Search

Background. The incidence and prevalence of haemodialysis vary widely across countries. The variation may be attributable to differences in the incidence of end-stage renal disease and/or in the availability of haemodialysis. Previous studies have identified differences in nephrologists’ opinions about the availability of haemodialysis and its appropriateness for patients with comorbidities. We studied the associations between nephrologists’ opinions, availability of haemodialysis, patient characteristics and comorbidities, and facilities’ withdrawal rates.Methods. Most of our analyses used data from 242 haemodialysis units in six countries (France, Germany, Italy, Spain, UK and the USA) in the first phase of the Dialysis Outcomes and Practice Patterns Study (DOPPS I). Opinions about access to and practice patterns in dialysis facilities, measured by the level of agreement with standardized statements, were collected from medical directors and nurse managers. A sub-analysis considered data from corresponding facilities in DOPPS II.Results. We found wide variations in the prevalence of waiting lists for new dialysis patients (UK 60%; USA 25%; Germany 0%; P < 0.05), in agreement with starting haemodialysis for patients with advanced age, dementia and comorbidities (UK, France < USA < other countries; P < 0.05), and in agreement with withdrawing dialysis (other countries < UK/USA; P < 0.05). The estimated glomerular filtration rate at the start of dialysis was not significantly different in units with waiting lists. Significant associations were found between nephrologists’ opinions and the odds of patients being ≥80 years old, and between opinions and the rate and relative risk of withdrawal of haemodialysis. No significant associations were found between opinions and patients’ comorbidities or dependency.Conclusion. Differences within and across countries in nephrologists’ opinions regarding starting and withdrawing haemodialysis reflect differences in access to haemodialysis and the practice of withdrawal of haemodialysis in their facilities. [ABSTRACT FROM AUTHOR]

Background. The optimal vascular access for chronic maintenance haemodialysis (HD) is the native arteriovenous fistula (AVF). Vascular access practice patterns are reported for a Canadian cohort of patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS II).Methods. DOPPS II is a prospective, observational study in 12 countries, including Canada. A representative random sample of 20 Canadian HD facilities and patients within those units were studied during 2002–2004. Canadian results were compared with those found in Europe and the USA.Results. AVF use in Canadian prevalent (53%) and incident (26%) patients was lower than Canadian guidelines recommend (60%), and lower than in Europe [prevalent (74%), incident (50%)]. Despite 85% of Canadian HD patients having seen a nephrologist for >1 month prior to starting dialysis, central venous catheter use in Canada (33% in prevalent patients, 70% in incident patients) was much higher than in Europe (prevalent 18%, incident 46%) and slightly higher than in the USA (prevalent 25%, incident 66%). This pattern is contrary to the preferences of Canadian medical directors and vascular access surgeons. The typical time from referral until permanent vascular access creation is substantially longer in Canada (61.7 days) than in Europe (29.4 days) or the USA (16 days). This longer delay time and higher catheter use in Canada may be a consequence of the significantly lower number of access surgeons per 100 HD patients in Canada (2.9) compared with the USA (8.1) and Europe (4.6). Furthermore, the median hours per week devoted to vascular access-related surgery per 100 patients is substantially lower in Canada (0.027 h) compared with the USA (0.082 h) and Europe (0.059 h).Conclusion. These findings suggest that Canadian chronic HD patients often rely on central venous catheters for vascular access, despite their known association with numerous detrimental outcomes in HD. Nephrologists, vascular access surgeons, interventional radiologists, other physicians and health care funding bodies must be more broadly educated about the priority of AVF creation as the preferred vascular access for chronic HD patients. They must work together to secure both the human and financial resources and other health care system enhancements to increase AVF creation rates in a timely manner. [ABSTRACT FROM AUTHOR]

