This document discusses issues related to end-stage renal disease (ESRD) and dialysis treatment in the United States. It notes that ESRD represents 7% of the Medicare budget while only treating 1% of the US population. Total Medicare spending on dialysis has risen steadily to over $35 billion per year. The dialysis patient population has also increased over time and now exceeds 500,000 patients, though the annual growth rate has fallen below 2%. Despite increased spending, health outcomes like mortality and hospitalization rates have stabilized in recent years. The document suggests that the main challenge for dialysis is in managing chronic conditions like hypertension, left ventricular hypertrophy, and heart failure, which are major drivers of morbidity and mortality
Advancingdialysis.org cardiac arrhythmia in thrice weekly hemodialysisAdvancingDialysis.org
This study used continuous cardiac monitoring to examine arrhythmias in hemodialysis patients over 6 months. It found that:
- Nearly all patients (97%) experienced arrhythmias, with clinically significant arrhythmias occurring in 2/3 of patients. Bradycardia was the most common arrhythmia.
- Arrhythmia rates were highest during the first dialysis session of the week and the long interdialytic gap between sessions. Bradycardic events peaked late in the long gap.
- Atrial fibrillation spiked during dialysis and gradually decreased after, climbing again in the last 36 hours of the long gap.
- Dialysis prescriptions like higher dialysate
Advancing dialysis: Recasting kidney failure as cardiovascular diseaseAdvancingDialysis.org
The document discusses issues related to end stage renal disease (ESRD) and dialysis treatment in the United States. It notes that ESRD represents 7% of the Medicare budget while only treating 1% of the population. While total Medicare spending and spending per patient on dialysis has stabilized in recent years, the total number of dialysis patients has continued to increase and now exceeds 500,000. The document discusses challenges with the current conventional dialysis treatment approach, including its inability to adequately manage issues like fluid overload, hypertension, and cardiovascular disease - which are the major drivers of mortality in ESRD patients. It suggests alternative home dialysis modalities may help address these issues but barriers need to be addressed to increase their utilization
Presented November, 3 2017.
Peter McCullough, MD, MPH, FACC, FACP, FCCP, FAHA, FNKF
Baylor University Medical Center
EMERGING PRESCRIPTION PROTOCOL FOR MORE FREQUENT HEMODIALYSIS
Ultrafiltration controlled prescription guide that improves treatment tolerability, reduces dialysis-induced cardiomyopathy, addresses chronic fluid overload while meeting clinical targets.
Discussion lead:
Allan Collins, MD, FACP
University of Minnesota School of Medicine
Chief Medical Officer, NxStage Medical, Inc.
CURBSIDE CONSULTATION: HOME DIALYSIS PATIENT CONSIDERATIONS
Biochemical, health-related quality of life, and economic factors when transitioning patients home.
Discussion lead:
Paul Komenda, MD, MHA, FRCPC
Seven Oaks General Hospital
REAL LIFE EXPERIENCE: PHYSICIAN AND PATIENT LEARNINGS
Dr. Kraus will discuss the prescribed regimen while Mr. Davis shares his clinical and lifestyle experiences as a more frequent hemodialysis patient.
Discussion leads:
Michael Kraus, MD, FACP
Indiana University School of Medicine
Evernard Davis III
Current Dialysis Patient, Retired Energy Consultant:
Advancing dialysis.org recent findings better management of volume with inten...AdvancingDialysis.org
The document discusses the challenges of managing fluid volume in patients undergoing standard hemodialysis treatment. Fluid accumulates between the three weekly sessions, putting stress on the heart. While ultrafiltration rates have decreased in recent years, cardiovascular hospitalization rates have risen. Standard hemodialysis treatment may not adequately address fluid management issues between, during, and after sessions, indicating poor fluid control.
This document summarizes findings from a study on outcomes for patients transitioning from peritoneal dialysis to hemodialysis. It finds that planned transitions and transitioning to home hemodialysis can improve outcomes, including lower mortality rates and higher rates of kidney transplantation compared to emergency transitions and in-center hemodialysis. Specifically, the study found a 24% lower risk of death and 36% higher likelihood of transplantation for patients who transitioned to home hemodialysis. The document also provides indicators that can help medical teams better manage patient transitions from peritoneal dialysis to hemodialysis.
Advancing dialysis.org recent findings better management of volume with inten...AdvancingDialysis.org
The document discusses the challenges of managing fluid volume in patients undergoing standard hemodialysis treatment given the constraints of a 3 session per week schedule. Fluid accumulates in the body during the long interdialytic gaps, putting stress on the heart and increasing risks. While ultrafiltration rates have decreased slightly over time, cardiovascular hospitalization rates have risen, suggesting fluid management remains a key issue. Studies link higher fluid overload levels to increased mortality risk, indicating more consistent volume control through increased treatment frequency and/or time could help address remaining unmet needs.
Advancing dialysis multinational guidelines for increased time and frequency ...AdvancingDialysis.org
This document summarizes guidelines from 5 medical societies regarding intensive hemodialysis. The guidelines agree that increasing hemodialysis time or frequency should be considered for patients with large weight gains, high ultrafiltration rates, poorly controlled blood pressure, difficulty achieving dry weight, or poor metabolic control. Specifically, the guidelines recommend intensive hemodialysis for patients with refractory fluid overload, uncontrolled hypertension, hyperphosphataemia, cardiovascular disease, hemodynamic instability, or impaired phosphate control. The conclusion states that physician judgment combined with clinical guidelines should guide decisions about intensive hemodialysis for patients.
This document summarizes a consensus document on hypertension in dialysis patients. It discusses how hypertension is common in dialysis patients and associated with shorter survival. The principal causes of hypertension include volume overload, arterial stiffness, sympathetic nervous system activation, and renin-angiotensin-aldosterone system activation. Treatment strategies should focus on correcting the primary causes of hypertension, which are sodium and volume excess. Non-pharmacological strategies like reducing salt intake, individualizing dialysate sodium, and increasing treatment length and frequency can help reduce blood pressure by managing volume status.
Advancingdialysis.org cardiac arrhythmia in thrice weekly hemodialysisAdvancingDialysis.org
This study used continuous cardiac monitoring to examine arrhythmias in hemodialysis patients over 6 months. It found that:
- Nearly all patients (97%) experienced arrhythmias, with clinically significant arrhythmias occurring in 2/3 of patients. Bradycardia was the most common arrhythmia.
- Arrhythmia rates were highest during the first dialysis session of the week and the long interdialytic gap between sessions. Bradycardic events peaked late in the long gap.
- Atrial fibrillation spiked during dialysis and gradually decreased after, climbing again in the last 36 hours of the long gap.
- Dialysis prescriptions like higher dialysate
Advancing dialysis: Recasting kidney failure as cardiovascular diseaseAdvancingDialysis.org
The document discusses issues related to end stage renal disease (ESRD) and dialysis treatment in the United States. It notes that ESRD represents 7% of the Medicare budget while only treating 1% of the population. While total Medicare spending and spending per patient on dialysis has stabilized in recent years, the total number of dialysis patients has continued to increase and now exceeds 500,000. The document discusses challenges with the current conventional dialysis treatment approach, including its inability to adequately manage issues like fluid overload, hypertension, and cardiovascular disease - which are the major drivers of mortality in ESRD patients. It suggests alternative home dialysis modalities may help address these issues but barriers need to be addressed to increase their utilization
Presented November, 3 2017.
Peter McCullough, MD, MPH, FACC, FACP, FCCP, FAHA, FNKF
Baylor University Medical Center
EMERGING PRESCRIPTION PROTOCOL FOR MORE FREQUENT HEMODIALYSIS
Ultrafiltration controlled prescription guide that improves treatment tolerability, reduces dialysis-induced cardiomyopathy, addresses chronic fluid overload while meeting clinical targets.
Discussion lead:
Allan Collins, MD, FACP
University of Minnesota School of Medicine
Chief Medical Officer, NxStage Medical, Inc.
CURBSIDE CONSULTATION: HOME DIALYSIS PATIENT CONSIDERATIONS
Biochemical, health-related quality of life, and economic factors when transitioning patients home.
