Matthew J. Oliver

Background: Fistulas are the preferred form of vascular access and historically, have been recommended by guidelines because they were associated with improved clinical outcomes and costs. However, there has never been a randomized comparison of catheters to fistulas and the evidence on which recommendations were based is observational with potential for bias. Methods: A pilot randomized controlled trial was conducted in 12 hemodialysis centers in Canada and Australia. Individuals aged 55 years and older who started hemodialysis using a tunneled or non-tunneled central venous catheter for vascular access were randomized to an attempt at fistula creation or continued use of a tunneled, central venous hemodialysis catheter. The primary outcome was feasibility, as measured by the proportion of eligible patients who consented to randomization and the proportion of patients randomized to the fistula group who underwent fistula placement within 90 days. Secondary outcomes included invasive access-related procedures, hospitalizations, access-related infections, tissue plasminogen activator usage, and death. Results: A total of 1287 patients were screened and 67 patients underwent randomization. A total of 25% of eligible patients agreed to randomization and 71% randomized to the fistula arm underwent fistula placement within 90 days. The most common reason patients declined to participate in the trial was that they preferred to continue to dialyze with their catheter. Patients randomized to fistulas had nominally more access-related interventions, hospitalizations, and bacteremia (the majority of which were catheter-related), while the catheter group experienced greater reliance on thrombolytic therapy. Conclusions: Findings from this trial suggest that conducting a definitive randomized trial of fistulas versus catheters is not feasible in the current climate. There was no signal of harm associated with randomization to the catheter strategy and most outcomes favored the catheter group. Patients exhibited strong preferences regarding choice of vascular access.

Home-based peritoneal dialysis (PD) is less resource-intensive than in-center hemodialysis. When provided with a choice, many patients prefer home-based therapies. The Starting Dialysis on Time, At Home on the Right Therapy (START) project was a quality improvement initiative aiming to increase PD use in Alberta, Canada. The START project provided site-specific audit and feedback reports on the processes of care for PD and increased the use of PD. In this current study, we conducted a retrospective cost analysis of the START project. We used the perspective of a publicly funded healthcare system to compare the costs before and after the START intervention. We used a decision analytic model stratifying the patient cohort by age (under and over 65 years) and estimated the impact of the START intervention on the overall cost of care at 1, 3, 5, and 10 years. Sensitivity analyses were performed. We found cost savings of $CAD 1.2 million, $CAD 1.9 million, $CAD 2.4 million, and $CAD 2.7 million for the START intervention at 1, 3, 5, and 10 years, respectively. Results were robust to a variety of sensitivity and scenario analyses. Even modest increases in PD utilization led to cost savings. We found that the implementation of a quality improvement initiative to increase PD resulted in substantial cost savings over time.

Key Points: Approximately half of people on maintenance hemodialysis exhibited impairment on a standardized, performance-based assessment of functional cognition. The functional cognitive test correlated strongly with a traditional cognitive screening tool but weakly with self-report functional assessments. Older age and ethnic minority were significant predictors of functional cognitive impairment. Background: People on maintenance hemodialysis are often unable to perform everyday activities without assistance. The extent to which their functional limitations are related to cognitive impairment is unclear. Our primary aim was to estimate the proportion of people on maintenance hemodialysis who demonstrate impairment on a standardized, performance-based test of functional cognition. Methods: We conducted a quantitative descriptive, cross-sectional study across two dialysis centers in Toronto, Canada. We administered a functional cognitive assessment (University of California San Diego Performance-Based Skills Assessment-Brief [UPSA-B]), a cognitive screening tool (Montreal Cognitive Assessment [MoCA]), and two self-report measures of everyday functioning (Barthel Index and Lawton-Brody Instrumental Activities of Daily Living [IADL] scale) during the first hour of a hemodialysis session. We calculated the proportion of participants with UPSA-B scores indicating functional cognitive impairment (r =0.67, P < 0.001) and weak correlations between the UPSA-B and the Barthel Index ( r =0.38, P < 0.001) and Lawton-Brody IADL scale ( r =0.39, P < 0.001). Older age (odds ratio, 1.13; 95% CI, 1.07 to 1.20) and ethnicity (odds ratio, 17.8; 95% CI, 4.71 to 67.50) were significant predictors of impairment on the UPSA-B in multivariable modeling. Conclusions: Functional cognitive impairment appears to be common in people on hemodialysis. Future research should investigate approaches such as cognitive rehabilitation to support everyday functioning in this population.

