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Munshi R, Swartz SJ. Incremental dialysis: review of the literature with pediatric perspective. Pediatr Nephrol 2024; 39:49-55. [PMID: 37306719 DOI: 10.1007/s00467-023-06030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/24/2023] [Accepted: 05/12/2023] [Indexed: 06/13/2023]
Abstract
Drivers towards initiation of kidney replacement therapy in advanced chronic kidney disease include metabolic and fluid derangements, growth, and nutritional status with focus on health optimization. Once initiated, prescription of dialysis is often uniform despite variability in patient characteristics and etiology of kidney failure. Preservation of residual kidney function has been associated with improved outcomes in patients with advanced chronic kidney disease on dialysis. Incremental dialysis is the approach of reducing the dialysis dose by reduction in treatment time, days, or efficiency of clearance. Incremental dialysis has been described in adults at initiation of kidney replacement therapy, to better preserve residual kidney function and meet the individual needs of the patient. Consideration of incremental dialysis in pediatrics may be reasonable in a subset of children with continued emphasis on promotion of growth and development.
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Affiliation(s)
- Raj Munshi
- Division of Pediatric Nephrology, Department of Pediatrics, Seattle Children's, University of Washington, Seattle, WA, USA.
| | - Sarah J Swartz
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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2
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Roux C, Verollet K, Prouvot J, Prelipcean C, Pambrun E, Moranne O. Choosing the right chronic medication for hemodialysis patients. A short ABC for the dialysis nephrologist. J Nephrol 2023; 36:521-536. [PMID: 36472789 DOI: 10.1007/s40620-022-01477-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adapting drug treatments for patients on hemodialysis with multiple chronic pathologies is a complex affair. When prescribing a medication, the risk-benefit analysis usually focuses primarily on the indication of the drug class prescribed. However, the pharmacokinetics of the chosen drug should also be taken into account. The purpose of our review was to identify the drugs to be favored in each therapeutic class, according to their safety and pharmacokinetic profiles, for the most common chronic diseases in patients on chronic hemodialysis. METHODS We conducted a narrative review of the literature using Medline and Web of Science databases, targeting studies on the most commonly-prescribed drugs for non-communicable diseases in patients on chronic hemodialysis. RESULTS The search identified 1224 articles, 95 of which were further analyzed. The main classes of drugs included concern the cardiovascular system (anti-hypertensives, anti-arrhythmics, anti-thrombotics, hypocholesterolemics), the endocrine and metabolic pathways (anti-diabetics, gastric anti-secretory, anticoagulant, thyroid hormones, anti-gout) and psychiatric and neurological disorders (antidepressants, anxiolytics, antipsychotics and anti-epileptics). CONCLUSION We report on the most often prescribed drugs for chronic pathologies in patients on chronic hemodialysis. Most of them require adaptation, and in some cases one better alternative stands out among the drug class. More pharmacokinetic data are needed to define the pharmacokinetics in the various dialysis techniques.
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Affiliation(s)
- Clarisse Roux
- Service Pharmacie, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France.
- Institut Desbrest d'Epidemiologie et Santé publique (IDESP), INSERM, Montpellier, France.
| | - Kristelle Verollet
- Service Pharmacie, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Julien Prouvot
- Institut Desbrest d'Epidemiologie et Santé publique (IDESP), INSERM, Montpellier, France
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Camelia Prelipcean
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Emilie Pambrun
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Olivier Moranne
- Institut Desbrest d'Epidemiologie et Santé publique (IDESP), INSERM, Montpellier, France.
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France.