Discussion lead:
Paul Komenda, MD, MHA, FRCPC
Seven Oaks General Hospital
REAL LIFE EXPERIENCE: PHYSICIAN AND PATIENT LEARNINGS
Dr. Kraus will discuss the prescribed regimen while Mr. Davis shares his clinical and lifestyle experiences as a more frequent hemodialysis patient.
Discussion leads:
Michael Kraus, MD, FACP
Indiana University School of Medicine
Evernard Davis III
Current Dialysis Patient, Retired Energy Consultant:
Advancing dialysis.org recent findings better management of volume with inten...AdvancingDialysis.org
The document discusses the challenges of managing fluid volume in patients undergoing standard hemodialysis treatment. Fluid accumulates between the three weekly sessions, putting stress on the heart. While ultrafiltration rates have decreased in recent years, cardiovascular hospitalization rates have risen. Standard hemodialysis treatment may not adequately address fluid management issues between, during, and after sessions, indicating poor fluid control.
This document summarizes findings from a study on outcomes for patients transitioning from peritoneal dialysis to hemodialysis. It finds that planned transitions and transitioning to home hemodialysis can improve outcomes, including lower mortality rates and higher rates of kidney transplantation compared to emergency transitions and in-center hemodialysis. Specifically, the study found a 24% lower risk of death and 36% higher likelihood of transplantation for patients who transitioned to home hemodialysis. The document also provides indicators that can help medical teams better manage patient transitions from peritoneal dialysis to hemodialysis.
Advancing dialysis.org recent findings better management of volume with inten...AdvancingDialysis.org
The document discusses the challenges of managing fluid volume in patients undergoing standard hemodialysis treatment given the constraints of a 3 session per week schedule. Fluid accumulates in the body during the long interdialytic gaps, putting stress on the heart and increasing risks. While ultrafiltration rates have decreased slightly over time, cardiovascular hospitalization rates have risen, suggesting fluid management remains a key issue. Studies link higher fluid overload levels to increased mortality risk, indicating more consistent volume control through increased treatment frequency and/or time could help address remaining unmet needs.
Advancing dialysis multinational guidelines for increased time and frequency ...AdvancingDialysis.org
This document summarizes guidelines from 5 medical societies regarding intensive hemodialysis. The guidelines agree that increasing hemodialysis time or frequency should be considered for patients with large weight gains, high ultrafiltration rates, poorly controlled blood pressure, difficulty achieving dry weight, or poor metabolic control. Specifically, the guidelines recommend intensive hemodialysis for patients with refractory fluid overload, uncontrolled hypertension, hyperphosphataemia, cardiovascular disease, hemodynamic instability, or impaired phosphate control. The conclusion states that physician judgment combined with clinical guidelines should guide decisions about intensive hemodialysis for patients.
This document summarizes a consensus document on hypertension in dialysis patients. It discusses how hypertension is common in dialysis patients and associated with shorter survival. The principal causes of hypertension include volume overload, arterial stiffness, sympathetic nervous system activation, and renin-angiotensin-aldosterone system activation. Treatment strategies should focus on correcting the primary causes of hypertension, which are sodium and volume excess. Non-pharmacological strategies like reducing salt intake, individualizing dialysate sodium, and increasing treatment length and frequency can help reduce blood pressure by managing volume status.
Advancing dialysis - Improving Outcomes for Dialysis Patientsnxstage
Intensive hemodialysis through short daily or frequent nocturnal treatments has been shown in multiple randomized clinical trials to have promising benefits compared to conventional in-center hemodialysis, including reduced risks of death and cardiovascular hospitalization, lower blood pressure and left ventricular mass, improved physical and mental health-related quality of life, and decreased need for phosphate binders and antihypertensive medications. However, the effects on individual outcomes varied between trials.
This document summarizes research on the cardiovascular benefits of intensive hemodialysis compared to conventional hemodialysis. It finds that intensive hemodialysis significantly reduces left ventricular mass and lowers the risks of cardiovascular hospitalization and death. Specifically, short daily hemodialysis was associated with lower risks of hospitalization for heart failure, cerebrovascular disease, and hypertension compared to conventional in-center hemodialysis or peritoneal dialysis.
The SPRINT study compared an intensive blood pressure treatment target of less than 120 mm Hg to a standard target of less than 140 mm Hg in 9,361 patients at high risk for cardiovascular events but without diabetes. At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive group and 136.2 mm Hg in the standard group. After a median follow up of 3.26 years, the primary composite outcome of heart attack, acute coronary syndrome, stroke, heart failure or cardiovascular death occurred less frequently in the intensive group compared to the standard group. All-cause mortality was also lower in the intensive group, though rates of some adverse events were higher.
1) Many hemodialysis patients and their caregivers report fatigue, low blood pressure during dialysis, and muscle cramps as more important symptoms to address than life expectancy.
2) Intensive hemodialysis is associated with significantly lower rates of intradialytic hypotension compared to conventional hemodialysis.
3) Longer post-dialysis recovery times of over 2 hours are linked to higher risks of hospitalization and death for hemodialysis patients, while intensive hemodialysis can significantly reduce average recovery times.
Anticoagulation in chronic kidney disease dr. mohsen el kossiFarragBahbah
Based on the information provided:
- Her stroke risk can be assessed using CHA2DS2-VASc score:
C = 1 (Congestive heart failure)
H = 1 (Hypertension)
A = 1 (Age 65-74)
D = 1 (Diabetes)
S = 1 (Stroke/TIA/TE)
V = 0
A = 0
S = 1 (Sex category)
c = 2
She has a high stroke risk.
- Given her moderate CKD, I would recommend anticoagulation. A NOAC like Apixaban 2.5mg BD could be used given her eGFR of 32ml/min is above the recommended
Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...Moh'd sharshir
1) This study compared early goal-directed therapy (EGDT) to usual care in patients with septic shock. EGDT aimed to optimize tissue oxygen delivery through monitoring of physiological targets like central venous pressure and central venous oxygen saturation.
2) The study found no significant difference in 90-day mortality between the EGDT and usual care groups. Patients in the EGDT group received more intravenous fluids and vasopressors but this did not impact mortality outcomes.
3) The study concludes that EGDT did not decrease mortality in patients presenting with septic shock compared to usual resuscitation practices. The value of incorporating EGDT into international guidelines is questionable.
Advancing Dialysis - Symptoms During Dialysisnxstage
This document summarizes key findings from studies on intensive hemodialysis treatment. It reports that intensive hemodialysis significantly reduces the risks of intradialytic hypotension and shorter post-dialysis recovery times compared to conventional hemodialysis. Specifically, intensive hemodialysis was found to reduce levels of intradialytic hypotension by 21-67% and decrease average post-dialysis recovery time from 7.9 hours to 1.1 hours. Shorter recovery times were further associated with lower risks of hospitalization and death.
Patient under dialysis with uncontrolled hypertension Haytham Ghareeb
This patient has uncontrolled hypertension despite being on dialysis twice a week and taking multiple antihypertensive medications. There were several issues with his treatment: he was not placed on fluid or sodium restrictions; his interdialytic weight gain was too high; and dialysis frequency and duration were insufficient. Additionally, lifestyle factors like a high salt diet were not addressed. The nephrologist made changes to the dialysis protocol and recommended the patient follow dietary sodium and fluid restrictions to achieve better volume control. Drug therapy was also optimized based on pharmacokinetic properties during dialysis. The goal is to control hypertension while avoiding overly low blood pressure, as both can increase mortality risk in dialysis patients.
Five medical societies from North America, Europe, and Asia have released clinical practice guidelines since 2006 that largely agree intensive hemodialysis should be considered for patients with:
- Large weight gains between treatments
- High rates of fluid removal during treatments
- Poorly controlled blood pressure
- Difficulty achieving their dry weight
- Poor control of minerals like phosphorus or potassium
The guidelines indicate intensive hemodialysis may help patients with these issues by providing more frequent or longer hemodialysis sessions. Physician judgment is also important when determining if intensive hemodialysis is appropriate for a given patient.
