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Le D, Grams ME, Coresh J, Shin JI. Sacubitril-Valsartan in Patients Requiring Hemodialysis. JAMA Netw Open 2024; 7:e2429237. [PMID: 39163041 DOI: 10.1001/jamanetworkopen.2024.29237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2024] Open
Abstract
Importance Randomized clinical trials have shown that sacubitril-valsartan reduces the risks of mortality and hospitalization in patients with heart failure with reduced ejection fraction (HFrEF), but patients with kidney failure requiring dialysis were excluded. Objective To investigate the comparative effectiveness of sacubitril-valsartan vs angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs or ARBs) in patients with HFrEF requiring hemodialysis. Design, Setting, and Participants This retrospective, 1:1 propensity score-matched comparative effectiveness study included patients who were 18 years or older with HFrEF, enrolled in Medicare Parts A, B, and D, and survived at least 90 days receiving in-center hemodialysis from July 8, 2015, to December 31, 2020. Patients were excluded for less than 180 days of continuous Medicare Parts A, B, and D primary payer coverage or prior dispensing of sacubitril-valsartan. Data analysis was conducted from September 23, 2023, to June 25, 2024. Exposures New use of sacubitril-valsartan vs new or continued use of ACEIs or ARBs. Main Outcomes and Measures The associations between initiation of sacubitril-valsartan therapy and all-cause mortality, cardiovascular mortality, all-cause hospitalization, and HF hospitalization were assessed using Cox proportional hazards regression models in a propensity score-matched sample. Results Participants included 1:1 matched pairs of 1434 sacubitril-valsartan users and 1434 ACEI or ARB users (mean [SD] age, 64 [13] years). Of the 2868 matched participants, 996 (65%) were male; 987 (34%) were Black or African American and 1677 (58%) were White; and median dialysis vintage was 3.8 (IQR, 1.8-6.3) years. The median follow-up was 0.9 (IQR, 0.4-1.7) years. Sacubitril-valsartan (vs ACEI or ARB) therapy was associated with a reduction in all-cause mortality (hazard ratio [HR], 0.82 [95% CI, 0.73-0.92]) and all-cause hospitalization (HR, 0.86 [95% CI, 0.79-0.93]) but not cardiovascular mortality (HR, 1.01 [95% CI, 0.86-1.19]) or HF hospitalization (HR, 0.91 [95% CI, 0.82-1.02]). There was a decrease in hyperkalemia (HR, 0.71 [95% CI, 0.62-0.81]) and no difference in hypotension (HR, 0.99 [95% CI, 0.83-1.19]). Only 195 participants (14%) ever received the maximum combination dose of sacubitril (97 mg twice daily) and valsartan (103 mg twice daily). Conclusions and Relevance In this comparative effectiveness study of patients with HFrEF requiring hemodialysis, sacubitril-valsartan therapy was associated with beneficial effects in all-cause mortality and all-cause hospitalization.
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Affiliation(s)
- Dustin Le
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Morgan E Grams
- Division of Precision Medicine, Department of Medicine, New York University, New York, New York
| | - Josef Coresh
- Optimal Aging Institute, Department of Medicine, New York University, New York, New York
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Tabibzadeh N, Wang D, Karaboyas A, Schaeffner E, Jacobson SH, Vega A, Nitta K, Bieber B, Pecoits-Filho R, Torres PAU. Diuretic prescriptions in the first year of haemodialysis: international practice patterns and associations with outcomes. Clin Kidney J 2024; 17:sfae141. [PMID: 38989279 PMCID: PMC11233991 DOI: 10.1093/ckj/sfae141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Indexed: 07/12/2024] Open
Abstract
Background The use of diuretics in patients on haemodialysis (HD) is thought to maintain diuresis. However, this assumption and the optimal dose are based on little scientific evidence, and associations with clinical outcomes are unclear. Methods We reported international variations in diuretic use and loop diuretic dose across 27 759 HD patients with dialysis vintage <1 year in the Dialysis Outcomes and Practice Patterns Study phases 2-5 (2002-2015), a prospective cohort study. Doses of torsemide (4:1) and bumetanide (80:1) were converted to oral furosemide-equivalent doses. Adjusted Cox, logistic and linear regressions were used to investigate the association of diuretic use and dose with outcomes. Results Diuretic utilization varied widely by country at vintage <3 months, ranging from >80% in Germany and Sweden to <35% in the USA, at a median dose ranging from 400-500 mg/day in Germany and Sweden to <100 mg/day in Japan and the USA. Neither diuretic use nor higher doses were associated with a lower risk of all-cause mortality, a higher risk of hospitalization for fracture or elevated parathyroid hormone levels, but the prescription of higher doses (>200 mg/day) was associated with a higher risk of all-cause hospitalization. Conclusions Substantial international differences exist in diuretic prescriptions, with use and doses much higher in some European countries than the USA. The prescription and higher doses of loop diuretics was not associated with improved outcomes.
