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Background and objectives Higher fruit and vegetable intake is associated with lower cardiovascular and all-cause mortality in the general population. It is unclear whether this association occurs in patients on hemodialysis, in whom high fruit and vegetable intake is generally discouraged because of a potential risk of hyperkalemia. We aimed to evaluate the association between fruit and vegetable intake and mortality in hemodialysis. Design, setting, participants, & measurements Fruit and vegetable intake was ascertained by the Global Allergy and Asthma European Network food frequency questionnaire within the Dietary Intake, Death and Hospitalization in Adults with ESKD Treated with Hemodialysis study, a multinational cohort study of 9757 adults on hemodialysis, of whom 8078 (83%) had analyzable dietary data. Adjusted Cox regression analyses clustered by country were conducted to evaluate the association between tertiles of fruit and vegetable intake with all-cause, cardiovascular, and noncardiovascular mortality. Estimates were calculated as hazard ratios with 95% confidence intervals (95% CIs). Results During a median follow up of 2.7 years (18,586 person-years), there were 2082 deaths (954 cardiovascular). The median (interquartile range) number of servings of fruit and vegetables was 8 (4–14) per week; only 4% of the study population consumed at least four servings per day as recommended in the general population. Compared with the lowest tertile of servings per week (0–5.5, median 2), the adjusted hazard ratios for the middle (5.6–10, median 8) and highest (>10, median 17) tertiles were 0.90 (95% CI, 0.81 to 1.00) and 0.80 (95% CI, 0.71 to 0.91) for all-cause mortality, 0.88 (95% CI, 0.76 to 1.02) and 0.77 (95% CI, 0.66 to 0.91) for noncardiovascular mortality and 0.95 (95% CI, 0.81 to 1.11) and 0.84 (95% CI, 0.70 to 1.00) for cardiovascular mortality, respectively. Conclusions Fruit and vegetable intake in the hemodialysis population is low and a higher consumption is associated with lower all-cause and noncardiovascular death.

Background and Aims Although high-dose haemodiafiltration (HDF) has shown some promising survival advantage compared with high-flux haemodialysis (HD), the evidence remains controversial. In view of these discrepant results, a definitive trial is required to determine whether high-dose HDF is superior to high-flux HD. The comparison of high-dose HDF with high-flux HD (CONVINCE) study will assess the benefits and harms of high-dose HDF versus conventional high-flux HD in adults with end-stage kidney disease (ESKD). Here we provide information on the baseline characteristics of the included patients and evaluate whether the patients randomised to HDF were able to reach a high-dose convection volume. Method This international, prospective, open label, randomised, controlled trial is aiming to recruit 1800 ESKD adults treated with high-flux HD in 9 European countries. Patients will be randomised 1:1 to high-dose HDF versus continuation of conventional high-flux HD. High-dose HDF is defined as a convection volume per session of ≥23 L (range ±1 L). The trial is designed with a follow-up time for each patient of at least 24 months and will assess all-cause mortality, cause-specific mortality, cardiovascular events, hospitalisation, patient-reported outcomes, and cost-effectiveness. For this study we tabulated the baseline characteristics for all randomised participants by treatment groups. For the patients randomised to HDF, we calculated the proportion of the patients reaching a convection volume of ≥ 23L. session on the first visit after baseline (i.e. 3 months) and compared baseline and treatment characteristics with the patients with a convection volume of Results CONVINCE has recruited, until the start of January 2021, 1139 patients in eight European countries. The mean age was 62.4 (SD: 13.2) years and 62% (n=709) patients were men. The mean dialysis vintage was 5.0 (6.1) years. The mean systolic blood pressure (BP) was 141 (22) mmHg, the diastolic BP was 73 (14) mmHg, and the body mass index (BMI) was 27.6 (5.7) kg/m2. Approximately one-third the patients had diabetes mellitus and 21% had a history of coronary heart disease at baseline. Of the patients randomised to HDF, over 85% achieved a convection volume of ≥23L/session. There were no apparent differences in baseline and treatment characteristics between the patients who reached a convective volume of ≥23L/session versus those who did not: the vascular access was, respectively, a fistula (82% vs 81%), catheter (13% vs 14%), and graft (5% vs 5%) access. Conclusion The CONVINCE study will run up to 2023 and addresses the question of benefits and harms, regarding survival, hospitalisation, patient-reported outcomes, and cost-effectiveness of high-dose HDF compared with high-flux HD in patients with ESKD. This first analysis shows that achievement of high-dose HDF is feasible for most patients and, most importantly, could be maintained during the present trial period.

