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Davies SJ. The Elusive Promise of Bioimpedance in Fluid Management of Patients Undergoing Dialysis. Clin J Am Soc Nephrol 2020; 15:597-599. [PMID: 32381550 PMCID: PMC7269206 DOI: 10.2215/cjn.01770220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Lambie M, Teece L, Johnson DW, Petrie M, Mactier R, Solis-Trapala I, Belcher J, Bekker HL, Wilkie M, Tupling K, Phillips-Darby L, Davies SJ. Estimating risk of encapsulating peritoneal sclerosis accounting for the competing risk of death. Nephrol Dial Transplant 2020; 34:1585-1591. [PMID: 30820552 PMCID: PMC6735880 DOI: 10.1093/ndt/gfz034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Indexed: 02/06/2023] Open
Abstract
Background Risk of encapsulating peritoneal sclerosis (EPS) is strongly associated with the duration of peritoneal dialysis (PD), such that patients who have been on PD for some time may consider elective transfer to haemodialysis to mitigate the risk of EPS. There is a need to determine this risk to better inform clinical decision making, but previous studies have not allowed for the competing risk of death. Methods This study included new adult PD patients in Australia and New Zealand (ANZ; 1990–2010) or Scotland (2000–08) followed until 2012. Age, time on PD, primary renal disease, gender, data set and diabetic status were evaluated as predictors at the start of PD, then at 3 and 5 years after starting PD using flexible parametric competing risks models. Results In 17 396 patients (16 162 ANZ, 1234 Scotland), EPS was observed in 99 (0.57%) patients, less frequently in ANZ patients (n = 65; 0.4%) than in Scottish patients (n = 34; 2.8%). The estimated risk of EPS was much lower when the competing risk of death was taken into account (1 Kaplan–Meier = 0.0126, cumulative incidence function = 0.0054). Strong predictors of EPS included age, primary renal disease and time on PD. The risk of EPS was reasonably discriminated at the start of PD (C-statistic = 0.74–0.79) and this improved at 3 and 5 years after starting PD (C-statistic = 0.81–0.92). Conclusions EPS risk estimates are lower when calculated using competing risk of death analyses. A patient’s estimated risk of EPS is country-specific and can be predicted using age, primary renal disease and duration of PD.
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Harris DC, Davies SJ, Finkelstein FO, Jha V. The second Global Kidney Health Summit outputs: developing a strategic plan to increase access to integrated end-stage kidney disease care worldwide. Kidney Int Suppl (2011) 2020; 10:e1-e2. [PMID: 32154795 PMCID: PMC7031682 DOI: 10.1016/j.kisu.2019.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
ObjectivePeritoneal membrane function influences dialysis prescription and clinical outcome and may change with time on treatment. Increasingly sophisticated tools, ranging from the peritoneal equilibration test (PET) to the standard permeability analysis (SPA) and personal dialysis capacity (PDC) test, are available to the clinician and clinical researcher. These tests allow assessment of a number of aspects of membrane function, including solute transport rates, ultrafiltration capacity, effective reabsorption, transcellular water transport, and permeability to macromolecules. In considering which tests are of greatest value in monitoring long-term membrane function, two criteria were set: those that result in clinically relevant interpatient differences in achieved ultrafiltration or solute clearances, and those that change with time in treatment.Study SelectionClinical validation studies of the PET, SPA, and PDC tests. Studies reporting membrane function using these methods in either long-term (5 years) peritoneal dialysis patients or longitudinal observations (> 2 years).Data ExtractionDirectly from published data. Additional, previously unpublished analysis of data from the Stoke PD Study.ResultsSolute transport is the most important parameter. In addition to predicting patient and technique survival at baseline, there is strong evidence that it can increase with time on treatment. Whereas patients with initially high solute transport drop out early from treatment, those with low transport remain longer on treatment, although, over 5 years, a proportion develop increasing transport rates. Ultrafiltration capacity, while being a composite measure of membrane function, is a useful guide for the clinician. Using the PET (2.27% glucose), a net ultrafiltration capacity of < 200 mL is associated with a 50% chance of achieving less than 1 L daily ultrafiltration at the expense of 1.8 hypertonic (3.86%) exchanges in anuric patients. Using a SPA (3.86% glucose), a net ultrafiltration capacity of < 400 mL indicates ultrafiltration failure. While there is circumstantial evidence that, with time on peritoneal dialysis, loss of transcellular water transport might contribute to ultrafiltration failure, none of the current tests is able to demonstrate this unequivocally. Of the other membrane parameters, evidence that interpatient differences are clinically relevant (permeability to macro-molecules), or that they change significantly with time on treatment (effective reabsorption), is lacking.ConclusionA strong case can be made for the regular assessment by clinicians of solute transport and ultrafiltration capacity, a task made simple to achieve using any of the three tools available.
