Search

Rationale & Objective Persons with chronic kidney disease (CKD) are often unaware of their disease status. Efforts to improve CKD awareness may be most effective if focused on persons at highest risk for progression to kidney failure. Study Design Serial cross-sectional surveys. Setting & Participants Nonpregnant adults (aged ≥20 years) with CKD glomerular filtration rate categories 3-4 (G3-G4) who participated in the National Health and Nutrition Examination Survey from 1999 to 2016 (n = 3,713). Predictor 5-year kidney failure risk, estimated using the Kidney Failure Risk Equation. Predicted risk was categorized as minimal ( Outcome CKD awareness, defined by answering “yes” to the question “Have you ever been told by a doctor or other health professional that you had weak or failing kidneys?” Analytical Approach Prevalence of CKD awareness was estimated within each risk group using complex sample survey methods. Associations between Kidney Failure Risk Equation risk and CKD awareness were assessed using multivariable logistic regression. CKD awareness was compared with awareness of hypertension and diabetes during the same period. Results In 2011 to 2016, unadjusted CKD awareness was 9.6%, 22.6%, 44.7%, and 49.0% in the minimal-, low-, intermediate-, and high-risk groups, respectively. In adjusted analyses, these proportions did not change over time. Awareness of CKD, including among the highest risk group, remains consistently below that of hypertension and diabetes and awareness of these conditions increased over time. Limitations Imperfect sensitivity of the “weak or failing kidneys” question for ascertaining CKD awareness. Conclusions Among adults with CKD G3-G4 who have 5-year estimated risks for kidney failure of 5%

RATIONALE & OBJECTIVE: Women with end stage kidney disease (ESKD) have decreased fertility and are at increased risk for pregnancy complications. This study examined secular trends and outcomes of obstetric deliveries in a US cohort of women with ESKD. STUDY DESIGN: Retrospective cohort study SETTING & PARTICIPANTS: Women aged 18–44 years with ESKD and registered in the United States Renal Data System (USRDS) from 2002 – 2015. EXPOSURE: ESKD modality (hemodialysis, peritoneal dialysis, transplant) OUTCOMES: Infant delivery, pre-term delivery, cesarean delivery ANALYTICAL APPROACH: Unadjusted delivery rates were expressed as the number of delivering women per 1000 patient-years among women 18–44 within each year over the study period, stratified by ESKD modality. Logistic regression models were used to evaluate associations of delivery, pre-term delivery, and cesarean delivery, with patient characteristics. RESULTS: The delivery rate in women undergoing HD and in women with a kidney transplant increased from 2.1 to 3.6 and 3.1 to 4.6 per 1000 patient-years, respectively (p

Background Although incidence rates of end-stage renal disease (ESRD) in the United States are reported routinely by the US Renal Data System (USRDS), risks (probabilities) are not reported. Short- and long-term risk estimates need to be updated and expanded to minority populations, including Native Americans, Asian/Pacific Islanders, and Hispanics. Study Design Risk estimation from surveillance data in large populations using life-table methods. A competing-risks framework was applied by constructing a hypothetical cohort followed from birth to death. Setting & Participants Total US population. Incidence and mortality rates of ESRD were obtained from the USRDS; all-cause mortality rates were obtained from CDC WONDER. Predictors Age, sex, race/ethnicity, and year. Outcomes 10-year to lifetime risks (cumulative incidence) of ESRD. Results Among males, lifetime risks of ESRD from birth using 2013 data were 3.1% (95% CI, 3.0%-3.1%) for non-Hispanic whites, 8.0% (95% CI, 7.9%-8.2%) for non-Hispanic blacks, 3.8% (95% CI, 3.4%-4.9%) for non-Hispanic Native Americans, 5.1% (95% CI, 4.8%-5.4%) for non-Hispanic Asians/Pacific Islanders, and 6.2% (95% CI, 6.1%-6.4%) for Hispanics. Among females, lifetime risks were 2.0% (95% CI, 2.0%-2.1%) for non-Hispanic whites, 6.8% (95% CI, 6.7%-6.9%) for non-Hispanic blacks, 3.6% (95% CI, 3.3%-4.2%) for non-Hispanic Native Americans, 3.8% (95% CI, 3.6%-4.0%) for non-Hispanic Asian/Pacific Islanders, and 4.3% (95% CI, 4.2%-4.5%) for Hispanics. Lifetime risk of ESRD from birth increased from 3.5% in 2000 to 4.0% in 2013 in males and decreased from 3.0% to 2.8% in females. Limitations Standard life-time assumption of fixed age-specific rates over time and possible ESRD misclassification. To be useful in clinical practice, this application will require additional predictors (eg, comorbid conditions and chronic kidney disease stage). Conclusions ESRD risk in the United States varies more than 2-fold among racial/ethnic groups for both sexes.

