Several comparisons of peritoneal dialysis (PD) and hemodialysis (HD) in incident patients with ESRD demonstrate superior survival in PD-treated patients within the first 1 to 2 years. These survival differences may be due to higher HD-related mortality as a result of high rates of incident central venous catheter (CVC) use or due to an initial survival advantage conferred by PD. We compared the survival of incident PD patients with those who initiated HD with a CVC (HD-CVC) or with a functional arteriovenous fistula or arteriovenous graft (HD-AVF/AVG). We used multivariable piece-wise exponential nonproportional and proportional hazards models to evaluate early (1 year) mortality as well as overall mortality during the period of observation using an intention-to-treat approach. We identified 40,526 incident adult dialysis patients from the Canadian Organ Replacement Register (2001Register ( to 2008. Compared with the 7412 PD patients, 1-year mortality was similar for the 6663 HD-AVF/AVG patients but was 80% higher for the 24,437 HD-CVC patients (adjusted HR, 1.8; 95% confidence intervals [CI], 1.6 to 1.9). During the entire period of follow-up, HD-AVF/AVG patients had a lower risk for death, and HD-CVC patients had a higher risk for death compared with patients on PD. In conclusion, the use of CVCs in incident HD patients largely accounts for the early survival benefit seen with PD.

No abstract

Dialysis patients are increasingly older and more disabled. In community-dwelling seniors without kidney disease, falls commonly predict hospitalization, the onset of frailty, and the need for institutional care. Effective fall prevention strategies are available. On the basis of retrospective data, it was hypothesized that the fall rates of older (>65 yr) chronic outpatient hemodialysis (HD) patients would be higher than published rates for community-dwelling seniors (0.6 to 0.8 falls/patientyear). It also was hypothesized that risk factors for falls in dialysis outpatients would include polypharmacy, dialysis-related hypotension, cognitive impairment, and decreased functional status. Using a prospective cohort study design, HD patients who were >65 yr of age at a large academic dialysis unit were recruited. All study participants underwent baseline screening for fall risk factors. Patients were followed prospectively for a minimum of 1 yr. Falls were identified through biweekly patient interviews in the HD unit. A total of 162 patients (mean age 74.7 yr) were recruited; 57% were male. A total of 305 falls occurred in 76 (47%) patients over 190.5 person-years of follow-up (fall-incidence 1.60 falls/person-year). Injuries occurred in 19% of falls; 41 patients had multiple falls. Associated risk factors included age, comorbidity, mean predialysis systolic BP, and a history of falls. In the HD population, the fall risk is higher than in the general community, and fall-related morbidity is high. Better identification of HD patients who are at risk for falls and targeted fall intervention strategies are required.

As the dialysis population ages, their limitations in performing daily activities affect the well-being of the patients as well as increase the burden on caregivers and the use of health services. In this cross-sectional study, we measured the proportion of patients 65 years and older undergoing chronic outpatient hemodialysis who needed help with day-to-day activities and identified the clinical characteristics of this population at most risk. Their dependence in performance of basic self-care tasks and instrumental activities such as driving were measured by the Barthel and Lawton Scales. Associations between disability in four basic activities to age, gender, education, multiple prescription drug needs, diabetes, cognition, depressive symptoms, and physical performance were examined using logistic regression. Of the 162 mostly male participants averaging 75 years old, eight had no disability, 69 had only instrumental dependence, and 85 had combined disability. Multiple prescription drug needs, poor timing in 'up-and-go' mobility performance, and education level were associated with basic dependency. Our study shows that the disability in self-care is common among older patients on hemodialysis. Strategies are needed to routinely identify those older dialysis patients at risk of functional impairment and to limit their disabilities.

Age should not be a limiting factor when determining candidacy for AVF creation due to equivalent survival and procedural rates. Failure of fistula maturation is a primary concern to patients of all ages and demands further study.

No abstract

Background and objectives Patient self-management has been shown to improve health outcomes. We developed a smartphone-based system to boost self-care by patients with CKD and integrated its use into usual CKD care. We determined its acceptability and examined changes in several clinical parameters.Design, setting, participants, & measurements We recruited patients with stage 4 or 5 CKD attending outpatient renal clinics who responded to a general information newsletter about this 6-month proof-of-principle study. The smartphone application targeted four behavioral elements: monitoring BP, medication management, symptom assessment, and tracking laboratory results. Prebuilt customizable algorithms provided real-time personalized patient feedback and alerts to providers when predefined treatment thresholds were crossed or critical changes occurred. Those who died or started RRT within the first 2 months were replaced. Only participants followed for 6 months after recruitment were included in assessing changes in clinical measures. ResultsIn total, 47 patients (26 men; mean age =59 years old; 33% were $65 years old) were enrolled; 60% had never used a smartphone. User adherence was high (.80% performed $80% of recommended assessments) and sustained. The mean reductions in home BP readings between baseline and exit were statistically significant (systolic BP, 23.4 mmHg; 95% confidence interval, 25.0 to 21.8 and diastolic BP, 22.1 mmHg; 95% confidence interval, 22.9 to 21.2); 27% with normal clinic BP readings had newly identified masked hypertension. One hundred twenty-seven medication discrepancies were identified; 59% were medication errors that required an intervention to prevent harm. In exit interviews, patients indicated feeling more confident and in control of their condition; clinicians perceived patients to be better informed and more engaged.Conclusions Integrating a smartphone-based self-management system into usual care of patients with advanced CKD proved feasible and acceptable, and it appeared to be clinically useful. The results provide a strong rationale for a randomized, controlled trial.

Background Patients on chronic dialysis have among the highest mortality and hospitalization rates. In the non-renal literature, functional dependence is recognized as a contributor to subsequent disability, recurrent hospitalization, and increased mortality. A higher burden of functional dependence with progressive worsening of renal function has been observed in several studies, suggesting functional dependence may contribute to both morbidity and mortality in dialysis patients. Study Design Prospective cohort study Setting & Participants 7,226 hemodialysis patients from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 4 (2009–2011) with self-reported data on functional status (FS). Predictor Patients’ ability to perform 13 basic and instrumental Activities of Daily Living (ADL) was summarized to create an overall FS score ranging from 1.25 (most dependent) to 13 (functionally independent). Outcome Cox regression was used to estimate the association between FS and all-cause mortality, adjusting for several demographic and clinical risk factors for mortality. Median follow-up was 17.2 months. Results The proportion of patients who could perform each ADL task without assistance ranged from 97% (eating) to 47% (doing housework). 36% of patients could perform all 13 tasks without assistance (FS=13), and 14% of patients had high functional dependence (FS < 8). Functionally independent patients were younger and had many indicators of better health status including higher quality of life. Compared with functionally independent patients, the adjusted hazard ratio for mortality was 2.37 (95% confidence interval =1.92–2.94) for patients with FS < 8. Limitations Possible non-response bias and residual confounding Conclusions We found a high burden of functional dependence across all age groups and across all DOPPS countries. When adjusting for several known mortality risk factors, including age, access type, cachexia and multi-morbidity, functional dependence was a strong, consistent predictor of mortality.