The study found that patients who received aminoglycoside treatment for perioperative cardiac surgery had a substantially higher risk of requiring postoperative dialysis, and this risk was independent of dose size and number. Some findings, such as the disappearance of risk when adjusting for confounding factors in endocarditis patients, were unexpected. Clinicians should be aware of the increased risk of postoperative dialysis associated with aminoglycoside use in cardiac surgery patients.
This document summarizes findings from multiple studies on the effects of intensive hemodialysis on blood pressure and antihypertensive medication use. It finds that over 60% of patients receiving conventional hemodialysis have elevated pre-dialysis blood pressure despite using multiple medications. Randomized clinical trials showed intensive hemodialysis significantly lowers blood pressure by 8-11 mmHg. Studies also found the number of antihypertensive medications prescribed per patient declined by around 36% with intensive hemodialysis.
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
ICN VIctoria: John Botha on Critical Care Renal FailureGerard Fennessy
Professor John Botha from Frankston Hospital in Melbourne talks at the April 2014 Victorian Intensive Care Network meeting on Renal Failure in Critical Care
This document discusses various potential therapies for acute heart failure. It begins by reviewing the historical focus on diuresis, vasodilators, and inotropes from 1970-2010. Currently, over 90% of patients receive intravenous diuretics as the primary treatment. The document then evaluates several promising new treatment approaches that are being studied, including natriuretic peptides, levosimendan, relaxin, soluble guanylate cyclase activators, rolofylline, cardiac myosin activators, and SERCA2a activators. It provides details on clinical trials and mechanisms of action for these novel therapies. Throughout, the document provides a critical look at challenges and limitations for further developing these new
Cardiovascular disease is very common in patients with chronic kidney disease.
- CVD is the leading cause of death in patients with CKD, even in early stages of kidney disease and those with low levels of albuminuria. Reduced kidney function and increased albuminuria are associated with higher risk of CVD events and mortality.
- The prevalence of CVD is extremely high in patients on dialysis, with over 70% of dialysis patients having CVD. CVD is responsible for about 40% of all deaths in dialysis patients.
- Both traditional CVD risk factors like hypertension and diabetes as well as nontraditional risk factors related to CKD contribute to the elevated CVD risk in this population. Targeting modifiable
This document discusses incremental dialysis, which is an approach to adjusting dialysis dose based on a patient's residual kidney function (RKF). The key points are:
1) Patients starting dialysis often have some remaining RKF, and incorporating this into their dialysis prescription through an incremental approach may help preserve RKF longer.
2) Observational studies have found associations between preserving higher levels of RKF and benefits like improved survival, volume control, and lower inflammation.
3) The optimal approach is to start dialysis at the correct time and adjust the dose incrementally as RKF declines, individualizing treatment for each patient. Some studies found twice-weekly hemodialysis may better preserve RKF
Early Goal-Directed Therapy in Septic Shockshivabirdi
Early goal directed therapy (EGDT) aims to balance oxygen delivery and demand through manipulating cardiac preload, afterload and contractility using measures like lactate, base deficit and ScvO2. A study of 263 patients with severe sepsis or septic shock found that those receiving EGDT in the emergency department for at least 6 hours had significantly lower in-hospital, 28-day and 60-day mortality compared to standard therapy. EGDT also resulted in fewer organ dysfunctions, less coagulation abnormalities and cardiovascular collapse.
Impact of statins and beta-blocker therapy on mortality after coronary artery...Paul Schoenhagen
Abstract
Background: We conducted a retrospective cohort study of patients after first-time isolated coronary artery bypass graft surgery (CABG) and assessed the impact of a discharge regimen including beta-blockers and statin therapy and their relationship to long-term all cause mortality and major adverse cardiovascular events (MACE).
Methods: We identified patients age >18 years, undergoing first time isolated CABG from 1993 to 2005. Patients were identified using the Cardiovascular Information Registry (CVIR). We collected follow-up information at 30, 60, 90 days and yearly follow-up. The registry is approved for use in research by the institutional review broad.
Results: We identified 5,205 patients who underwent single isolated CABG between January 1993 and December 2005. The mean age was 64.5±9.7 years and over 70% were male. There was a significant difference in the low density lipoproteins (LDL) concentration between those with or without statin medications (134±41.9 mg/dL) (no statin) vs. 126±44.8 mg/dL (with statin), P=0.001. A discharge regimen with statin therapy was associated with and overall reduction in 30 day, 1 year and long-term mortality. In addition, overall the triple ischemic endpoint of death, myocardial infarction (MI) and stroke was also significantly lower in the statin vs. no-statin group. In addition, statin and beta-blockers exerted synergistic effect on overall mortality outcomes short-term and in the long-term. We note that the predictors of overall death include no therapy with statin therapy and age [hazard ratios (HR) 1.1, 95% CI: 1.04-1.078, P<0.001] and presence of renal failure (HR 2.0, P=0.005). The estimated 11-year Kaplan Meier curves for mortality between the two groups starts to diverge immediately post discharge after single isolated CABG and continue to diverge through out the follow-up period.
Conclusions: A post-discharge regimen of statins independently reduces overall and 1 year mortality. These results confirm those of earlier studies within a contemporary surgical population and support the current clinical guidelines.
Intensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular DiseaseAdvancingDialysis.org
Cardiovascular-related deaths in prevalent dialysis patients are common.
The long interdialytic interval, commonly referred to as the 2-day “Killer Gap,” is a time of heightened risk of mortality and morbidity with conventional hemodialysis. Multiple randomized clinical trials show intensive hemodialysis significantly reduces left ventricular mass and more frequent hemodialysis has associated with lower risk of cardiovascular-related hospitalizations.
Sepsis and Early Goal Directed Therapy: Approach in ED outlines sepsis definitions, the theory and components of early goal directed therapy (EGDT) for treating sepsis. EGDT aims to optimize oxygen delivery through fluid resuscitation, vasopressors to maintain blood pressure, scvO2 monitoring and blood transfusions if needed. The document recommends beginning IV antibiotics within 1 hour of recognizing sepsis to improve survival rates. Timely implementation of EGDT's components in the emergency department can help reduce mortality from sepsis.
This presentation reviews ETC participant assessment, aggregation, and payment mechanisms, including achievement benchmarks for measurement years 1-, 2-, and 3-.
Chronic Kidney Disease Challenges and New SolutionsViewics
A critical population management challenge concerns chronic kidney disease (CKD), which impacts about half of the Medicare population and of diabetics. More than 50% of adults over 30 years of age are likely to develop CKD during their lifetime, and the prevalence of CKD is expected to climb over the next 15 years. Current CKD management is variable and suboptimal, as categorizing the very heterogeneous CKD patient population into risk cohorts for purposes of appropriate treatment is inaccurate. Without accurate risk classification, many patients are over-treated, leading to wasted expenses and adverse events, while others are not identified in time to receive interventions that change the course of the disease.
A new algorithm has been created that predicts patients’ risk of renal failure based on a specific set of laboratory tests combined with patient age and gender. Validated by more than 720,000 patients spanning 30 countries, it can reliably predict a patient’s risk of experiencing renal failure requiring dialysis or transplant. Studies show that a lab-based analytics program that incorporates this algorithm with care protocols, dashboards, and educational patient reports can generate substantial savings and improved outcomes for ACOs and health systems.
Advancing dialysis - Improving Outcomes for Dialysis Patientsnxstage
Intensive hemodialysis through short daily or frequent nocturnal treatments has been shown in multiple randomized clinical trials to have promising benefits compared to conventional in-center hemodialysis, including reduced risks of death and cardiovascular hospitalization, lower blood pressure and left ventricular mass, improved physical and mental health-related quality of life, and decreased need for phosphate binders and antihypertensive medications. However, the effects on individual outcomes varied between trials.
This document summarizes research on the cardiovascular benefits of intensive hemodialysis compared to conventional hemodialysis. It finds that intensive hemodialysis significantly reduces left ventricular mass and lowers the risks of cardiovascular hospitalization and death. Specifically, short daily hemodialysis was associated with lower risks of hospitalization for heart failure, cerebrovascular disease, and hypertension compared to conventional in-center hemodialysis or peritoneal dialysis.
