Kirsten Johansen - Academia.edu (original) (raw)
Papers by Kirsten Johansen
Journal of the American Society of Nephrology Jasn, Aug 1, 2006
Patients who are on hemodialysis commonly experience muscle wasting and weakness, which have a ne... more Patients who are on hemodialysis commonly experience muscle wasting and weakness, which have a negative effect on physical functioning and quality of life. The objective of this study was to determine whether anabolic steroid administration and resistance exercise training induce anabolic effects among patients who receive maintenance hemodialysis. A randomized 2 ؋ 2 factorial trial of anabolic steroid administration and resistance exercise training was conducted in 79 patients who were receiving maintenance hemodialysis at University of California, San Francisco-affiliated dialysis units. Interventions included double-blinded weekly nandrolone decanoate (100 mg for women; 200 mg for men) or placebo injections and lower extremity resistance exercise training for 12 wk during hemodialysis sessions three times per week using ankle weights. Primary outcomes included change in lean body mass (LBM) measured by dual-energy x-ray absorptiometry, quadriceps muscle cross-sectional area measured by magnetic resonance imaging, and knee extensor muscle strength. Secondary outcomes included changes in physical performance, self-reported physical functioning, and physical activity. Sixty-eight patients completed the study. Patients who received nandrolone decanoate increased their LBM by 3.1 ؎ 2.2 kg (P < 0.0001). Exercise did not result in a significant increase in LBM. Quadriceps muscle cross-sectional area increased in patients who were assigned to exercise (P ؍ 0.01) and to nandrolone (P < 0.0001) in an additive manner. Patients who exercised increased their strength in a training-specific fashion, and exercise was associated with an improvement in self-reported physical functioning (P ؍ 0.04 compared with nonexercising groups). Nandrolone decanoate and resistance exercise produced anabolic effects among patients who were on hemodialysis. Further studies are needed to determine whether these interventions improve survival.
Clinical journal of the American Society of Nephrology : CJASN, Jan 13, 2015
Infection-related hospitalizations have increased dramatically over the last 10 years in patients... more Infection-related hospitalizations have increased dramatically over the last 10 years in patients receiving in-center hemodialysis. Patient and dialysis facility characteristics associated with the rate of infection-related hospitalization were examined, with consideration of the region of care, rural-urban residence, and socioeconomic status. The US Renal Data System linked to the American Community Survey and Rural-Urban Commuting Area codes was used to examine factors associated with hospitalization for infection among Medicare beneficiaries starting in-center hemodialysis between 2005 and 2008. A Poisson mixed effects model was used to examine the associations among patient and dialysis facility characteristics and the rate of infection-related hospitalization. Among 135,545 Medicare beneficiaries, 38,475 (28%) had at least one infection-related hospitalization. The overall rate of infection-related hospitalization was 40.2 per 100 person-years. Age ≥85 years old, cancer, chroni...
Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation, Jan 27, 2015
To test the performance of appetite assessment tools among patients receiving hemodialysis (HD). ... more To test the performance of appetite assessment tools among patients receiving hemodialysis (HD). Cross-sectional. Two hundred twenty-one patients receiving HD enrolled in seven dialysis facilities in Northern California. We assessed 5 appetite assessment tools (self-assessment of appetite, subjective assessment of appetite, visual analog scale [VAS], Functional Assessment of Anorexia/Cachexia Therapy [FAACT] score, and the Anorexia Questionnaire [AQ]). Reported food intake, normalized protein catabolic rate, and change in body weight were used as criterion measures, and we assessed associations among the appetite tools and biomarkers associated with nutrition and inflammation. Patients were asked to report their appetite and the percentage of food eaten (from 0% to 100%) during the last meal compared to usual intake. Fifty-eight (26%) patients reported food intake ≤ 50% (defined as poor appetite). The prevalence of anorexia was 12% by self-assessment of appetite, 6% by subjective as...
Clinical journal of the American Society of Nephrology : CJASN, Jan 28, 2015
Anemia guidelines for CKD recommend withholding intravenous iron in the setting of active infecti... more Anemia guidelines for CKD recommend withholding intravenous iron in the setting of active infection, although no data specifically support this recommendation. This study aimed to examine the association between intravenous iron and clinical outcomes among hemodialysis patients hospitalized for infection. This was a retrospective observational cohort study using data from the US Renal Data System of 22,820 adult Medicare beneficiaries on in-center hemodialysis who had received intravenous iron in the 14 days preceding their first hospitalization for bacterial infection in 2010. In multivariable analyses, the association between receipt of intravenous iron at any point from the day of hospital admission to discharge and all-cause 30-day mortality, mortality in 2010, length of hospital stay, and readmission for infection or death within 30 days of discharge was evaluated. There were 2463 patients (10.8%) who received intravenous iron at any point from the day of admission to discharge...
Journal of the American Society of Nephrology : JASN, Jan 8, 2015
Obesity is associated with less access to transplantation among adults with ESRD. To examine the ... more Obesity is associated with less access to transplantation among adults with ESRD. To examine the association between body mass index at ESRD onset and survival and transplantation in children, we performed a retrospective analysis of children ages 2-19 years old beginning RRT from 1995 to 2011 using the US Renal Data System. Among 13,172 children, prevalence of obesity increased from 14% to 18%, whereas prevalence of underweight decreased from 12% to 9% during this period. Over a median follow-up of 7.0 years, 10,004 children had at least one kidney transplant, and 1675 deaths occurred. Risk of death was higher in obese (hazard ratio [HR], 1.17; 95% confidence interval [95% CI], 1.03 to 1.32) and underweight (HR, 1.26; 95% CI, 1.09 to 1.47) children than children with normal body mass indices. Obese and underweight children were less likely to receive a kidney transplant (HR, 0.92; 95% CI, 0.87 to 0.97; HR, 0.83; 95% CI, 0.78 to 0.89, respectively). Obese children had lower odds of ...
