Tobias Bomholt, Marianne Rix, Thomas Almdal, Filip K. Knop, Susanne Rosthøj, Morten B. Jørgensen, Bo Feldt-Rasmussen, Mads Hornum
Introduction
Hemodialysis (HD) induces several physiological changes that can affect plasma glucose levels in patients with diabetes and in turn their glycemic control. Studies using continuous glucose monitoring (CGM) to assess glucose variations on dialysis days compared with nondialysis days report conflicting results. Here, we used CGM to examine glucose variations induced by HD in patients with type 2 diabetes.
Methods
Patients with type 2 diabetes undergoing maintenance HD were included. CGM (Ipro2®, Medtronic) was performed at baseline and Week 4, 8, 12, and 16 for up to 7 days at each visit. CGM profiles on days where participants received HD were compared with days without HD using a linear mixed model.
Findings
Twenty-seven patients were included. The median number of CGM days performed was 8 (interquartile range [IQR] 6–10) for dialysis days and 16 (IQR 12–17) for nondialysis days. The median sensor glucose was 9.4 (95% confidence interval [CI] 8.8–10.2) mmol/L on dialysis days compared with 9.5 (95% CI 8.9–10.2) mmol/L on nondialysis days (p = 0.58). Nocturnal mean sensor glucose was higher on dialysis days compared with nondialysis days: 8.8 (95% CI 8.0–9.6) mmol/L versus 8.4 (95% CI 7.7–9.2) mmol/L (p = 0.029).
Discussion
Similar median sensor glucose values were found for days on and off HD. Nocturnal glucose levels were modestly increased on dialysis days. Our findings indicate that antidiabetic treatment does not need to be differentiated on dialysis versus nondialysis days in patients with type 2 diabetes undergoing maintenance HD.
{"title":"Glucose variability in maintenance hemodialysis patients with type 2 diabetes: Comparison of dialysis and nondialysis days","authors":"Tobias Bomholt, Marianne Rix, Thomas Almdal, Filip K. Knop, Susanne Rosthøj, Morten B. Jørgensen, Bo Feldt-Rasmussen, Mads Hornum","doi":"10.1111/hdi.13073","DOIUrl":"10.1111/hdi.13073","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Hemodialysis (HD) induces several physiological changes that can affect plasma glucose levels in patients with diabetes and in turn their glycemic control. Studies using continuous glucose monitoring (CGM) to assess glucose variations on dialysis days compared with nondialysis days report conflicting results. Here, we used CGM to examine glucose variations induced by HD in patients with type 2 diabetes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Patients with type 2 diabetes undergoing maintenance HD were included. CGM (Ipro2®, Medtronic) was performed at baseline and Week 4, 8, 12, and 16 for up to 7 days at each visit. CGM profiles on days where participants received HD were compared with days without HD using a linear mixed model.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>Twenty-seven patients were included. The median number of CGM days performed was 8 (interquartile range [IQR] 6–10) for dialysis days and 16 (IQR 12–17) for nondialysis days. The median sensor glucose was 9.4 (95% confidence interval [CI] 8.8–10.2) mmol/L on dialysis days compared with 9.5 (95% CI 8.9–10.2) mmol/L on nondialysis days (<i>p</i> = 0.58). Nocturnal mean sensor glucose was higher on dialysis days compared with nondialysis days: 8.8 (95% CI 8.0–9.6) mmol/L versus 8.4 (95% CI 7.7–9.2) mmol/L (<i>p</i> = 0.029).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Discussion</h3>\u0000 \u0000 <p>Similar median sensor glucose values were found for days on and off HD. Nocturnal glucose levels were modestly increased on dialysis days. Our findings indicate that antidiabetic treatment does not need to be differentiated on dialysis versus nondialysis days in patients with type 2 diabetes undergoing maintenance HD.</p>\u0000 </section>\u0000 </div>","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/hdi.13073","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9360367","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The native arteriovenous fistula (AVF) is the gold standard for long-term hemodialysis access. When native vein options are exhausted, arteriovenous graft (AVG) becomes the next choice. An ulcer over an AVF or AVG is a serious condition with the potential for life-threatening hemorrhage.
Objectives
This study aims to present our experience with surgical management of ulcers over AVFs or AVGs.
Materials and Methods
Electronic records of 26 patients who underwent 27 consecutive surgical procedures for ulcers over AVFs or AVGs from December 31, 2016 to December 31, 2021 at the Royal Liverpool University Hospital were retrospectively analyzed.
Results
The majority were males (14/26, 53.8%) and the median age was 64.5 years. Operative repair was required for 25 ulcers over 24 AVFs and 2 ulcers over 2 AVGs. Ten patients (37%) presented with bleeding. Seventeen (63%) had impending bleeding suggested by a thin soft tissue covering or a false aneurysm at the site of the ulcer. Previous endovascular intervention for fistula outflow stenosis was a significant predictor for presenting with bleeding (p = 0.031). All ulcers (27/27, 100%) underwent excision and primary skin closure. Fistula wall defects were directly repaired in 18/27 (66.7%). Four/26 (14.8%) fistulas had to be ligated and 2 (7.4%) had end-to-end re-anastomosis after excision of damaged segments. Three/26 (11.53%) fistulas thrombosed immediately after the intervention. The overall fistula salvage rate was 73.08% (19/26). There was 1 (3.7%) patient mortality due to bleeding from wound breakdown after surgery.