Background. The Dialysis Outcomes and Practice Patterns Study (DOPPS) is a prospective, observational study based on data collected from nationally representative samples of haemodialysis facilities. The burden of anaemia in haemodialysis patients is substantial, leading to considerable morbidity, mortality and reduced quality of life. This study examines anaemia management and outcomes based on data from five European countries participating in the DOPPS: France, Germany, Italy, Spain and the UK. Methods. Baseline data on demographics, co-morbidities and anaemia management in 4591 haemodialysis patients from 101 nephrology facilities were collected in 1998-2000. Using multivariate Cox survival analyses to adjust for patient characteristics, relationships between haemoglobin concentration at study entry and rates of mortality and hospitalization were evaluated. Results. For a year 2000 sample of prevalent patients on haemodialysis >180 days, mean haemoglobin concentration was 11.0 g/dl; 53% had a haemoglobin concentration ≥11 g/dl [1998-1999 = 44% (P < 0.05)]. In 2000, 84% of prevalent patients were prescribed recombinant human erythropoietin (rHuEpo). Higher haemoglobin concentrations were associated with decreased relative risk (RR) for mortality (RR = 0.95 for every 1 g/dl higher haemoglobin, P = 0.03) and hospitalization (RR = 0.96, P = 0.02). Patients with haemoglobin <10 g/dl were 29% more likely to be hospitalized than patients with haemoglobin 11-12 g/dl (P < 0.001). Conclusion. Even after adjustment, lower haemoglobin concentrations were associated with higher morbidity and mortality in European haemodialysis patients. A trend to increased haemoglobin concentrations was observed following publication of the European Best Practice Guidelines (EBPG) on anaemia management for chronic kidney disease patients, but efforts must continue to achieve EBPG goals. [ABSTRACT FROM AUTHOR]

Background. Mortality and hospitalization rates are reported for nationally representative random samples of haemodialysis patients treated at randomly selected dialysis facilities in five European countries participating in the Dialysis Outcomes and Practice Pattern Study (DOPPS) (France, Germany, Italy, Spain and the UK). Results. In the UK, 28.1% of haemodialysis patients received prior peritoneal dialysis treatment compared with 4.2-8.3% in other countries. Kidney transplantation rates ranged from 3.3 (per 100 patient years) in Italy to 11.6 in Spain. The relative risk (RR) of mortality, adjusted for age, sex and diabetes status was significantly higher in the UK (RR = 1.39, P = 0.02) compared with Italy (reference) and increased in association with age (RR = 1.60 for every 10 years older, P <0.001), diabetes as cause of end-stage renal disease (ESRD) (RR = 1.55, P < 0.001), male patients <65 years (RR = 1.29, P = 0.02) and peritoneal dialysis in the 12 months prior to starting haemodialysis (RR = 1.72, P = 0.06). Hospitalization for cardiovascular disease was highest in France and Germany (0.40 and 0.43 hospitalizations per patient year, respectively) and lowest in the UK (0.19), although cardiovascular comorbidity was similar in the UK and France. Hospitalization rates for vascular access-related infection ranged from 0.01 hospitalizations per patient year in Italy to 0.08 in the UK, consistent with the higher dialysis catheter use in the UK (25%) vs Italy (5%). Hospitalization risk was significantly higher in France than in other Euro-DOPPS countries and was significantly (P < 0.05) associated with prior peritoneal dialysis therapy, peripheral vascular disease, gastrointestinal bleeding in the prior 12 months, diabetes, cancer, cardiac disease, psychiatric disease and recent onset of ESRD (within 30 days of study entry). Conclusions. The large differences in haemodialysis practice and outcomes in the Euro-DOPPS countries suggest opportunities for improvement in patient care. [ABSTRACT FROM AUTHOR]

Background. The Dialysis Outcomes and Practice Patterns Study (DOPPS) is a prospective, observational study designed to evaluate practice patterns in random samples of haemodialysis facilities and patients across three continents. Participating countries include France, Germany, Italy, Spain and the UK (Euro-DOPPS), Japan and the USA. DOPPS data collection has used the same questionnaires and protocols across all participating countries to assess components of dialysis therapy and outcomes. This study focuses on dialysis prescription, adherence and nutrition among the Euro-DOPPS countries. Methods. In each Euro-DOPPS country, patients were selected randomly from 20-21 representative facilities. Simple means and frequencies were calculated to compare relevant data elements to gain insights into differences in therapeutic aspects among nationally representative patients. Participants entering the study within 90 days of beginning dialysis therapy were excluded from these analyses. Results. Among the five countries, mean delivered dose as measured by normalized urea clearance (Kt/V) varied from 1.28 to 1.50 and was accompanied by differences in dialysis prescription components, including blood flow rates, treatment times, and dialyser membrane and flux characteristics. By country, a nearly 2-fold difference was observed in indicators of patient adherence and management (skipping and shortening dialysis, hyperkalaemia, hyperphosphataemia and high interdialytic weight gain). Indicators of malnutrition varied substantially. Conclusions. This study demonstrates differences in the management of haemodialysis patients across Euro-DOPPS and offers opportunities for improving dialysis dose, adherence and nutrition. Correlation of differences in practice patterns at the dialysis unit level with patient outcomes will offer new insights into improving dialysis therapy. [ABSTRACT FROM AUTHOR]