The SPRINT study compared an intensive blood pressure treatment target of less than 120 mm Hg to a standard target of less than 140 mm Hg in 9,361 patients at high risk for cardiovascular events but without diabetes. At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive group and 136.2 mm Hg in the standard group. After a median follow up of 3.26 years, the primary composite outcome of heart attack, acute coronary syndrome, stroke, heart failure or cardiovascular death occurred less frequently in the intensive group compared to the standard group. All-cause mortality was also lower in the intensive group, though rates of some adverse events were higher.
1) Many hemodialysis patients and their caregivers report fatigue, low blood pressure during dialysis, and muscle cramps as more important symptoms to address than life expectancy.
2) Intensive hemodialysis is associated with significantly lower rates of intradialytic hypotension compared to conventional hemodialysis.
3) Longer post-dialysis recovery times of over 2 hours are linked to higher risks of hospitalization and death for hemodialysis patients, while intensive hemodialysis can significantly reduce average recovery times.
Anticoagulation in chronic kidney disease dr. mohsen el kossiFarragBahbah
Based on the information provided:
- Her stroke risk can be assessed using CHA2DS2-VASc score:
C = 1 (Congestive heart failure)
H = 1 (Hypertension)
A = 1 (Age 65-74)
D = 1 (Diabetes)
S = 1 (Stroke/TIA/TE)
V = 0
A = 0
S = 1 (Sex category)
c = 2
She has a high stroke risk.
- Given her moderate CKD, I would recommend anticoagulation. A NOAC like Apixaban 2.5mg BD could be used given her eGFR of 32ml/min is above the recommended
Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...Moh'd sharshir
1) This study compared early goal-directed therapy (EGDT) to usual care in patients with septic shock. EGDT aimed to optimize tissue oxygen delivery through monitoring of physiological targets like central venous pressure and central venous oxygen saturation.
2) The study found no significant difference in 90-day mortality between the EGDT and usual care groups. Patients in the EGDT group received more intravenous fluids and vasopressors but this did not impact mortality outcomes.
3) The study concludes that EGDT did not decrease mortality in patients presenting with septic shock compared to usual resuscitation practices. The value of incorporating EGDT into international guidelines is questionable.
Advancing Dialysis - Symptoms During Dialysisnxstage
This document summarizes key findings from studies on intensive hemodialysis treatment. It reports that intensive hemodialysis significantly reduces the risks of intradialytic hypotension and shorter post-dialysis recovery times compared to conventional hemodialysis. Specifically, intensive hemodialysis was found to reduce levels of intradialytic hypotension by 21-67% and decrease average post-dialysis recovery time from 7.9 hours to 1.1 hours. Shorter recovery times were further associated with lower risks of hospitalization and death.
Patient under dialysis with uncontrolled hypertension Haytham Ghareeb
This patient has uncontrolled hypertension despite being on dialysis twice a week and taking multiple antihypertensive medications. There were several issues with his treatment: he was not placed on fluid or sodium restrictions; his interdialytic weight gain was too high; and dialysis frequency and duration were insufficient. Additionally, lifestyle factors like a high salt diet were not addressed. The nephrologist made changes to the dialysis protocol and recommended the patient follow dietary sodium and fluid restrictions to achieve better volume control. Drug therapy was also optimized based on pharmacokinetic properties during dialysis. The goal is to control hypertension while avoiding overly low blood pressure, as both can increase mortality risk in dialysis patients.
Five medical societies from North America, Europe, and Asia have released clinical practice guidelines since 2006 that largely agree intensive hemodialysis should be considered for patients with:
- Large weight gains between treatments
- High rates of fluid removal during treatments
- Poorly controlled blood pressure
- Difficulty achieving their dry weight
- Poor control of minerals like phosphorus or potassium
The guidelines indicate intensive hemodialysis may help patients with these issues by providing more frequent or longer hemodialysis sessions. Physician judgment is also important when determining if intensive hemodialysis is appropriate for a given patient.
The study found that patients who received aminoglycoside treatment for perioperative cardiac surgery had a substantially higher risk of requiring postoperative dialysis, and this risk was independent of dose size and number. Some findings, such as the disappearance of risk when adjusting for confounding factors in endocarditis patients, were unexpected. Clinicians should be aware of the increased risk of postoperative dialysis associated with aminoglycoside use in cardiac surgery patients.
This document summarizes findings from multiple studies on the effects of intensive hemodialysis on blood pressure and antihypertensive medication use. It finds that over 60% of patients receiving conventional hemodialysis have elevated pre-dialysis blood pressure despite using multiple medications. Randomized clinical trials showed intensive hemodialysis significantly lowers blood pressure by 8-11 mmHg. Studies also found the number of antihypertensive medications prescribed per patient declined by around 36% with intensive hemodialysis.
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
ICN VIctoria: John Botha on Critical Care Renal FailureGerard Fennessy
Professor John Botha from Frankston Hospital in Melbourne talks at the April 2014 Victorian Intensive Care Network meeting on Renal Failure in Critical Care
This document discusses various potential therapies for acute heart failure. It begins by reviewing the historical focus on diuresis, vasodilators, and inotropes from 1970-2010. Currently, over 90% of patients receive intravenous diuretics as the primary treatment. The document then evaluates several promising new treatment approaches that are being studied, including natriuretic peptides, levosimendan, relaxin, soluble guanylate cyclase activators, rolofylline, cardiac myosin activators, and SERCA2a activators. It provides details on clinical trials and mechanisms of action for these novel therapies. Throughout, the document provides a critical look at challenges and limitations for further developing these new
Cardiovascular disease is very common in patients with chronic kidney disease.
- CVD is the leading cause of death in patients with CKD, even in early stages of kidney disease and those with low levels of albuminuria. Reduced kidney function and increased albuminuria are associated with higher risk of CVD events and mortality.
- The prevalence of CVD is extremely high in patients on dialysis, with over 70% of dialysis patients having CVD. CVD is responsible for about 40% of all deaths in dialysis patients.
- Both traditional CVD risk factors like hypertension and diabetes as well as nontraditional risk factors related to CKD contribute to the elevated CVD risk in this population. Targeting modifiable
This document discusses incremental dialysis, which is an approach to adjusting dialysis dose based on a patient's residual kidney function (RKF). The key points are:
1) Patients starting dialysis often have some remaining RKF, and incorporating this into their dialysis prescription through an incremental approach may help preserve RKF longer.
2) Observational studies have found associations between preserving higher levels of RKF and benefits like improved survival, volume control, and lower inflammation.
3) The optimal approach is to start dialysis at the correct time and adjust the dose incrementally as RKF declines, individualizing treatment for each patient. Some studies found twice-weekly hemodialysis may better preserve RKF
Early Goal-Directed Therapy in Septic Shockshivabirdi
Early goal directed therapy (EGDT) aims to balance oxygen delivery and demand through manipulating cardiac preload, afterload and contractility using measures like lactate, base deficit and ScvO2. A study of 263 patients with severe sepsis or septic shock found that those receiving EGDT in the emergency department for at least 6 hours had significantly lower in-hospital, 28-day and 60-day mortality compared to standard therapy. EGDT also resulted in fewer organ dysfunctions, less coagulation abnormalities and cardiovascular collapse.
Impact of statins and beta-blocker therapy on mortality after coronary artery...Paul Schoenhagen
Abstract
Background: We conducted a retrospective cohort study of patients after first-time isolated coronary artery bypass graft surgery (CABG) and assessed the impact of a discharge regimen including beta-blockers and statin therapy and their relationship to long-term all cause mortality and major adverse cardiovascular events (MACE).
Methods: We identified patients age >18 years, undergoing first time isolated CABG from 1993 to 2005. Patients were identified using the Cardiovascular Information Registry (CVIR). We collected follow-up information at 30, 60, 90 days and yearly follow-up. The registry is approved for use in research by the institutional review broad.