Conclusions
An acceptable fistula salvage rate can be expected following surgical repair of ulcers over AVFs and AVGs. A history of previous endovascular interventions for fistula outflow stenosis was a predictor of bleeding from these ulcers.
{"title":"Outcomes of operative intervention for ulcers over hemodialysis arteriovenous access","authors":"Thilina Gunawardena, Hemant Sharma, Sanjay Mehra","doi":"10.1111/hdi.13075","DOIUrl":"10.1111/hdi.13075","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>The native arteriovenous fistula (AVF) is the gold standard for long-term hemodialysis access. When native vein options are exhausted, arteriovenous graft (AVG) becomes the next choice. An ulcer over an AVF or AVG is a serious condition with the potential for life-threatening hemorrhage.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>This study aims to present our experience with surgical management of ulcers over AVFs or AVGs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Materials and Methods</h3>\u0000 \u0000 <p>Electronic records of 26 patients who underwent 27 consecutive surgical procedures for ulcers over AVFs or AVGs from December 31, 2016 to December 31, 2021 at the Royal Liverpool University Hospital were retrospectively analyzed.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The majority were males (14/26, 53.8%) and the median age was 64.5 years. Operative repair was required for 25 ulcers over 24 AVFs and 2 ulcers over 2 AVGs. Ten patients (37%) presented with bleeding. Seventeen (63%) had impending bleeding suggested by a thin soft tissue covering or a false aneurysm at the site of the ulcer. Previous endovascular intervention for fistula outflow stenosis was a significant predictor for presenting with bleeding (<i>p</i> = 0.031). All ulcers (27/27, 100%) underwent excision and primary skin closure. Fistula wall defects were directly repaired in 18/27 (66.7%). Four/26 (14.8%) fistulas had to be ligated and 2 (7.4%) had end-to-end re-anastomosis after excision of damaged segments. Three/26 (11.53%) fistulas thrombosed immediately after the intervention. The overall fistula salvage rate was 73.08% (19/26). There was 1 (3.7%) patient mortality due to bleeding from wound breakdown after surgery.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>An acceptable fistula salvage rate can be expected following surgical repair of ulcers over AVFs and AVGs. A history of previous endovascular interventions for fistula outflow stenosis was a predictor of bleeding from these ulcers.</p>\u0000 </section>\u0000 </div>","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9354764","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Derek M. Blankenship, Len Usvyat, Michael A. Kraus, Dinesh K. Chatoth, Rachel Lasky, Joseph E. Turk Jr., Franklin W. Maddux
Introduction
Inadequate predialysis care and education impacts the selection of a dialysis modality and is associated with adverse clinical outcomes. Transitional care units (TCUs) aim to meet the unmet educational needs of incident dialysis patients, but their impact beyond increasing home dialysis utilization has been incompletely characterized.
Methods
This retrospective study included adults initiating in-center hemodialysis at a TCU, matched to controls (1:4) with no TCU history initiating in-center hemodialysis. Patients were followed for up to 14 months. TCUs are dedicated spaces where staff provide personalized education and as-needed adjustments to dialysis prescriptions. For many patients, therapy was initiated with four to five weekly dialysis sessions, with at least some sessions delivered by home dialysis machines. Outcomes included survival, first hospitalization, transplant waiting-list status, post-TCU dialysis modality, and vascular access type.
Findings
The study included 724 patients initiating dialysis across 48 TCUs, with 2892 well-matched controls. At the end of 14 months, patients initiating dialysis in a TCU were significantly more likely to be referred and/or wait-listed for a kidney transplant than controls (57% vs. 42%; p < 0.0001). Initiation of dialysis at a TCU was also associated with significantly lower rates of receiving in-center hemodialysis at 14 months (74% vs. 90%; p < 0.0001) and higher rates of arteriovenous access (70% vs. 63%; p = 0.003). Although not statistically significant, TCU patients were more likely to survive and less likely to be hospitalized during follow-up than controls.
Discussion
Although TCUs are sometimes viewed as only a means for enhancing utilization of home dialysis, patients attending TCUs exhibited more favorable outcomes across all endpoints. In addition to being 2.5-fold more likely to receive home dialysis, TCU patients were 42% more likely to be referred for transplantation. Our results support expanding utilization of TCUs for patients with inadequate predialysis support.
