Francesca Tentori

Key Points: Glucagon-like peptide-1 receptor agonist have shown clinical benefits in patients with chronic kidney disease, but there are no randomized trials to support their efficacy in ESKD. This matched retrospective cohort study used electronic health record from a dialysis provider and was conducted in diabetic, incident in-center hemodialysis patients. Results indicated that continued use of glucagon-like peptide-1 receptor agonist is associated with a 9% lower hospitalization and a 17% lower mortality rate. Background: The recent clinical trial FLOW showed that semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1 RA), reduced the risk of clinical outcomes and death from cardiovascular causes in patients with CKD and type 2 diabetes. Given the substantial benefit to patients with CKD, the question remains whether these drugs benefit patients with ESKD. We sought to evaluate the impact of GLP-1 RA use in patients with incident ESKD on clinical outcomes. Methods: Patients included in this matched retrospective cohort study were adult patients with ESKD who initiated thrice-weekly in-center hemodialysis at a kidney care organization between January 2018 and April 2024. Using internal electronic health record data, eligible patients who initiated dialysis on a GLP-1 RA (with evidence of a GLP-1 RA prescription in the first 30 days after dialysis initiation; n =2492) were matched 1:1 to those not on a prescription. Patients were followed from index date until death or the end of the study (July 31, 2024). Incident rate ratios were estimated using a negative binomial distribution with a random intercept to account for the matched nature of the data. Results: Patients with a GLP-1 RA prescription in the first month of dialysis had a mean±SD age of 63±12 years and were predominately male (59%). Compared with other eligible dialysis patients, nearly all patients on a GLP-1 RA had a known diagnosis of diabetes (98% versus 73%), a majority had evidence of predialysis nephrology care (76% versus 67%), were of White race (46% versus 39%), and had a mean±SD body mass index of 33±8 kg/m ² (versus 30±8). After matching and adjustment, GLP-1 RAs were independently associated with lower hospitalization (incidence rate ratios, 0.91 [0.87 to 0.96]) and mortality (Incidence rate ratios, 0.83 [0.73 to 0.95]) rates. Conclusions: Among incident in-center hemodialysis patients, GLP-1 RA use was independently associated with a 9% lower hospitalization rate and a 17% lower mortality rate.

Rationale and Objective: Compared to in-center hemodialysis, home dialysis may better address the needs of some individuals with end-stage kidney disease (ESKD). However, home dialysis utilization is lower in African American and Hispanic individuals with ESKD. We sought to identify the factors that most influence dialysis modality choice, specifically home dialysis, in these individuals and their care partners. Study Design: Qualitative research study using focus groups. Setting and Participants: Fifty-seven participants, including African American and Spanish-speaking Mexican American individuals on dialysis (both in-center and home) and care partners, were recruited to in-person focus groups in five US metropolitan areas. Mexican American focus groups were held in Spanish language and translated in real time by a certified interpreter; recordings for all focus groups were transcribed verbatim for analyses. Analytical Approach: Participant responses were analyzed using inductive thematic analysis techniques. Results: Physician guidance was cited as the most important factor in making the initial modality decision for all groups. African American respondents primarily relied on healthcare professionals for information, but also seek independent validation (e.g., “trust but verify”). Mexican American respondents stated that trust in physician recommendation is largely unquestioned, influenced by factors such as cultural respect for physician authority, limited literacy, and language barriers. African American respondents desire additional education about modalities, particularly when they feel ready to comprehend content (sequenced to recognize how overwhelming it can be at the initial diagnosis of kidney failure). Although most individuals on dialysis and their care partners acknowledged the clinical benefits of home dialysis, significant barriers to choosing a home modality included the fear of being solely responsible for a complex procedure and loss of social interaction and/or support from other individuals on dialysis and center staff. Limitations: As the focus groups were all conducted in metropolitan areas, the transferability of the findings to other settings is uncertain. Conclusions: Improved educational programs on dialysis modality choice should build on the strong preference for physician-led health information to better address educational needs of African American and Mexican American individuals facing the choice of a dialysis modality. Tackling issues pertaining to understanding kidney disease pathogenesis and addressing trust in healthcare professionals is necessary in African American individuals. In Mexican American communities, specific emphasis should be placed on addressing literacy and language barriers. Home dialysis educational material for both groups should also incorporate content regarding concerns about safety and social isolation.