American Journal of Nephrology, 2015
Patients on chronic hemodialysis have a high prevalence of heart disease and poor self-reported p... more Patients on chronic hemodialysis have a high prevalence of heart disease and poor self-reported physical function. The association between structural heart disease and self-reported physical function in patients on hemodialysis is unknown. We studied the association between elevated pulmonary artery systolic pressure (PASP) and self-reported physical function in ESRD in 253 patients in the USRDS ACTIVE/ADIPOSE study between 2009 and 2011. We used multivariate linear regression with PASP obtained from clinical echocardiogram reports as the primary predictor and the Physical Function (PF) subscale of the SF-36 as the primary outcome. To determine whether associations between PASP and PF were driven by fluid overload or left ventricular hypertrophy, we assessed whether PASP was associated with bioimpedance spectroscopy (BIS)-derived extracellular water (ECW) and with left ventricular posterior wall thickness. In a multivariable model, each 10 mm Hg higher PASP was associated with a 3.32-point lower PF score (95% CI -5.95, -0.68). In a multivariable model that included BIS estimates, both left ventricular posterior wall thickness (LVPW, per 5 mm) and ECW were associated with a higher PASP (LVPW 4.21 mm Hg, 95% 0.38-8.04; ECW 1.12 mm Hg per liter, 95% CI 0.07-2.18). Higher LVPW and ECW were independently associated with a lower PF score. Left ventricular hypertrophy and elevated pulmonary pressure are associated with worse self-reported physical function in patients on hemodialysis. The role of chronic volume overload on PASP and PF score should be evaluated in a prospective manner. © 2015 S. Karger AG, Basel.
Current Opinion in Nephrology and Hypertension, 2015
To summarize the latest information on body composition among patients with chronic kidney diseas... more To summarize the latest information on body composition among patients with chronic kidney disease and its association with outcomes. Obesity is increasing among patients with end-stage renal disease and is more prevalent when direct measures of adiposity are used rather than BMI. High BMI is not associated with better survival among patients with earlier chronic kidney disease or after kidney transplantation, suggesting that excess fat is most protective among the sickest patients. Despite the positive association between BMI and survival among patients with end-stage renal disease, visceral fat is associated with coronary artery calcification and adverse cardiovascular events. Muscle wasting is prominent among patients with chronic kidney disease, sometimes even in the setting of obesity. Obesity and muscle wasting are associated with worse physical functioning. Indicators of low muscle size and strength are associated with higher mortality. Some interventions can affect body composition, but whether they affect survival has not been determined. Recent studies show that a high BMI is not protective for all patients with chronic kidney disease and is associated with poor physical functioning and frailty. Visceral adiposity is associated with adverse cardiovascular outcomes. Sarcopenia is common among patients with end-stage renal disease and is associated with worse physical performance and higher mortality.
BMC nephrology, 2015
Multiple factors influence timing of dialysis initiation. The impact of supply of nephrology work... more Multiple factors influence timing of dialysis initiation. The impact of supply of nephrology workforce on timing and incidence of dialysis initiation is not well known. We determined the number of pediatric and adult nephrologists in each state using data from the American Medical Association and American Boards of Internal Medicine and Pediatrics. We ascertained state population data from the 2010 US Census. United States Renal Data System (USRDS) data were used to determine estimated glomerular filtration rate (eGFR) at dialysis initiation and dialysis incidence for adults (≥18 years) in 2008 and children (<18 years) in 2007-2009 by state. Across all states, there were a median of 3.0 (IQR 2.3 to 3.4) adult nephrologists per 100,000 adults and 0.5 (IQR 0.2 to 0.9) pediatric nephrologists per 100,000 children. The median eGFR at start of dialysis was 9.8 mL/min/1.73 m2 (IQR 7.1-13.1) in adults and 8.5 mL/min/1.73 m2 (IQR 6.2-11.4) in children. Neither the number of adult (Spearm...
Journal of Renal Nutrition, 2015
Trimethylamine N-oxide (TMAO) is a product of metabolism of phosphatidylcholine (lecithin) and ca... more Trimethylamine N-oxide (TMAO) is a product of metabolism of phosphatidylcholine (lecithin) and carnitine by the intestinal microbiome. Elevated serum concentrations of TMAO have been linked to adverse cardiovascular outcomes in the general population. We examined correlates of serum TMAO and the relations among serum TMAO concentrations, all-cause mortality, and cardiovascular mortality and hospitalizations in a nationally derived cohort of patients new to hemodialysis (HD). We quantified serum TMAO by liquid chromatography and online tandem mass spectrometry and assessed nutritional and cardiovascular risk factors in 235 patients receiving HD and measured TMAO in pooled serum from healthy controls. We analyzed time to death and time to cardiovascular death or hospitalization using Cox proportional hazards regression. Serum TMAO concentrations of patients undergoing HD (median, 43 μM/L; 25th-75th percentile, 28-67 μM/L) were elevated compared with those with normal or near-normal kidney function (1.41 ± 0.49 μM/L). TMAO was directly correlated with serum albumin (Spearman rank correlation, 0.24; 95% CI, 0.12-0.35; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001), prealbumin (Spearman rank correlation, 0.19; 95% CI, 0.07-0.31; P = .003), and creatinine (Spearman rank correlation, 0.21; 95% CI, 0.08-0.33; P = .002) and inversely correlated with log C-reactive protein (Spearman rank correlation, -0.18; 95% CI, -0.30 to -0.06; P = .005). Higher serum concentrations of TMAO were not significantly associated with time to death (Spearman rank correlation, 0.84; CI, 0.65-1.09; P = .19) or time to cardiovascular hospitalization or cardiovascular death (Spearman rank correlation, 0.88; CI, 0.57-1.35; P = .55). Serum TMAO concentrations were markedly elevated and correlated directly with biochemical markers of nutritional status and inversely with markers of inflammation in patients receiving HD. There was no significant association between serum TMAO concentrations and all-cause mortality, cardiovascular death, or hospitalizations. In patients receiving dialysis-in contrast with the general population-adverse vascular effects of TMAO may be counterbalanced by associations with nutritional or inflammatory status.