透析前护理和教育不足会影响透析方式的选择，并与不良临床结果相关。过渡性护理单位(tcu)旨在满足意外透析患者未满足的教育需求，但其影响除了增加家庭透析利用率之外，尚未完全表征。方法本回顾性研究包括在TCU开始中心血液透析的成年人，与没有TCU病史开始中心血液透析的对照组(1:4)相匹配。对患者进行了长达14个月的随访。tcu是工作人员提供个性化教育和根据需要调整透析处方的专用空间。对于许多患者来说，治疗开始时每周透析四到五次，至少有一些是通过家用透析机进行的。结果包括生存、首次住院、移植等待名单状态、tcu后透析方式和血管通路类型。该研究包括48个tcu的724例开始透析的患者，以及2892例匹配良好的对照组。在14个月结束时，在TCU开始透析的患者比对照组更有可能转诊和/或等待肾移植(57% vs. 42%;p < 0.0001)。在TCU开始透析也与14个月时接受中心血液透析的比率显著降低相关(74%对90%;P < 0.0001)和更高的动静脉通路率(70% vs. 63%;p = 0.003)。虽然没有统计学意义，但在随访期间，TCU患者比对照组更有可能存活，住院的可能性更低。尽管tcu有时被视为只是提高家庭透析利用率的一种手段，但参加tcu的患者在所有终点都表现出更有利的结果。除了接受家庭透析的可能性高出2.5倍外，TCU患者转诊接受移植的可能性高出42%。我们的结果支持对透析前支持不足的患者扩大tcu的使用。
{"title":"Assessing the impact of transitional care units on dialysis patient outcomes: A multicenter, propensity score-matched analysis","authors":"Derek M. Blankenship, Len Usvyat, Michael A. Kraus, Dinesh K. Chatoth, Rachel Lasky, Joseph E. Turk Jr., Franklin W. Maddux","doi":"10.1111/hdi.13068","DOIUrl":"10.1111/hdi.13068","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Inadequate predialysis care and education impacts the selection of a dialysis modality and is associated with adverse clinical outcomes. Transitional care units (TCUs) aim to meet the unmet educational needs of incident dialysis patients, but their impact beyond increasing home dialysis utilization has been incompletely characterized.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This retrospective study included adults initiating in-center hemodialysis at a TCU, matched to controls (1:4) with no TCU history initiating in-center hemodialysis. Patients were followed for up to 14 months. TCUs are dedicated spaces where staff provide personalized education and as-needed adjustments to dialysis prescriptions. For many patients, therapy was initiated with four to five weekly dialysis sessions, with at least some sessions delivered by home dialysis machines. Outcomes included survival, first hospitalization, transplant waiting-list status, post-TCU dialysis modality, and vascular access type.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>The study included 724 patients initiating dialysis across 48 TCUs, with 2892 well-matched controls. At the end of 14 months, patients initiating dialysis in a TCU were significantly more likely to be referred and/or wait-listed for a kidney transplant than controls (57% vs. 42%; <i>p</i> < 0.0001). Initiation of dialysis at a TCU was also associated with significantly lower rates of receiving in-center hemodialysis at 14 months (74% vs. 90%; <i>p</i> < 0.0001) and higher rates of arteriovenous access (70% vs. 63%; <i>p</i> = 0.003). Although not statistically significant, TCU patients were more likely to survive and less likely to be hospitalized during follow-up than controls.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Discussion</h3>\u0000 \u0000 <p>Although TCUs are sometimes viewed as only a means for enhancing utilization of home dialysis, patients attending TCUs exhibited more favorable outcomes across all endpoints. In addition to being 2.5-fold more likely to receive home dialysis, TCU patients were 42% more likely to be referred for transplantation. Our results support expanding utilization of TCUs for patients with inadequate predialysis support.</p>\u0000 </section>\u0000 </div>","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9354766","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Susie Q. Lew, Gurleen Kaur, Neal Sikka, Kevin F. Erickson
To the Editor Centers for Medicare and Medicaid Services (CMS) issued a series of telehealth waivers in 2020 that lifted geographic restrictions and expanded originating sites to include the home and dialysis units. For the first time, all nephrology practitioners in the United States could conduct in-center hemodialysis patient visits through telehealth. We evaluated patient experiences with the use of telehealth by their nephrologist in hemodialysis. Hemodialysis patients from 2 units located in the District of Columbia completed a survey in July/August 2021 regarding the use of telehealth with their nephrologists during the COVID-19 pandemic. Telehealth was conducted while patients were receiving treatment in the dialysis unit, and the clinicians were in their home, office, or hospital. The nephrologist determined whether a telehealth visit occurred. During telehealth visits, renal dietitians facilitated videoconferencing by bringing to the chair-side a laptop or tablet installed with a Health Insurance Portability and Accountability Act (HIPAA) compliant video platform. According to the telepresenters, each session approximated 10 min, with a range of 5–60 min. The survey, with a response rate of 75%, reported 94 patients using telehealth while 54 patients did not. A p value of <0.05 was used to identify differences between patients who did and did not report receiving dialysis care via telehealth. Patient demographic characteristics, time on dialysis, education level, primary language, and risk factors of COVID-19 exposure and/or infection did not differ by the receipt of care via telehealth (Table S1). Using a Likert scale ranging from 1 to 10 (10 = extremely satisfied), patients reported an average telehealth satisfaction score of 8.0, with 42% of patients indicating the highest satisfaction rating and 74% indicating a score of 7 or higher (Figure 1). More than 90% of patients reported spending enough time with their physician during their virtual visits and most patients did not report concerns regarding internet security (85%), privacy (85%), or technical issues (92%).