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Davies SJ, Yewdall VMA, Ogg CS, Cameron JS. Peritoneal Defence Mechanisms and Staphylococcus Aureus in Patients Treated with Continuous Ambulatory Peritoneal Dialysis (CAPD). Perit Dial Int 2020. [DOI: 10.1177/089686089001000203] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients due to S. aureus is associated with an adverse clinical outcome, suggesting impaired clearance of this organism by the host. The ability of peritoneal macrophages (PMO) derived from CAPD patients to take up S. aureus and mount a respiratory burst was investigated. Whilst significant activity was observed in the absence of opsonin, both parameters of phagocytosis were augmented by addition of 20% pooled human serum (PHS), complement-depleted PHS, and fibronectin. When used as sole opsonin, fibronectin resulted in a dose-related increase in chemiluminescent response by both blood neutrophils and PMO. The opsonic activity of dialysis effluent, as judged by neutrophil chemiluminescence, correlated with IgG and fibronectin content, but not with complement as assessed by C3 levels. The addition of urokinase to dialysate improved its opsonic properties whilst having no effect on the activity of PHS-20%; this would suggest that the formation of fibrin in dialysate, promoted by S. aureus, interferes with phagocytosis. This and the low IgG, complement and fibronectin levels in dialysate may explain in part the relatively poor clearance of this organism from the peritoneum.
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Stompór T, Zdzienicka A, Motyka M, Dembińska–Kieć A, Davies SJ, Sulowicz W. Selected Growth Factors in Peritoneal Dialysis: Their Relationship to Markers of Inflammation, Dialysis Adequacy, Residual Renal Function, and Peritoneal Membrane Transport. Perit Dial Int 2020. [DOI: 10.1177/089686080202200605] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives Markers of chronic inflammation, acute-phase reactants, and growth factors may be concomitantly involved in a number of pathologic processes in the general population and uremic patients. In addition, growth factors may influence peritoneal membrane transport characteristics. However, the association between plasma growth factors, markers of chronic inflammation, and peritoneal membrane transport remains largely unknown. The aim of this study was to evaluate the relationship between plasma levels of selected growth factors [basic fibroblast growth factor (bFGF), transforming growth factor β1 (TGFβ1), vascular endothelial growth factor (VEGF)] and markers of chronic inflammation [interleukin (IL)-6, C-reactive protein (CRP), and fibrinogen] in continuous ambulatory peritoneal dialysis (CAPD) patients. The potential link between the above substances and dialysis adequacy was also explored. Design Single-center, cross-sectional study. Setting Peritoneal Dialysis Unit, Medical Faculty, Jagiellonian University Hospital, Kraków, Poland. Patients 32 stable end-stage renal disease patients (13 M, 19 F; mean age 53.6 ± 13.7 years) on CAPD for a median period of 19.5 months. Patients free from signs and symptoms of any inflammatory disease (including peritonitis) for at least 3 months were included into the study. All patients underwent measurements of dialysis dose [Kt/V, weekly creatinine clearance (wCCr)] and peritoneal solute transport using a standard peritoneal equilibration test (PET). Methods TGFβ1, bFGF, VEGF, and IL-6 were measured with ELISA, CRP was assayed with immunonephelometry, and fibrinogen with Multifibren U reagent (Dade Behring Marburg GmbH, Marburg, Germany). Nephron 97 for Windows software was used to assess dialysis adequacy. Results Significant positive correlations between plasma bFGF and IL-6, as well as fibrinogen concentrations ( R = 0.36, p < 0.05 and R = 0.39, p < 0.05, respectively), were found. VEGF correlated significantly with IL-6 and CRP ( R = 0.65, p < 0.0001 and R = 0.51, p < 0.005, respectively). An association between VEGF and bFGF was also found ( R = 0.59, p < 0.0005). Serum level of TGFβ1 revealed no relationship with any marker of acute-phase activation, remaining growth factors, or dialysis adequacy. Positive correlation between TGFβ1 concentration and dialysate-to-plasma ratio for creatinine in PET ( R = 0.35, p < 0.05) was found. In addition, patients with lower solute transport (low/low-average transporters) had lower serum levels of both bFGF and TGFβ1 compared to patients with higher solute transport. Patients with total wCCr > 60 L/week/m2 were characterized by lower levels of bFGF and IL-6. Serum level of IL-6 and plasma levels of bFGF and VEGF were significantly lower among subjects with residual renal function (RRF) > 2.0 mL/minute. Conclusions Our results indicate that systemic inflammation in peritoneal dialysis patients is associated with increased plasma VEGF and bFGF but not TGFβ1. The negative correlation with RRF suggests that either the renal clearance of these cytokines and growth factors may contribute to their elimination, or cytokines and growth factors have a negative impact on RRF. We also suggest an association between serum levels of growth factors tested and peritoneal membrane function.