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Affiliation(s)
- Nahid Tabibzadeh
- Nephrology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Dongyu Wang
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Elke Schaeffner
- Department of Nephrology, Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Almudena Vega
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Pablo Antonio Ureña Torres
- Department of Dialysis, AURA Nord Saint Ouen, Saint-Ouen, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
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Murea M, Raimann JG, Divers J, Maute H, Kovach C, Abdel-Rahman EM, Awad AS, Flythe JE, Gautam SC, Niyyar VD, Roberts GV, Jefferson NM, Shahidul I, Nwaozuru U, Foley KL, Trembath EJ, Rosales ML, Fletcher AJ, Hiba SI, Huml A, Knicely DH, Hasan I, Makadia B, Gaurav R, Lea J, Conway PT, Daugirdas JT, Kotanko P. Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial). Trials 2024; 25:424. [PMID: 38943204 PMCID: PMC11212207 DOI: 10.1186/s13063-024-08281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/20/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients. METHODS An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients). DISCUSSION Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers. TRIAL REGISTRATION Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA.
| | | | - Jasmin Divers
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Harvey Maute
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Emaad M Abdel-Rahman
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Alaa S Awad
- Division of Nephrology, University of Florida, Jacksonville, FL, USA
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Samir C Gautam
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Vandana D Niyyar
- Division of Nephrology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Glenda V Roberts
- External Relations and Patient Engagement, Division of Nephrology, Department of Medicine, Kidney Research Institute and Center for Dialysis Innovation, University of Washington, Seattle, WA, USA
| | | | - Islam Shahidul
- Department of Foundations of Medicine, Center for Population and Health Services Research, NYU Grossman Long Island School of Medicine, New York, NY, USA
| | - Ucheoma Nwaozuru
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kristie L Foley
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Alison J Fletcher
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Sheikh I Hiba
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Anne Huml
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Daphne H Knicely
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Irtiza Hasan
- Division of Nephrology, University of Florida, Jacksonville, FL, USA
| | | | - Raman Gaurav
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Janice Lea
- Division of Nephrology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Paul T Conway
- American Association of Kidney Patients, Tampa, FL, USA
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Peter Kotanko
- Department of Internal Medicine, Section on Nephrology, LLC Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Obi Y, Raimann JG, Kalantar-Zadeh K, Murea M. Residual Kidney Function in Hemodialysis: Its Importance and Contribution to Improved Patient Outcomes. Toxins (Basel) 2024; 16:298. [PMID: 39057938 PMCID: PMC11281084 DOI: 10.3390/toxins16070298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/27/2024] [Accepted: 06/11/2024] [Indexed: 07/28/2024] Open
Abstract
Individuals afflicted with advanced kidney dysfunction who require dialysis for medical management exhibit different degrees of native kidney function, called residual kidney function (RKF), ranging from nil to appreciable levels. The primary focus of this manuscript is to delve into the concept of RKF, a pivotal yet under-represented topic in nephrology. To begin, we unpack the definition and intrinsic nature of RKF. We then juxtapose the efficiency of RKF against that of hemodialysis in preserving homeostatic equilibrium and facilitating physiological functions. Given the complex interplay of RKF and overall patient health, we shed light on the extent of its influence on patient outcomes, particularly in those living with advanced kidney dysfunction and on dialysis. This manuscript subsequently presents methodologies and measures to assess RKF, concluding with the potential benefits of targeted interventions aimed at preserving RKF.
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Affiliation(s)
- Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, The University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Jochen G. Raimann
- Renal Research Institute, New York, NY 10065, USA;
- Katz School of Science and Health, Yeshiva University, New York, NY 10033, USA
| | - Kamyar Kalantar-Zadeh
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA;
- The Lundquist Institute at Harbor, UCLA Medical Center, Torrance, CA 90502, USA
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
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Siddiqui R, Obi Y, Dossabhoy NR, Shafi T. Is There a Role for SGLT2 Inhibitors in Patients with End-Stage Kidney Disease? Curr Hypertens Rep 2024:10.1007/s11906-024-01314-3. [PMID: 38913113 DOI: 10.1007/s11906-024-01314-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE OF REVIEW Chronic kidney disease and end-stage kidney disease (ESKD) are well-established risk factors for cardiovascular disease (CVD), the leading cause of mortality in the dialysis population. Conventional therapies, such as statins, blood pressure control, and renin-angiotensin-aldosterone system blockade, have inadequately addressed this cardiovascular risk, highlighting the unmet need for effective treatment strategies. Sodium-glucose transporter 2 (SGLT2) inhibitors have demonstrated significant renal and cardiovascular benefits among patients with type 2 diabetes, heart failure, or CKD at risk of progression. Unfortunately, efficacy data in dialysis patients is lacking as ESKD was an exclusion criterion for all major clinical trials of SGLT2 inhibitors. This review explores the potential of SGLT2 inhibitors in improving cardiovascular outcomes among patients with ESKD, focusing on their direct cardiac effects. RECENT FINDINGS Recent clinical and preclinical studies have shown promising data for the application of SGLT2 inhibitors to the dialysis population. SGLT2 inhibitors may provide cardiovascular benefits to dialysis patients, not only indirectly by preserving the remaining kidney function and improving anemia but also directly by lowering intracellular sodium and calcium levels, reducing inflammation, regulating autophagy, and alleviating oxidative stress and endoplasmic reticulum stress within cardiomyocytes and endothelial cells. This review examines the current clinical evidence and experimental data supporting the use of SGLT2 inhibitors, discusses its potential safety concerns, and outlines ongoing clinical trials in the dialysis population. Further research is needed to evaluate the safety and effectiveness of SGLT2 inhibitor use among patients with ESKD.