Background and Aims Patient safety programs need a well-structured organization to facilitate proactive and fair reporting, prompt evaluation analysis and timely feedback followed by measure implementation and auditing. To analyze all types of incidents in our network from Jan.1st to Sept. 30th, 2019 by two different levels (Corporate and Country) of medical management alert. Method Our institution has tracked all incidents under a structured process program for the last 10 years, according to 4 incident types (Patient related, Staff-visitors, Products and Equipment) and 54 subcodes. Incidents are considered as serious when they may be life-threatening or result in death, impaired body function/structure and/or are deemed serious based on appropriate medical judgment. Communication to Health Authorities applies in accordance with local country regulations. “Serious incidents” are immediately notified to the Corporate Office and to each Country Medical lead, whilst different codes may generate alerts into Corporate or Country. Results A total of 68.399 incidents (2.7 incident/patient/year) were reported during Q1-Q3 2019. Total incidents/1000 treatments were 17.1 (12.1 were patients related incidents). Causes for alerts at corporate level (n=65) were: cardiorespiratory arrest (28%); unexpected death (15%); seroconversion (9%); hemolysis (8%), severe hypotension (6%) and air embolism (3%). Reported incidents at country level (n=655) were almost half ascribed to equipment [water supply, power failure and flooding (41%)], medication errors (36%), venous needle dislodgment (19%) and Injuries (3%). Conclusion Despite continuous efforts to get better results, there is room for improvement on better staff compliance with our standard operating procedures especially regarding medications and venous needle dislodgment risk assessment.

Background and Aims With the exception of some national registries, data referred to mortality or hospitalization within a single large international peritoneal dialysis (PD) institution are seldom reported. To study all-cause mortality, transplantation rate, hospitalizations and peritonitis rates in our large PD program during 2018. Method Observational, prospective registry in 8 countries. The following variables were tracked: crude mortality rate and causes, hospitalization variables (nº of hospitalization days per patient; nº of hospitalization episodes per patient; nº of days per hospitalization episode; causes of hospitalization), peritonitis rate (episodes/year at risk and patient months at risk to a peritonitis episode) and transplantation rate. Results By the end of December 2018, 1207 pt. were treated (11 countries) but only 8 countries submitted data. Evaluated population as “patients treated at risk during the year”: AR (319.5), RO (173.5), DE (137), HU (103), PL (97), UR (69.5), CL (27), KZ (7). Crude mortality rate was 13.1%, same if first 90 days on therapy were excluded. Lowest mortality was seen in HU (9.9%) and highest in DE (19.3%). Causes of death: cardiac 32%, all type infections 22% [Sepsis 78%, PD related 11% (as 0.7% of total mortality), pulmonary 3.7%, others 7.4%], vascular 10%, gastrointestinal 3.3%, unknown 10.7% (highest in DE, 23%), other known causes 21.5%. Hospitalization rates: 0.55 episodes/per patient-year and 7.6 days of hospitalization per patient-year. Nº of days per hospitalization episode was 13.7. Causes of hospitalization: PD related 38%, cardiovascular 17%, non-PD infection sepsis 10.7% (higher in LA, 16.6%), vascular access 2.1%, unknown 4.5%, others 23.3%. Global peritonitis rate was 0.18 episodes/pt-year at risk (1 episode every 66 m.). However, large differences were seen among countries. Transplantation rate was 6.5% (much higher in UR). PD was withdrawal in 35% of pt. Country specific data have been evaluated but are not shown here. Conclusion The use of a common registry in our institution increases quality and allows homogeneous comparisons across countries that if promptly addressed may increase patients’ outcomes. Our series may bring light into the PD community as one of the ever largest tracked in a single institution.