Results: We identified 5,205 patients who underwent single isolated CABG between January 1993 and December 2005. The mean age was 64.5±9.7 years and over 70% were male. There was a significant difference in the low density lipoproteins (LDL) concentration between those with or without statin medications (134±41.9 mg/dL) (no statin) vs. 126±44.8 mg/dL (with statin), P=0.001. A discharge regimen with statin therapy was associated with and overall reduction in 30 day, 1 year and long-term mortality. In addition, overall the triple ischemic endpoint of death, myocardial infarction (MI) and stroke was also significantly lower in the statin vs. no-statin group. In addition, statin and beta-blockers exerted synergistic effect on overall mortality outcomes short-term and in the long-term. We note that the predictors of overall death include no therapy with statin therapy and age [hazard ratios (HR) 1.1, 95% CI: 1.04-1.078, P<0.001] and presence of renal failure (HR 2.0, P=0.005). The estimated 11-year Kaplan Meier curves for mortality between the two groups starts to diverge immediately post discharge after single isolated CABG and continue to diverge through out the follow-up period.
Conclusions: A post-discharge regimen of statins independently reduces overall and 1 year mortality. These results confirm those of earlier studies within a contemporary surgical population and support the current clinical guidelines.
Intensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular DiseaseAdvancingDialysis.org
Cardiovascular-related deaths in prevalent dialysis patients are common.
The long interdialytic interval, commonly referred to as the 2-day “Killer Gap,” is a time of heightened risk of mortality and morbidity with conventional hemodialysis. Multiple randomized clinical trials show intensive hemodialysis significantly reduces left ventricular mass and more frequent hemodialysis has associated with lower risk of cardiovascular-related hospitalizations.
Sepsis and Early Goal Directed Therapy: Approach in ED outlines sepsis definitions, the theory and components of early goal directed therapy (EGDT) for treating sepsis. EGDT aims to optimize oxygen delivery through fluid resuscitation, vasopressors to maintain blood pressure, scvO2 monitoring and blood transfusions if needed. The document recommends beginning IV antibiotics within 1 hour of recognizing sepsis to improve survival rates. Timely implementation of EGDT's components in the emergency department can help reduce mortality from sepsis.
This presentation reviews ETC participant assessment, aggregation, and payment mechanisms, including achievement benchmarks for measurement years 1-, 2-, and 3-.
Chronic Kidney Disease Challenges and New SolutionsViewics
A critical population management challenge concerns chronic kidney disease (CKD), which impacts about half of the Medicare population and of diabetics. More than 50% of adults over 30 years of age are likely to develop CKD during their lifetime, and the prevalence of CKD is expected to climb over the next 15 years. Current CKD management is variable and suboptimal, as categorizing the very heterogeneous CKD patient population into risk cohorts for purposes of appropriate treatment is inaccurate. Without accurate risk classification, many patients are over-treated, leading to wasted expenses and adverse events, while others are not identified in time to receive interventions that change the course of the disease.
A new algorithm has been created that predicts patients’ risk of renal failure based on a specific set of laboratory tests combined with patient age and gender. Validated by more than 720,000 patients spanning 30 countries, it can reliably predict a patient’s risk of experiencing renal failure requiring dialysis or transplant. Studies show that a lab-based analytics program that incorporates this algorithm with care protocols, dashboards, and educational patient reports can generate substantial savings and improved outcomes for ACOs and health systems.
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Empowering Healthcare Leaders: The Business Case for Language Access provides a framework for calculating total potential encounters with limited English patients, the economic benefit and cost of not providing language access and a frame work to align the economic benefits with organizational goals under the Affordable Care Act.
Chronic Kidney Disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. It affects over 26 million Americans and is a major public health issue. The leading causes are diabetes and hypertension. As CKD progresses, kidney function declines and complications increase like anemia and bone disease. Cardiovascular disease risk also rises substantially. Inflammation, lipid abnormalities, and genetic factors can all contribute to CKD progression if not properly managed.
Prof Ken Mc Donald , Associate Clinical Professor UCD/ St Vincent'sInvestnet
The document discusses improved diagnostics and pathways for heart failure patients using an integrated approach. It summarizes the challenges of chronic disease management using the current reactive care model and outlines goals and solutions based on the heart failure management program. Key points include:
- Chronic diseases account for most health care visits, hospitalizations, and costs, posing major challenges for healthcare systems.
- New models of chronic disease management are needed to prevent illness onset, keep patients well in their communities, and reduce emergency visits and hospitalizations.
- The heart failure program demonstrates potential solutions through virtual consultations, reduced travel, and use of natriuretic peptides to personalize risk assessment and focus resources.
- Preliminary results
The document discusses the rationale and logistics for establishing a chronic kidney disease (CKD) clinic. It notes that CKD is a growing problem due to the rise of lifestyle diseases like diabetes and hypertension. A CKD clinic would take a multidisciplinary team approach to managing CKD patients and aim to slow disease progression, control comorbidities, and delay the need for renal replacement therapies. Studies show that CKD clinics that coordinate specialized care result in better health outcomes for patients than traditional nephrology care models.
The document discusses strategies for preventing and treating end stage renal disease (ESRD) in developing countries. It notes that treatment is most effective and cost efficient when focused on high-risk groups through measures like screening diabetics and their relatives, and using ACE inhibitors. Kidney transplants are also effective but availability of donors is limited. Developing countries need to expand access to renal replacement therapies while focusing on primary prevention through lifestyle changes and secondary prevention with pharmaceuticals to reduce ESRD burden over time.
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Assessment of intravascular volume statusDetalo Health
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Prevalence of cvd risk factors among qatari patients with type 2 diabetes mel...Dr. Anees Alyafei
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This document discusses the growing epidemic of diabesity, which refers to the concurrent rise in diabetes and obesity. Some key points made include:
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- Diabesity costs the healthcare system $44 billion in direct costs and $138 billion in total costs annually.
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Running head MEDICAL CARE PLANNING FOR PATIENTS WITH CHRONIC KIDN.docxjeanettehully
Running head: MEDICAL CARE PLANNING FOR PATIENTS WITH CHRONIC KIDNEY DISEASE
Medical care planning for patients with Chronic Kidney DiseaseNorys GilSouth University
Medical care planning for patients with Chronic Kidney Disease
Introduction
Chronic Kidney is a disorder that disturbs the correct working of the kidney, which is increasingly becoming a challenge to the health care sector. Just like any other chronic disease, CKD comes with the responsibility of ensuring that a patient gets maximum medical treatment facilities and attention as much as possible. “The definition and classification of chronic kidney disease (CKD) have evolved, but current international guidelines define this condition as decreased kidney function as shown by glomerular filtration rate (GFR) of less than 60 mL/min per 1·73 m2 or markers of kidney damage, or both, of at least three months duration, regardless of the underlying cause”, Morton & Masson, 2017.
Morbidity and comorbidity of chronic Kidney disease
Weak/low results are closely associated with CKD; this is because of the burdens that are so high when it comes to comorbidity. Many pieces of research have indicated that CKD relates to diabetes and hypertension conditions. Intense conditions of chronic kidney disease also lead to heart complications. There is little information on the mental difficulties that come with CKD.
“Chronic kidney disease (CKD) can be associated with adverse clinical outcomes, poor quality of life, and high health-care costs; clinicians need to understand that these observations result from a high burden of comorbidity among CKD patients”, (Manns &Hemmelgarn 2010). Key morbidities of CKD, therefore, include pulmonary complications, diabetes, hypertension, and atrial fibrillation. CKD, to a very high degree, leads to characteristics such as myocardial infarction, dementia, hypothyroidism, depression, and stroke. All comorbidities remain classified as concordant others that closely relate with CKD but ranked as discordant include; asthma, constipation, lymphoma dementia, etc.
Impacts of chronic kidney disease
Various medical reports by the health care agencies and organizations, including the World Health Organization show that CKD is a growing complication that has become a big concern of the public health care sector not just in the United States but around the globe. An estimation of over 26 million people is affected by CKD in the country. Annual reports have shown that this number is likely to increase if serious investments are in the health care sector. Hypertension and diabetes are proven, leading causes of kidney complications. To an individual, CKD can lead to other primary complications such as nephropathy, lupus, and continuity of kidney failure. The country invests billions of money annually, something that is becoming hard to sustain because of the annual increase in population and the number of those affected by CKD.