Background Incremental peritoneal dialysis (PD) can be defined as a PD prescription that is less than the standard, full dose prescription and is typically used for patients initiating PD with residual kidney function. It has been suggested that use of incremental peritoneal dialysis may help preserve residual kidney function and may offer better quality of life due to the lower treatment burden, however published evidence is limited. In this study we assessed the associations between incremental peritoneal dialysis use and both clinical outcomes and quality of life measures in a large cohort of incident peritoneal dialysis patients in the US. Methods We considered adult patients initiating peritoneal dialysis between 31 July, 2015 and 31 May, 2019 within a single dialysis organization. Patients with body weight < 40 kg, amputation, or an estimated glomerular filtration rate > 20 mL/min during the first 4 weeks on peritoneal dialysis were excluded. Patients were assigned to exposure groups based on peritoneal dialysis prescription during dialysis weeks 5–8. Incremental peritoneal dialysis was defined by treatment frequency, number of exchanges/day, and exchange volume (for continuous ambulatory peritoneal dialysis patients) or by treatment frequency and presence/absence of last fill (for automated peritoneal dialysis patients). Analyses were performed separately for continuous ambulatory peritoneal dialysis and automated peritoneal dialysis. For each analysis, incremental peritoneal dialysis patients were propensity score matched to eligible full-dose peritoneal dialysis patients. Patients were followed for a maximum of 12 months until censoring for loss to follow-up or study end. Outcomes were compared using Poisson models (mortality, hospitalization, peritoneal dialysis discontinuation), linear mixed models (estimated glomerular filtration rate), and paired t tests (KDQOL domain scores). Results Among continuous ambulatory peritoneal dialysis patients, compared to full-dose peritoneal dialysis, incremental peritoneal dialysis use was associated with better KDQOL scores on 3 domains: physical composite score (42.5 vs 37.7, p = 0.03), burden of kidney disease (60.2 vs 45.6, p = 0.003), effects of kidney disease (79.4 vs 72.3, p = 0.05). Hospitalization and mortality rates were numerically lower (0.77 vs 1.12 admits/pt-year, p = 0.09 and 5.0 vs 10.2 deaths/100 pt-years, p = 0.22), while no associations were found with estimated glomerular filtration rate or peritoneal dialysis discontinuation rate. Use of incremental peritoneal dialysis was not associated with any discernable effects on outcomes in automated peritoneal dialysis patients. Conclusion These results suggest that there may be benefits of using incremental PD in the context of continuous ambulatory peritoneal dialysis, particularly with respect to quality of life as a prescription strategy when initiating peritoneal dialysis. While no significant benefits of incremental peritoneal dialysis were detected among patients initiating automated peritoneal dialysis, no detrimental effects of using incremental schedules were observed for either peritoneal dialysis type. Graphical abstract

Following publication of the original article [1], the authors reported an error in Figs. 3 and S3.

In their correspondence, Hays et al. raise two main critiques of our recently published article entitled “Use of the KDQOL-36™ for assessment of health-related quality of life among dialysis patients in the United States.” First, Hays et al. expressed concerns regarding the comparison of mean scores on five Kidney Disease Quality of Life (KDQOL) subscales, given that the Physical Component Summary (PCS) and Mental Component Summary (MCS) are scored on a different numeric scale compared to the other three subscales. Second, Hays et al. note that the correlations reported in our manuscript between the general health perceptions item (“In general, would you say your health is excellent, very good, good, fair, or poor”) and the 5 KDQOL subscales were inconsistent with findings derived from other KDQOL datasets. Here, we respond to these two critiques.

For some patients with kidney failure, particularly those who have limited life expectancy or severe comorbidities, the “standard” dialysis treatment regimen may be perceived as excessively burdensome and may not align well with the patient's own priorities. For such patients, a palliative approach to the provision of dialysis—whereby treatment is tailored to the needs of the individual so as to optimize quality of life and minimize disease‐related symptoms, but limit treatment burden—might offer a way to better align the delivery of care with the life goals of the patient. Here, we discuss the fundamental principles of palliative dialysis: the patients who might most benefit from this approach, treatment strategies and considerations for implementation, as well as potential barriers to its provision.