BMC nephrology, 2014
New information from various clinical settings suggests that tight blood pressure control may not... more New information from various clinical settings suggests that tight blood pressure control may not reduce mortality and may be associated with more side effects. We performed cross-sectional multivariable ordered logistic regression to examine the association between predialysis blood pressure and the short physical performance battery (SPPB) in a cohort of 749 prevalent hemodialysis patients in the San Francisco and Atlanta areas recruited from July 2009 to August 2011 to study the relationship between systolic blood pressure and objective measures of physical function. Mean blood pressure for three hemodialysis sessions was analyzed in the following categories: <110 mmHg, 110-129 mmHg (reference), 130-159 mmHg, and ≥160 mmHg. SPPB includes three components: timed repeated chair stands, timed 15-ft walk, and balance tests. SPPB was categorized into ordinal groups (≤6, 7-9, 10-12) based on prior literature. Patients with blood pressure 130-159 mmHg had lower odds (OR 0.57, 95% CI ...
Kidney International, 2014
Background: New information from various clinical settings suggests that tight blood pressure con... more Background: New information from various clinical settings suggests that tight blood pressure control may not reduce mortality and may be associated with more side effects. Methods: We performed cross-sectional multivariable ordered logistic regression to examine the association between predialysis blood pressure and the short physical performance battery (SPPB) in a cohort of 749 prevalent hemodialysis patients in the San Francisco and Atlanta areas recruited from July 2009 to August 2011 to study the relationship between systolic blood pressure and objective measures of physical function. Mean blood pressure for three hemodialysis sessions was analyzed in the following categories: <110 mmHg, 110-129 mmHg (reference), 130-159 mmHg, and ≥160 mmHg. SPPB includes three components: timed repeated chair stands, timed 15-ft walk, and balance tests. SPPB was categorized into ordinal groups (≤6, 7-9, 10-12) based on prior literature. Results: Patients with blood pressure 130-159 mmHg had lower odds (OR 0.57, 95% CI 0.35-0.93) of scoring in a lower SPPB category than those whose blood pressure was between 110 and 129 mmHg, while those with blood pressure ≥160 mmHg had 0.56 times odds (95% CI 0.33-0.94) of scoring in a lower category when compared with blood pressure 110-129 mmHg. When individual components were examined, blood pressure was significantly associated with chair stand (130-159 mmHg: OR 0.59, 95% CI 0.38-0.92) and gait speed (≥160 mmHg: OR 0.59, 95% CI 0.35-0.98). Blood pressure ≥160 mmHg was not associated with substantially higher SPPB score compared with 130-159 mmHg. Conclusions: Patients with systolic blood pressure at or above 130 mmHg had better physical performance than patients with lower blood pressure in the normotensive range. The risk-benefit tradeoff of aggressive blood pressure control, particularly in low-functioning patients, should be reexamined.
Journal of Renal Nutrition, 2015
Physical activity questionnaires usually focus on moderate to vigorous activities and may not acc... more Physical activity questionnaires usually focus on moderate to vigorous activities and may not accurately capture physical activity or variation in levels of activity among extremely inactive groups like dialysis patients. Cross-sectional study. Three dialysis facilities in the San Francisco Bay Area. Sixty-eight prevalent hemodialysis patients. We administered a new physical activity questionnaire designed to capture activity in the lower end of the range, the Low Physical Activity Questionnaire (LoPAQ). Outcome measures were correlation with a validated physical activity questionnaire, the Minnesota Leisure Time Activity (LTA) questionnaire and with self-reported physical function (physical function score of the SF-36) and physical performance (gait speed, chair stand, balance, and short physical performance battery). We also determined whether patients who were frail or reported limitations in activities of daily living were less active on the LoPAQ. Sixty-eight participants (mean age 59 ± 14 years, 59% men) completed the study. Patients were inactive according to the LoPAQ, with a median (interquartile range) of 517 (204-1190) kcal/week of physical activity. Although activity from the LTA was lower than on the LoPAQ (411 [61-902] kcal/week), the difference was not statistically significant (P = .20), and results from the 2 instruments were strongly correlated (rho = 0.62, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). In addition, higher physical activity measured by the LoPAQ was correlated with better self-reported functioning (rho = 0.64, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), better performance on gait speed (rho = 0.32, P = .02), balance (rho = 0.45, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), and chair rising (rho = -0.32, P = .03) tests and with higher short physical performance battery total score (rho = 0.51, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Frail patients and patients with activities of daily living limitations were less active than those who were not frail or limited. The LoPAQ performed similarly to the Minnesota LTA questionnaire in our cohort despite being shorter and easier to administer.