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Davies SJ, Bryan J, Phillips L, Russell GI. The Predictive Value of Kt/V and Peritoneal Solute Transport in Capd Patients is Dependent on the Type of Comorbidity Present. Perit Dial Int 2020. [DOI: 10.1177/089686089601601s29] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Comorbidity, age, dialysis dose (KT/Vurea)’ plasma albumin, and peritoneal function (DIP treat) were measured cross-sectionally in 228 continuous ambulatory peritoneal dialysis (CAPD) patients, who were then followed up for a mean of two years. Comorbidity, utilizing a semiquantitative score described previously, was the most powerful predictor of mortality in both univariate and multivariate analysis. Using univariate analysis, all the variables predicted outcome with statistical significance, mortality being associated with lower KT/V and plasma albumin and a higher DIP treat On multivariate analysis only comorbidity, age, and KT/V remained independent predictors. Data was further analyzed on the basis of type of comorbid condition. In those patients without comorbid disease (n = 127) neither KT/V, albumin nor DIP retreamendicted outcome. In patients with clinical evidence of ischemic heart disease the KT/V was a significant predictor of favorable outcome. In those with clinical evidence of left ventricular function, mortality was significantly and independently associated with low plasma albumin, high DIP treat’ and KT/V. It is suggested that the concept of treatment adequacy in CAPD patients must include both measures of dialysis dose and peritoneal function, particularly in the context of the patient's comorbidity.
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Davies SJ, Animashaun A, Taylor AE, Young GA, Turney JH. Fibronectin and Fibrinogen in the Plasma and Dialysate of Patients on CAPD. Perit Dial Int 2020. [DOI: 10.1177/089686088700700406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Plasma and dialysate fluid from 18 patients treated with continuous ambulatory peritoneal dialysis (CAPD) while peritonitis -free, were analysed for fibronectin (FN), fibrinogen (FG), albumin (ALB) and total protein (TP). Mean plasma FG (6.24 g/l) was higher than for normal controls (4.23 g/1; p < 0.001) whereas FN (0.31 g/l) was lower than for normal (0.36 g/l; p < 0.02). Twenty-four hour losses of proteins into the dialysate were as follows: TP = 10.9 g, ALB = 5.2 g, FN = 15.6 mg and FG = 221 mg. Mean dialysate concentration for FN was 2.09 mg/1 and FG 31.1 mg/l. Dialysate FN and FG correlated with dialysate ALB (r = 0.92; p < 0.001, r = 0.60; p < 0.01 respectively) suggesting an ultrafiltrate rather than synthesis within the peritoneum.