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Affiliation(s)
- Rehma Siddiqui
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, USA.
| | - Neville R Dossabhoy
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, USA
| | - Tariq Shafi
- Division of Kidney Diseases, Hypertension, & Transplantation, Houston Methodist Hospital, Houston, TX, USA
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Ethier I, Hayat A, Pei J, Hawley CM, Johnson DW, Francis RS, Wong G, Craig JC, Viecelli AK, Htay H, Ng S, Leibowitz S, Cho Y. Peritoneal dialysis versus haemodialysis for people commencing dialysis. Cochrane Database Syst Rev 2024; 6:CD013800. [PMID: 38899545 PMCID: PMC11187793 DOI: 10.1002/14651858.cd013800.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Peritoneal dialysis (PD) and haemodialysis (HD) are two possible modalities for people with kidney failure commencing dialysis. Only a few randomised controlled trials (RCTs) have evaluated PD versus HD. The benefits and harms of the two modalities remain uncertain. This review includes both RCTs and non-randomised studies of interventions (NRSIs). OBJECTIVES To evaluate the benefits and harms of PD, compared to HD, in people with kidney failure initiating dialysis. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies from 2000 to June 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. MEDLINE and EMBASE were searched for NRSIs from 2000 until 28 March 2023. SELECTION CRITERIA RCTs and NRSIs evaluating PD compared to HD in people initiating dialysis were eligible. DATA COLLECTION AND ANALYSIS Two investigators independently assessed if the studies were eligible and then extracted data. Risk of bias was assessed using standard Cochrane methods, and relevant outcomes were extracted for each report. The primary outcome was residual kidney function (RKF). Secondary outcomes included all-cause, cardiovascular and infection-related death, infection, cardiovascular disease, hospitalisation, technique survival, life participation and fatigue. MAIN RESULTS A total of 153 reports of 84 studies (2 RCTs, 82 NRSIs) were included. Studies varied widely in design (small single-centre studies to international registry analyses) and in the included populations (broad inclusion criteria versus restricted to more specific participants). Additionally, treatment delivery (e.g. automated versus continuous ambulatory PD, HD with catheter versus arteriovenous fistula or graft, in-centre versus home HD) and duration of follow-up varied widely. The two included RCTs were deemed to be at high risk of bias in terms of blinding participants and personnel and blinding outcome assessment for outcomes pertaining to quality of life. However, most other criteria were assessed as low risk of bias for both studies. Although the risk of bias (Newcastle-Ottawa Scale) was generally low for most NRSIs, studies were at risk of selection bias and residual confounding due to the constraints of the observational study design. In children, there may be little or no difference between HD and PD on all-cause death (6 studies, 5752 participants: RR 0.81, 95% CI 0.62 to 1.07; I2 = 28%; low certainty) and cardiovascular death (3 studies, 7073 participants: RR 1.23, 95% CI 0.58 to 2.59; I2 = 29%; low certainty), and was unclear for infection-related death (4 studies, 7451 participants: RR 0.98, 95% CI 0.39 to 2.46; I2 = 56%; very low certainty). In adults, compared with HD, PD had an uncertain effect on RKF (mL/min/1.73 m2) at six months (2 studies, 146 participants: MD 0.90, 95% CI 0.23 to 3.60; I2 = 82%; very low certainty), 12 months (3 studies, 606 participants: MD 1.21, 95% CI -0.01 to 2.43; I2 = 81%; very low certainty) and 24 months (3 studies, 334 participants: MD 0.71, 95% CI -0.02 to 1.48; I2 = 72%; very low certainty). PD had uncertain effects on residual urine volume at 12 months (3 studies, 253 participants: MD 344.10 mL/day, 95% CI 168.70 to 519.49; I2 = 69%; very low certainty). PD may reduce the risk of RKF loss (3 studies, 2834 participants: RR 0.55, 95% CI 0.44 to 0.68; I2 = 17%; low certainty). Compared with HD, PD had uncertain effects on all-cause death (42 studies, 700,093 participants: RR 0.87, 95% CI 0.77 to 0.98; I2 = 99%; very low certainty). In an analysis restricted to RCTs, PD may reduce the risk of all-cause death (2 studies, 1120 participants: RR 0.53, 95% CI 0.32 to 0.86; I2 = 0%; moderate certainty). PD had uncertain effects on both cardiovascular (21 studies, 68,492 participants: RR 0.96, 95% CI 0.78 to 1.19; I2 = 92%) and infection-related death (17 studies, 116,333 participants: RR 0.90, 95% CI 0.57 to 1.42; I2 = 98%) (both very low certainty). Compared with HD, PD had uncertain effects on the number of patients experiencing bacteraemia/bloodstream infection (2 studies, 2582 participants: RR 0.34, 