American Journal of Kidney Diseases, 2014
A well-accepted definition of frailty includes measurements of physical performance, which may li... more A well-accepted definition of frailty includes measurements of physical performance, which may limit its clinical utility. In a cross-sectional study, we compared prevalence and patient characteristics based on a frailty definition that uses self-reported function to the classic performance-based definition and developed a modified self-report-based definition. Prevalent adult patients receiving hemodialysis in 14 centers around San Francisco and Atlanta in 2009-2011. Self-report-based frailty definition in which a score lower than 75 on the Physical Function scale of the 36-Item Short Form Health Survey (SF-36) was substituted for gait speed and grip strength in the classic definition; modified self-report definition with optimized Physical Function score cutoff points derived in a development (one-half) cohort and validated in the other half. Performance-based frailty defined as 3 of the following: weight loss, weakness, exhaustion, low physical activity, and slow gait speed. 387 (53%) patients were frail based on self-reported function, of whom 209 (29% of the cohort) met the performance-based definition. Only 23 (3%) met the performance-based definition of frailty only. The self-report definition had 90% sensitivity, 64% specificity, 54% positive predictive value, 93% negative predictive value, and 72.5% overall accuracy. Intracellular water per kilogram of body weight and serum albumin, prealbumin, and creatinine levels were highest among nonfrail individuals, intermediate among those who were frail by self-report, and lowest among those who also were frail by performance. Age, percentage of body fat, and C-reactive protein level followed an opposite pattern. The modified self-report definition had better accuracy (84%; 95% CI, 79%-89%) and superior specificity (88%) and positive predictive value (67%). Our study did not address prediction of outcomes. Patients who meet the self-report-based but not the performance-based definition of frailty may represent an intermediate phenotype. A modified self-report definition can improve the accuracy of a questionnaire-based method of defining frailty.
American journal of kidney diseases : the official journal of the National Kidney Foundation, Jan 30, 2015
Infection is a common cause of hospitalization in adults receiving hemodialysis. Limited data are... more Infection is a common cause of hospitalization in adults receiving hemodialysis. Limited data are available about downstream events resulting from or following these hospitalizations. Retrospective cohort study using the US Renal Data System. Medicare beneficiaries initiating in-center hemodialysis therapy in 2005 to 2008. Demographics, dual Medicare/Medicaid eligibility, body mass index, comorbid conditions, initial vascular access type, nephrology care prior to dialysis therapy initiation, residence in a care facility, tobacco use, biochemical measures, and type of infection. 30-day hospital readmission or death following first infection-related hospitalization. 60,270 Medicare beneficiaries had at least one hospitalization for infection. Of those who survived the initial hospitalization, 15,113 (27%) were readmitted and survived the 30 days following hospital discharge, 1,624 (3%) were readmitted to the hospital and then died within 30 days of discharge, and 2,425 (4%) died witho...
... Since most of the procedures we describe are major, some patients may be willing to accept th... more ... Since most of the procedures we describe are major, some patients may be willing to accept this travel burden for the benefit of a potentially lower risk of death. ... J Cardiovasc Manag. 1995;6:21-23. Medline. 3. Hofer TP, Hayward RA. Identifying poor-quality hospitals. Med Care. ...
Nephron Clinical Practice, 2010
An evaluation of exercise counseling practices among nephrologists in 2001 demonstrated few clini... more An evaluation of exercise counseling practices among nephrologists in 2001 demonstrated few clinicians assessing patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; levels of physical activity (PA) and counseling to increase activity. Recent Kidney Disease Outcomes Quality Initiative (KDOQI) cardiovascular guidelines recommended that nephrologists counsel patients to increase PA. Our objective was to ascertain whether nephrologists&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; counseling practices have changed. We administered a 30-item survey regarding exercise counseling to nephrologists attending the ASN meeting in 2007. Some questions were adapted from a prior survey administered in 2001 to assess differences in practice patterns compared to 6 years earlier. Participants answered questions regarding opinions and practices relevant to PA (n = 198), KDOQI guidelines, self-reported PA, and demographic information (n = 173). Participants were 44 ± 11 years of age, 48% practicing in the USA, and 76% male. In multivariate analysis, older nephrologists (OR; 95% CI) (3.3; 1.2-9.0) and those more physically active (5.5; 2.0-14) were more likely to ask and counsel patients about PA. Opinions associated with less counseling behavior included lack of confidence in ability to discuss PA (0.2; 0.05-0.5). Multivariate comparison to previous respondents (n = 503) showed current nephrologists were not asking and counseling more (1.2; 0.81-1.8). Despite new guidelines, counseling behavior has not increased. Published guidelines are insufficient to reach younger nephrologists.
Seminars in Dialysis, 2013
The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m 2 ) appears to have b... more The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m 2 ) appears to have been based on conventional wisdoms that are not supported by evidence. Observational studies using administrative databases report worse comorbidity-adjusted dialysis survival with early dialysis initiation. Although some have concluded that the IDEAL randomized controlled trial of dialysis start provided evidence that patients become symptomatic with late dialysis start, there is no definitive support for this view. The potential harms of early start of dialysis, including the loss of residual renal function (RRF), have been well documented. The rate of RRF loss (renal function trajectory) is an important consideration for the timing of the dialysis initiation decision. Patients with low glomerular filtration rate (GFR) may have sufficient RRF to be maintained off
Seminars in Dialysis, 2013
Frailty is a physiologic state of increased vulnerability to stressors that results from decrease... more Frailty is a physiologic state of increased vulnerability to stressors that results from decreased physiologic reserves or dysregulation of multiple physiologic systems. The construct of frailty has been operationalized as a composite of poor physical function, exhaustion, low physical activity, and weight loss. Several studies have now examined the prevalence of frailty among chronic kidney disease (CKD) or end-stage renal disease (ESRD) patients and have found frailty to be more common among individuals with CKD than among those without. Furthermore, frailty is associated with adverse outcomes among incident dialysis patients, including higher risk of hospitalization and death. Recent evidence shows that frail patients are started on dialysis earlier (at a higher estimated glomerular filtration rate [eGFR]) on average than nonfrail patients, but it remains unclear whether these patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; frailty is a result of uremia or is independent of CKD. The survival disadvantage that has been associated with early initiation of dialysis in observational studies could be mediated in part through confounding on the basis of unmeasured frailty. However, available data do not suggest improvement in frailty upon initiation of dialysis; rather, the trajectory appears to be toward higher levels of dependence in activities of daily living (ADLs) after dialysis initiation. Overall, there are no data to suggest that frail patients derive any benefit from early initiation of dialysis either in the form of improved survival or functional status.