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Asghar RB, Green S, Engel B, Davies SJ. Relationship of Demographic, Dietary, and Clinical Factors to the Hydration Status of Patients on Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080402400305] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
ObjectivesTo establish which clinical factors are associated with an increased proportion of extracellular fluid (ECF) in peritoneal dialysis (PD) patients.DesignA single-center, cross-sectional analysis of 68 stable PD patients.MethodBioelectrical impedance measurements (RJL, single frequency; RJL Systems, Clinton, Michigan, USA) of resistance and reactance were used to determine the proportion of ECF comprising total body water (TBW) in 68 stable PD patients attending for routine clearance and membrane studies. All patients underwent detailed dietetic, adequacy, and membrane function tests. Blood pressure and antihypertensive requirements were also documented.ResultsSignificant gender differences in body composition were observed, such that women had lower absolute TBW and fat-free mass per kilogram body weight, but proportionately more ECF for a given TBW, mean ECF:TBW 0.5 ± 0.03 versus 0.44 ± 0.05, p < 0.005. In view of this, patients were split into two groups, defined as “over-” or “normally” hydrated, either by using the single discriminator (median ECF:TBW = 0.47) for the whole population, which resulted in groups distorted by gender, or by using different discriminators according to gender (women: 0.49, men 0.45). In both analyses, overhydrated patients were older, had significantly lower plasma albumin, less total fluid removal per kilogram body weight, and higher peritoneal solute transport. When split by a single discriminator, the overhydrated patients had lower sodium removal and significantly less intracellular fluid volume due to an excess of women in this group who also had less residual function and had been on dialysis longer. Using gender-specific discrimination, overhydrated patients were heavier due to expansion of the ECF volume: 20 ± 4.1 L versus 16 ± 3.3 L, p < 0.001. Stepwise multivariate analysis found age ( p = 0.001), albumin ( p = 0.009), and fluid losses per kilogram body weight ( p = 0.025) to be independent predictors of gender-adjusted hydration status. Sodium intake did not vary according to hydration status.ConclusionGender influences the assessment of hydration status of PD patients when employing bioimpedance, such that women tend to have more ECF. Taking this into account, age, albumin, and achieved fluid removal appear to be independently associated with hydration status, whereas peritoneal solute transport is not. Advice on dietary sodium should take account of hydration status and achievable losses.
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Davies SJ, Phillips L, Griffiths AM, Russell LH, Naish PF, Russel GI. Impact of Peritoneal Membrane Function on Long Term Clinical Outcome in Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686089901902s14] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
It is increasingly clear that peritoneal membrane transport status has clinical implications. The role of the peritoneum in dialysis delivery becomes para mount once residual renal function is lost, particularly as the membrane characteristics may change for the worse with time on treatment. These findings have several important implications: Clinicians need to take solute transport character istics into account as they assess their patients. Adverse effects of high solute transport include reduced ultrafiltration, solute removal (in particular, sodium), and increased peritoneal protein losses. A need exists to replace lost residual renal function, not just with enhanced solute removal, but also with adequate salt and water removal. The interpretation of urea and creatinine clear ances in anuric PD patients needs further consideration and validation. Hypoalbuminemia in PD patients will result from the combined effects of high protein losses, over hydration, comorbidity, and malnutrition.
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Brown EA, Davies SJ, Heimbürger O, Meeus F, Mellotte G, Rosman J, Rutherford P, Van Bree M, Borras M, Brown E, Caillette–Beaudoin A, Clutterbuck E, Davies S, D'Auzac C, Ekstrand A, Frandsen N, Freida P, Heimbürger O, Kuypers+ D, Gasthuisberg+ A, Mactier R, MacNamara E, Malmsten G, Mastrangelo F, Meeus F, Melotte G, Perez–Contreras J, Riegel W, Rodrigues A, Rodriguez–Carmona A, Rosman J, Rutherford P, Scanziani R, Vega Diaz N, Vychytil A, Weinreich T. Adequacy Targets Can be Met in Anuric Patients by Automated Peritoneal Dialysis: Baseline Data from Eapos. Perit Dial Int 2020. [DOI: 10.1177/089686080102103s19] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
