administrative health and immigration datasets, the researchers categorized adults residing in Ontario in 2014 as long-term Canadian residents or immigrants. ESRD-D prevalence among those adults was determined and age-adjusted prevalence ratios (PRs) comparing immigrants to long-term residents were calculated. Among individuals who immigrated to Ontario between 1990 and 2012, age-adjusted incidence of ESRD-D was calculated by world region and country of birth; immigrants from Western nations were the referent group.
Of 1,902,394 immigrants, 0.09% (n=1700) presented with ESRD-D; among 8,860,283 long-term residents, 0.10% (n=8909) did so. Following adjustment for age, the prevalence of ESRD-D was higher among immigrants from sub-Saharan Africa (PR, 2.17; 95% confidence interval [CI], 1.84-2.57), Latin America and the Caribbean (PR, 2.11; 95% CI, 1.90-2.34), South Asia (PR, 1.45; 95% CI, 1.32-1.59) and East Asia and the Pacific (PR, 1.34; 95% CI, 1.22-1.46).
The highest age-adjusted ESRD-D PRs relative to long-term residents were seen in immigrants from Somalia (PR, 4.18; 95% CI, 3.11-5.61), Trinidad and Tobago (PR, 2.88; 95% CI, 2.23-3.73), Jamaica (PR, 2.88; 95% CI, 2.40-3.44), Sudan (PR, 2.84; 95% CI, 1.53-5.27), and Guyana (PR, 2.69; 95% CI, 2.19-3.29). Immigrants from those countries also had higher incidence of age-adjusted ESRD-D compared with immigrants from Western nations.
In conclusion, the researchers said, “Among immigrants in Canada, those from sub-Saharan Africa and the Caribbean have the highest ESRD-D risk. Tailored kidney-protective interventions should be developed for these susceptible populations.”
GERIATRIC AND PALLIATIVE CARE
Hemodialysis versus Conservative Medical Management for Elderly Patients with ESRD
Journal of Hospice & Palliative Nursing. 2018;20(3):279-285
When patients with end-stage renal disease (ESRD) are involved in choice of treatment modality such as hemodialysis or conservative medical management, one consideration may be symptom improvement with the goal of attaining a good quality of life. Such a consideration aligns with the principles of palliative care.
Kathryn Eckert, MSN, CRNP, and colleagues report results of research examining whether elderly patients with ESRD who opt for conservative medical management have improved quality of life compared with those who opt for hemodialysis. Conservative medical management focuses on symptom management, with emphasis on holistic care. Results of recent research demonstrate that conservative medical management in elderly patients with ESRD leads to a maintained quality of life. However, the improvement in quality of life comes at the expense of a reduced survival rate compared with patients who are treated with hemodialysis.
“A patient’s wishes regarding quality of life need to be considered when choosing a treatment modality; integrating palliative care as an extra layer of support can help providers, patients, and caregivers decide and implement the treatment that best aligns with the patient’s healthcare goals,” the authors said.