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3
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Dialysis symptom index burden and symptom clusters in a prospective cohort of dialysis patients. J Nephrol 2022; 35:1427-1436. [PMID: 35429297 PMCID: PMC9217843 DOI: 10.1007/s40620-022-01313-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/19/2022] [Indexed: 12/16/2022]
Abstract
Background Dialysis patients experience a high symptom burden, which may adversely impact their quality of life. Whereas other specialties emphasize routine symptom assessment, symptom burden is not well-characterized in dialysis patients. We sought to examine the prevalence and severity of unpleasant symptoms in a prospective hemodialysis cohort. Methods Among 122 hemodialysis patients from the prospective Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease (CKD) study, CKD-associated symptoms were ascertained by the Dialysis Symptom Index, a validated survey assessing symptom burden/severity (with higher scores indicating greater symptom severity), over 6/2020–10/2020. We examined the presence of (1) individual symptoms and symptom severity scores, and (2) symptom clusters (defined as ≥ 2 related concurrent symptoms), as well as correlations with clinical characteristics. Results Symptom severity scores were higher among non-Hispanic White and Hispanic patients, whereas scores were lower in Black and Asian/Pacific Islander patients. In the overall cohort, the most common individual symptoms included feeling tired/lack of energy (71.3%), dry skin (61.5%), trouble falling asleep (44.3%), muscle cramps (42.6%), and itching (42.6%), with similar patterns observed across racial/ethnic groups. The most prevalent symptom clusters included feeling tired/lack of energy + trouble falling asleep (37.7%); trouble falling asleep + trouble staying asleep (34.4%); and feeling tired/lack of energy + trouble staying asleep (32.0%). Lower hemoglobin, iron stores, and dialysis adequacy correlated with higher individual and overall symptom severity scores. Conclusion We observed a high prevalence of unpleasant symptoms and symptom clusters in a diverse hemodialysis cohort. Further studies are needed to identify targeted therapies that ameliorate symptom burden in CKD. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s40620-022-01313-0.
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Chen W, Wang M, Zhang M, Zhang W, Shi J, Weng J, Huang B, Kalantar-Zadeh K, Chen J. Benefits of Incremental Hemodialysis Seen in a Historical Cohort Study. Ther Clin Risk Manag 2021; 17:1177-1186. [PMID: 34803381 PMCID: PMC8598204 DOI: 10.2147/tcrm.s332218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/25/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Previous research on incremental hemodialysis transition has mainly focused on one or two benefits or prognoses. We aimed to conduct a comprehensive analysis by investigating whether incremental hemodialysis was simultaneously associated with adequate dialysis therapy, stable complication indicators, long-lasting arteriovenous vascular access, and long-lasting preservation of residual kidney function (RKF) without increasing mortality or hospitalization. Patients and Methods Incident hemodialysis patients from Huashan Hospital in Shanghai, China, over the period of 2012 to 2019, were enrolled and followed every three months until death or the time of censoring. Changes in complication indicators from baseline to all post-baseline visits were analyzed by mixed-effects models. The outcomes of RKF loss, arteriovenous vascular access complications, and the composite of all-cause mortality and cardiovascular events were compared between incremental and conventional hemodialysis by Cox proportional hazards model. Results Of the 113 patients enrolled in the study, 45 underwent incremental and 68 conventional hemodialysis. There were no significant differences in the changes from baseline to post-baseline visits in complication indicators between the two groups. Incremental hemodialysis reduced the risks of RKF loss (HR, 0.33; 95% CI, 0.14–0.82), de novo arteriovenous access complication (HR, 0.26; 95% CI, 0.08–0.82), and recurrent arteriovenous access complications under the Andersen–Gill (AG) model (HR, 0.27; 95% CI, 0.10–0.74) and the Prentice, Williams and Peterson Total Time (PWP-TT) model (HR, 0.31; 95% CI, 0.12–0.80). There were no significant differences in all-cause hospitalization or the composite outcome between groups. Conclusion Incremental hemodialysis is an effective dialysis transition strategy that preserves RKF and arteriovenous access without affecting dialysis adequacy, patient stability, hospitalization risk and mortality risk. Randomized controlled trials are warranted.
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Affiliation(s)
- Weisheng Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Mengjing Wang
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Minmin Zhang
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Weichen Zhang
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Jun Shi
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Jiamin Weng
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Bihong Huang
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Fielding School of Public Health at UCLA, Los Angeles, CA, USA.,Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
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Torreggiani M, Fois A, Njandjo L, Longhitano E, Chatrenet A, Esposito C, Fessi H, Piccoli GB. Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis. Expert Rev Mol Diagn 2021; 21:1119-1137. [PMID: 34595991 DOI: 10.1080/14737159.2021.1987216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis. AREAS COVERED In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis. EXPERT OPINION In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.