♦ Objective Conventional continuous ambulatory peritoneal dialysis (CAPD) in patients without residual renal function and with high solute transport is associated with worse clinical outcomes. Automated peritoneal dialysis (APD) has the potential to improve both solute clearance and ultrafiltration in these circumstances, but its efficacy as a treatment modality is unknown. The European Automated Peritoneal Dialysis Outcomes Study (EAPOS) is a 2-year, prospective, European multi-center study designed to determine APD feasibility and clinical outcomes in anuric patients. The present article describes the baseline data for patients recruited into the study. ♦ Design All PD patients treated in the participating centers were screened for inclusion criteria [urinary output < 100 mL/24 h, or residual renal function (RRF) < 1 mL/min, or both]. After enrollment, changes were made to the dialysis prescription to achieve a weekly creatinine clearance above 60 L per 1.73 m2 and an ultrafiltration rate above 750 mL in 24 hours. ♦ Setting The study is being conducted in 26 dialysis centers in 13 European countries. ♦ Baseline Data Collection The information collected includes patient demographics, dialysis prescription, achieved weekly creatinine clearance, and 24-hour ultra-filtration (UF). ♦ Results The study enrolled 177 anuric patients. Median dialysis duration before enrollment was 22.5 months (range: 0 – 285 months). Mean solute transport measured as the dialysate-to-plasma ratio of creatinine (D/PCr) was 0.74 ± 0.12. Patients received APD for a median of 9.0 hours overnight (range: 7 – 12 hours) using a median of 11.0 L of fluid (range: 6 – 28.75 L). Median daytime volume was 4.0 L (range: 0.0 – 9.0 L). Tidal dialysis was used in 26 patients, and icodextrin in 86 patients. At baseline, before treatment optimization, the weekly mean total creatinine clearance was 65.2 ± 14.4 L/1.73 m2, with 105 patients (60%) achieving the target of more than 60 L/1.73 m2. At baseline, 81% of patients with high transport, 69% with high-average transport, and 40% with low-average transport met the target. At baseline, 70% of patients with a body surface area (BSA) below 1.7 m2, 60% with a BSA of 1.7 – 2.0 m2, and 56% with a BSA above 2.0 m2 achieved 60 L/1.73 m2 weekly. Median UF was 1090 mL/24 h, and 75% of patients achieved the UF target of more than 750 mL/24 h. ♦ Conclusion This baseline analysis of anuric patients recruited into the EAPOS study demonstrates that a high proportion of anuric patients on APD can achieve dialysis and ultrafiltration targets using a variety of regimes. This 2-year follow-up study aims to optimize APD prescription to reach predefined clearance and ultrafiltration targets, and to observe the resulting clinical outcomes.
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Abstract
Background Patients returning to dialysis treatment after a period with a functioning allograft represent a special case in the integrated care model of renal replacement therapy. They are known to nephrologists— and thus are ideal candidates for a timely commencement of dialysis—but they have had time to accrue additional cardiovascular risk. Furthermore, they have been exposed to prolonged immunosuppression. Purpose The present study aimed to establish the clinical outcomes of patients returning to peritoneal dialysis (PD) with failing allografts [survival, technique survival, longitudinal residual renal function (Kt/VR), peritoneal membrane function (solute transport), and plasma albumin] and to compare those outcomes with outcomes in new, contemporary patients. Setting The study was conducted in a single center where prospective collection of data now known to be important in determining outcome on peritoneal dialysis (age, comorbidity, albumin, Kt/VR, and solute transport) has been performed since 1989. Methods All patients commencing PD between 1989 and 2001 after failure of an allograft that had functioned for more than 6 months were identified. Outcomes in that group were compared to outcomes in all new PD patients and in all dialysis patients with failed grafts who were returning to hemodialysis (HD) in the same period. Results The study identified 45 patients with failed allografts: 28 were commencing PD treatment, and 17 were commencing HD treatment. Those patients were significantly younger than the 469 new patients commencing PD [FailedTx→ PD 41.2 years, FailedTx→ HD 38.9 years, NewPD 54.7 years; analysis of variance (ANOVA): p < 0.001]. We saw no significant difference in the survival of failed transplant patients commencing PD as compared with those commencing HD (log rank: p = 0.11). Kaplan–Meier plots of patient survival were better for failed transplant patients as compared with all new PD patients. When corrected using Cox regression, the survival advantage was seen to be due to age and comorbidity at start of PD. Pure technique failure (excluding death) was not different between the groups. Compared with all new PD patients, patients with failed allografts had similar longitudinal plasma albumin and a tendency toward an earlier increase in solute transport, but a more rapid loss of Kt/VR, ( p < 0.05 at 6 – 48 months). Conclusions Peritoneal dialysis would appear to be a good option for patients with failing allografts. Co-morbidity is the predominant determinant of survival. That finding underlines the need for attention to factors that might prevent accrual of cardiovascular risk during the post-transplantation period. The earlier loss of Kt/VR in those patients might be prevented by developing strategies of continued immunosuppression after commencement of dialysis, although infection risk is an important issue.