Nephrology Dialysis Transplantation, 2013
Nephrology Dialysis Transplantation, 2014
Journal of the American Society of Nephrology Jasn, Aug 1, 2006
Patients who are on hemodialysis commonly experience muscle wasting and weakness, which have a ne... more Patients who are on hemodialysis commonly experience muscle wasting and weakness, which have a negative effect on physical functioning and quality of life. The objective of this study was to determine whether anabolic steroid administration and resistance exercise training induce anabolic effects among patients who receive maintenance hemodialysis. A randomized 2 ؋ 2 factorial trial of anabolic steroid administration and resistance exercise training was conducted in 79 patients who were receiving maintenance hemodialysis at University of California, San Francisco-affiliated dialysis units. Interventions included double-blinded weekly nandrolone decanoate (100 mg for women; 200 mg for men) or placebo injections and lower extremity resistance exercise training for 12 wk during hemodialysis sessions three times per week using ankle weights. Primary outcomes included change in lean body mass (LBM) measured by dual-energy x-ray absorptiometry, quadriceps muscle cross-sectional area measured by magnetic resonance imaging, and knee extensor muscle strength. Secondary outcomes included changes in physical performance, self-reported physical functioning, and physical activity. Sixty-eight patients completed the study. Patients who received nandrolone decanoate increased their LBM by 3.1 ؎ 2.2 kg (P < 0.0001). Exercise did not result in a significant increase in LBM. Quadriceps muscle cross-sectional area increased in patients who were assigned to exercise (P ؍ 0.01) and to nandrolone (P < 0.0001) in an additive manner. Patients who exercised increased their strength in a training-specific fashion, and exercise was associated with an improvement in self-reported physical functioning (P ؍ 0.04 compared with nonexercising groups). Nandrolone decanoate and resistance exercise produced anabolic effects among patients who were on hemodialysis. Further studies are needed to determine whether these interventions improve survival.
Clinical journal of the American Society of Nephrology : CJASN, Jan 13, 2015
Infection-related hospitalizations have increased dramatically over the last 10 years in patients... more Infection-related hospitalizations have increased dramatically over the last 10 years in patients receiving in-center hemodialysis. Patient and dialysis facility characteristics associated with the rate of infection-related hospitalization were examined, with consideration of the region of care, rural-urban residence, and socioeconomic status. The US Renal Data System linked to the American Community Survey and Rural-Urban Commuting Area codes was used to examine factors associated with hospitalization for infection among Medicare beneficiaries starting in-center hemodialysis between 2005 and 2008. A Poisson mixed effects model was used to examine the associations among patient and dialysis facility characteristics and the rate of infection-related hospitalization. Among 135,545 Medicare beneficiaries, 38,475 (28%) had at least one infection-related hospitalization. The overall rate of infection-related hospitalization was 40.2 per 100 person-years. Age ≥85 years old, cancer, chroni...
Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation, Jan 27, 2015
To test the performance of appetite assessment tools among patients receiving hemodialysis (HD). ... more To test the performance of appetite assessment tools among patients receiving hemodialysis (HD). Cross-sectional. Two hundred twenty-one patients receiving HD enrolled in seven dialysis facilities in Northern California. We assessed 5 appetite assessment tools (self-assessment of appetite, subjective assessment of appetite, visual analog scale [VAS], Functional Assessment of Anorexia/Cachexia Therapy [FAACT] score, and the Anorexia Questionnaire [AQ]). Reported food intake, normalized protein catabolic rate, and change in body weight were used as criterion measures, and we assessed associations among the appetite tools and biomarkers associated with nutrition and inflammation. Patients were asked to report their appetite and the percentage of food eaten (from 0% to 100%) during the last meal compared to usual intake. Fifty-eight (26%) patients reported food intake ≤ 50% (defined as poor appetite). The prevalence of anorexia was 12% by self-assessment of appetite, 6% by subjective as...
Clinical journal of the American Society of Nephrology : CJASN, Jan 28, 2015
Anemia guidelines for CKD recommend withholding intravenous iron in the setting of active infecti... more Anemia guidelines for CKD recommend withholding intravenous iron in the setting of active infection, although no data specifically support this recommendation. This study aimed to examine the association between intravenous iron and clinical outcomes among hemodialysis patients hospitalized for infection. This was a retrospective observational cohort study using data from the US Renal Data System of 22,820 adult Medicare beneficiaries on in-center hemodialysis who had received intravenous iron in the 14 days preceding their first hospitalization for bacterial infection in 2010. In multivariable analyses, the association between receipt of intravenous iron at any point from the day of hospital admission to discharge and all-cause 30-day mortality, mortality in 2010, length of hospital stay, and readmission for infection or death within 30 days of discharge was evaluated. There were 2463 patients (10.8%) who received intravenous iron at any point from the day of admission to discharge...
Journal of the American Society of Nephrology : JASN, Jan 8, 2015
Obesity is associated with less access to transplantation among adults with ESRD. To examine the ... more Obesity is associated with less access to transplantation among adults with ESRD. To examine the association between body mass index at ESRD onset and survival and transplantation in children, we performed a retrospective analysis of children ages 2-19 years old beginning RRT from 1995 to 2011 using the US Renal Data System. Among 13,172 children, prevalence of obesity increased from 14% to 18%, whereas prevalence of underweight decreased from 12% to 9% during this period. Over a median follow-up of 7.0 years, 10,004 children had at least one kidney transplant, and 1675 deaths occurred. Risk of death was higher in obese (hazard ratio [HR], 1.17; 95% confidence interval [95% CI], 1.03 to 1.32) and underweight (HR, 1.26; 95% CI, 1.09 to 1.47) children than children with normal body mass indices. Obese and underweight children were less likely to receive a kidney transplant (HR, 0.92; 95% CI, 0.87 to 0.97; HR, 0.83; 95% CI, 0.78 to 0.89, respectively). Obese children had lower odds of ...