BackgroundHigh interdialytic weight gain (IDWG) is associated with adverse outcomes in hemodialysis (HD) patients. We identified temporal and regional trends in IDWG, predictors of IDWG, and associations of IDWG with clinical outcomes.Study DesignAnalysis 1: sequential cross-sections to identify facility- and patient-level predictors of IDWG and their temporal trends. Analysis 2: prospective cohort study to assess associations between IDWG and mortality and hospitalization risk.Setting & Participants21,919 participants on HD therapy for 1 year or longer in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 2 to 5 (2002-2014).PredictorsAnalysis 1: study phase, patient demographics and comorbid conditions, HD facility practices. Analysis 2: relative IDWG, expressed as percentage of post-HD weight (

Predialysis serum sodium concentrations recently have been linked to patient characteristics and outcomes in hemodialysis patients and may have implications for the dialysate sodium prescription.Prospective cohort study.11,555 patients from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS), phases I (1996-2001) and III (2005-2008).Demographics, comorbid conditions, laboratory measurements (model 1); mean serum sodium level, dialysate sodium concentration (model 2).Serum sodium level, using adjusted linear mixed models (model 1); all-cause mortality, using Cox proportional hazards models (model 2).Median follow-up was 12 months, with 1,727 deaths (15%) occurring during the study period (12,274 patient-years). Mean serum sodium level in the DOPPS countries was 138.5 ± 2.8 mEq/L. Japan had the highest (139.1 ± 2.6 mEq/L) and Australia/New Zealand had the lowest mean serum sodium level (137.4 ± 2.8 mEq/L). Serum sodium level was associated positively with male sex, black race, body mass index, serum albumin level, and creatinine level and negatively with neurologic and psychiatric disease, white blood cell count, and intradialytic weight loss (0.16 mEq/L lower per 1% loss). Higher serum sodium level was associated with lower adjusted all-cause mortality in a continuous model (HR, 0.95 per 1 mEq/L higher; 95% CI, 0.93-0.97). Dialysate sodium prescription was not associated with serum sodium level. Mortality analyses restricted to the serum sodium tertile with the highest mortality (serum sodium137 mEq/L) showed lower mortality risk in patients with dialysate sodium prescriptions140 mEq/L.Causality cannot be established in this observational study, which does not consider potential effects of dialysate sodium level on postdialysis thirst, dietary salt and water intake, interdialytic weight gain, and cardiovascular stability.Lower serum sodium levels are associated with certain hemodialysis patient characteristics and higher adjusted risk of death. The lower mortality observed in our adjusted analyses in patients with serum sodium levels137 mEq/L dialyzed against dialysate sodium prescriptions140 mEq/L is intriguing, may be related to intradialytic cardiovascular stability, and deserves further study.

Sleep-related problems, which have been associated with poor health outcomes, have not been investigated thoroughly in people with chronic kidney disease (CKD). We examined the prevalence of a variety of sleep-related problems in persons with and without CKD.National cross-sectional survey (National Health and Nutrition Examination Survey 2005-2008).Community-based survey of 9,110 noninstitutionalized US civilian residents 20 years or older.CKD, defined as estimated glomerular filtration rate (eGFR) of 15-59 mL/min/1.73 m(2) (stages 3 and 4) or eGFR ≥60 mL/min/1.73 m(2) and albumin-creatinine ratio ≥30 mg/g (stages 1 and 2).Sleep quality, defined using self-report in a multi-item sleep questionnaire including items from previously validated instruments.Albuminuria and eGFR assessed from urine and blood samples; sleep, demographics, and comorbid conditions assessed using a standardized questionnaire.Inadequate sleep (≤6 hours per night) differed by CKD severity (37.4%, 43.0%, and 30.9% for no CKD, CKD stages 1 and 2, and CKD stages 3 and 4, respectively; P = 0.003). Frequent sleeping pill use (8.4%, 9.9%, and 16.6%), leg symptoms (39.2%, 48.0%, and 50.9%), and nocturia (20.9%, 35.2%, and 43.6%; P0.001 for all) also differed by CKD severity. After adjustment for age, sex, race/ethnicity, obesity, diabetes, and cardiovascular disease, the prevalence of these sleep-related problems remained higher in people with CKD stages 1 and 2 relative to no CKD. Most other measures of sleep quality, disorder, and functional outcomes did not differ by CKD.Inability to establish causality and possible unmeasured confounding.Providers should be aware of early sleep-related CKD manifestations, including inadequate sleep, leg symptoms, and nocturia, and of the high rate of reported sleep medication use in this population.