95% CI 0.10 to 1.18; I2 = 68%) and the number of patients experiencing infection episodes (3 studies, 277 participants: RR 1.23, 95% CI 0.93 to 1.62; I2 = 20%) (both very low certainty). PD may reduce the number of bacteraemia/bloodstream infection episodes (2 studies, 2637 participants: RR 0.44, 95% CI 0.27 to 0.71; I2 = 24%; low certainty). Compared with HD; It is uncertain whether PD reduces the risk of acute myocardial infarction (4 studies, 110,850 participants: RR 0.90, 95% CI 0.74 to 1.10; I2 = 55%), coronary artery disease (3 studies, 5826 participants: RR 0.95, 95% CI 0.46 to 1.97; I2 = 62%); ischaemic heart disease (2 studies, 58,374 participants: RR 0.86, 95% CI 0.57 to 1.28; I2 = 95%), congestive heart failure (3 studies, 49,511 participants: RR 1.10, 95% CI 0.54 to 2.21; I2 = 89%) and stroke (4 studies, 102,542 participants: RR 0.94, 95% CI 0.90 to 0.99; I2 = 0%) because of low to very low certainty evidence. Compared with HD, PD had uncertain effects on the number of patients experiencing hospitalisation (4 studies, 3282 participants: RR 0.90, 95% CI 0.62 to 1.30; I2 = 97%) and all-cause hospitalisation events (4 studies, 42,582 participants: RR 1.02, 95% CI 0.81 to 1.29; I2 = 91%) (very low certainty). None of the included studies reported specifically on life participation or fatigue. However, two studies evaluated employment. Compared with HD, PD had uncertain effects on employment at one year (2 studies, 593 participants: RR 0.83, 95% CI 0.20 to 3.43; I2 = 97%; very low certainty). AUTHORS' CONCLUSIONS The comparative effectiveness of PD and HD on the preservation of RKF, all-cause and cause-specific death risk, the incidence of bacteraemia, other vascular complications (e.g. stroke, cardiovascular events) and patient-reported outcomes (e.g. life participation and fatigue) are uncertain, based on data obtained mostly from NRSIs, as only two RCTs were included.
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Affiliation(s)
- Isabelle Ethier
- Department of Nephrology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Health innovation and evaluation hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Ashik Hayat
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Juan Pei
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Ross S Francis
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Germaine Wong
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Htay Htay
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Samantha Ng
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Saskia Leibowitz
- Department of Nephrology, Logan Hospital, Meadowbrook, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
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Sirich TL, Tan Z, Highland BR, Lin Z, Russell GB, Murea M. Longitudinal Changes in Kidney Solute Clearance in a Prospective Cohort of Patients Initiating Chronic Hemodialysis. Kidney Int Rep 2024; 9:1774-1782. [PMID: 38899221 PMCID: PMC11184396 DOI: 10.1016/j.ekir.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 02/26/2024] [Accepted: 03/11/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction Longitudinal changes in residual kidney function have not been well-examined in patients starting chronic hemodialysis (HD). Methods We analyzed urine volume and kidney solute clearances from timed urine collections and corresponding plasma samples from 42 patients randomized to incremental HD (n = 21) and conventional HD (n = 21) in the TwoPlus pilot study. Samples were collected before HD initiation (baseline); and at 6, 12, 24, and 48 weeks. We assessed temporal trends in urine volume, kidney urea and creatinine clearance, and correlations between urine volume and kidney solute clearance. Results Residual kidney function parameters in all patients declined over time; the pattern of decline differed between urine volume and kidney solute clearances. Urine volume declined at a steady rate with median (quartile 1, quartile 3) percentage change relative to baseline of -10% (-36 to 29) at week 6 and -47% (-76 to 5) by week 48. Kidney urea and creatinine clearances exhibited a larger decline than urine volume at week 6, -32% (-61 to 8) and -47% (-57 to -20), respectively. The rate of decline subsequently slowed, reaching about 61% decline for both solutes by week 48. Conventional HD demonstrated larger declines in urine volume and kidney urea clearance than incremental HD at week 6. Urine volume showed moderate correlation with urea (R = 0.47) and weaker correlation with creatinine (R = 0.34). Conclusion Despite gradual decrement in urine volume and kidney solute clearances, residual kidney function persists nearly 1 year after HD initiation. This knowledge could motivate increased practice of individualizing HD prescriptions by incorporating residual kidney function.