{"title":"In-center hemodialysis unit patient experience with telehealth","authors":"Susie Q. Lew, Gurleen Kaur, Neal Sikka, Kevin F. Erickson","doi":"10.1111/hdi.13065","DOIUrl":"10.1111/hdi.13065","url":null,"abstract":"To the Editor Centers for Medicare and Medicaid Services (CMS) issued a series of telehealth waivers in 2020 that lifted geographic restrictions and expanded originating sites to include the home and dialysis units. For the first time, all nephrology practitioners in the United States could conduct in-center hemodialysis patient visits through telehealth. We evaluated patient experiences with the use of telehealth by their nephrologist in hemodialysis. Hemodialysis patients from 2 units located in the District of Columbia completed a survey in July/August 2021 regarding the use of telehealth with their nephrologists during the COVID-19 pandemic. Telehealth was conducted while patients were receiving treatment in the dialysis unit, and the clinicians were in their home, office, or hospital. The nephrologist determined whether a telehealth visit occurred. During telehealth visits, renal dietitians facilitated videoconferencing by bringing to the chair-side a laptop or tablet installed with a Health Insurance Portability and Accountability Act (HIPAA) compliant video platform. According to the telepresenters, each session approximated 10 min, with a range of 5–60 min. The survey, with a response rate of 75%, reported 94 patients using telehealth while 54 patients did not. A p value of <0.05 was used to identify differences between patients who did and did not report receiving dialysis care via telehealth. Patient demographic characteristics, time on dialysis, education level, primary language, and risk factors of COVID-19 exposure and/or infection did not differ by the receipt of care via telehealth (Table S1). Using a Likert scale ranging from 1 to 10 (10 = extremely satisfied), patients reported an average telehealth satisfaction score of 8.0, with 42% of patients indicating the highest satisfaction rating and 74% indicating a score of 7 or higher (Figure 1). More than 90% of patients reported spending enough time with their physician during their virtual visits and most patients did not report concerns regarding internet security (85%), privacy (85%), or technical issues (92%).","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-02-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9354598","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Derek M. Blankenship, Len Usvyat, Rachel Lasky, Franklin W. Maddux
To the Editor: Patients with end-stage kidney disease (ESKD) are particularly vulnerable to adverse clinical outcomes associated with COVID-19, with an estimated 20%–30% mortality risk.1–4 There is limited information on clinical outcomes, including mortality, following vaccination among patients on dialysis, with many relevant phase 3 trials excluding patients with “serious kidney disease” and chronic conditions. To characterize the impact of COVID-19 vaccination on all-cause mortality, we conducted a retrospective analysis using data from all US adults (i.e., aged ≥18 years) with ESKD receiving dialysis through Fresenius Medical Care (FMC) between March 1 and September 18, 2021. Data for a total of 239,660 patients were available with clinical and demographic, including vaccination status, being updated throughout the study period. As of March 1, 2021, 16,140 patients were classified as fully vaccinated (defined as the time period beginning 2 weeks after either an Ad26.COV2.S vaccination or a second mRNA vaccination), 39,938 were partially vaccinated (defined as the time period up to 2 weeks after vaccination with Ad26.COV2.S or the period from initial vaccination to 2 weeks after a second mRNA vaccination), and 114,403 were unvaccinated (defined as having no COVID-19 vaccination history). Among patients at the start of the study period (N = 170,481), 13.8% were on peritoneal dialysis, 3.8% were on home hemodialysis, and 82.4% were on in-center hemodialysis, 42.6% were female, 63.9% had a history of diabetes, and 51.6% were younger than age 65. Patient demographics remained relatively consistent throughout the study period. Overall, 102,717 patient-years of follow-up were available for analysis: 30,689 for unvaccinated patients, 14,478 for partially vaccinated patients, and 57,550 for fully vaccinated patients. During the analysis period, 19,356 deaths occurred, equating to an overall mortality rate of 18.8 deaths per 100 patient-years. The unadjusted rate of death (per 100 patient-years) was 29.6, 13.8, and 14.4 among unvaccinated, partially vaccinated, and fully vaccinated patients, respectively. When adjusted for sex, age, race/ ethnicity, diabetes history, and US geographic region, the risk of death was 159% higher among unvaccinated patients than that observed during times when patients were vaccinated (hazard ratio [HR]: 2.6). Unvaccinated patients were at higher risk regardless of modality (Figure 1). In FMC electronic medical records, COVID-19 was listed as the primary or secondary cause of death in 1207 of the total 19,356 deaths (1.18 deaths/100 years) and as the primary cause of death in 832 patients (0.81 deaths/100 years). It was estimated unvaccinated patients were six times more likely than fully vaccinated patients to have a COVID-19-related death using either definition (Figure 2). Furthermore, cardiovascular causes were listed as the primary or secondary cause of death for a total of 9280 patients; estimated unvaccinated patie