Background and Aims Patient safety is considered of paramount importance under any qualified provision of care, but results from routine tracking of incidents have scarcely been reported, even when that may negatively impact survival. To analyze all types of incidents in a multinational renal service provider network from Jan.1st to Sept. 30th, 2019. Method For the last 10 years, our institution has tracked all incidents under a structured process program, as well as, educated our staff in the importance of proactively reporting and analyzing incidents in a quarterly basis at the clinic, by country and globally. Incidents are categorized in 4 different types: A-Patient related; B-Staff and visitors; C-Products and D-Equipment. Different incident codes are assigned to each type. Results A total of 68.399 incidents (2.7 incidents/patient/year) have been reported during Q1-Q3 2019 (higher than in 2018: 2.2). This means an increase of 20% in the total number of reported incidents. Total incidents/1000 treatments was 17.1 (12.1 patient-related incidents). Reporting follows a heterogeneous pattern among countries, being lowest in Argentina and highest in the UK. Top 5 reported incidents were as follows: Codes A15 (voluntarily shortened treatment) and A14 (Patient did not show up), both related to patient adherence to treatment, accounted for 36% of total incidents, vascular access (VA) complications (A4) for 10.5%, change of dialyzer and/or blood lines due to clotting (A2) for 8.6% and recurrent minor monitor malfunction (D1) for 6.7% of incidents. Codes related with unexpected death or cardiorespiratory arrest are not present among the total global top 10 incidents. Conclusion Detailed tracking of incidents and comparison between countries have potential to increase quality of care. Room for improvement recently made the Corporate Medical Office to launch new strategies on VA management, anticoagulation and patient compliance, among others. This large series may help other institutions to better monitor and standardize patient safety.

Background and Aims Peritoneal dialysis (PD) practice is not universally homogeneous, best clinical practices are not completely understood as reference values are often obtained from small sized populations and/or frequently based on chronic kidney disease (CKD) and/or hemodialysis data. To evaluate two years of follow up of compliance with PD-related quality indicators (QIs) following definition of new targets in an international PD network. Method All English and Spanish language CKD and PD guidelines were reviewed. Twelve Qis were considered being of significant relevance and targets for these QIs were defined (see table). Retrospective data analysis. Results Achievement of QI targets for years 2017-2018 is shown in table. Variability among countries not shown. Conclusion There was a significant increase in QIs achievement in 2018 vs. 2017. ≥75% of patients met the target for the following variables: total weekly Kt/Vurea, 24 h fluid removal, mean arterial blood pressure and serum albumin. Peritonitis rates are clearly over International objectives and were improving. Due to the lack of referral source data, these series may help to understand PD practice and outcomes in a global setting.

Background and Aims Decision-Making Tools (DMTs) are still not widely used but are considered the Gold Standard to ensure patients are well informed to choose renal replacement therapy (RRT) modality. To analyze the impact of a structured modality information program (via DMTs) on RRT modality choice and start. Method All 2014-2017 predialysis patients (pts) with CKD G4-G5 and those starting unplanned dialysis without a prior information process underwent a DMTs process for RRT choice and were followed up to Dec.31st, 2018. DMTs included values evaluation, RRT information with different tools, staff deliberation support and patient modality choice. Results shown as percentage of pts who reached a certain stage over the total number of pts under evaluation. Results 2012 pts (mean age 61 y.) from 48 clinics (cl.) in Poland (PL, 19 cl., 980 pts), Romania (RO, 12 cl., 351 pts), Hungary (HU, 10 cl., 341 pts), Germany (DE, 6 cl., 292 pts) and Argentina (AR, 1 cl., 48 pts) underwent DMTs. Staff considered PD contraindicated in 29% of pts, hence optimal candidates for HD/PD were 1408 pts. (mean age 60y. and 46% prone for a home therapy). Early referral (≥3 m. in clinic before DMT started): 51%. Aids used included written information (97% of pts), DVD in 27% and HD/PD utility visits in 49%. Relatives’ participation in the process was 82%. Most pts (91%) considered the program useful whilst 64% of staff felt that this program was better than the prior one. PD choice (35%) varied among countries: 15% (RO), 30% (PL), 36% (HU), 62% (DE) and 98% (AR). For pts who had started dialysis by study closure (n=948), PD as chronic RRT was 31% (9% after an unplanned HD start); 13% (RO), 27% (PL), 34% (HU), 54% (GE) and 83% (AR). Conclusion Use of DMTs at the time of RRT modality choice complies with patient empowerment and decision sharing (patients-relatives-staff). PD choice and take-on varied among countries. Most patients who chose PD were chronically ascribed to PD representing at least one third of the suitable patients for both dialysis modalities.