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Affiliation(s)
| | - Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Linda Njandjo
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France.,Laboratory "Movement, Interactions, Performance" (EA 4334), Le Mans University, Le Mans, France
| | - Ciro Esposito
- Nephrology and Dialysis, ICS Maugeri S.p.A. Sb, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Hafedh Fessi
- Department of Nephrology, Hospital Tenon, Paris, France
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6
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Stewart J, Stewart P, Walker T, Viramontes-Hörner D, Lucas B, White K, Taal MW, Selby NM, Morris M. An iterative run-to-run learning model to derive continuous brachial pressure estimates from arterial and venous lines during dialysis treatment. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2020.102346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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7
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Piccoli GB, Di Iorio BR, Chatrenet A, D'Alessandro C, Nazha M, Capizzi I, Vigotti FN, Fois A, Maxia S, Saulnier P, Cabiddu G, Cupisti A. Dietary satisfaction and quality of life in chronic kidney disease patients on low-protein diets: a multicentre study with long-term outcome data (TOrino-Pisa study). Nephrol Dial Transplant 2020; 35:790-802. [PMID: 31435654 DOI: 10.1093/ndt/gfz147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 06/27/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Concerns about adherence and quality of life (QoL) limit the diffusion of low-protein diets (LPDs) as a way to slow chronic kidney disease (CKD) progression and postpone dialysis. The aim of this multicentre study is to assess dietary satisfaction in stable CKD patients. METHODS This was a multicentre cross-sectional study with long-term follow-up data. Prevalent patients on LPD for at least 6 months were selected in four Italian centres. QoL was assessed using the World Health Organization Quality of Life questionnaire, and diet satisfaction with the Modification of Diet in Renal Disease satisfaction questionnaire. Comorbidity was assessed by Charlson Comorbidity Index, estimated glomerular filtration rate (eGFR) was calculated by the CKD Epidemiology Collaboration equation and protein intake by Maroni-Mitch formula. Survival was analysed with Kaplan-Meier curves and Cox Proportional Hazard Model. RESULTS Four hundred and twenty-two CKD Stages 3-5 patients were enrolled. Over 95% were on moderately restricted diets (0.6 g/kg/day). Compliance was good (protein intake: 0.59 g/kg/day at baseline, 0.72 at the end of follow-up). Median dietary satisfaction was 4 on a 1-5 scale. QoL was not affected by the type of diet, but was influenced by age, comorbidity and setting of care. Two years later, at the end of follow-up, 66.6% of the patients were still on a diet; the main causes of discontinuation were dialysis and death. The dropout rate was low (5.5%); in Cox analysis, patient and renal survival were influenced by age and eGFR, but not by QoL, setting of care or type of diet. CONCLUSIONS LPDs are compatible with high dietary satisfaction and minimal dropout, at least in patients who are able to follow such a diet for at least 6 months.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Specialized Medicine, Nephrology, Centre Hospitalier Le Mans, Le Mans, France.,Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | | | - Antoine Chatrenet
- Department of Specialized Medicine, Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | | | - Marta Nazha
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Irene Capizzi
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | | | - Antioco Fois
- Department of Specialized Medicine, Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Stefania Maxia
- Nephrology, Department of Medicine, Ospedale Brotzu, Cagliari, Italy
| | | | | | - Adamasco Cupisti
- Nephrology, Department of Medicine, University of Pisa, Pisa, Italy
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8
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Stewart J, Stewart P, Walker T, Horner DV, Lucas B, White K, Muggleton A, Morris M, Selby NM, Taal MW. A Feasibility Study of Non-Invasive Continuous Estimation of Brachial Pressure Derived From Arterial and Venous Lines During Dialysis. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE-JTEHM 2020; 9:2700209. [PMID: 33200053 PMCID: PMC7665243 DOI: 10.1109/jtehm.2020.3035988] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/07/2020] [Accepted: 10/19/2020] [Indexed: 12/12/2022]
Abstract
Objective: Intradialytic haemodynamic instability is a significant clinical problem, leading to end-organ ischaemia and contributing to morbidity and mortality in haemodialysis patients. Non-invasive continuous blood pressure monitoring is not currently part of routine practice but may aid detection and prevention of significant falls in blood pressure during dialysis. Brachial blood pressure is currently recorded intermittently during haemodialysis via a sphygmomanometer. Current methods of continuous non-invasive blood pressure monitoring tend to restrict movement, can be sensitive to external disturbances and patient movement, and can be uncomfortable for the wearer. Additionally, poor patient blood circulation can lead to unreliable measurements. In this feasibility study we performed an initial validation of a novel method and associated technology to continuously estimate blood pressure using pressure sensors in the extra-corporeal dialysis circuit, which does not require any direct contact with the person receiving dialysis treatment. Method: The paper describes the development of the measurement system and subsequent in vivo patient feasibility study with concurrent measurement validation by Finapres Nova physiological measurement device. Real-time physiological data is collected over the entire period of (typically 4-hour) dialysis treatment. Results: We identify a quasi-linear mathematical function to describe the relationship between arterial line pressure and brachial artery BP, which is confirmed in a patient study. The results from this observational study suggest that it is feasible to derive a continuous measurement of brachial pressure from continuous measurements of arterial and venous line pressures via an empirically based and updated mathematical model. Conclusion: The methodology presented requires no interfacing to proprietary dialysis machine systems, no sensors to be attached to the patient directly, and is robust to patient movement during treatment and also to the effects of the cyclical pressure waveforms induced by the hemodialysis peristaltic blood pump. This represents a key enabling factor to the development of a practical continuous blood pressure monitoring device for dialysis patients.