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Acquired hemophilia is a rare disorder and if missed can cost lives. This presentation has been prepared keeping in view the non hematologist health care workers to broaden their index of suspicion and increase their awareness. The target people are medical residents those who work in ER and ICUs.
This document discusses the challenges of caring for elderly patients with end-stage renal disease (ESRD). It notes that the population is aging rapidly worldwide, increasing the number of elderly patients with kidney disease and ESRD. Caring for elderly ESRD patients is complex due to multiple age-related physiological changes in kidney function as well as high rates of comorbidities. The document advocates for a multidisciplinary approach to care that considers patients' medical, cognitive, functional, and palliative care needs in making treatment decisions for this complex patient population.
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Benefits of Regular Exercise:
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Mental Benefits: Explains the psychological advantages, including stress reduction, improved mood, and better sleep.
Tips for Staying Active:
Encourages consistency, variety in exercises, setting realistic goals, and finding enjoyable activities to maintain motivation.
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Integrating Nutrition and Exercise: Suggests meal planning and incorporating physical activity into daily routines.
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2. AdvancingDialysis.org
ESRD:
Represents 7% of the Medicare Budget
TREATS ONLY 1% OF THE US POPULATION1
• The rising number and costs of the dialysis population continues to attract policy
makers attention.
‒ Policy makers including, the US Government Accountability Office, suggest
home therapies should be expanded and barriers addresses
• The challenge with increasing the use of home therapies centers on the type of
the dialysis modality used, how they are applied and the barriers to utilization
• The modalities need to address the chronic diseases which are major drivers of
morbidity and mortality as compared to “uremia”
• How home dialysis modalities address these chronic diseases and how patients
feel on therapy is the ongoing challenge to moving more patients to the home
setting while improving efficacy of therapy
1USRDS 2018 Vol 2 Figure 9.2: Trends in (a) total Medicare & ESRD fee-for-service spending ($, in billions),
and (b) ESRD spending as percentage of Medicare fee-for-service spending, 2004-2016
3. AdvancingDialysis.org
$19.9 Billion
$25.4 Billion
$29.2 Billion
$31.3 Billion
$32.9 Billion
$35.4 Billion
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
US DOLLARS
Inpatient Outpatient Physician/supplier Part D Drugs
Total Medicare Healthcare
Expenditures for Dialysis Patients
USRDS 2005 & 2018 Ref Table K.1: Total Medicare spending ($) of reported ESRD patients by claim type
STEADILY HAS RISEN TO MORE
THAN $35 BILLION/YEAR
4. AdvancingDialysis.org
Medicare per Capita
Expenditures have Stabilized
USRDS 2018 Ref Table K.6 & USRDS 2005 Ref Table K.5: Per person per year spending ($): dialysis patients, with
unknown modalities dropped (model 1); period prevalent patients, as-treated model, primary payer only, by age, sex,
race, ethnicity & primary diagnosis. 2005:as-treated model, Medicare primary payor only
$68,020
$80,099
$85,845 $89,689
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
MEDICARE DIALYSIS
EXPENDITURE PER PERSON
SPEND PER PATIENT:
RELATIVELY FLAT SINCE 2009
5. AdvancingDialysis.org
Dialysis Patient Population Increasing
2016 POPULATION: OVER 500,000+
USRDS 2018 Ref Table D.1: Percentages & counts of reported ESRD patients: by treatment modality incident
& December 31 point prevalent patients
343,015
382,976
414,503
443,649
478,681
509,014
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
US DIALYSIS PATIENTS
All Dialysis
INCREASED SPEND DRIVEN BY
INCREASED PATIENT CENSUS
11. AdvancingDialysis.org
Unmet Need in the
Causal Path of Heart Disease
CHRONIC FLUID OVERLOAD
1Rocco MV, Burkart JM. Prevalence of missed treatments and early sign-offs in hemodialysis patients. J Am
Soc Nephrol. 1993 Nov;4(5):1178-83.
Fluid
Overload
Uncontrolled
Hypertension
Left Ventricular
Hypertrophy
Heart Failure
Hospitalization
and Death
Early Sign-Offs
and No-Shows1
High
Ultrafiltration
Rate
Intradialytic
Hypotension
Cramping,
Dizziness,
Nausea, etc.
Long Post-
Dialysis
Recovery
Time
Poor HRQoL
Cardiac &
organ system
Stunning
Limits Use of
Cardioprotective
Medicines
12. AdvancingDialysis.org
Long Interdialytic Interval is Problematic
HOSPITALIZATIONS AND MORTALITY AFTER THE 2-DAY “KILLER GAP”1
• The long interdialytic interval, commonly
referred to as the 2-day “Killer Gap,” is a time
of heightened risk of mortality and morbidity
with conventional hemodialysis.1
• Rates of death and cardiovascular
hospitalization were 23% and 124% higher
after the gap, respectively, than on other days.1
FIGURE:
Rates of death and cardiovascular hospitalization on the day after
the 2-day gap in dialysis treatment and on all others days.1
1Foley, R. N., Gilbertson, D. T., Murray, T., & Collins, A. J. (2011). Long interdialytic interval and mortality
among patients receiving hemodialysis. New England Journal of Medicine, 365(12), 1099-1107.
13. AdvancingDialysis.org
Increased Risk of
Sudden Cardiac Death1
• Decreased eGFR has been
suggested to cause endocardial
and diffuse myocardial fibrosis that
could increase the risk of life-
threatening ventricular arrhythmias
and sudden cardiac death (SCD)2
• Each 10 mL/min/1.73 m2 decline in
eGFR has been associated with an
11% increased risk of SCD1
General
population
1.5
CVD, GFR >60
3.8
CKD stage III, IV
7.3
CKD stage V,
non-dialysis
12.6
Dialysis
24.2
0 5 10 15 20 25 30
EVENTS PER 1000 PATIENT YEARS
RATES OF SUDDEN CARDIAC DEATH IN
SELECTED POPULATIONS1,3
1Pun, P.H. et al. Chronic kidney disease is associated with
increased risk of sudden cardiac death among patients with
coronary artery disease. Kidney International (2009) 76, 652–658.
2Mark PB, Johnston N, Groenning BA et al. Redefinition of uremic
cardiomyopathy by contrast-enhanced cardiac magnetic
resonance imaging. Kidney Int 2006; 69: 1839–1845.
3Hayashi M., Shimizu W., Albert C.M. The Spectrum of
Epidemiology Underlying Sudden Cardiac Death. Circulation
Research. 2015;116:1887-1906
14. AdvancingDialysis.org
• Incidence rate of clinically
significant arrhythmias was
4.5 events per patient-month
(1,678 events)
‒ Leading arrhythmia was
bradycardia
• 3.9 events per patient-
month
‒ Significantly lower rate of
ventricular tachycardia or
asystole
1Roy-Chaudhury, P., et al. Primary outcomes of the Monitoring in
Dialysis Study indicate that clinically significant arrhythmias are common
in hemodialysis patients and related to dialytic cycle. Kidney Int.
2018;93:941–951.
2/3 Patients Experienced
Clinically Significant Arrhythmias1
15. AdvancingDialysis.org
97% Patients Experienced
Confirmed Arrhythmias1
• Incidence rate of arrhythmias not
meeting definition of clinically significant
arrhythmias (CSA) were
33.74 events per patient-month
(12,480 events)
‒ Leading arrhythmias were atrial
and sinus tachycardia
‒ Significantly lower rate of
ventricular tachycardia or
asystole; similar to CSA findings
1Roy-Chaudhury, P., et al. Primary outcomes of the Monitoring in
Dialysis Study indicate that clinically significant arrhythmias are
common in hemodialysis patients and related to dialytic cycle. Kidney
Int. 2018;93:941–951.
16. AdvancingDialysis.org
Ultrafiltration Rates over 6mL/kg/hr.