Rationale & Objective Clinical practice guidelines for dietary intake in hemodialysis focus on individual nutrients. Little is known about associations of dietary patterns with survival. We evaluated the associations of dietary patterns with cardiovascular and all-cause mortality among adults treated by hemodialysis. Study Design Prospective cohort study. Setting & Participants 8,110 of 9,757 consecutive adults on hemodialysis (January 2014 to June 2017) treated in a multinational private dialysis network and with analyzable dietary data. Exposures Data-driven dietary patterns based on the GA2LEN food frequency questionnaire. Participants received a score for each identified pattern, with higher scores indicating closer resemblance of their diet to the identified pattern. Quartiles of standardized pattern scores were used as primary exposures. Outcomes Cardiovascular and all-cause mortality. Analytical Approach Principal components analysis with varimax rotation to identify common dietary patterns. Adjusted proportional hazards regression analyses with country as a random effect to estimate the associations between dietary pattern scores and mortality. Associations were expressed as adjusted HRs with 95% CIs, using the lowest quartile score as reference. Results During a median follow-up of 2.7 years (18,666 person-years), there were 2,087 deaths (958 cardiovascular). 2 dietary patterns, “fruit and vegetable” and “Western,” were identified. For the fruit and vegetable dietary pattern score, adjusted HRs, in ascending quartiles, were 0.94 (95% CI, 0.76-1.15), 0.83 (95% CI, 0.66-1.06), and 0.91 (95% CI, 0.69-1.21) for cardiovascular mortality and 0.95 (95% CI, 0.83-1.09), 0.84 (95% CI, 0.71-0.99), and 0.87 (95% CI, 0.72-1.05) for all-cause mortality. For the Western dietary pattern score, the corresponding estimates were 1.10 (95% CI, 0.90-1.35), 1.11 (95% CI, 0.87-1.41), and 1.09 (95% CI, 0.80-1.49) for cardiovascular mortality and 1.01 (95% CI, 0.88-1.16), 1.00 (95% CI, 0.85-1.18), and 1.14 (95% CI, 0.93-1.41) for all-cause mortality. Limitations Self-reported food frequency questionnaire, data-driven approach. Conclusions These findings did not confirm an association between mortality among patients receiving long-term hemodialysis and the extent to which dietary patterns were either high in fruit and vegetables or consistent with a Western diet.

Background Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets associate with lower cardiovascular and all-cause mortality in the general population, but the benefits for patients on hemodialysis are uncertain. Methods Mediterranean and DASH diet scores were derived from the GA(2)LEN Food Frequency Questionnaire within the DIET-HD Study, a multinational cohort study of 9757 adults on hemodialysis. We conducted adjusted Cox regression analyses clustered by country to evaluate the association between diet score tertiles and all-cause and cardiovascular mortality (the lowest tertile was the reference category). Results During the median 2.7-year follow-up, 2087 deaths (829 cardiovascular deaths) occurred. The adjusted hazard ratios (95% confidence intervals) for the middle and highest Mediterranean diet score tertiles were 1.20 (1.01 to 1.41) and 1.14 (0.90 to 1.43), respectively, for cardiovascular mortality and 1.10 (0.99 to 1.22) and 1.01 (0.88 to 1.17), respectively, for all-cause mortality. Corresponding estimates for the same DASH diet score tertiles were 1.01 (0.85 to 1.21) and 1.19 (0.99 to 1.43), respectively, for cardiovascular mortality and 1.03 (0.92 to 1.15) and 1.00 (0.89 to 1.12), respectively, for all-cause mortality. The association between DASH diet score and all-cause death was modified by age (P=0.03); adjusted hazard ratios for the middle and highest DASH diet score tertiles were 1.02 (0.81 to 1.29) and 0.70 (0.53 to 0.94), respectively, for younger patients (≤60 years old) and 1.05 (0.93 to 1.19) and 1.08 (0.95 to 1.23), respectively, for older patients. Conclusions Mediterranean and DASH diets did not associate with cardiovascular or total mortality in hemodialysis.

