Factors influencing withdrawal from dialysis: a national registry study

Background The immediate and longer-term effects of hemodialysis on cerebral circulation, cerebral structure, and cognitive function are poorly understood.Methods In a prospective observational cohort study of 97 adults (median age 59 years) receiving chronic hemodialysis, we used transcranial Doppler ultrasound to measure cerebral arterial mean flow velocity (MFV) throughout dialysis. Using a well validated neuropsychological protocol, we assessed cognitive function during and off dialysis and after 12 months of treatment. We also used brain magnetic resonance imaging (MRI) to assess atrophy, white matter hyperintensities (WMHs), and diffusion parameters, and tested correlations between MFV, cognitive scores, and changes on MRI.Results MFV declined significantly during dialysis, correlating with ultrafiltrate volumes. Percentage of decline in MFV correlated with intradialytic decline in cognitive function, including global function, executive function, and verbal fluency. At follow-up, 73 patients were available for repeat testing, 34 of whom underwent repeat MRI. In a subgroup of patients followed for 12 months of continued dialysis, percentage of decline in MFV correlated significantly with lower global and executive function and with progression of WMH burden (a marker of small vessel disease). Twelve of 15 patients who received renal transplants during follow-up had both early and follow-up off-dialysis assessments. After transplant, patients' memory (on a delayed recall test) improved significantly; increased fractional anisotropy of white matter (a measure of cerebral diffusion) in these patients correlated with improving executive function.Conclusions Patients undergoing hemodialysis experience transient decline in cerebral blood flow, correlating with intradialytic cognitive dysfunction. Progressive cerebrovascular disease occurred in those continuing dialysis, but not in transplanted patients. Cognitive function and cerebral diffusion improved after transplant.

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“…Morbidity aside, cognitive dysfunction is also associated with all-cause mortality 25,26 and dialysis withdrawal. 28…”

Section: Cognitive Function In Esrd: Incidence and Consequencesmentioning

confidence: 99%

Investigating the Relationship between Cerebral Blood Flow and Cognitive Function in Hemodialysis Patients

Findlay

Dawson

Dickie

et al. 2018

JASN

140

116

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“…The growth in the prevalent dialysis population has been driven mainly by increases in longevity. 1,2 Consequently, appropriate use of conservative care for end-stage renal disease (ESRD), [3][4][5][6] palliative care in nephrology, [7][8][9][10][11][12] and elective withdrawal from dialysis [13][14][15][16][17][18][19] are issues currently engaging the nephrology community.…”

Section: Introductionmentioning

confidence: 99%

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Wetmore

Roetker

Gilbertson

et al. 2019

Hemodialysis International

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Introduction: Whether and how factors associated with elective hemodialysis withdrawal differ from those associated with non‐withdrawal death soon after maintenance hemodialysis initiation have not been well studied. Methods: A retrospective cohort analysis was performed using USRDS data from 2011 to 2014. Patients were randomly categorized 2:1 into training and validation samples. Elective withdrawal deaths were identified using the Death Notification form. Multinomial logistic regression was used to fit a prediction model for three outcome categories (withdrawal, non‐withdrawal death, survival at 6 months) as a function of demographic, comorbidity, and functional status. Findings: The training sample comprised 80,284 hemodialysis patients. Mean age was 71.7 ± 11.4 years, 44.9% were female, 72.9% were white, and 22.8% were black. Within 6 months, 19.1% died, of whom 2099 (2.6%) withdrew and 13,223 (16.5%) died of a non‐withdrawal cause; 13.7% of all deaths were withdrawals. Baseline characteristics and event rates were similar among the 40,142 patients in the validation sample. The model was calibrated adequately and could discriminate moderately well between withdrawal and survival (area under ROC curve [AUC]: 0.77) and between non‐withdrawal death and survival (AUC: 0.73). However, discrimination between withdrawal and non‐withdrawal death was relatively low (AUC: 0.62). Older age and white, compared with non‐white, race were each associated with greater odds of death, and these associations were stronger for withdrawal than for non‐withdrawal death. Discussion: Advanced age and white, as opposed to black, race were most strongly associated with early elective hemodialysis withdrawal compared with non‐withdrawal death. However, it is difficult to differentiate between patients who will experience early withdrawal vs. non‐withdrawal death, as many factors are similarly associated with both outcomes.

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“…UAE recently expand its national dialysis service to meet the demand of increasing prevalence of chronic kidney diseases (CKDs). However, many patients with ESKD suffer from multiple comorbidities and have high symptom burdens [3–5]. The nephrologists would more often experience decisions of end-of-life renal care with or without dialysis treatment [6–8].…”

Section: Introductionmentioning

confidence: 99%

Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians

Alshamsi

Chaaban

Alrukhaimi

et al. 2018

Libyan Journal of Medicine

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Patients with end stage kidney disease (ESKD) with severely impaired cognitive function have no survival benefit from dialysis. We therefore undertook a survey to explore the renal physicians’ practices of withholding and withdrawal of dialysis treatment in vegetative state patients in the United Arab Emirates (UAE). A cross sectional survey of 29 nephrology practices in UAE exploring physicians’ practices in making decisions of withholding and withdrawal of dialysis treatment during provision end-of-life care for patients in persistent vegetative state (PVS).The majority of participants practice in governmental non-for-profit dialysis units (79%), and think they are well prepared to make decision with patients and family on issues of dialysis withdrawal and withholding (69%). If a chronic dialysis patient became permanently unconscious only few respondents (17%) indicated probability of stopping dialysis. On the other hand, more respondents (48%) reported that dialysis is likely to be withheld in PVS patients who develop kidney failure. In high risk or poor prognosis ESKD patients and given how likely they would consider each option independently, respondents reported they are likely to consider time-limited dialysis in 78% of the time followed by stopping (46%) or forgoing (27%) dialysis. Majority of the participants perceived that their decisions in providing renal care for PVS patients in UAE were influenced by the family sociocultural beliefs (76% of participants), the current hospital policies (72% of participants), and by Islamic beliefs (66% of participants). Only few perceived access to palliative care (30%) and treatment cost (17%) to have an impact on their decision making.Decisions of initiation and continuation of dialysis treatment to ESKD patients in PVS are prevalent among nephrology practices in UAE. Development of local guidelines based on the societal values along with early integration of palliative kidney failure management care would be required to improve the quality of provision of end-of-life renal care in UAE.Abbreviations: ESKD: stage kidney disease; UAE: United Arab Emirates; PVS: persistent vegetative state; RPA: Renal Physicians Association; ASN: American Society of Nephrology; EMAN: Emirates Medical Association Nephrology Society; CPR: cardiopulmonary resuscitation.

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Factors influencing withdrawal from dialysis: a national registry study

Cited by 45 publications

References 21 publications

Investigating the Relationship between Cerebral Blood Flow and Cognitive Function in Hemodialysis Patients

Investigating the Relationship between Cerebral Blood Flow and Cognitive Function in Hemodialysis Patients

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians

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