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Affiliation(s)
- Tammy L. Sirich
- Department of Medicine, Stanford University, Palo Alto, California, USA
- Department of Medicine, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Zijian Tan
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Benjamin R. Highland
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Zhidong Lin
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gregory B. Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Zhang Q, Wang X, Chao Y, Liu L. Focus on oliguria during renal replacement therapy. J Anesth 2024:10.1007/s00540-024-03342-4. [PMID: 38777933 DOI: 10.1007/s00540-024-03342-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
Oliguria is a clinical symptom characterized by decreased urine output, which can occur at any stage of acute kidney injury and also during renal replacement therapy. In some cases, oliguria may resolve with adjustment of blood purification dose or fluid management, while in others, it may suggest a need for further evaluation and intervention. It is important to determine the underlying cause of oliguria during renal replacement therapy and to develop an appropriate treatment plan. This review looks into the mechanisms of urine production to investigate the mechanism of oliguria during renal replacement therapy from two aspects: diminished glomerular filtration rate and tubular abnormalities. The above conditions all implying a renal oxygen supply-demand imbalance, which is the signal of worsening kidney injury. It also proposes a viable clinical pathway for the treatment and management of patients with acute kidney injury receiving renal replacement therapy.
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Affiliation(s)
- Qian Zhang
- Department of Intensive Care Unit (ICU), The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, 550004, People's Republic of China
| | - Xiaoting Wang
- Department of Intensive Care Unit (ICU), Peking Union Medical College Hospital, Beijing, 100005, People's Republic of China
| | - Yangong Chao
- Department of Intensive Care Unit (ICU), The First Affiliated Hospital of Tsinghua University, Beijing, 100016, People's Republic of China
| | - Lixia Liu
- Department of Intensive Care Unit (ICU), The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People's Republic of China.
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9
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Khatri P, Davenport A. Dialysis for older adults: why should the targets be different? J Nephrol 2024; 37:841-850. [PMID: 38180729 PMCID: PMC11239777 DOI: 10.1007/s40620-023-01835-1] [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: 09/13/2023] [Accepted: 11/18/2023] [Indexed: 01/06/2024]
Abstract
The number of patients aged > 75-years treated by dialysis continues to increase, particularly in developed countries. Haemodialysis is a well-established treatment with national and international clinical guidelines designed to provide patients with optimal treatment. However, these were developed when the dialysis population was younger, and less co-morbid. This change in patient demographics questions whether these guideline targets still apply to older patients. More patients now start dialysis with residual kidney function and could benefit from a less frequent dialysis schedule. Older patients have a lower thirst drive, so lower interdialytic gains, reduced appetite, muscle mass and physical activity would potentially allow starting dialysis with less frequent sessions a practical option. Similarly, patients with residual kidney function and lower metabolic activity may not need to meet current dialyser Kt/Vurea clearance targets to remain healthy. Instead, some elderly patients may be at risk of malnutrition and might need liberalisation of the low salt, potassium and phosphate dietary restrictions, or even additional supplements to ensure adequate protein intake. Although a fistula is the preferred vascular access, a forearm fistula may not be an option due to vascular disease, while a brachial fistula can potentially compromise cardiovascular reserve, so a dialysis catheter becomes the de facto access, especially in patients with limited life expectancy. Thus, clinical guideline targets designed for a younger less co-morbid dialysis population may not be equally applicable to the older patient initiating dialysis, and so a more individualised approach to dialysis prescription and vascular access is required.
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Affiliation(s)
- Priyanka Khatri
- Fast and Chronic Programmes, Alexandra Hospital, Queenstown, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, Rowland Hill Street, London, NW3 2PF, UK.
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10
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Wu N, Chen S, Peng F, Luo C, Li P, Chen Y, Zhou W, Long H, Yang Q. The relationship between decline rate of residual renal function in the first year and mortality in peritoneal dialysis patients. Ther Apher Dial 2024; 28:255-264. [PMID: 37873689 DOI: 10.1111/1744-9987.14075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/21/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION To assess the relationship between the rate of residual renal function (RRF) decline in the first year and all-cause and cardiovascular mortality in peritoneal dialysis (PD) patients. METHODS Incident PD patients were divided into two groups by the corresponding RRF decline value, when hazard ratio (HR) = 1 was found by the restricted cubic spline. The associations of rate of decline of RRF in the first year with mortality were evaluated. RESULTS Of 497 PD patients, 122 patients died. After adjusting for confounding factors, patients in fast-decline group had a significant increase risk of all-cause and cardiovascular mortality (HR: 1.97 and 2.09, respectively). Each 0.1-mL/min/1.73 m2 /month decrease in RRF in the first year of PD was associated with a 19% and 20% higher risk of all-cause and cardiovascular mortality, respectively. CONCLUSIONS Faster decline of RRF in the first year was independently associated with all-cause and cardiovascular mortality in PD patients.