{"title":"COVID-19 vaccination status impact on mortality in end-stage kidney disease","authors":"Derek M. Blankenship, Len Usvyat, Rachel Lasky, Franklin W. Maddux","doi":"10.1111/hdi.13072","DOIUrl":"10.1111/hdi.13072","url":null,"abstract":"To the Editor: Patients with end-stage kidney disease (ESKD) are particularly vulnerable to adverse clinical outcomes associated with COVID-19, with an estimated 20%–30% mortality risk.1–4 There is limited information on clinical outcomes, including mortality, following vaccination among patients on dialysis, with many relevant phase 3 trials excluding patients with “serious kidney disease” and chronic conditions. To characterize the impact of COVID-19 vaccination on all-cause mortality, we conducted a retrospective analysis using data from all US adults (i.e., aged ≥18 years) with ESKD receiving dialysis through Fresenius Medical Care (FMC) between March 1 and September 18, 2021. Data for a total of 239,660 patients were available with clinical and demographic, including vaccination status, being updated throughout the study period. As of March 1, 2021, 16,140 patients were classified as fully vaccinated (defined as the time period beginning 2 weeks after either an Ad26.COV2.S vaccination or a second mRNA vaccination), 39,938 were partially vaccinated (defined as the time period up to 2 weeks after vaccination with Ad26.COV2.S or the period from initial vaccination to 2 weeks after a second mRNA vaccination), and 114,403 were unvaccinated (defined as having no COVID-19 vaccination history). Among patients at the start of the study period (N = 170,481), 13.8% were on peritoneal dialysis, 3.8% were on home hemodialysis, and 82.4% were on in-center hemodialysis, 42.6% were female, 63.9% had a history of diabetes, and 51.6% were younger than age 65. Patient demographics remained relatively consistent throughout the study period. Overall, 102,717 patient-years of follow-up were available for analysis: 30,689 for unvaccinated patients, 14,478 for partially vaccinated patients, and 57,550 for fully vaccinated patients. During the analysis period, 19,356 deaths occurred, equating to an overall mortality rate of 18.8 deaths per 100 patient-years. The unadjusted rate of death (per 100 patient-years) was 29.6, 13.8, and 14.4 among unvaccinated, partially vaccinated, and fully vaccinated patients, respectively. When adjusted for sex, age, race/ ethnicity, diabetes history, and US geographic region, the risk of death was 159% higher among unvaccinated patients than that observed during times when patients were vaccinated (hazard ratio [HR]: 2.6). Unvaccinated patients were at higher risk regardless of modality (Figure 1). In FMC electronic medical records, COVID-19 was listed as the primary or secondary cause of death in 1207 of the total 19,356 deaths (1.18 deaths/100 years) and as the primary cause of death in 832 patients (0.81 deaths/100 years). It was estimated unvaccinated patients were six times more likely than fully vaccinated patients to have a COVID-19-related death using either definition (Figure 2). Furthermore, cardiovascular causes were listed as the primary or secondary cause of death for a total of 9280 patients; estimated unvaccinated patie","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-02-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9353871","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Junqing Liang MD, RN, Ying Wang BSN, RN, Weilin Zhang BSN, RN, Hong Ding RN, Yanjun Gao RN, Rui Wang RN, Xiaofei Sun RN, Ying Peng RN, Liangying Gan PhD, MD, Li Zuo PhD, MD
Introduction
Patients undergoing hemodialysis (HD) are at a higher risk of falls than healthy individuals. Further knowledge regarding the risk of falls could lead to better risk prevention strategies. We designed a multicenter, prospective cohort study according to the strengthening of the reporting of observational studies in epidemiology (STROBE) guidelines to investigate the incidence and risk factors of falls in patients undergoing hemodialysis in Northern China.
Methods
Patients undergoing hemodialysis in six hemodialysis units were recruited from January 2019 to January 2020. Data on demographics and disease conditions were collected at baseline. Data on other variables, the incidence of falls, and related conditions were collected every 3 months during a 1-year follow-up. The Generalized Estimating Equation model was used to evaluate factors associated with falls.
Findings
This study included 472 patients. The incidence of falls was 0.31 per patient year. In patients aged 45–64 years (p = 0.01; odds ratio [OR]: 14.801; 95% confidence interval [CI]: 1.897–115.453) and ≥ 65 years (p = 0.007; OR: 16.562; 95% CI: 2.118–129.521), anemia (p = 0.015; OR: 2.122; 95% CI: 1.154–3.902) and moderately (p = 0.003; OR: 5.439; 95% CI: 1.791–16.516) and severely abnormal timed up and go test (TUGT) levels (p = 0.001; OR: 7.032; 95% CI: 2.226–22.216) were identified as independent risk factors of falls.
Discussion
Falls are prevalent among patients undergoing in-center hemodialysis. Advanced age, anemia, and moderately and severely abnormal TUGT levels may be risk factors of falls.