Recognizing that autologous arteriovenous fistula use was associated with improved outcomes in hemodialysis patients, the 1997 Dialysis Outcomes Quality Initiative (DOQI) vascular access practice guidelines from the National Kidney Foundation stressed fistulas as the optimal means of dialysis vascular access. In the United States, this emphasis has continued with the Fistula First Breakthrough Initiative. Much of the data supporting fistulas for dialysis access are derived from longitudinal cohorts, including the Dialysis Outcomes and Practice Patterns Study (DOPPS), dialysis provider databases, and other sources. This article reviews major findings from these data sources, focusing on specific practices and characteristics associated with greater arteriovenous fistula use in dialysis facilities worldwide. Important and often overlooked characteristics that are discussed in detail include specific preferences of dialysis staff regarding access type and the emphasis placed on fistula primacy and the number of fistulas created during surgical training. For example, in the DOPPS, the risk of initial fistula failure was 34% lower when fistulas were placed by surgeons who had created at least 25 fistulas during training (P = 0.002). It is imperative that dialysis clinicians advocate actively for specific dialysis access types on behalf of individual patients. Vascular surgery teaching programs must supervise adequate numbers of fistula procedures for every trainee.

Background The Hispanic ethnic group is heterogeneous, with distinct genetic, cultural, and socioeconomic characteristics, but most prior studies of patients with end-stage renal disease focus on the overall Hispanic ethnic group without further granularity. We examined survival differences among Mexican-American, Puerto Rican, and Cuban-American dialysis patients in the United States. Study Design Prospective observational study. Setting & Participants Data from individuals randomly selected for the End-Stage Renal Disease Clinical Performance Measures Project (2001 to 2005) were examined. Mexican-American (n = 2,742), Puerto Rican (n = 838), Cuban-American (n = 145), and Hispanic-other dialysis patients (n = 942) were compared with each other and with non-Hispanic (n = 33,076) dialysis patients in the United States. Predictors Patient characteristics of interest included ethnicity/race, comorbidities, and specific available laboratory values. Outcomes The major outcome of interest was mortality. Results In the fully adjusted multivariable model, 2-year mortality risk was significantly lower for the Mexican-American and Hispanic-other groups compared with non-Hispanics (adjusted hazard ratio, 0.79; 95% confidence interval, 0.73 to 0.85; adjusted hazard ratio, 0.81; 95% confidence interval, 0.71 to 0.92, respectively). Differences in 2-year mortality rates within the Hispanic ethnic groups were statistically significant ( P = 0.004) and ranged from 21% lower mortality in Mexican Americans to 3% higher mortality in Puerto Ricans compared with non-Hispanics. Limitations Include those inherent to an observational study, potential ethnic group misclassification, and small sample sizes for some Hispanic subgroups. Conclusion Mexican-American and Hispanic-other dialysis patients have a survival advantage compared with non-Hispanics. Furthermore, Mexican Americans, Cuban Americans, and Hispanic others had a survival advantage compared with their Puerto Rican counterparts. Future research should continue to examine subgroups within Hispanic ethnicity to understand underlying reasons for observed differences that may be masked by examining the Hispanic ethnic group as only a single entity.

A substantial number of patients return to dialysis therapy after a renal transplant fails. It is not clear whether mortality increases among patients with graft failure relative to those on the waiting list who have not yet received a kidney transplant.Data from the Scientific Registry of Transplant Recipients were analyzed (N = 175,436). Cox regression with time-dependent covariates was used to compare mortality between post-graft failure dialysis patients and primary transplant candidates on dialysis therapy. Mortality hazard ratios (HRs) were adjusted for age, sex, race, cause of end-stage renal disease, pre-waiting list time on dialysis therapy, calendar year of wait-listing, and organ procurement organization.Overall, the post-graft failure dialysis group experienced a significant 78% greater mortality (HR, 1.78; P0.0001) relative to the transplant candidate group. The post-graft failure dialysis/transplant candidate HR was relatively constant across age groups, but significantly greater (P0.0001) among patients with diabetes (HR, 1.93) than among those without diabetes (HR, 1.69). The HR was greatest during the first week after graft failure (HR, 13.6; P0.0001) and decreased steadily thereafter. However, despite leveling off, the HR remained significantly elevated well after graft failure, including the 5- to 10-year period after graft failure.Based on national data, mortality among patients on dialysis therapy after primary graft failure increases significantly relative to mortality among patients still awaiting primary kidney transplantation. Additional studies are urgently needed to define the mechanism of the increased risk and strategies to decrease mortality.