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Affiliation(s)
- Na Wu
- Department of Nephrology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Sijia Chen
- Department of Nephrology and Rheumatology, The First Hospital of Changsha, Changsha, China
| | - Fenfen Peng
- Department of Nephrology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Congwei Luo
- Department of Nephrology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Peilin Li
- Department of Nephrology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yihua Chen
- Department of Nephrology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Weidong Zhou
- Department of Nephrology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Haibo Long
- Department of Nephrology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Qixuan Yang
- Department of Nephrology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Lakshmipathy D, Ye X, Kuti JL, Nicolau DP, Asempa TE. A New Dosing Frontier: Retrospective Assessment of Effluent Flow Rates and Residual Renal Function Among Critically Ill Patients Receiving Continuous Renal Replacement Therapy. Crit Care Explor 2024; 6:e1065. [PMID: 38533293 PMCID: PMC10962883 DOI: 10.1097/cce.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVES In 2020, cefiderocol became the first Food and Drug Administration-approved medication with continuous renal replacement therapy (CRRT) dosing recommendations based on effluent flow rates (QE). We aimed to evaluate the magnitude and frequency of factors that may influence these recommendations, that is, QE intrapatient variability and residual renal function. DESIGN Retrospective observational cohort study. SETTING ICUs within Hartford Hospital (890-bed, acute-care hospital) in Connecticut from 2017 to 2023. PATIENTS Adult ICU patients receiving CRRT for greater than 72 hours. MEASUREMENTS AND MAIN RESULTS CRRT settings including QE and urine output (UOP) were extracted from the time of CRRT initiation (0 hr) and trends were assessed. To assess the impact on antibiotic dosing, cefiderocol doses were assigned to 0 hour, 24 hours, 48 hours, and 72 hours QE values per product label, and the proportion of antibiotic dose changes required as a result of changes in inpatient's QE was evaluated. Among the 380 ICU patients receiving CRRT for greater than 72 hours, the median (interquartile range) 0 hour QE was 2.96 (2.35-3.29) L/hr. Approximately 9 QE values were documented per patient per 24-hour window. QE changes of greater than 0.75 L/hr were observed in 21.6% of patients over the first 24 hours and in 7.9% (24-48 hr) and 5.8% (48-72 hr) of patients. Approximately 40% of patients had UOP greater than 500 mL at 24 hours post-CRRT initiation. Due to QE changes within 24 hours of CRRT initiation, a potential cefiderocol dose adjustment would have been warranted in 38% of patients (increase of 21.3%; decrease of 16.6%). QE changes were less common after 24 hours, warranting cefiderocol dose adjustments in less than 15% of patients. CONCLUSIONS Results highlight the temporal and variable dynamics of QE and prevalence of residual renal function. Data also demonstrate a risk of antibiotic under-dosing in the first 24 hours of CRRT initiation due to increases in QE. For antibiotics with QE-based dosing recommendations, empiric dose escalation may be warranted in the first 24 hours of CRRT initiation.
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Affiliation(s)
- Damini Lakshmipathy
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT
| | - Xiaoyi Ye
- Division of Nephrology, Hartford Hospital, Hartford, CT
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT
- Division of Infectious Diseases, Hartford Hospital, Hartford, CT
| | - Tomefa E Asempa
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT
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Yeter HH, Fettahoglu F, Yesiloglu E, Akcay O, Korucu B, Bali M, Derici U. Risk Factors for Posttransplant Erythrocytosis: Parathyroid Hormone Paradox? EXP CLIN TRANSPLANT 2024; 22:103-107. [PMID: 32370696 DOI: 10.6002/ect.2019.0287] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Posttransplant erythrocytosis affects 8% to 26% of kidney transplant recipients. In this study, our aim was to define associations among hypercalcemia, persistent hyperparathyroidism, and posttransplant erythrocytosis. We also investigated the effects of biologic sex, age, and dialysis modality before transplant on posttransplant erythrocytosis development. MATERIALS AND METHODS We enrolled 247 patients [159 (64%) male and 88 (36%) female] who underwent kidney transplant between 2009 and 2018. All demographic and laboratory parameters were retrospectively analyzed as possible factors associated with posttransplant erythrocytosis. RESULTS Fifty-nine (24%) of total patients had posttransplant erythrocytosis. The median time to posttransplant erythrocytosis development was 16 months (range, 8-34 mo). Male sex, the use of peritoneal dialysis as maintenance renal replacement therapy before kidney transplant, and persistent hyperparathyroidism were defined as independent risk factors for posttransplant erythrocytosis development in our multivariate logistic regression analyses (odds ratio = 5.228, 3.963, and 4.109, respectively). In addition, high serum creatinine levels were associated with a lower incidence of posttransplant erythrocytosis (odds ratio = 0.253). Although significance did not remain after multivariate analysis, hypercalcemia was found to be significantly associated with posttransplant erythrocytosis in univariate analyses (odds ratio = 1.768). In subgroup analyses, where only male patients were evaluated, persistent hyperparathyroidism and peritoneal dialysis were found to be independent risk factors for posttransplant erythrocytosis development (odds ratio = 4.176 and 5.003). CONCLUSIONS Persistent hyperparathyroidism and hypercalcemia could precipitate development of posttransplant erythrocytosis. The preserved residue renal function may be associated with increased endogenous erythropoietin, which could lead to posttransplant erythrocytosis development.