{"title":"Incidence and risk factors of falls in patients undergoing hemodialysis: A multicenter survey in northern China","authors":"Junqing Liang MD, RN, Ying Wang BSN, RN, Weilin Zhang BSN, RN, Hong Ding RN, Yanjun Gao RN, Rui Wang RN, Xiaofei Sun RN, Ying Peng RN, Liangying Gan PhD, MD, Li Zuo PhD, MD","doi":"10.1111/hdi.13064","DOIUrl":"10.1111/hdi.13064","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Patients undergoing hemodialysis (HD) are at a higher risk of falls than healthy individuals. Further knowledge regarding the risk of falls could lead to better risk prevention strategies. We designed a multicenter, prospective cohort study according to the strengthening of the reporting of observational studies in epidemiology (STROBE) guidelines to investigate the incidence and risk factors of falls in patients undergoing hemodialysis in Northern China.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Patients undergoing hemodialysis in six hemodialysis units were recruited from January 2019 to January 2020. Data on demographics and disease conditions were collected at baseline. Data on other variables, the incidence of falls, and related conditions were collected every 3 months during a 1-year follow-up. The Generalized Estimating Equation model was used to evaluate factors associated with falls.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>This study included 472 patients. The incidence of falls was 0.31 per patient year. In patients aged 45–64 years (<i>p</i> = 0.01; odds ratio [OR]: 14.801; 95% confidence interval [CI]: 1.897–115.453) and ≥ 65 years (<i>p</i> = 0.007; OR: 16.562; 95% CI: 2.118–129.521), anemia (<i>p</i> = 0.015; OR: 2.122; 95% CI: 1.154–3.902) and moderately (<i>p</i> = 0.003; OR: 5.439; 95% CI: 1.791–16.516) and severely abnormal timed up and go test (TUGT) levels (<i>p</i> = 0.001; OR: 7.032; 95% CI: 2.226–22.216) were identified as independent risk factors of falls.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Discussion</h3>\u0000 \u0000 <p>Falls are prevalent among patients undergoing in-center hemodialysis. Advanced age, anemia, and moderately and severely abnormal TUGT levels may be risk factors of falls.</p>\u0000 </section>\u0000 </div>","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-02-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9347713","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Babitha Selvananthan, Omar Aziz, Arvind D. Lee, Keagan Werner-Gibbings, Bhadran Bose, Kamal Sud
Blood leak alarms are increasingly rare and may be triggered by rupture of the dialyzer membrane, or intravascular hemolysis. We report two patients who developed hemolysis following Angiojet™ thrombolysis and thrombectomy of thrombosed arteriovenous fistulas, triggering blood leak alarms on hemodialysis, the occurrence of which has not been reported before. AngioJet™-induced hemolysis should be considered in the differential diagnosis for blood leak alarms occurring soon after an intervention on an arterio-venous (AV) fistula.
{"title":"Angiojet™ mechanical thrombectomy-induced hemolysis triggering blood-leak alarms","authors":"Babitha Selvananthan, Omar Aziz, Arvind D. Lee, Keagan Werner-Gibbings, Bhadran Bose, Kamal Sud","doi":"10.1111/hdi.13062","DOIUrl":"10.1111/hdi.13062","url":null,"abstract":"<p>Blood leak alarms are increasingly rare and may be triggered by rupture of the dialyzer membrane, or intravascular hemolysis. We report two patients who developed hemolysis following Angiojet™ thrombolysis and thrombectomy of thrombosed arteriovenous fistulas, triggering blood leak alarms on hemodialysis, the occurrence of which has not been reported before. AngioJet™-induced hemolysis should be considered in the differential diagnosis for blood leak alarms occurring soon after an intervention on an arterio-venous (AV) fistula.</p>","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-02-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9411969","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Data on the incidence rates of hungry bone syndrome after parathyroidectomy in patients on dialysis are inconsistent, as the published rates vary from 15.8% to 92.9%.
Methods
Between 2009 and 2019, 120 hemodialysis patients underwent parathyroidectomy for secondary hyperparathyroidism at the Chang Gung Memorial Hospital. The patients were stratified into two groups based on the presence (n = 100) or absence (n = 20) of hungry bone syndrome after parathyroidectomy.
Findings
Subtotal parathyroidectomy was the most common surgery performed (76.7%), followed by total parathyroidectomy with autoimplantation (23.3%). Pathological examination revealed parathyroid hyperplasia. Hungry bone syndrome developed within 0.3 ± 0.3 months and lasted for 11.1 ± 14.7 months. After surgery, compared with patients without hungry bone syndrome, patients with hungry bone syndrome had lower levels of nadir corrected calcium (P < 0.001), as well as lower nadir (P < 0.001) and peak (P < 0.001) intact parathyroid hormone levels. During 59.3 ± 44.0 months of follow-up, persistence and recurrence of hyperparathyroidism occurred in 25 (20.8%) and 30 (25.0%) patients, respectively. Furthermore, patients with hungry bone syndrome had a lower rate of persistent hyperparathyroidism than those without hungry bone syndrome (P < 0.001). Four patients (3.3%) underwent a second parathyroidectomy. Patients with hungry bone syndrome received fewer second parathyroidectomies than those without hungry bone syndrome (P < 0.001). Finally, a multivariate logistic regression model revealed that the preoperative blood ferritin level was a negative predictor of the development of hungry bone syndrome (P = 0.038).
Discussion
Hungry bone syndrome is common (83.3%) after parathyroidectomy for secondary hyperparathyroidism in patients undergoing hemodialysis, and this complication should be monitored and managed appropriately.