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Affiliation(s)
- Jill Stewart
- School of Health and Social CareUniversity of DerbyDerbyDE22 1GBU.K
| | - Paul Stewart
- School of Health and Social CareUniversity of DerbyDerbyDE22 1GBU.K
| | - Thomas Walker
- School of Health and Social CareUniversity of DerbyDerbyDE22 1GBU.K
| | - Daniela Viramontes Horner
- Centre for Kidney Research and InnovationUniversity of NottinghamNottinghamNG7 2RDU.K.,Renal UnitRoyal Derby HospitalDerbyDE22 3NEU.K
| | - Bethany Lucas
- Centre for Kidney Research and InnovationUniversity of NottinghamNottinghamNG7 2RDU.K.,Renal UnitRoyal Derby HospitalDerbyDE22 3NEU.K
| | - Kelly White
- Renal UnitRoyal Derby HospitalDerbyDE22 3NEU.K
| | | | - Mel Morris
- MStart Foundation and iTrend Medical Research Ltd.DerbyDE24 8DZU.K
| | - Nicholas M Selby
- Centre for Kidney Research and InnovationUniversity of NottinghamNottinghamNG7 2RDU.K.,Renal UnitRoyal Derby HospitalDerbyDE22 3NEU.K
| | - Maarten W Taal
- Centre for Kidney Research and InnovationUniversity of NottinghamNottinghamNG7 2RDU.K.,Renal UnitRoyal Derby HospitalDerbyDE22 3NEU.K
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9
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Ikizler TA. Dialysis: learning dialysis through computation, experimentation, and implementation. Kidney Int 2020; 98:246-250. [PMID: 32709282 DOI: 10.1016/j.kint.2020.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 11/19/2022]
Affiliation(s)
- T Alp Ikizler
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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10
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Residual Urine Output and Mortality in a Prospective Hemodialysis Cohort. Kidney Int Rep 2020; 5:643-653. [PMID: 32405586 PMCID: PMC7210610 DOI: 10.1016/j.ekir.2020.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 01/11/2020] [Accepted: 02/03/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction Although residual urine output (UOP) is associated with better survival and quality of life in dialysis patients, frequent measurement by 24-hour urine collection is burdensome. We thus sought to examine the association of patients’ self-reported residual UOP, as an alternative proxy of measured residual UOP, with mortality risk in a prospective hemodialysis cohort study. Methods Among 670 hemodialysis patients from the prospective multicenter Malnutrition, Diet, and Racial Disparities in Kidney Disease study, we examined associations of residual UOP, ascertained by patient self-report, with all-cause mortality. Patients underwent protocolized surveys assessing presence and frequency of UOP (absent, every 1–3 days, >1 time per day) every 6 months from 2011 to 2015. We examined associations of baseline and time-varying UOP with mortality using Cox regression. Results In analyses of baseline UOP, absence of UOP was associated with higher mortality in expanded case-mix adjusted Cox models (ref: presence of UOP): hazard ratio (HR), 1.78 (95% confidence interval [CI], 1.16–2.72). In analyses examining baseline frequency of UOP, point estimates suggested a graded association between lower frequency of UOP and higher mortality, although estimates for UOP every 1 to 3 days did not reach statistical significance (reference: UOP >1 time per day): HR, 1.29 (95% CI, 0.82–2.05) and HR, 1.97 (95% CI, 1.24–3.12) for UOP every 1 to 3 days and absence of UOP, respectively. Similar findings were observed in analyses of time-varying UOP. Conclusion In hemodialysis patients, there is a graded association between lower frequency of self-reported UOP and higher mortality. Further studies are needed to determine the clinical impact of more frequent assessment of residual UOP using self-reported methods.