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Affiliation(s)
- Hasan Haci Yeter
- From the Department of Nephrology, Gazi University, Ankara, Turkey
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13
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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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14
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Morrison SA, Thanamayooran A, Tennankore K, Vinson AJ. Association Between First Post-operative Day Urine Output Following Kidney Transplantation and Short-Term and Long-Term Outcomes: A Retrospective Cohort Study. Can J Kidney Health Dis 2023; 11:20543581231221630. [PMID: 38161390 PMCID: PMC10757439 DOI: 10.1177/20543581231221630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 11/05/2023] [Indexed: 01/03/2024] Open
Abstract
Background The relationship between post-operative urine output (UO) following kidney transplantation and long-term graft function has not been well described. Objective In this study, we examined the association between decreased UO on post-operative day 1 (POD1) and post-transplant outcomes. Design This is a retrospective cohort study. Setting Atlantic Canada. Patients Patients from the 4 Atlantic Canadian provinces (Nova Scotia, New Brunswick, Newfoundland, and Prince Edward Island) who received a live or deceased donor kidney transplant from 2006 through 2019 through the multiorgan transplant program at the Queen Elizabeth II Health Sciences Centre (QEII) hospital in Halifax, Nova Scotia. Measurements Using multivariable Cox proportional hazards models, we assessed the association of low POD1 UO (defined as ≤1000 mL) with death-censored graft loss (DCGL). In secondary analyses, we used adjusted logistic regression or Cox models as appropriate to assess the impact of UO on delayed graft function (DGF), prolonged length of stay (greater than the median for the entire cohort), and death. Results Of the 991 patients included, 151 (15.2%) had a UO ≤1000 mL on POD1. Low UO was independently associated with DCGL (hazard ratio [HR] = 4.00, 95% confidence interval [CI] = 95% CI = 1.55-10.32), DGF (odds ratio [OR] = 45.25, 95% CI = 23.00-89.02), and prolonged length of stay (OR = 5.06, 95% CI = 2.95-8.69), but not death (HR = 0.81, 95% CI = 0.31-2.09). Limitations This was a single-center, retrospective, observational study and therefore has inherent limitations of generalizability, data collection, and residual confounding. Conclusions Overall, reduced post-operative UO following kidney transplantation is associated with an increased risk of DCGL, DGF, and prolonged hospital length of stay.
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Affiliation(s)
- Steven A. Morrison
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Aran Thanamayooran
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karthik Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amanda J. Vinson
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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15
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Çankaya E, Altunok M. Comparison of mortality according to baseline, first year, and mean albumin levels in peritoneal dialysis: a retrospective study. Ren Fail 2023; 45:2176165. [PMID: 36762995 PMCID: PMC9930840 DOI: 10.1080/0886022x.2023.2176165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND The relationship between hypoalbuminemia in peritoneal dialysis (PD) and mortality, risk of peritonitis, and decreased residual renal function (RRF) is known. However, we have not encountered a comprehensive study on which of the mean albumin values, at the beginning of peritoneal dialysis, in the first year, and during the peritoneal dialysis period, provide more predictive predictions regarding mortality, peritonitis risk, and RRF reduction. METHODS A total of 407 PD patients in whom PD was initiated and followed up and PD was terminated were included in the study. Albumin levels, peritonitis, and RRF at the beginning of PD and at 3-month periods during PD were recorded. RESULTS In the evaluation of the patients, there was a significant relationship between mean, first-year albumin values in RRF loss (p = 0.001, p = 0.006, respectively) and peritonitis (p < 0.001), but no significant correlation was found with baseline albumin values (p = 0.213, p = 0.137, respectively). In the comparison of mortality ROC analysis of PD patients, a significant correlation was found with mortality at baseline, first year, and mean albumin values (p < 0.001). However, in the multivariate Cox regression analysis, it was determined that there was a more significant relationship between first-year albumin and mean albumin values compared to baseline albumin values (HR 0.918 [95% CI 0.302-0.528] (p < 0.001)), (HR 1.161 [95% CI 0.229-0.429] (p < 0.001)), (HR 0.081 [95% CI 0.718-1.184] (p = 0.525)). CONCLUSIONS In conclusion, mean and first-year mean albumin levels provide more determinative predictions for mortality, risk of peritonitis, and maintenance of residual renal functions in peritoneal dialysis patients compared to baseline albumin.