{"title":"Hungry bone syndrome after parathyroid surgery","authors":"Ya-Ling Tai, Hsin-Yi Shen, Wei-Hsuan Nai, Jen-Fen Fu, I-Kuan Wang, Chien-Chang Huang, Cheng-Hao Weng, Cheng-Chia Lee, Wen-Hung Huang, Huang-Yu Yang, Ching-Wei Hsu, Tzung-Hai Yen","doi":"10.1111/hdi.13067","DOIUrl":"10.1111/hdi.13067","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Data on the incidence rates of hungry bone syndrome after parathyroidectomy in patients on dialysis are inconsistent, as the published rates vary from 15.8% to 92.9%.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Between 2009 and 2019, 120 hemodialysis patients underwent parathyroidectomy for secondary hyperparathyroidism at the Chang Gung Memorial Hospital. The patients were stratified into two groups based on the presence (<i>n</i> = 100) or absence (<i>n</i> = 20) of hungry bone syndrome after parathyroidectomy.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>Subtotal parathyroidectomy was the most common surgery performed (76.7%), followed by total parathyroidectomy with autoimplantation (23.3%). Pathological examination revealed parathyroid hyperplasia. Hungry bone syndrome developed within 0.3 ± 0.3 months and lasted for 11.1 ± 14.7 months. After surgery, compared with patients without hungry bone syndrome, patients with hungry bone syndrome had lower levels of nadir corrected calcium (<i>P</i> < 0.001), as well as lower nadir (<i>P</i> < 0.001) and peak (<i>P</i> < 0.001) intact parathyroid hormone levels. During 59.3 ± 44.0 months of follow-up, persistence and recurrence of hyperparathyroidism occurred in 25 (20.8%) and 30 (25.0%) patients, respectively. Furthermore, patients with hungry bone syndrome had a lower rate of persistent hyperparathyroidism than those without hungry bone syndrome (<i>P</i> < 0.001). Four patients (3.3%) underwent a second parathyroidectomy. Patients with hungry bone syndrome received fewer second parathyroidectomies than those without hungry bone syndrome (<i>P</i> < 0.001). Finally, a multivariate logistic regression model revealed that the preoperative blood ferritin level was a negative predictor of the development of hungry bone syndrome (<i>P</i> = 0.038).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Discussion</h3>\u0000 \u0000 <p>Hungry bone syndrome is common (83.3%) after parathyroidectomy for secondary hyperparathyroidism in patients undergoing hemodialysis, and this complication should be monitored and managed appropriately.</p>\u0000 </section>\u0000 </div>","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-01-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9347705","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Peiheng Zhang, Yang Yu, Ying Gao, Geheng Yuan, Junqing Zhang, Wei Wang
The most appropriate surgical procedure for tertiary hyperparathyroidism is still controversial. Medical management may be considered in those patients with failed previous surgical intervention. There are limited medical options for tertiary hyperparathyroidism with renal dysfunction. The monoclonal antibody denosumab has been used in patients with osteoporosis and hypercalcemia of malignancy. We report a case of medically refractory hypercalcemia caused by tertiary hyperparathyroidism treated with denosumab. A 46-year-old female was on hemodialysis for 10 years. She was diagnosed with tertiary hyperparathyroidism due to hypercalcemia with a high level of intact parathyroid hormone (iPTH, 1411 pg/ml). After right parathyroidectomy 6 weeks, her serum calcium remained persistently elevated (Ca, 3.17 mmoL/L). Denosumab (60 mg) was administered subcutaneously, and her serum calcium quickly decreased (from 3.43 to 2.04 mmoL/L within 8 days) and was slightly elevated (Ca, 2.8 mmoL/L) 3 months later. We conclude that denosumab has a significant effect on the reduction of serum calcium for tertiary hyperparathyroidism patients. The long-term treatment effect and safety warrant more studies in the future.
{"title":"Denosumab treatment for refractory hypercalcemia in a hemodialysis patient with tertiary hyperparathyroidism","authors":"Peiheng Zhang, Yang Yu, Ying Gao, Geheng Yuan, Junqing Zhang, Wei Wang","doi":"10.1111/hdi.13063","DOIUrl":"10.1111/hdi.13063","url":null,"abstract":"<p>The most appropriate surgical procedure for tertiary hyperparathyroidism is still controversial. Medical management may be considered in those patients with failed previous surgical intervention. There are limited medical options for tertiary hyperparathyroidism with renal dysfunction. The monoclonal antibody denosumab has been used in patients with osteoporosis and hypercalcemia of malignancy. We report a case of medically refractory hypercalcemia caused by tertiary hyperparathyroidism treated with denosumab. A 46-year-old female was on hemodialysis for 10 years. She was diagnosed with tertiary hyperparathyroidism due to hypercalcemia with a high level of intact parathyroid hormone (iPTH, 1411 pg/ml). After right parathyroidectomy 6 weeks, her serum calcium remained persistently elevated (Ca, 3.17 mmoL/L). Denosumab (60 mg) was administered subcutaneously, and her serum calcium quickly decreased (from 3.43 to 2.04 mmoL/L within 8 days) and was slightly elevated (Ca, 2.8 mmoL/L) 3 months later. We conclude that denosumab has a significant effect on the reduction of serum calcium for tertiary hyperparathyroidism patients. The long-term treatment effect and safety warrant more studies in the future.</p>","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-01-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9354039","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Michael Schmiedecker, Simon Krenn, Maximilian Waller, Christopher Paschen, Sebastian Mussnig, Janosch Niknam, Peter Wabel, Christopher C. Mayer, Manfred Hecking, Daniel Schneditz
Introduction
Prescribing the ultrafiltration in hemodialysis patients remains challenging and might benefit from the information on absolute blood volume, estimated by intradialytic dialysate bolus administration. Here, we aimed at determining the relationship between absolute blood volume, normalized for body mass (specific blood volume, Vs), and ultrafiltration-induced decrease in relative blood volume (∆RBV) as well as clinical parameters including body mass index (BMI).