Background. Retrospective studies of haemodialysis patients from large dialysis organizations in the United States have indicated that intravenous vitamin D may be associated with a survival benefit. However, patients prescribed vitamin D are generally healthier than those who are not, suggesting that treatment by indication may have biased previous findings. Additionally, no survival benefit associated with vitamin D has been shown in a recent meta-analysis in CKD patients. Because treatment-by-indication bias due to both measured and unmeasured confounders cannot be completely accounted for in standard regression or marginal structural models (MSMs), this study evaluates the association between vitamin D and mortality among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS) using standard regression and MSMs with an expanded set of covariates, as well as by instrumental variable models to minimize potential bias due to unmeasured confounders. Methods. Data from 38 066 DOPPS participants from 12 countries between 1996 and 2007 were analysed. Mortality risk was assessed using standard baseline and time-varying Cox regression models, adjusted for demographics and detailed comorbidities, and MSMs. In models similar to instrumental variable analysis, the facility percentage of patients prescribed vitamin D, adjusted for the patient case mix, was used to predict patient-level mortality. Results. Vitamin D prescription was significantly higher in the USA compared to other countries. On average, patients prescribed vitamin D had fewer comorbidities compared to those who were not. Vitamin D therapy was associated with lower mortality in adjusted time-varying standard regression models [relative ratio (RR) = 0.92 (95% confidence interval: 0.87–0.96)] and baseline MSMs [RR = 0.84 (0.78–0.98)] and time-varying MSMs [RR = 0.78 (0.73–0.84)]. No significant differences in mortality were observed in adjusted baseline standard regression models for patients with or without vitamin D prescription [RR = 0.98 (0.93–1.02)] or for patients in facility practices where vitamin D prescription was more frequent [RR for facilities in 75th versus 25th percentile of vitamin D prescription = 0.99 (0.94–1.04)]. Conclusions. Vitamin D was associated with a survival benefit in models prone to bias due to unmeasured confounding. In agreement with a meta-analysis of randomized controlled studies, no difference in mortality was observed in instrumental variable models that tend to be more independent of unmeasured confounding. These findings indicate that a randomized controlled trial of vitamin D and clinical outcomes in haemodialysis patients are needed and can be ethically conducted. [ABSTRACT FROM AUTHOR]

Background. The Dialysis Outcomes and Practice Patterns Study (DOPPS) database was used to develop and validate a practice-related risk score (PRS) based on modifiable practices to help facilities assess potential areas for improving patient care. Methods. Relative risks (RRs) from a multivariable Cox mortality model, based on observational haemodialysis (HD) patient data from DOPPS I (1996–2001, seven countries), were used. The four practices were the percent of patients with Kt/V ≥1.2, haemoglobin ≥11 g/dl (110 g/l), albumin ≥4.0 g/dl (40g/l) and catheter use, and were significantly related to mortality when modelled together. DOPPS II data (2002–2004, 12 countries) were used to evaluate the relationship between PRS and mortality risk using Cox regression. Results. For facilities in DOPPS I and II, changes in PRS over time were significantly correlated with changes in the standardized mortality ratio (SMR). The PRS ranged from 1.0 to 2.1. Overall, the adjusted RR of death was 1.05 per 0.1 points higher PRS (P N = 119), a 0.2 decrease in PRS was associated with a 0.19 decrease in SMR (P = 0.005). On average, facilities that improved PRS practices showed significantly reduced mortality over the same time frame. Conclusions. The PRS assesses modifiable HD practices that are linked to improved patient survival. Further refinements might lead to improvements in the PRS and will address regional variations in the PRS/mortality relationship. [ABSTRACT FROM AUTHOR]