Patients on hemodialysis suffer from high risk of premature death, which is largely attributed to cardiovascular disease, but interventions targeting traditional cardiovascular risk factors have made little or no difference. Long chain n-3 polyunsaturated fatty acids (n-3 PUFA) are putative candidates to reduce cardiovascular disease. Diets rich in n-3 PUFA are recommended in the general population, although their role in the hemodialysis setting is uncertain. We evaluated the association between the dietary intake of n-3 PUFA and mortality for hemodialysis patients.The DIET-HD study is a prospective cohort study (January 2014-June 2017) in 9757 adults treated with hemodialysis in Europe and South America. Dietary n-3 PUFA intake was measured at baseline using the GADuring a median follow up of 2.7 years (18,666 person-years), 2087 deaths were recorded, including 829 attributable to cardiovascular causes. One third of the study participants consumed sufficient (at least 1.75 g/week) n-3 PUFA recommended for primary cardiovascular prevention, and less than 10% recommended for secondary prevention (7-14 g/week). Compared to patients with the lowest tertile of dietary n-3 PUFA intake (0.37 g/week), the adjusted hazard ratios (95% confidence interval) for cardiovascular mortality for patients in the middle (0.37 to1.8 g/week) and highest (≥1.8 g/week) tertiles of n-3 PUFA were 0.82 (0.69-0.98) and 1.03 (0.84-1.26), respectively. Corresponding adjusted hazard ratios for all-cause mortality were 0.96 (0.86-1.08) and 1.00 (0.88-1.13), respectively.Dietary n-3 PUFA intake was not associated with cardiovascular or all-cause mortality in patients on hemodialysis. As dietary n-3 PUFA intake was low, the possibility that n-3 PUFA supplementation might mitigate cardiovascular risk has not been excluded.

Background Periodontitis is associated with cardiovascular mortality in the general population and adults with chronic diseases. However, it is unclear whether periodontitis predicts survival in the setting of kidney failure. Methods ORAL-D was a propensity matched analysis in 3338 dentate adults with end-stage kidney disease treated in a hemodialysis network in Europe and South America designed to examine the association between periodontitis and all-cause and cardiovascular-related mortality in people on long-term hemodialysis. Participants were matched 1:1 on their propensity score for moderate to severe periodontitis assessed using the World Health Organization Community Periodontal Index. A random-effects Cox proportional hazards model was fitted with shared frailty to account for clustering of mortality risk within countries. Results Among the 3338 dentate participants, 1355 (40.6%) had moderate to severe periodontitis at baseline. After using propensity score methods to generate a matched cohort of participants with periodontitis similar to those with none or mild periodontal disease, moderate to severe periodontitis was associated with a lower risk of all-cause (9.1 versus 13.0 per 100 person years, hazard ratio 0.74, 95% confidence interval 0.61 to 0.90) and cardiovascular (4.3 versus 6.9 per 100 person years, hazard ratio 0.67, 0.51 to 0.88) mortality. These associations were not changed substantially when participants were limited to those with 12 or more natural teeth and when accounting for competing causes of cardiovascular death. Conclusion In contrast to the general population, periodontitis does not appear to be associated with an increased risk of early death in adults treated with hemodialysis. Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0574-x) contains supplementary material, which is available to authorized users.

Sexual dysfunction may affect 80% of women in hemodialysis. However the specific patterns and clinical correlates of sexual functioning remain poorly described. The aim of this study was to assess prevalence and correlates of the individual domains of sexual functioning in women treated with hemodialysis. We recruited, into this multinational cross-sectional study, women treated with long-term hemodialysis (Collaborative Working Group on Depression and Sexual dysfunction in Hemodialysis study). Self-reported domains of sexual functioning were assessed by the Female Sexual Function Index, which is routinely administered within the network of dialysis patients followed by the working group. Lower scores represented lower sexual functioning. Socio-demographic and clinical correlates of each domain of sexual functioning were identified by stepwise multivariable linear regression. Sensitivity analyses were restricted to women who reported being sexually active. We found that of 1309 enrolled women, 659 (50.3%) provided complete responses to FSFI survey questions and 232 (35%) reported being sexually active. Overall, most respondents reported either no sexual activity or low sexual functioning in all measured domains (orgasm 75.1%; arousal 64.0%; lubrication 63.3%; pain 60.7%; satisfaction 60.1%; sexual desire 58.0%). Respondents who were waitlisted for a kidney transplant reported scores with higher sexual functioning, while older respondents reported scores with lower functioning. The presence of depression was associated with worse lubrication and pain scores [mean difference for depressed versus non-depressed women (95% CI) -0.42 (-0.73 to -0.11), -0.53 (-0.89 to -0.16), respectively] while women who had experienced a previous cardiovascular event reported higher pain scores [-0.77 (-1.40- to -0.13)]. In conclusion, women in hemodialysis reported scores consistent with marked low sexual functioning across a range of domains; the low functioning appeared to be associated with comorbidity.