Associated with Increased Risk of Death
AGGRESSIVE FLUID REMOVAL RATES AND ALL-CAUSE MORTALITY
METHODS:
118,394 hemodialysis
patients in DaVita facilities,
2008-2012, with mean
follow-up of 2.3 years. Mean
UF rate was characterized
during a 30-day baseline
interval.1
Fine and Gray proportional
sub-distribution hazards
regression models with
kidney transplantation and
dialysis modality change
treated as competing risks
were used to estimate the
ultrafiltration rate and all-
cause mortality association.1
1Assimon, M.M. et al. Ultrafiltration Rate and Mortality in Maintenance Hemodialysis Patients. Am J Kidney Dis.
2016;68(6):911-922
1.00 1.03
1.09
1.15
1.23
1.43
0.80
1.00
1.20
1.40
1.60
<6 6 to 8 8 to 10 10 to 12 12 to 14 >14
Rate of fluid removal from the patient -- mL/kg/hr
RiskofDeath(HR)
17. AdvancingDialysis.org
Chronic Fluid Overload Adds Mortality Risk
ACROSS ALL BLOOD PRESSURE STRATA1
1Zoccali et al. Chronic Fluid Overload and Mortality in ESRD. J Am Soc Nephrol. 2017 Aug;28(8):2491-2497
Figure 4.
1-year cumulative Fluid
Overload (FO) and mortality in
patients stratified by predialysis
systolic BP. Data are adjusted.
Fluid-overloaded patients had a
significantly higher risk of death
compared with non-overloaded
patients across all BP strata (all
P<0.001).1
4.8 Kg above dry ECF
0.9 Kg above dry ECF
18. AdvancingDialysis.org
Class Patient Symptoms
Class I (mild) No limitation of physical activity. Ordinary physical activity does not
cause undue fatigue, palpitation, or dyspnea.
Class II (mild) Slight limitation of physical activity. Comfortable at rest, but ordinary
physical activity results in fatigue, palpitation, or dyspnea.
Class III (moderate) Marked limitation of physical activity. Comfortable at rest, but less than
ordinary activity causes fatigue, palpitation, or dyspnea.
Class IV (severe) Unable to carry out any physical activity without discomfort. Symptoms
of cardiac insufficiency at rest. If any physical activity is undertaken,
discomfort is increased.
Characterizations of Heart Failure
CLASSES BY SEVERITY OF SYMPTOMS
COMMONLY CITED: NEW YORK HEART ASSOCIATION FUNCTION CLASSIfiCATIONS:1
1The Criteria Committee of the New York Heart Association. Diseases of the Heart and Blood Vessels:
Nomenclature and Criteria for Diagnosis. 6th edition. Boston, MA: Little Brown, 1964.
19. AdvancingDialysis.org
ESRD “Reactive” Classification System
ADQI DYSPNEA ASSESSMENT
• Dyspnea pre and post hemodialysis
treatment assessment
• Class assignment assumes the
achievement of dry weight and usual
level of pre/post dyspnea
• Patients scored by their post-
treatment dyspnea assessment:
‒ If dyspnea symptoms improve to
class I levels, the patient would
be classified as class 2R
‒ If dyspnea symptoms improve to
class II levels, the patient would
be classified as class 3R.
Chawla LS, Herzog CA, Costanzo MR et al. Proposal for a Functional Classification System of Heart Failure in
Patients With End-Stage Renal Disease. J Am Coll Cardiol 2014;63:1246–52
20. AdvancingDialysis.org
NKF-KDOQI
HEMODIALYSIS ADEQUACY GUIDELINE: 2015 UPDATE
Consider additional hemodialysis sessions or longer
hemodialysis treatment times for patients with:
• Large weight gains
• High ultrafiltration rates
• Poorly controlled blood pressure
• Difficulty achieving dry weight
• Poor metabolic control (such as hyperphosphatemia,
metabolic acidosis, and/or hyperkalemia)
• Inadequate sodium/water removal to manage
hypertension, hypervolemia, and left ventricular
hypertrophy
National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am
J Kidney Dis. 2015;66(5):884-930.
21. AdvancingDialysis.org
Home Dialysis Utilization
INCREASE IN NUMBER OF HOME DIALYSIS PATIENTS
*USRDS 2017 ADR Reference Table D.1: Percentages & counts of reported ESRD patients: by treatment
modality
28,317 28,955
36,083
46,772
51,057
2,081
4,378
7,049 8,523 8,987
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
US HOME DIALYSIS
PATIENTS
Peritoneal Dialysis Home hemodialysis
HOME DIALYSIS UTILIZATION:
REMAINS <12% OF PATIENTS
22. AdvancingDialysis.org
Addressing Consistent Volume Control
INCREASED TREATMENT TIME AND FREQUENCY
*See references on slides 28-30
Clinical Considerations for Number of
Hemodialysis Treatments per Week:*
3 Tx 3.5 – 4 Tx 5+ Tx
(“Daily”)
5+ Tx
(“Nocturnal”)
• Longer hemodialysis
treatment time (ex.
nocturnal treatments)
has improved mortality
in observational studies1
• Could mitigate the 2-day
killer gap2
• Possibility to decrease
UFR with 2-3 additional
hours of time per
treatment3,4
• Improved BP control &
survival1,4-8
• Reduced LVH &
cardiovascular
hospitalizations4,7,8,10
• Reduced UFR, recovery
time & hypotensive
episodes3-5,10-15
• Improvements in sleep
quality, RLS &
HRQoL5,16-18
• Limits volume loading
between treatments
Benefits from 5+ days per
week plus:
• Improved sleep and
obstructive sleep
apnea14,17
• Best dialytic PO4
control4,20,21
• Increased reduction in
post dialysis recovery
time15
23. AdvancingDialysis.org
Broader context as summarized by Dr. Allan J. Collins:
Trends in the US Dialysis population:
• Rate of growth of the US dialysis has slowed to less than 2% per year
• Progress on reducing death rates has not only slowed, but stagnated from 2014 to 2016
• US hospitalization rates flattened with expanding use of emergency room visits and
observation stays is a new, major concern
• Cardiovascular disease and infection remain the leading causes of hospital visits with little
progress in recent years
• Long weekend, interdialytic interval is a risk for death and hospitalization on the first run of
the week
• How are these populations going to be managed to reduce morbidity, mortality and cost
over the coming decade with shortages of physicians, nurses and inflationary costs?
Dr. Collins has held several leadership roles at the National Kidney Foundation (NKF), serving as
president for two years, and on the NKF scientific advisory board for six years, and with the Kidney
Dialysis Outcomes Quality Initiative. Dr. Collins is the Chief Medical Officer for NxStage Medical, Inc.
24. AdvancingDialysis.org
Critical, unmet needs in current dialysis patient care:
‒ Chronic fluid overload
‒ Aggressive ultrafiltration rates
‒ Recovery time
‒ Cardiovascular-related hospitalizations and death
• Reactive classifications and care pose challenges to adequate interventions to treat heart
disease and cardiovascular complications
• Multiple randomized clinical trials and large observational cohort studies have shown
hemodialysis that 5 or 6 sessions per week can positively address heart disease
• Proactive disease management should be our aim for current and future patients entrusted to
our care
Dr. Collins has held several leadership roles at the National Kidney Foundation (NKF), serving as
president for two years, and on the NKF scientific advisory board for six years, and with the Kidney
Dialysis Outcomes Quality Initiative. Dr. Collins is the Chief Medical Officer for NxStage Medical, Inc.
25. AdvancingDialysis.org
Proactive for either secondary or primary prevention of cardiovascular
disease:
• Transplant candidates
‒ Poor control of CVD and BMD while on waitlist could be alleviated with more frequent treatments
• Pregnant patients
‒ Physiologic volume-loaded state is best treated with more frequent hemodialysis
‒ Long-term health of the mother should be a rationale for more frequent and longer treatments
• Sleep apnea patients
‒ Likely represents a volume loaded state with central edema, hypoxia and pulmonary
hypertension with right heart overload
‒ Could be mitigated with more frequent or nocturnal hemodialysis
• Restless leg syndrome patients
‒ Likely represents persistent uremia toxins nervous system toxicity which is treated with more
frequent hemodialysis
• Hyper oxalosis patients
‒ Best treated with maximum long nocturnal, daily hemodialysis therapy
26. AdvancingDialysis.org
About this presentation
This presentation is one in an ongoing series focused on recent articles, clinical findings or
guidelines related to issues affecting dialysis patients.