Background. Poor sleep quality (SQ) affects many haemodialysis (HD) patients and could potentially predict their morbidity, mortality, quality of life (QOL) and patterns of medication use. Methods. Data on SQ were collected from 11 351 patients in 308 dialysis units in seven countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS) between 1996 and 2001 through a patient self-reported SQ scale, ranging from 0 (worst) to 10 (best). A score of Results. Nearly half (49%) of patients experienced poor SQ. Mean SQ scores varied by country, ranging from 4.9 in Germany to 6.5 in Japan. Patients with poor SQ were more likely to be prescribed antihistamines, antidepressants, anti-inflammatories, narcotics, gastrointestinal (GI) medications, anti-asthmatics or hypnotics. Physical exercise at least once a week (vs P vs 10). The RR of mortality was 16% higher for HD patients with poor SQ. Conclusions. Poor SQ is common among HD patients in DOPPS countries and is independently associated with several QOL indices, medication use patterns and mortality. Assessment and management of SQ should be an important component of care. [ABSTRACT FROM AUTHOR]

Background. Identification of haemodialysis patients with problems related to lack of appetite should help prevent adverse outcomes. We studied whether a single question about being bothered by lack of appetite within the prior 4 weeks is related to nutritional status, inflammation and risks of death and hospitalization. Additionally, we assessed associations of lack of appetite with depression, dialysis dose and length of haemodialysis. Methods. This study is an analysis of baseline and longitudinal data from 14 406 patients enrolled in the Dialysis Outcomes and Practice Pattern Study. Cox regression was used to assess whether the degree (not, somewhat, moderately, very much, extremely) that patients were bothered by lack of appetite is an independent predictor of death and hospitalization. Logistic regression was used to identify baseline characteristics associated with being bothered by lack of appetite. Results. The risk of death was more than 2-fold higher [relative risk (RR) = 2.23; 95% confidence interval (CI) = 1.90–2.62] and the risk of hospitalization 33% higher (RR = 1.33; 95% CI = 1.19–1.48) among patients extremely bothered, compared with not bothered, by lack of appetite. These associations followed a dose–response fashion and remained statistically significant after adjustments for 14 comorbidities. Depression, shorter haemodialysis session, hypoalbuminaemia, lower concentration of serum creatinine and normalized protein catabolic rate, lower body mass index and higher leucocyte and neutrophil counts were independently associated with higher odds of being bothered by lack of appetite. Conclusions. The data suggest that a single question about lack of appetite helps identify haemodialysis patients with poorer nutritional status, inflammation, depression and higher risks of hospitalization and death. The study calls attention to a possible beneficial effect of longer haemodialysis on appetite. [ABSTRACT FROM AUTHOR]

Background. The Dialysis Outcomes and Practice Patterns Study (DOPPS) reported high incidence of depression in haemodialysis patients. Hypercalcaemia and high parathyroid hormone (PTH) levels are aetiological factors of psychological disorders. We examined the association between mineral metabolism abnormalities and mental health in Japanese-DOPPS patients. Methods. We used baseline data of Japan-DOPPS, Phase 1 (2755 patients, 1999–2001) and Phase 2 (2286 patients, 2002–03). The outcome variable was mental health using the mental health domain of SF-36. We examined the association between serum corrected calcium, phosphorus, calcium × phosphorus product and intact PTH concentrations, and mental health using analysis of covariance and also the associations between corrected calcium levels and current use of vitamin D and calcium-containing phosphate binder. Results. There was a significant association between mental health and corrected calcium levels. A significantly lower mental health score was noted in patients with corrected calcium ≥ 11 mg/dl than in P = 0.04), ≥8.4 to P = 0.009) and ≥10.2 to P = 0.003). The association was significant even after adjustment for age, sex and other confounders. However, there was no relationship between intact PTH and mental health. High-corrected calcium levels were significantly associated with the use of intravenous active vitamin D and calcium-containing phosphate binder. Conclusions. Hypercalcaemia, but not high intact PTH, is associated with poor mental health in dialysis patients. While a cause–effect relationship between hypercalcaemia and deterioration of mental health needs further confirmation by longitudinal and prospective studies, our observational findings suggest the importance of control of serum calcium concentration in dialysis patients. [ABSTRACT FROM AUTHOR]