American Journal of Nephrology, 2015
Patients on chronic hemodialysis have a high prevalence of heart disease and poor self-reported p... more Patients on chronic hemodialysis have a high prevalence of heart disease and poor self-reported physical function. The association between structural heart disease and self-reported physical function in patients on hemodialysis is unknown. We studied the association between elevated pulmonary artery systolic pressure (PASP) and self-reported physical function in ESRD in 253 patients in the USRDS ACTIVE/ADIPOSE study between 2009 and 2011. We used multivariate linear regression with PASP obtained from clinical echocardiogram reports as the primary predictor and the Physical Function (PF) subscale of the SF-36 as the primary outcome. To determine whether associations between PASP and PF were driven by fluid overload or left ventricular hypertrophy, we assessed whether PASP was associated with bioimpedance spectroscopy (BIS)-derived extracellular water (ECW) and with left ventricular posterior wall thickness. In a multivariable model, each 10 mm Hg higher PASP was associated with a 3.32-point lower PF score (95% CI -5.95, -0.68). In a multivariable model that included BIS estimates, both left ventricular posterior wall thickness (LVPW, per 5 mm) and ECW were associated with a higher PASP (LVPW 4.21 mm Hg, 95% 0.38-8.04; ECW 1.12 mm Hg per liter, 95% CI 0.07-2.18). Higher LVPW and ECW were independently associated with a lower PF score. Left ventricular hypertrophy and elevated pulmonary pressure are associated with worse self-reported physical function in patients on hemodialysis. The role of chronic volume overload on PASP and PF score should be evaluated in a prospective manner. © 2015 S. Karger AG, Basel.
Current Opinion in Nephrology and Hypertension, 2015
To summarize the latest information on body composition among patients with chronic kidney diseas... more To summarize the latest information on body composition among patients with chronic kidney disease and its association with outcomes. Obesity is increasing among patients with end-stage renal disease and is more prevalent when direct measures of adiposity are used rather than BMI. High BMI is not associated with better survival among patients with earlier chronic kidney disease or after kidney transplantation, suggesting that excess fat is most protective among the sickest patients. Despite the positive association between BMI and survival among patients with end-stage renal disease, visceral fat is associated with coronary artery calcification and adverse cardiovascular events. Muscle wasting is prominent among patients with chronic kidney disease, sometimes even in the setting of obesity. Obesity and muscle wasting are associated with worse physical functioning. Indicators of low muscle size and strength are associated with higher mortality. Some interventions can affect body composition, but whether they affect survival has not been determined. Recent studies show that a high BMI is not protective for all patients with chronic kidney disease and is associated with poor physical functioning and frailty. Visceral adiposity is associated with adverse cardiovascular outcomes. Sarcopenia is common among patients with end-stage renal disease and is associated with worse physical performance and higher mortality.
BMC nephrology, 2015
Multiple factors influence timing of dialysis initiation. The impact of supply of nephrology work... more Multiple factors influence timing of dialysis initiation. The impact of supply of nephrology workforce on timing and incidence of dialysis initiation is not well known. We determined the number of pediatric and adult nephrologists in each state using data from the American Medical Association and American Boards of Internal Medicine and Pediatrics. We ascertained state population data from the 2010 US Census. United States Renal Data System (USRDS) data were used to determine estimated glomerular filtration rate (eGFR) at dialysis initiation and dialysis incidence for adults (≥18 years) in 2008 and children (<18 years) in 2007-2009 by state. Across all states, there were a median of 3.0 (IQR 2.3 to 3.4) adult nephrologists per 100,000 adults and 0.5 (IQR 0.2 to 0.9) pediatric nephrologists per 100,000 children. The median eGFR at start of dialysis was 9.8 mL/min/1.73 m2 (IQR 7.1-13.1) in adults and 8.5 mL/min/1.73 m2 (IQR 6.2-11.4) in children. Neither the number of adult (Spearm...
Journal of Renal Nutrition, 2015
Trimethylamine N-oxide (TMAO) is a product of metabolism of phosphatidylcholine (lecithin) and ca... more Trimethylamine N-oxide (TMAO) is a product of metabolism of phosphatidylcholine (lecithin) and carnitine by the intestinal microbiome. Elevated serum concentrations of TMAO have been linked to adverse cardiovascular outcomes in the general population. We examined correlates of serum TMAO and the relations among serum TMAO concentrations, all-cause mortality, and cardiovascular mortality and hospitalizations in a nationally derived cohort of patients new to hemodialysis (HD). We quantified serum TMAO by liquid chromatography and online tandem mass spectrometry and assessed nutritional and cardiovascular risk factors in 235 patients receiving HD and measured TMAO in pooled serum from healthy controls. We analyzed time to death and time to cardiovascular death or hospitalization using Cox proportional hazards regression. Serum TMAO concentrations of patients undergoing HD (median, 43 μM/L; 25th-75th percentile, 28-67 μM/L) were elevated compared with those with normal or near-normal kidney function (1.41 ± 0.49 μM/L). TMAO was directly correlated with serum albumin (Spearman rank correlation, 0.24; 95% CI, 0.12-0.35; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001), prealbumin (Spearman rank correlation, 0.19; 95% CI, 0.07-0.31; P = .003), and creatinine (Spearman rank correlation, 0.21; 95% CI, 0.08-0.33; P = .002) and inversely correlated with log C-reactive protein (Spearman rank correlation, -0.18; 95% CI, -0.30 to -0.06; P = .005). Higher serum concentrations of TMAO were not significantly associated with time to death (Spearman rank correlation, 0.84; CI, 0.65-1.09; P = .19) or time to cardiovascular hospitalization or cardiovascular death (Spearman rank correlation, 0.88; CI, 0.57-1.35; P = .55). Serum TMAO concentrations were markedly elevated and correlated directly with biochemical markers of nutritional status and inversely with markers of inflammation in patients receiving HD. There was no significant association between serum TMAO concentrations and all-cause mortality, cardiovascular death, or hospitalizations. In patients receiving dialysis-in contrast with the general population-adverse vascular effects of TMAO may be counterbalanced by associations with nutritional or inflammatory status.