Background: Sexual dysfunction is an under-recognized problem in men and women with chronic kidney disease (CKD). The prevalence, correlates, and predictors of this condition in patients with CKD have not been evaluated comprehensively. Study Design: Systematic review and meta-analysis. Setting & Population: Patients treated using dialysis (dialysis patients), patients treated using transplant (transplant recipients), and patients with CKD not treated using dialysis or transplant (nondialysis nontransplant patients with CKD). Selection Criteria for Studies: Observational studies conducted in patients with CKD only or including a control group without CKD. Predictor: Type of study population. Outcomes: Sexual dysfunction in men and women with CKD using validated tools, such as the International Index of Erectile Function, the Female Sexual Function Index (FSFI), or other measures as reported by study investigators. Results: 50 studies (8,343 patients) of variable size (range, 16-1,023 patients) were included in this review. Almost all studies explored sexual dysfunction in men and specifically erectile dysfunction. The summary estimate of erectile dysfunction in men with CKD was 70% (95% CI, 62%-77%; 21 studies, 4,389 patients). Differences in reported prevalence rates of erectile dysfunction between different studies were attributable primarily to age, study populations, and type of study tool used to assess the presence of erectile dysfunction. In women, the reported prevalence of sexual dysfunction was assessed in only 306 patients from 2 studies and ranged from 30%-80%. Compared with the general population, women with CKD had a significantly lower overall FSFI score (8 studies or subgroups, 407 patients; mean difference, 9.28; 95% CI, 12.92 to 5.64). Increasing age, diabetes mellitus, and depression consistently were found to correlate with sexual dysfunction in 20 individual studies of patients with CKD using different methods. Limitations: Suboptimal and lack of uniform assessment of outcome measures. Conclusions: Sexual dysfunction is highly prevalent in both men and women with CKD, especially among those on dialysis. Larger studies enrolling different ethnic groups, using validated

Background Oral disease is a potentially treatable determinant of mortality and quality of life. No comprehensive multinational study to quantify oral disease burden and to identify candidate preventative strategies has been performed in the dialysis setting. Methods The ORAL disease in hemoDialysis (ORALD) study was a prospective study in adults treated with hemodialysis in Europe (France, Hungary, Italy, Poland, Portugal and Spain) and Argentina. Oral disease was assessed using standardized WHO methods. Participants self-reported oral health practices and symptoms. Sociodemographic and clinical factors associated with oral diseases were determined and assessed within nation states. Results Of 4726 eligible adults, 4205 (88.9%) participated. Overall, 20.6% were edentulous [95% confidence interval (CI), 19.4-21.8]. Participants had on average 22 (95% CI 21.7-22.2) decayed, missing or filled teeth, while moderate to severe periodontitis affected 40.6% (95% CI 38.9-42.3). Oral disease patterns varied markedly across countries, independent of participant demographics, comorbidity and health practices. Participants in Spain, Poland, Italy and Hungary had the highest mean adjusted odds of edentulousness (2.31, 1.90, 1.90 and 1.54, respectively), while those in Poland, Hungary, Spain and Argentina had the highest odds of ≥14 decayed, missing or filled teeth (23.2, 12.5, 8.14 and 5.23, respectively). Compared with Argentina, adjusted odds ratios for periodontitis were 58.8, 58.3, 27.7, 12.1 and 6.30 for Portugal, Italy, Hungary, France and Poland, respectively. National levels of tobacco consumption, diabetes and child poverty were associated with edentulousness within countries. Conclusions Oral disease in adults on hemodialysis is very common, frequently severe and highly variable among countries, with much of the variability unexplained by participant characteristics or healthcare. Given the national variation and high burden of disease, strategies to improve oral health in hemodialysis patients will require implementation at a country level rather than at the level of individuals.