The putative benefits of cinacalcet therapy for management of secondary hyperparathyroidism (SHPT) are thought to be most manifested when patients are taking it consistently and as prescribed. Real-world descriptions of cinacalcet prescription discontinuation and reinitiation in European hemodialysis patients are lacking. To address this knowledge gap, we used Dialysis Outcomes and Practice Patterns Study (DOPPS) data, based on dialysis facility medical records, from seven European countries to estimate rates and predictors of cinacalcet prescription discontinuation and reinitiation in hemodialysis patients and to describe the trajectories of CKD-MBD laboratory values after discontinuation. Cox regression analyses were used to predict (1) cinacalcet discontinuation among 613 patients with ≥3 consecutive months without cinacalcet prescription immediately prior to a new cinacalcet prescription and (2) cinacalcet reinitiation among 415 patients with a newly discontinued cinacalcet prescription immediately after ≥3 consecutive months of prescribed use. Cinacalcet was discontinued in 21 and 35% of new users after 6 and 12 months, respectively. Cinacalcet was reinitiated in 38 and 49% of newly-discontinued users after 6 and 12 months, respectively. Predictors of discontinuation included lower parathyroid hormone (PTH) in the previous month (< 150 pg/ml vs. 150–299, HR = 2.57 [95% CI: 1.52–4.33]) and lower serum calcium in the previous month (< 8.4 mg/dl vs. 8.4–10.19, HR = 1.67 [95% CI: 1.08–2.59]). Predictors of reinitiation included higher PTH in the previous month (300–599 pg/ml vs. 150–299, HR = 1.88 [95% CI = 1.19–2.97]; 600+ pg/ml, HR = 3.02 [95% CI = 1.92–4.76]). After cinacalcet discontinuation, mean serum PTH increased from 408 to 510 pg/ml, mean serum calcium briefly rose from 9.12 to 9.22 mg/dl before declining to 9.06 mg/dl, and mean serum phosphorus showed little change. Nephrologist discontinuation of cinacalcet therapy is common in European countries. Additional research is needed to identify optimal cinacalcet treatment strategies for SHPT management, including comparisons of intermittent cinacalcet therapy versus sustained treatment with reduced dose or frequency.

Health-related quality of life (HRQOL) is a key outcome for dialysis patients, and its assessment is mandated by the Centers for Medicaid and Medicare Services. The Kidney Disease Quality of Life (KDQOL-36™) survey is widely used for this assessment. KDQOL-36™ completion rates, and the distributions of scores and item responses, have not been examined in a large, nationally representative cohort of dialysis patients. This retrospective, observational study considered 413,951 survey opportunities contributed by adult patients who received dialysis at a large dialysis organization in the United States during calendar years 2014, 2015, and 2016 and were not Veterans Affairs beneficiaries. During the study period, 240,343 unique patients completed a total of 330,412 surveys (overall completion rate 79.8%). Mean domain scores on the physical component summary (PCS), mental component summary (MCS), burden of kidney disease (BKD), symptoms and problems of kidney disease (SPKD), and effects of kidney disease (EKD) subscales were 36.6, 49.0, 51.3, 78.1, and 73.0, respectively. Scores were similar across dialysis modalities. Patient perceptions of general health were not correlated (R < 0.05) with PCS or SPKD. The SPKD showed ceiling effects: among patients treated with in-center hemodialysis, for all 12 items, < 10% of patients were “extremely bothered,” while > 65% of patients reported being “not at all” or only “somewhat bothered;” for 3 items, > 85% of patients gave these latter two responses. Interdialytic weight gain was not correlated with patient-reported shortness of breath, PCS, or SPKD. Survey completion rates for the KDQOL-36™ were high, and scores were similar across dialysis modalities. Ceiling effects were observed for SPKD. Revision of the KDQOL-36™ to address factors that are most important to contemporary dialysis patients may be warranted.

Patients reaching end-stage renal disease must make a difficult decision regarding renal replacement therapy (RRT) options. Because the choice between dialysis modalities should include patient preferences, it is critical that patients are engaged in the dialysis modality decision. As part of the Empowering Patients on Choices for RRT (EPOCH-RRT) study, we assessed dialysis patients’ perceptions of their dialysis modality decision-making process and the impact of their chosen modality on their lives. A 39-question survey was developed in collaboration with a multi-stakeholder advisory panel to assess perceptions of patients on either peritoneal dialysis (PD) or in-center hemodialysis (HD). The survey was disseminated to participants in the large US cohorts of the Dialysis Outcomes and Practice Patterns Study (DOPPS) and the Peritoneal DOPPS (PDOPPS). Survey responses were compared between PD and in-center HD patients using descriptive statistics, adjusted logistic generalized estimating equation models, and linear mixed regression models. Six hundred fourteen PD and 1346 in-center HD participants responded. Compared with in-center HD participants, PD participants more frequently reported that they were engaged in the decision-making process, were provided enough information, understood differences between dialysis modalities, and felt satisfied with their modality choice. PD participants also reported more frequently than in-center HD participants that partners or spouses (79% vs. 70%), physician assistants (80% vs. 66%), and nursing staff (78% vs. 60%) had at least some involvement in the dialysis modality decision. Over 35% of PD and in-center HD participants did not know another dialysis patient at the time of their modality decision and over 60% did not know the disadvantages of their modality type. Participants using either dialysis modality perceived a moderate to high impact of dialysis on their lives. PD participants were more engaged in the modality decision process compared to in-center HD participants. For both modalities, there is room for improvement in patient education and other support for patients choosing a dialysis modality.