Methods
This retrospective analysis comprised 77 patients who had their dialysate bolus-based absolute blood volume extracted routinely with an automated method. Patient-specific characteristics and ∆RBV were analyzed as a function of Vs, dichotomizing the data above or below a previously proposed threshold of 65 ml/kg for Vs. Statistical methodology comprised descriptive analyses, two-group comparisons, and correlation analyses.
Findings
Median Vs was 68.6 ml/kg (54.9 ml/kg [Quartile 1], 83.4 ml/kg [Quartile 3]). Relative blood volume decreased by 6.3% (2.6%, 12.2%) over the entire hemodialysis session. Vs correlated inversely with BMI (rs = −0.688, p < 0.001). ∆RBV was 9.8% in the group of patients with Vs <65 ml/kg versus 6.0% in the group of patients with Vs ≥65 ml/kg (p = 0.024). The two groups did not differ significantly regarding their specific ultrafiltration volume, normalized for body mass, which amounted to 34.1 ml/kg and 36.0 ml/kg in both groups, respectively (p = 0.630). ∆RBV correlated inversely with Vs (rs = −0.299, p = 0.008).
Discussion
The present study suggests that patients with higher BMI and lower Vs experience larger blood volume changes, despite similar ultrafiltration requirements. These results underline the clinical plausibility and importance of dialysate bolus-based absolute blood volume determination in the assessment of target weight, especially in view of a previous study where intradialytic morbid events could be decreased when the target weight was adjusted, based on Vs.
{"title":"Ultrafiltration-induced decrease in relative blood volume is larger in hemodialysis patients with low specific blood volume: Results from a dialysate bolus administration study","authors":"Michael Schmiedecker, Simon Krenn, Maximilian Waller, Christopher Paschen, Sebastian Mussnig, Janosch Niknam, Peter Wabel, Christopher C. Mayer, Manfred Hecking, Daniel Schneditz","doi":"10.1111/hdi.13066","DOIUrl":"10.1111/hdi.13066","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Prescribing the ultrafiltration in hemodialysis patients remains challenging and might benefit from the information on absolute blood volume, estimated by intradialytic dialysate bolus administration. Here, we aimed at determining the relationship between absolute blood volume, normalized for body mass (specific blood volume, Vs), and ultrafiltration-induced decrease in relative blood volume (∆RBV) as well as clinical parameters including body mass index (BMI).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This retrospective analysis comprised 77 patients who had their dialysate bolus-based absolute blood volume extracted routinely with an automated method. Patient-specific characteristics and ∆RBV were analyzed as a function of Vs, dichotomizing the data above or below a previously proposed threshold of 65 ml/kg for Vs. Statistical methodology comprised descriptive analyses, two-group comparisons, and correlation analyses.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>Median Vs was 68.6 ml/kg (54.9 ml/kg [Quartile 1], 83.4 ml/kg [Quartile 3]). Relative blood volume decreased by 6.3% (2.6%, 12.2%) over the entire hemodialysis session. Vs correlated inversely with BMI (r<sub>s</sub> = −0.688, <i>p</i> < 0.001). ∆RBV was 9.8% in the group of patients with Vs <65 ml/kg versus 6.0% in the group of patients with Vs ≥65 ml/kg (<i>p</i> = 0.024). The two groups did not differ significantly regarding their specific ultrafiltration volume, normalized for body mass, which amounted to 34.1 ml/kg and 36.0 ml/kg in both groups, respectively (<i>p</i> = 0.630). ∆RBV correlated inversely with Vs (r<sub>s</sub> = −0.299, <i>p</i> = 0.008).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Discussion</h3>\u0000 \u0000 <p>The present study suggests that patients with higher BMI and lower Vs experience larger blood volume changes, despite similar ultrafiltration requirements. These results underline the clinical plausibility and importance of dialysate bolus-based absolute blood volume determination in the assessment of target weight, especially in view of a previous study where intradialytic morbid events could be decreased when the target weight was adjusted, based on Vs.</p>\u0000 </section>\u0000 </div>","PeriodicalId":12815,"journal":{"name":"Hemodialysis International","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2023-01-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/hdi.13066","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9347696","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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