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Davies SJ, Brown EA, Reigel W, Clutterbuck E, Heimbürger O, Diaz NV, Mellote GJ, Perez–Contreras J, Scanziani R, D'Auzac C, Kuypers D, Filho JCD. What is the Link between Poor Ultrafiltration and Increased Mortality in Anuric Patients on Automated Peritoneal Dialysis? Analysis of Data from Eapos. Perit Dial Int 2020. [DOI: 10.1177/089686080602600410] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Primary analysis of the European Automated Peritoneal Dialysis Outcomes Study (EAPOS) found that patients with daily ultrafiltration (UF) below a predefined target of 750 mL at baseline experienced increased mortality and continuing low UF over 2 years. Setting Multicenter, prospective observational study of prevalent, functionally anuric patients on automated peritoneal dialysis (APD) treated to predefined standards. Methods Secondary data analysis to determine clinical covariates that might support a link between poor UF and outcome, including pattern of comorbidity, prescription, nutrition as determined by Subjective Global Assessment (SGA), membrane function, and blood pressure (BP). Ultrafiltration was treated as a categorical (comparing patients above and below target at baseline) and continuous dependent variable in univariate and multivariate regression. The relationship between BP and survival was also explored. Results Of 177 patients recruited from 28 centers across Europe, 43 were below the UF target at baseline. Compared to those above target, there were no differences in the spread of comorbidity, type of APD prescription, SGA, BP, hemoglobin, HCO3, or parathyroid hormone, at baseline or at any later time. At baseline, plasma calcium and, at 12 months, plasma phosphate were lower in the low UF group. There was a weak positive correlation between baseline systolic or diastolic BP and UF, which remained on multivariate analysis but accounted for just 9% of the variability in BP. There was no clear relationship between baseline BP and survival, although, if anything, low BP was associated with earlier death. Poor UF was associated with lower mean dialysate glucose concentration during the first 4 months and with consistently worse membrane function. Conclusions The increased mortality associated with poor UF is likely multifactorial and not easily explained by clear differences in comorbidity, nutritional state, or other indices of treatment at baseline. The lower plasma phosphate suggests a subsequent fall in appetite. Poor BP control is unlikely to be the explanation, and a link between lower BP, reduced UF, and earlier death is suggested. Failure to achieve adequate UF due to worse membrane function remains an important and potentially reversible or preventable cause.
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Davies SJ, Brown EA. What have we Learned about PD from Recent Major Clinical Trials? Perit Dial Int 2020. [DOI: 10.1177/089686080702700205] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hole B, Hemmelgarn B, Brown E, Brown M, McCulloch MI, Zuniga C, Andreoli SP, Blake PG, Couchoud C, Cueto-Manzano AM, Dreyer G, Garcia Garcia G, Jager KJ, McKnight M, Morton RL, Murtagh FEM, Naicker S, Obrador GT, Perl J, Rahman M, Shah KD, Van Biesen W, Walker RC, Yeates K, Zemchenkov A, Zhao MH, Davies SJ, Caskey FJ. Supportive care for end-stage kidney disease: an integral part of kidney services across a range of income settings around the world. Kidney Int Suppl (2011) 2020; 10:e86-e94. [PMID: 32149013 DOI: 10.1016/j.kisu.2019.11.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/11/2019] [Accepted: 11/07/2019] [Indexed: 12/11/2022] Open
Abstract
A key component of treatment for all people with advanced kidney disease is supportive care, which aims to improve quality of life and can be provided alongside therapies intended to prolong life, such as dialysis. This article addresses the key considerations of supportive care as part of integrated end-stage kidney disease care, with particular attention paid to programs in low- and middle-income countries. Supportive care should be an integrated component of care for patients with advanced chronic kidney disease, patients receiving kidney replacement therapy (KRT), and patients receiving non-KRT conservative care. Five themes are identified: improving information on prognosis and support, developing context-specific evidence, establishing appropriate metrics for monitoring care, clearly communicating the role of supportive care, and integrating supportive care into existing health care infrastructures. This report explores some general aspects of these 5 domains, before exploring their consequences in 4 health care situations/settings: in people approaching end-stage kidney disease in high-income countries and in low- and middle-income countries, and in people discontinuing KRT in high-income countries and in low- and middle-income countries.