Background Dental disease is more extensive in adults with chronic kidney disease, but whether dental health and behaviors are associated with survival in the setting of hemodialysis is unknown. Study Design Prospective multinational cohort. Setting & Participants 4,205 adults treated with long-term hemodialysis, 2010 to 2012 (Oral Diseases in Hemodialysis [ORAL-D] Study). Predictors Dental health as assessed by a standardized dental examination using World Health Organization guidelines and personal oral care, including edentulousness; decayed, missing, and filled teeth index; teeth brushing and flossing; and dental health consultation. Outcomes All-cause and cardiovascular mortality at 12 months after dental assessment. Measurements Multivariable-adjusted Cox proportional hazards regression models fitted with shared frailty to account for clustering of mortality risk within countries. Results During a mean follow-up of 22.1 months, 942 deaths occurred, including 477 cardiovascular deaths. Edentulousness (adjusted HR, 1.29; 95% CI, 1.10-1.51) and decayed, missing, or filled teeth score ≥ 14 (adjusted HR, 1.70; 95% CI, 1.33-2.17) were associated with early all-cause mortality, while dental flossing, using mouthwash, brushing teeth daily, spending at least 2 minutes on oral hygiene daily, changing a toothbrush at least every 3 months, and visiting a dentist within the past 6 months (adjusted HRs of 0.52 [95% CI, 0.32-0.85], 0.79 [95% CI, 0.64-0.97], 0.76 [95% CI, 0.58-0.99], 0.84 [95% CI, 0.71-0.99], 0.79 [95% CI, 0.65-0.95], and 0.79 [95% CI, 0.65-0.96], respectively) were associated with better survival. Results for cardiovascular mortality were similar. Limitations Convenience sample of clinics. Conclusions In adults treated with hemodialysis, poorer dental health was associated with early death, whereas preventive dental health practices were associated with longer survival.

Background. The diagnosis of analgesic nephropathy has improved significantly with modern imaging techniques. We reviewed a large portion of the Hungarian dialysis population to obtain additional insight into the problem. Methods. Twenty-two participating dialysis units enrolled 1400 patients on renal replacement therapy between 1 January 1995 and 1 January 1998. Patients with no known aetiology (n ¼ 284) were interviewed and studied with renal imaging. We assessed the presence of decreased renal mass combined with either bumpy contours, papillary calcification, or both. The subjects studied were interrogated extensively. Results. Our survey suggested analgesic nephropathy in 47 of 1400 patients (3.3%), 3-fold higher than the EDTA database estimate for Hungary. The analgesics most commonly abused were phenacetin-containing mixtures. The driving symptoms were mainly headache and joint pain. Cardiovascular complications were more common than in the rest of the dialysis population, independent of smoking and lipid values (P

Objectives To evaluate patient experiences of specific aspects of haemodialysis care across several countries. Design Cross-sectional survey using the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) questionnaire. Setting Haemodialysis clinics within a single provider in Europe and South America. Participants 2748 adults treated in haemodialysis. Primary and secondary outcomes The primary outcome was patient satisfaction with overall care. Secondary outcomes included patient experiences of individual aspects of dialysis care. Results 2145 (78.1%) adults responded to the questionnaire. Fewer than half (46.5% (95% CI 44.5% to 48.6%)) rated their overall care as excellent. Global perceptions of care were uninfluenced by most respondent characteristics except age and depressive symptoms; older respondents were less critical of their care (adjusted OR for excellent rating 1.44 (1.01 to 2.04)) and those with depressive symptoms were less satisfied (0.56 (0.44 to 0.71)). Aspects of care that respondents most frequently ranked as excellent were staff attention to dialysis vascular access (54% (52% to 56%)); caring of nurses (53% (51% to 55%)); staff responsiveness to pain or discomfort (51% (49% to 53%)); caring, helpfulness and sensitivity of dialysis staff (50% (48% to 52%)); and ease of reaching dialysis staff by telephone (48% (46% to 50%)). The aspects of care least frequently ranked as excellent were information provided when choosing a dialysis modality (23% (21% to 25%)), ease of seeing a social worker (28% (24% to 32%)), information provided about dialysis (34% (32% to 36%)), accuracy of information from nephrologist (eg, about prognosis or likelihood of a kidney transplant; 37% (35% to 39%)) and accuracy of nephrologists’ instructions (39% (36% to 41%)). Conclusions Haemodialysis patients are least satisfied with the complex aspects of care. Patients’ expectations for accurate information, prognosis, the likelihood of kidney transplantation and their options when choosing dialysis treatment need to be considered when planning healthcare research and practices.