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11
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Sy J, Kalantar-Zadeh K. Combining Peritoneal and Hemodialysis in the Same Patient: Furthering Precision Medicine in Dialysis Transitions. Kidney Int Rep 2020; 5:389-391. [PMID: 32281987 PMCID: PMC7136427 DOI: 10.1016/j.ekir.2020.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- John Sy
- University of California Irvine, Orange, California, USA
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12
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Hospitalization for Patients on Combination Therapy With Peritoneal Dialysis and Hemodialysis Compared With Hemodialysis. Kidney Int Rep 2020; 5:468-474. [PMID: 32280842 PMCID: PMC7136431 DOI: 10.1016/j.ekir.2020.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/31/2019] [Accepted: 01/13/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction Combination therapy with peritoneal dialysis and hemodialysis (PD+HD) is widely used for PD patients with decreased residual kidney function in Japan; however, hospitalization for this combined dialysis has not been investigated so far. We compared the risk of hospitalization for PD+HD with that for HD. Methods A multicenter, prospective observational study was conducted on 42 PD+HD and 42 HD patients matched for age and diabetic nephropathy. The main outcome measure was the cumulative incidence of hospitalization for any cause assessed with the Kaplan-Meier method. Hospitalization rates (the number of admissions per 100 patient-years) associated with dialysis modality were also calculated. The impact of dialysis modality on time to hospitalization was analyzed using the Cox proportional hazard model. Results There was no significant difference between groups in terms of age, sex, dialysis vintage, diabetic nephropathy, and comorbidities. The cumulative incidence of hospitalization did not significantly differ between the groups (log-rank test, P = 0.36). Although total hospitalization rates were 66.0 in PD+HD and 59.2 in HD, hospitalization rates for the sum of PD-related infections (a composite of catheter-related infection and peritonitis) and vascular access troubles were 21.7 in PD+HD and 7.2 in HD. On univariate Cox proportional hazard analysis, dialysis modality had no significant impact on time to hospitalization. Conclusion The risk of hospitalization was not significantly different between PD+HD and HD, although PD+HD patients had a higher risk of dialysis access–related complications than HD patients.
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14
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Abstract
In the United States, end-stage renal disease patients receiving hemodialysis have an exceedingly high risk of sudden cardiac death (SCD), accounting for 29% of death events, likely relating to their uremic milieu, recurring exposure to fluid and electrolyte fluxes, and underlying cardiovascular pathology. Furthermore, epidemiologic studies have shown that SCD events, as well as mortality and hospitalizations, occur most frequently on the first dialysis day after the long interdialytic gap, suggesting that abrupt fluctuations in the accumulation and removal of electrolytes, fluid, and uremic toxins over the dialysis cycle may be contributory. Some population-based observational studies have suggested that lower dialysate potassium concentrations appear to be associated with a heightened risk of postdialysis cardiac arrest in hemodialysis patients, although the optimal serum-to-dialysate potassium gradient remains unclear. Some observational studies have suggested that low dialysate calcium concentrations and high serum-to-dialysate calcium gradients may predispose patients to SCD. There is ongoing controversy about an association between higher dialysate bicarbonate concentrations and higher risk of cardiac arrest, likely owing to confounding by indication. Some observational studies also have shown that large interdialytic weight gains, fluid retention, and high ultrafiltration rates are linked with higher risk of SCD and mortality. However, there remains considerable controversy regarding the pros and cons of designating a specific upper ultrafiltration limit with extended treatment times as a clinical practice measure, and further studies are needed to define the optimal tools, metrics, targets, and implementation measures for volume control in the hemodialysis population. In this review, we highlight the epidemiology and pathophysiology of how specific aspects of the hemodialysis procedure may relate to the risk of SCD, as well as preventative strategies and future research directions that can address this risk.
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15
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Piccoli GB, Cabiddu G, Breuer C, Jadeau C, Testa A, Brunori G. Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices? J Clin Med 2019; 8:jcm8020276. [PMID: 30823518 PMCID: PMC6406585 DOI: 10.3390/jcm8020276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 12/15/2022] Open
Abstract
Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Conrad Breuer
- Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Christelle Jadeau
- Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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