AdvancingDialysis.org is dedicated to providing clinicians and patients with better access to
and more awareness of the reported clinical benefits and improved quality of life made
possible with home dialysis, including solo and nocturnal therapy schedules.
For more information, visit AdvancingDialysis.org
AdvancingDialysis.org is a project of NxStage Medical, Inc.
27. AdvancingDialysis.org
Risks and Responsibilities
Not everyone will experience the reported benefits of home and more frequent
hemodialysis. All forms of hemodialysis involve some risks. When vascular access is
exposed to more frequent use, infection of the site, and other access related complications
may also be potential risks.
Certain risks associated with hemodialysis treatment are increased when performing solo
home hemodialysis because no one is present to help the patient respond to health
emergencies.
Certain risks associated with hemodialysis treatment are increased when performing
nocturnal therapy due to the length of treatment time and because the patient and care
partner are sleeping.
28. AdvancingDialysis.org
Clinical Evidence for Benefits Of Increased
Frequency at Home
REFERENCES
1Rivara MB et al. Extended-hours hemodialysis is associated with lower mortality risk in patients with end-stage renal
disease. Kidney Int. 2016 Dec;90(6):1312-1320.
2Foley, R. N., Gilbertson, D. T., Murray, T., Collins, A. J. Long interdialytic interval and mortality among patients receiving
hemodialysis. NEJM. 2011;365(12):1099-1107.
3Raimann, J.G., et al. The Effect of Increased Frequency of Hemodialysis on Volume-Related Outcomes: A Secondary
Analysis of the Frequent Hemodialysis Network Trials. Blood Purif 2016;41:277–286.
4FHN Trial Group, Chertow, G.M., Levin, N.W., Beck, G.J. et al. In-center hemodialysis six times per week versus three times
per week. N Engl J Med. 2010; 363: 2287–2300.
5Morfin, J.A., Fluck, R.J., Weinhandl, E.D., Kansal, S., McCullough, P.A., and Komenda, P. Intensive hemodialysis and
treatment complications and tolerability. Am J Kidney Dis. 2016; 68: S43–S50.
6Bakris, G.L., Burkart, J.M., Weinhandl, E.D., McCullough, P.A., and Kraus, M.A. Intensive hemodialysis, blood pressure, and
antihypertensive medication use. Am J Kidney Dis. 2016; 68: S15–S23.
7Weinhandl ED, Gilbertson DT, Collins AJ. Mortality, Hospitalization, and Technique Failure in Daily Home Hemodialysis and
Matched Peritoneal Dialysis Patients: A Matched Cohort Study. Am J Kidney Dis. 2016;67(1):98-110.
8Weinhandl, E.D., Liu, J., Gilbertson, D.T., Arneson, T.J., Collins, A.J. Survival in daily home hemodialysis and matched thrice-
weekly in-center hemodialysis patients. J Am Soc Nephrol. 2012;23:895–904.
9Chan, C.T., Greene, T., Chertow, G.M. et al. Determinants of left ventricular mass in patients on hemodialysis: Frequent
Hemodialysis Network (FHN) Trials. Circ Cardiovasc Imaging. 2012; 5: 251–261.
29. AdvancingDialysis.org
10McCullough, P.A., Chan, C.T., Weinhandl, E.D., Burkart, J.M., and Bakris, G.L. Intensive hemodialysis, left ventricular
hypertrophy, and cardiovascular disease. Am J Kidney Dis. 2016; 68: S5–S14.
11Weinhandl, Collins, Kraus. Ultrafiltration Rates with More Frequent Home Hemodialysis. Oral Presentation. 2017 ADC.
12Stefánsson, B.V., Brunelli, S.M., Cabrera, C. et al. Intradialytic hypotension and risk of cardiovascular disease. Clin J Am
Soc Nephrol. 2014; 9: 2124–2132.
13Jefferies, H.J., et al. Frequent Hemodialysis Schedules Are Associated with Reduced Levels of Dialysis-induced Cardiac
Injury (Myocardial Stunning). Clin J Am Soc Nephrol. 2011 June; 6(6): 1326–1332.
14Jaber BL, Lee Y, Collins AJ, et al. Effect of daily hemodialysis on depressive symptoms and postdialysis recovery time:
interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements)
Study. Am J Kidney Dis. 2010;56(3):531-539.
15Lindsay RM, Heidenheim PA, Nesrallah G, Garg AX, Suri R, Daily Hemodialysis Study Group London Health Sciences
Centre. Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid,
and sensitive to change. CJASN. 2006;1(5):952-959.
16Jaber BL, et al. Impact of Short Daily Hemodialysis on Restless Legs Symptoms and Sleep Disturbances. CJASN May 2011
vol. 6 no. 5 1049-1056.
17Finkelstien FO, et al. At-home short daily hemodialysis improves the long-term health-related quality of life. Kidney
International (2012) 82, 561–569.
18Kraus, Michael A. et al. Intensive Hemodialysis and Health-Related Quality of Life. Am J of Kidney Dis. 2016;68:S33-S42.
Clinical Evidence for Benefits Of Increased
Frequency at Home
REFERENCES
30. AdvancingDialysis.org
19Hanley, P.J., Pierratos, A. Improvement of sleep apnea in patients with chronic renal failure who undergo nocturnal
hemodialysis. N Engl J Med: 2001; Vol. 344, No. 2.
20Daugirdas JT, Chertow GM, Larive B, et al. Effects of frequent hemodialysis on measures of CKD mineral and bone
disorder. JASN. 2012;23(4):727-738.
21Copland, M. et al. Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use. Am J Kid D: 2016;
Volume 68, Issue 5, Supplement 1, Pages S24–S32.
Clinical Evidence for Benefits Of Increased
Frequency at Home
REFERENCES
Add all dialysis only and transplant only due to opiate deaths
2 panel slide, this data smaller chart
Chronic Fluid Overload: The highest priority to address Unmet Need
Persistent hypertension and fluid overload are in the causal path for LVH and heart failure
Controlling fluid overload requires UFR on dialysis to be tolerable but may be challenging with conventional HD
Hypotension on dialysis limits the use of cardioprotective medicines
UFRs are related to cardiac stunning
UFRs are associated with recovery time
Controlling and reducing the UFR to achieve the desired volume control are challenging with conventional HD
Fluid removal rate is associated with increase mortality risk down to <6ml/kg/hr
Controlling fluid overload requires UFR on dialysis to be tolerable but may be challenging with conventional HD
Hypotension on dialysis limits the use of cardioprotective medicines
Conventional dialysis needs to change to address the unmet need directed at volume control
Risk factor awareness, treatment and control is needed in the dialysis population to address the chronic progressive CVD
Chronic Fluid Overload associated with higher risk of death
Reactive care
Define patient not tolerating therapy:
SOB, DOE, Orthopnea, PND (HF or Fluid Overload)
Hypotension, Cramps, Post treatment prolonged recovery time
Persistent hypertension greater 140/90 for 3-6 months, greater than 2-3 meds
LVH with or without reduced systolic function, LVM >125gm/m2,
NYHA class 2-4 CHF, consistently and persistently elevation NP-Pro BNP, elevated troponins,
Persistently high PO4 (5.5+ mg/dl) for 3-6 months
PD failures with volume overload
Start 2005 +
More Frequent HD limits volume loading between treatments
Reduces the long weekend loading associated with higher morbidity and mortality
UFRs are slower enabling vascular refilling reducing hypotension
MFHD consistently improves blood pressure control and decreases the use of anti-hypertensive medication without increasing complications on dialysis
Intensive BP control on conventional dialysis requires more medications and creates greater intra-dialytic complications