Background Achieving target levels of laboratory parameters of bone and mineral metabolism in chronic kidney disease (CKD) patients is important but also difficult in those living with end-stage kidney disease. This study aimed to determine if there are age-related differences in chronic kidney disease-mineral and bone disorder (CKD-MBD) characteristics, including treatment practice in Hungarian dialysis patients. Methods Data were collected retrospectively from a large cohort of dialysis patients in Hungary. Patients on hemodialysis and peritoneal dialysis were also included. The enrolled patients were allocated into two groups based on their age (

Introduction Integrated Care Settings (ICS) provide a holistic approach to the transition from chronic kidney disease into renal replacement therapy (RRT), offering at least both types of dialysis. Objectives To analyze which factors determine type of referral, modality provision and dialysis start on final RRT in ICS clinics. Methods Retrospective analysis of 626 patients starting dialysis in 25 ICS clinics in Poland, Hungary and Romania during 2012. Scheduled initiation of dialysis with a permanent access was considered as planned RRT start. Results Modality information (80% of patients) and renal education (87%) were more frequent (p8.2 ml/min, >2 months between information and RRT initiation and with vascular etiology after adjustment for age and gender. “Optimal care,” defined as ICS follow-up >12 months plus modality information and P start, occurred in 23%. Conclusions Despite the high rate of late referrals, information and education were widely provided. However, NP start was high and related to late referral and may explain the low frequency of PD.

Background People with end-stage kidney disease treated with dialysis experience high rates of premature death that are at least 30-fold that of the general population, and have markedly impaired quality of life. Despite this, interventions that lower risk factors for mortality (including antiplatelet agents, epoetins, lipid lowering, vitamin D compounds, or dialysis dose) have not been shown to improve clinical outcomes for this population. Although mortality outcomes may be improving overall, additional modifiable determinants of health in people treated with dialysis need to be identified and evaluated. Oral disease is highly prevalent in the general population and represents a potential and preventable cause of poor health in dialysis patients. Oral disease may be increased in patients treated with dialysis due to their lower uptake of public dental services, as well as increased malnutrition and inflammation, although available exploratory data are limited by small sample sizes and few studies evaluating links between oral health and clinical outcomes for this group, including mortality and cardiovascular disease. Recent data suggest periodontitis may be associated with mortality in dialysis patients and well-designed, larger studies are now required. Methods/design The ORAL Diseases in hemodialysis (ORAL-D) study is a multinational, prospective (minimum follow-up 12 months) study. Participants comprise consecutive adults treated with long-term in-center hemodialysis. Between July 2010 and February 2012, we recruited 4500 dialysis patients from randomly selected outpatient dialysis clinics in Europe within a collaborative network of dialysis clinics administered by a dialysis provider, Diaverum, in Europe (France, Hungary, Italy, Poland, Portugal, and Spain) and South America (Argentina). At baseline, dental surgeons with training in periodontology systematically assessed the prevalence and characteristics of oral disease (dental, periodontal, mucosal, and salivary) in all participants. Oral hygiene habits and thirst were evaluated using self-administered questionnaires. Data for hospitalizations and mortality (total and cause-specific) according to baseline oral health status will be collected once a year until 2022. Discussion This large study will estimate the prevalence, characteristics and correlations of oral disease and clinical outcomes (mortality and hospitalization) in adults treated with dialysis. We will further evaluate any association between periodontitis and risk of premature death in dialysis patients that has been suggested by existing research. The results from this study should provide powerful new data to guide strategies for future interventional studies for preventative and curative oral disease strategies in adults who have end-stage kidney disease.