Key Points: In maintenance dialysis patients, 90-day coronavirus disease 2019 (COVID-19) survivors did not have a higher long-term risk of death or adverse health outcomes. Prior COVID-19 infection was associated with a lower risk for subsequent COVID-19 infection. Background: There is concern regarding the long-term impact of coronavirus disease 2019 (COVID-19) on the maintenance dialysis population. This study describes the long-term morbidity and mortality of COVID-19 among patients receiving maintenance dialysis in comparison with uninfected controls. Methods: We conducted a population-based cohort study of patients receiving maintenance dialysis in Ontario, Canada, between March 14, 2020, and December 1, 2021 (pre-Omicron), with follow-up until March 31, 2023. We accounted for confounding using propensity scores to match each patient with COVID-19 to four uninfected controls. The primary outcome was all-cause mortality, whereas secondary outcomes included subsequent COVID-19 infection, COVID-19–associated death, a composite of cardiovascular (CV)-related death or hospitalization, all-cause hospitalization, and admission to long-term care or complex continuing care. Results: Our matched cohort included 3340 maintenance dialysis patients: 668 with COVID-19 and 2672 controls. Over a median of 1.8 years of follow-up, the rate of long-term all-cause mortality for 90-day COVID-19 survivors was 11.9 deaths per 100 person-years which did not differ from 13.9 deaths per 100 person-years in those without COVID-19 infection (hazard ratio [HR] 0.86; 95% confidence interval [CI], 0.72 to 1.03). Similarly, no significant difference was observed on a composite outcome of CV death or hospitalization, all-cause hospitalization, long-term care, or complex continuing care placement. Prior COVID-19 infection was associated with a reduced risk of subsequent COVID-19 infection (HR, 0.75; 95% CI, 0.63 to 0.88). Subsequent COVID-19 infection was associated with a higher rate of death (HR, 1.68; 95% CI, 1.42 to 1.98). Conclusions: Individuals receiving maintenance dialysis who survived their initial COVID-19 infection did not have an increased long-term risk of death, all-cause hospitalization, or CV disease compared with those without COVID-19. Subsequent COVID-19 infection during follow-up, however, was associated with increased mortality.

Background: Peritoneal dialysis (PD) is being promoted because it is cost-effective and has equivalent outcomes to facility-based hemodialysis (HD). Determining PD eligibility is critical but subjective, with high variability among renal programs. This study aimed to establish a predictive model for PD eligibility among individuals who started treatment with HD. A secondary objective was to identify predictors of PD eligibility and determine if eligible patients went on to receive PD. Methods: This retrospective cohort study included individuals starting HD at multiple hospitals in Alberta, Canada, as part of the START program between 1 October 2016 and 31 March 2018. Twenty-seven predictors, including patient characteristics, laboratory values, and comorbidities, were considered in logistic regression modeling. The outcome variable was PD eligibility, as determined by a standardized interdisciplinary assessment. The model selection was based on the Akaike information criterion. The confusion matrix was used for each model to compare the predicted versus observed eligibility. The final model was calibrated and presented. Results: Among the 598 participants, 391 (65.4%) were considered eligible for PD. The logistic regression model achieved a modest performance in discriminating patients who were eligible for PD, with a high sensitivity of 91.3%, an accuracy of 0.68 (95% CI, 0.65–0.72), and an area under the receiver operating characteristic curve ranging from 0.69 to 0.71. Age (OR = 0.98; 95% CI, 0.97–0.99), body mass index (OR = 0.95; 95% CI, 0.93–0.97), starting dialysis in intensive care unit (OR = 0.53; 95% CI, 0.31–0.92), and polycystic kidney disease (OR = 0.37; 95% CI, 0.13–0.99) were statistically significant factors associated with a lower likelihood of being considered eligible for PD. Out of the 391 eligible PD patients, 87 (22.3%) received PD treatment within 6 months of starting HD. Conclusions: The majority of patients starting HD were considered eligible for PD. Our model exhibits a high level of sensitivity and could serve as a valuable tool for screening potential candidates following the commencement of HD.

Key Points: Is performing a large definitive trial to establish the optimal anticoagulation strategy in dialysis recipients with atrial fibrillation feasible? One hundred fifty-one patients at 28 dialysis centers were enrolled and randomized to apixaban ( n =51), warfarin ( n =52), or no oral anticoagulation ( n =48). Despite coronavirus disease–related pauses, recruitment was completed in 30 months, with 83% of participants completing follow-up in their assigned treatment arm. Background: Atrial fibrillation is common in individuals receiving dialysis. The role of oral anticoagulation in this population is uncertain given its exclusion from previous seminal clinical trials. Our objective was to determine the feasibility of performing a large definitive trial to establish the optimal anticoagulation strategy in individuals with atrial fibrillation receiving dialysis. Methods: The Strategies for the Management of Atrial Fibrillation in Patients Receiving Dialysis trial was a parallel-group, open-label, allocation-concealed, pilot randomized control trial that took place at 28 centers in Canada and Australia. The trial included adults (18 years or older) undergoing dialysis with a history of nonvalvular atrial fibrillation who met the CHADS-65 criteria. Participants were randomized 1:1:1 to receive dose-adjusted warfarin, apixaban 5 mg twice daily, or no oral anticoagulation and followed for 26 weeks. The primary outcomes evaluated the following measures of feasibility: ( 1 ) recruitment of the target population within 2 years from the start of the trial and ( 2 ) adherence of >80% of randomized patients to the allocated treatment strategy at the conclusion of follow-up. Secondary outcomes included stroke and bleeding. Results: From December 2019 to June 2022, 151 patients were enrolled and randomized to apixaban ( n =51), warfarin ( n =52), or no oral anticoagulation ( n =48). Allowing for pauses related to the coronavirus disease pandemic, recruitment was completed in 30 months, and 123 (83%) of participants completed follow-up in their allocated treatment arm. There was one adjudicated stroke event. Eight participants had a major bleeding event (four warfarin, two apixaban, two no oral anticoagulation). Death occurred in 15 participants (nine warfarin, two apixaban, four no oral anticoagulation). Time in the therapeutic range for warfarin recipients was 58% (interquartile range, 47%–70%). Conclusions: We have demonstrated the feasibility of recruitment and adherence in a trial that compared different anticoagulation strategies in patients with atrial fibrillation receiving dialysis. Clinical Trial registry name and registration number: Strategies for the Management of Atrial Fibrillation in Patients Receiving Dialysis (SAFE-D), NCT03987711. Podcast: This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2025_04_09_ASN0000000000000495.mp3