BMC nephrology, 2014
New information from various clinical settings suggests that tight blood pressure control may not... more New information from various clinical settings suggests that tight blood pressure control may not reduce mortality and may be associated with more side effects. We performed cross-sectional multivariable ordered logistic regression to examine the association between predialysis blood pressure and the short physical performance battery (SPPB) in a cohort of 749 prevalent hemodialysis patients in the San Francisco and Atlanta areas recruited from July 2009 to August 2011 to study the relationship between systolic blood pressure and objective measures of physical function. Mean blood pressure for three hemodialysis sessions was analyzed in the following categories: <110 mmHg, 110-129 mmHg (reference), 130-159 mmHg, and ≥160 mmHg. SPPB includes three components: timed repeated chair stands, timed 15-ft walk, and balance tests. SPPB was categorized into ordinal groups (≤6, 7-9, 10-12) based on prior literature. Patients with blood pressure 130-159 mmHg had lower odds (OR 0.57, 95% CI ...
Kidney International, 2014
Background: New information from various clinical settings suggests that tight blood pressure con... more Background: New information from various clinical settings suggests that tight blood pressure control may not reduce mortality and may be associated with more side effects. Methods: We performed cross-sectional multivariable ordered logistic regression to examine the association between predialysis blood pressure and the short physical performance battery (SPPB) in a cohort of 749 prevalent hemodialysis patients in the San Francisco and Atlanta areas recruited from July 2009 to August 2011 to study the relationship between systolic blood pressure and objective measures of physical function. Mean blood pressure for three hemodialysis sessions was analyzed in the following categories: <110 mmHg, 110-129 mmHg (reference), 130-159 mmHg, and ≥160 mmHg. SPPB includes three components: timed repeated chair stands, timed 15-ft walk, and balance tests. SPPB was categorized into ordinal groups (≤6, 7-9, 10-12) based on prior literature. Results: Patients with blood pressure 130-159 mmHg had lower odds (OR 0.57, 95% CI 0.35-0.93) of scoring in a lower SPPB category than those whose blood pressure was between 110 and 129 mmHg, while those with blood pressure ≥160 mmHg had 0.56 times odds (95% CI 0.33-0.94) of scoring in a lower category when compared with blood pressure 110-129 mmHg. When individual components were examined, blood pressure was significantly associated with chair stand (130-159 mmHg: OR 0.59, 95% CI 0.38-0.92) and gait speed (≥160 mmHg: OR 0.59, 95% CI 0.35-0.98). Blood pressure ≥160 mmHg was not associated with substantially higher SPPB score compared with 130-159 mmHg. Conclusions: Patients with systolic blood pressure at or above 130 mmHg had better physical performance than patients with lower blood pressure in the normotensive range. The risk-benefit tradeoff of aggressive blood pressure control, particularly in low-functioning patients, should be reexamined.
Journal of Renal Nutrition, 2015
Physical activity questionnaires usually focus on moderate to vigorous activities and may not acc... more Physical activity questionnaires usually focus on moderate to vigorous activities and may not accurately capture physical activity or variation in levels of activity among extremely inactive groups like dialysis patients. Cross-sectional study. Three dialysis facilities in the San Francisco Bay Area. Sixty-eight prevalent hemodialysis patients. We administered a new physical activity questionnaire designed to capture activity in the lower end of the range, the Low Physical Activity Questionnaire (LoPAQ). Outcome measures were correlation with a validated physical activity questionnaire, the Minnesota Leisure Time Activity (LTA) questionnaire and with self-reported physical function (physical function score of the SF-36) and physical performance (gait speed, chair stand, balance, and short physical performance battery). We also determined whether patients who were frail or reported limitations in activities of daily living were less active on the LoPAQ. Sixty-eight participants (mean age 59 ± 14 years, 59% men) completed the study. Patients were inactive according to the LoPAQ, with a median (interquartile range) of 517 (204-1190) kcal/week of physical activity. Although activity from the LTA was lower than on the LoPAQ (411 [61-902] kcal/week), the difference was not statistically significant (P = .20), and results from the 2 instruments were strongly correlated (rho = 0.62, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). In addition, higher physical activity measured by the LoPAQ was correlated with better self-reported functioning (rho = 0.64, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), better performance on gait speed (rho = 0.32, P = .02), balance (rho = 0.45, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), and chair rising (rho = -0.32, P = .03) tests and with higher short physical performance battery total score (rho = 0.51, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Frail patients and patients with activities of daily living limitations were less active than those who were not frail or limited. The LoPAQ performed similarly to the Minnesota LTA questionnaire in our cohort despite being shorter and easier to administer.
American Journal of Kidney Diseases, 2014
A well-accepted definition of frailty includes measurements of physical performance, which may li... more A well-accepted definition of frailty includes measurements of physical performance, which may limit its clinical utility. In a cross-sectional study, we compared prevalence and patient characteristics based on a frailty definition that uses self-reported function to the classic performance-based definition and developed a modified self-report-based definition. Prevalent adult patients receiving hemodialysis in 14 centers around San Francisco and Atlanta in 2009-2011. Self-report-based frailty definition in which a score lower than 75 on the Physical Function scale of the 36-Item Short Form Health Survey (SF-36) was substituted for gait speed and grip strength in the classic definition; modified self-report definition with optimized Physical Function score cutoff points derived in a development (one-half) cohort and validated in the other half. Performance-based frailty defined as 3 of the following: weight loss, weakness, exhaustion, low physical activity, and slow gait speed. 387 (53%) patients were frail based on self-reported function, of whom 209 (29% of the cohort) met the performance-based definition. Only 23 (3%) met the performance-based definition of frailty only. The self-report definition had 90% sensitivity, 64% specificity, 54% positive predictive value, 93% negative predictive value, and 72.5% overall accuracy. Intracellular water per kilogram of body weight and serum albumin, prealbumin, and creatinine levels were highest among nonfrail individuals, intermediate among those who were frail by self-report, and lowest among those who also were frail by performance. Age, percentage of body fat, and C-reactive protein level followed an opposite pattern. The modified self-report definition had better accuracy (84%; 95% CI, 79%-89%) and superior specificity (88%) and positive predictive value (67%). Our study did not address prediction of outcomes. Patients who meet the self-report-based but not the performance-based definition of frailty may represent an intermediate phenotype. A modified self-report definition can improve the accuracy of a questionnaire-based method of defining frailty.