Analyses based on the National Cooperative Dialysis Study (NCDS) provided the impetus for routine quantification of delivered dialysis dose in hemodialysis practice throughout the world, by suggesting minimum targets for small solute (urea) clearance. Morbidity and mortality in dialysis populations remain high despite many technological advances in dialysis delivery. A number of observational studies reported association between higher dose of dialysis as measured by Kt/V urea or urea reduction ratio with lower mortality risk. During the 1990s, a steady increase in dialysis dose and a modest reduction in mortality on dialysis were observed. However, observational studies only reveal associations and are limited by selection bias and confounding. The Kidney Disease Outcomes Quality Initiative guidelines on dialysis adequacy are based on results of observational studies and expert opinion. Since the NCDS, the HEMO Study was the first major randomized clinical trial designed to study the effect of dose of dialysis and dialyzer flux on patient outcomes. Despite adequate separation of dose and flux, however, results of the trial did not prove a beneficial effect of higher dose. The Dialysis Outcomes and Practice Patterns Study (DOPPS), in a major international effort designed to examine the effect of practice patterns on outcomes, has made significant contributions to the topic of dialysis dose. The following review critically examines data from observational studies, including the DOPPS, and from the HEMO Study, emphasizing important lessons from both, and discusses future paradigms for achieving dialysis adequacy to improve patient outcomes.

Author(s): Saran, Rajiv; Li, Yi; Robinson, Bruce; Abbott, Kevin C; Agodoa, Lawrence YC; Ayanian, John; Bragg-Gresham, Jennifer; Balkrishnan, Rajesh; Chen, Joline LT; Cope, Elizabeth; Eggers, Paul W; Gillen, Daniel; Gipson, Debbie; Hailpern, Susan M; Hall, Yoshio N; He, Kevin; Herman, William; Heung, Michael; Hirth, Richard A; Hutton, David; Jacobsen, Steven J; Kalantar-Zadeh, Kamyar; Kovesdy, Csaba P; Lu, Yee; Molnar, Miklos Z; Morgenstern, Hal; Nallamothu, Brahmajee; Nguyen, Danh V; O'Hare, Ann M; Plattner, Brett; Pisoni, Ronald; Port, Friedrich K; Rao, Panduranga; Rhee, Connie M; Sakhuja, Ankit; Schaubel, Douglas E; Selewski, David T; Shahinian, Vahakn; Sim, John J; Song, Peter; Streja, Elani; Kurella Tamura, Manjula; Tentori, Francesca; White, Sarah; Woodside, Kenneth; Hirth, Richard A

Chronic Kidney Disease Surveillance for the United States: A Centers for Disease Control and Prevention Initiative Elizabeth Hedgeman, Laura Plantinga, Nilka Rios Burrows, Jerry Yee, Neil Powe, Desmond Williams and Rajiv Saran for the CDC CKD Surveillance System. University of Michigan, Ann Arbor, MI; University of California, San Francisco, CA; Centers for Disease Control and Prevention, Baltimore, MD; Henry Ford Health System, Detroit, MI. Chronic kidney disease (CKD) affects 10-15% of the population within the US, yet no comprehensive system has thus far existed to track the disease and its outcomes. In 2006, the Centers for Disease Control and Prevention (CDC), as a major part of its CKD Initiative, funded two teams to jointly develop and implement a CKD surveillance system. A Steering Committee and Advisory Group of external stakeholders provided input toward selection of priority measures and key data sources. Data from national and regional data sources have been analyzed and comprehensive written reports submitted to the CDC since 2008. All findings of the CDC CKD Surveillance System will be available at www.cdc.gov/ckd by early 2011. The website covers priority measures under six major topic areas (burden of disease, awareness, risk factors, health consequences, processes and quality of care and healthcare system capacity for CKD) from a variety a data sources selected to represent the population. Figures and tables of specific measures will be updated regularly including relevant stratifications and time trends. The system will evolve to reflect feedback, scientific advances and changing patterns of disease. We believe that the CDC CKD Surveillance System will heighten awareness and provide timely information to regulatory agencies, research and clinical communities, and the general public, thereby providing a solid basis toward stemming the national epidemic of CKD.