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O'Connell PJ, Brown M, Chan TM, Claure-Del Granado R, Davies SJ, Eiam-Ong S, Hassan MH, Kalantar-Zadeh K, Levin A, Martin DE, Muller E, Ossareh S, Tchokhonelidze I, Trask M, Twahir A, Were AJO, Yang CW, Zemchenkov A, Harden PN. The role of kidney transplantation as a component of integrated care for chronic kidney disease. Kidney Int Suppl (2011) 2020; 10:e78-e85. [PMID: 32149012 DOI: 10.1016/j.kisu.2019.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/11/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022] Open
Abstract
Kidney transplant provides superior outcomes to dialysis as a treatment for end-stage kidney disease. Therefore, it is essential that kidney transplantation be part of an integrated treatment and management plan for chronic kidney disease (CKD). Developing an effective national program of transplantation is challenging because of the requirement for kidney donors and the need for a multidisciplinary team to provide expert care for both donors and recipients. This article outlines the steps necessary to establish a national kidney transplant program, starting with the requirement for effective legislation that provides the legal framework for transplantation whilst protecting organ donors, their families, recipients, and staff and is an essential requirement to combat organ trafficking. The next steps involve capacity building with the development of a multiskilled workforce, the credentialing of transplant centers, and the reporting of outcomes through national or regional registries. Although it is accepted that most transplant programs will begin with living related kidney donation, it is essential to aspire to and develop a deceased donor program. This requires engagement with multiple stakeholders, especially the patients, the general community, intensivists, and health departments. Development of transplant centers should be undertaken in concert with the development of a dialysis program. Both are essential components of integrated care for CKD and both should be viewed as part of the World Health Organization's initiative for universal health coverage. Provisions to cover the costs of treatment for patients need to be developed taking into account the state of development of the overall health framework in each country.
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Cho Y, Davies SJ, Johnson DW. Raising the standard of trial registration, conduct, and reporting. Perit Dial Int 2020; 40:112-114. [PMID: 32063221 DOI: 10.1177/0896860820902009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Davies SJ, Finkelstein FO. Accuracy of the estimation of V and the implications this has when applying Kt/Vurea for measuring dialysis dose in peritoneal dialysis. Perit Dial Int 2020; 40:261-269. [DOI: 10.1177/0896860819893817] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Current guidelines for the prescription of peritoneal dialysis dose rely on a single cut-off ‘minimal’ value of K t/ V. To apply this in the clinic, this requires an accurate estimation of V, the volume of urea distribution that equates to the total body water (TBW). This analysis sought to determine the accuracy to which V can be estimated. Methods: A literature search was undertaken of studies comparing TBW estimation using two or three of the following methods: isotopic dilution (gold standard), anthropometric equations (e.g. Watson formula) and bioimpedance analysis. Studies of healthy and dialysis populations of all ages were included. Mean differences and 95% limits of agreement (LOA) were extracted and pooled. Results: In 44 studies (31 including dialysis subjects), the between-method population means were typically within 1–1.5 L of each other, although larger bias was seen when applying anthropometric equations to different racial groups. However, the 95% LOA for all comparisons were consistently wide, typically ranging ±12–18% of the TBW. For a typical individual whose TBW is 35 L with a measured K t/ V of 1.7, this translates into a range of K t/ V 1.4–2.05. Conclusions: There are limitations to the accuracy of estimation of V which call into question the validity of applying a single threshold K t/ V value as indicative of adequate dialysis. This should be taken into account in guideline development such that if a target K t/ V was deemed appropriate that this should be expressed as a range; alternatively single targets should be avoided and dialysis dose should be determined according to patient need.