American journal of kidney diseases : the official journal of the National Kidney Foundation, Jan 30, 2015
Infection is a common cause of hospitalization in adults receiving hemodialysis. Limited data are... more Infection is a common cause of hospitalization in adults receiving hemodialysis. Limited data are available about downstream events resulting from or following these hospitalizations. Retrospective cohort study using the US Renal Data System. Medicare beneficiaries initiating in-center hemodialysis therapy in 2005 to 2008. Demographics, dual Medicare/Medicaid eligibility, body mass index, comorbid conditions, initial vascular access type, nephrology care prior to dialysis therapy initiation, residence in a care facility, tobacco use, biochemical measures, and type of infection. 30-day hospital readmission or death following first infection-related hospitalization. 60,270 Medicare beneficiaries had at least one hospitalization for infection. Of those who survived the initial hospitalization, 15,113 (27%) were readmitted and survived the 30 days following hospital discharge, 1,624 (3%) were readmitted to the hospital and then died within 30 days of discharge, and 2,425 (4%) died witho...
... Since most of the procedures we describe are major, some patients may be willing to accept th... more ... Since most of the procedures we describe are major, some patients may be willing to accept this travel burden for the benefit of a potentially lower risk of death. ... J Cardiovasc Manag. 1995;6:21-23. Medline. 3. Hofer TP, Hayward RA. Identifying poor-quality hospitals. Med Care. ...
Nephron Clinical Practice, 2010
An evaluation of exercise counseling practices among nephrologists in 2001 demonstrated few clini... more An evaluation of exercise counseling practices among nephrologists in 2001 demonstrated few clinicians assessing patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; levels of physical activity (PA) and counseling to increase activity. Recent Kidney Disease Outcomes Quality Initiative (KDOQI) cardiovascular guidelines recommended that nephrologists counsel patients to increase PA. Our objective was to ascertain whether nephrologists&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; counseling practices have changed. We administered a 30-item survey regarding exercise counseling to nephrologists attending the ASN meeting in 2007. Some questions were adapted from a prior survey administered in 2001 to assess differences in practice patterns compared to 6 years earlier. Participants answered questions regarding opinions and practices relevant to PA (n = 198), KDOQI guidelines, self-reported PA, and demographic information (n = 173). Participants were 44 ± 11 years of age, 48% practicing in the USA, and 76% male. In multivariate analysis, older nephrologists (OR; 95% CI) (3.3; 1.2-9.0) and those more physically active (5.5; 2.0-14) were more likely to ask and counsel patients about PA. Opinions associated with less counseling behavior included lack of confidence in ability to discuss PA (0.2; 0.05-0.5). Multivariate comparison to previous respondents (n = 503) showed current nephrologists were not asking and counseling more (1.2; 0.81-1.8). Despite new guidelines, counseling behavior has not increased. Published guidelines are insufficient to reach younger nephrologists.
Seminars in Dialysis, 2013
The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m 2 ) appears to have b... more The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m 2 ) appears to have been based on conventional wisdoms that are not supported by evidence. Observational studies using administrative databases report worse comorbidity-adjusted dialysis survival with early dialysis initiation. Although some have concluded that the IDEAL randomized controlled trial of dialysis start provided evidence that patients become symptomatic with late dialysis start, there is no definitive support for this view. The potential harms of early start of dialysis, including the loss of residual renal function (RRF), have been well documented. The rate of RRF loss (renal function trajectory) is an important consideration for the timing of the dialysis initiation decision. Patients with low glomerular filtration rate (GFR) may have sufficient RRF to be maintained off
Seminars in Dialysis, 2013
Frailty is a physiologic state of increased vulnerability to stressors that results from decrease... more Frailty is a physiologic state of increased vulnerability to stressors that results from decreased physiologic reserves or dysregulation of multiple physiologic systems. The construct of frailty has been operationalized as a composite of poor physical function, exhaustion, low physical activity, and weight loss. Several studies have now examined the prevalence of frailty among chronic kidney disease (CKD) or end-stage renal disease (ESRD) patients and have found frailty to be more common among individuals with CKD than among those without. Furthermore, frailty is associated with adverse outcomes among incident dialysis patients, including higher risk of hospitalization and death. Recent evidence shows that frail patients are started on dialysis earlier (at a higher estimated glomerular filtration rate [eGFR]) on average than nonfrail patients, but it remains unclear whether these patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; frailty is a result of uremia or is independent of CKD. The survival disadvantage that has been associated with early initiation of dialysis in observational studies could be mediated in part through confounding on the basis of unmeasured frailty. However, available data do not suggest improvement in frailty upon initiation of dialysis; rather, the trajectory appears to be toward higher levels of dependence in activities of daily living (ADLs) after dialysis initiation. Overall, there are no data to suggest that frail patients derive any benefit from early initiation of dialysis either in the form of improved survival or functional status.
Nephrology Dialysis Transplantation, 2013
Nephrology Dialysis Transplantation, 2014