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Abstract
Incremental peritoneal dialysis (PD) has been variably defined. It involves taking advantage of the residual renal function that is usually present at initiation of dialysis to initially prescribe less onerous lower doses of PD while still achieving individualized clearance goals. We propose that incremental PD be defined as a strategy, rather than a particular regime, in which: (1) less than standard “full-dose” PD is initially prescribed in recognition of the value of residual renal function; (2) peritoneal clearance is initially less than the individualized clearance goal but the combination of peritoneal plus renal clearance achieves or exceeds that goal clearance; and (3) there is a clear intention to increase dose of PD as renal clearance declines and/or symptoms appear.Incremental PD by its nature lessens the workload of dialysis for those doing PD, reduces cost and exposure of the peritoneal membrane to glucose, and may lessen mechanical symptoms. Evidence that incremental PD improves clinical outcomes compared to the use of full-dose PD is lacking but one randomized controlled trial, multiple observational studies, and a systematic review all suggest that outcomes are at least as good. Given that incremental PD costs less and is inherently less onerous, it is reasonable, pending larger randomized trials, to adopt this strategy.
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Yankouskaya A, Boughey A, McCagh J, Neal A, de Bezenac C, Davies SJ. Illness Perception Mediates the Relationship Between the Severity of Symptoms and Perceived Health Status in Patients With Behçet Disease. J Clin Rheumatol 2019; 25:319-324. [PMID: 31764491 DOI: 10.1097/rhu.0000000000000872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between psychological representations of illness, perceived health status, and self-assessment of symptom severity in patients with Behçet disease, a rare long-term incurable condition with unclear etiology. METHODS Using cross-sectional survey design, data on self-administered questionnaires on illness perception, health status, symptoms severity, and demographic characteristics were collected from 273 patients with Behçet disease (age range, 18-65 years). The data were subjected to mediation analysis to test whether cognitive and emotional components of illness perception mediate the relationship between the severity of symptoms and heath status. RESULTS The results support our hypotheses that cognitive components of illness perception (perceived consequences and identity of the illness) mediate the link between symptom activity and pain, whereas emotional components of the illness (emotional representations about the illness) mediate the relationship between disease activity and perceived energy level. CONCLUSIONS The robustness of these mediation effects suggests potential directions for clinical psychologists and health care practitioners in developing support programs. We supplement our study with Open Access database containing information about type of medication, comorbid mood disorder, and detailed measurement of the severity of BD symptoms for sharing and accumulating multidisciplinary knowledge aiming to support the development of interventions. Addressing psychological aspects of BD will help to manage complex patients effectively.
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Perlman RL, Zhao J, Fuller DS, Bieber B, Li Y, Pisoni RL, Robinson BM, Johnson DW, Kawanishi H, Davies SJ, Schreiber MJ, Perl J. International Anemia Prevalence and Management in Peritoneal Dialysis Patients. Perit Dial Int 2019; 39:539-546. [PMID: 31582465 DOI: 10.3747/pdi.2018.00249] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/10/2019] [Indexed: 12/13/2022] Open
Abstract
Background:The optimal treatment for managing anemia in peritoneal dialysis (PD) patients and best clinical practices are not completely understood. We sought to characterize international variations in anemia measures and management among PD patients.Methods:The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) enrolled adult PD patients from 6 countries from 2014 to 2017. Hemoglobin (Hb), ferritin levels, and transferrin saturation (TSAT), as well as erythropoiesis stimulating agents (ESAs) and iron use were compared cross-sectionally at study enrollment in Australia and New Zealand (A/NZ), Canada, Japan, the United Kingdom (UK), and the United States (US).Results:Among 3,603 PD patients from 193 facilities, mean Hb ranged from 11.0 - 11.3 g/dL across countries. The majority of patients (range 53% - 59%) had Hb 10 - 11.9 g/dL, with 4% - 12% patients ≥ 13 g/dL and 16% - 23% < 10 g/dL. Use of ESAs was higher in Japan (94% of patients) than elsewhere (66% - 79% of patients). In the US, 63% of patients had a ferritin level > 500 ng/mL, compared with 5% - 38% in other countries. In the US and Japan, 87% - 89% of PD patients had TSAT ≥ 20%, compared with 73% - 76% in other countries. Intravenous (IV) iron use within 4 months of enrollment was higher in the US (55% of patients) than elsewhere (6% - 17% patients).Conclusions:In this largest international observational study of anemia and anemia management in patients receiving PD, comparable Hb levels across countries were observed but with notable differences in ESA and iron use. Peritoneal dialysis patients in the US have higher ferritin levels and higher IV iron use than other countries.
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