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Affiliation(s)
- Erdem Çankaya
- Department of Nephrology, Medical Faculty, Atatürk University, Erzurum, Turkey,CONTACT Erdem Çankaya Medical Faculty, Department of Nephrology, Atatürk University, Erzurum, 25240, Turkey
| | - Murat Altunok
- Department of Nephrology, Medical Faculty, Atatürk University, Erzurum, Turkey
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16
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Zhou D, Lei H, Wu S, Yang W, Cui W, Li L, Lin H, Yin A. Influencing factors for residual kidney function in incident peritoneal dialysis patients: a systematic review and meta-analysis. Ren Fail 2023; 45:2286328. [PMID: 38036948 PMCID: PMC11011231 DOI: 10.1080/0886022x.2023.2286328] [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: 09/08/2023] [Accepted: 11/16/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Residual kidney function (RKF) impacts patients' survival rate and quality of life when undergoing peritoneal dialysis (PD). This meta-analysis was conducted to systematically identify risk and protective factors associated with RKF decline and loss. METHODS We searched three English and one Chinese databases from inception to January 31, 2023, for cohort and cross-sectional studies exploring factors associated with RKF decline or loss. The random effects model was employed to aggregate risk estimates and 95% confidence intervals (CIs) from multivariate analysis. Sensitivity and subgroup analyses were performed to explore the heterogeneity among the studies. RESULTS Twenty-seven studies comprising 13549 individuals and 14 factors were included in the meta-analysis. Based on the meta-analysis results, risk factors involving male gender (hazard ratio (HR) 1.689, 95%CI 1.385-2.061), greater body mass index (BMI) (odds ratio (OR) 1.081, 95% confidence interval (CI) 1.029-1.135), higher systolic blood pressure (SBP) (HR 1.014, 95%CI 1.005-1.024), diabetes mellitus (DM) (HRRKF loss 1.873, 95%CI 1.475-2.378), DM (ORRKF decline 1.906, 95%CI 1.262-2.879), peritonitis (relative ratio (RR) 2.291, 95%CI 1.633-3.213), proteinuria (OR 1.223, 95%CI 1.117-1.338), and elevated serum phosphorus (RR 2.655, 95%CI 1.679-4.201) significantly contributed to the risk of RKF decline and loss in PD patients. Conversely, older age (HR 0.968, 95%CI 0.956-0.981), higher serum albumin (OR 0.834, 95%CI 0.720-0.966), weekly Kt/V urea (HR 0.414, 95%CI 0.248-0.690), baseline urine volume (UV) (HR 0.791, 95%CI 0.639-0.979), baseline RKF (HR 0.795, 95%CI 0.739-0.857) exhibited protective effects. However, diuretics use, automatic peritoneal dialysis (APD) modality and baseline RKF did not significantly impact RKF decline. CONCLUSIONS Patients with male gender, greater BMI, higher SBP, DM, peritonitis, proteinuria, and elevated serum phosphorus might have a higher risk of RKF decline and loss. In contrast, older age, higher serum albumin, weekly Kt/V urea, baseline UV, and baseline RKF might protect against RKF deterioration.
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Affiliation(s)
- Dan Zhou
- Department of Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- First Affiliated Hospital, Dalian Medical University, Dalian, China
- College of Integrative Medicine, Dalian Medical University,Dalian, China
| | - Hong Lei
- Graduate School, Dalian Medical University, Dalian, China
| | - Shuran Wu
- Department of Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Wei Yang
- Department of Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Wenting Cui
- Department of Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Longkai Li
- Department of Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Hongli Lin
- Department of Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Anchun Yin
- First Affiliated Hospital, Dalian Medical University, Dalian, China
- College of Integrative Medicine, Dalian Medical University,Dalian, China
- Graduate School, Dalian Medical University, Dalian, China
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Dopierała M, Schwermer K, Hoppe K, Kupczyk M, Pawlaczyk K. Benefits of Preserving Residual Urine Output in Patients Undergoing Maintenance Haemodialysis. Int J Nephrol Renovasc Dis 2023; 16:231-240. [PMID: 37868106 PMCID: PMC10590073 DOI: 10.2147/ijnrd.s421533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/01/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Chronic kidney disease is a widespread medical problem that leads to higher morbidity, mortality, and a decrease in the overall well-being of the general population. This is especially expressed in patients with end-stage renal disease (ESRD) undergoing maintenance haemodialysis. Several variables could be used to evaluate those patients' well-being and mortality risk. One of them is the presence of residual urine output. Materials and Methods The study was conducted on 485 patients treated with maintenance haemodialysis. After enrollment in the study, which consisted of medical history, physical examination, hydration assessment, and blood sampling, each patient was followed up for 24 months. We used residual urine output (RUO) as a measure of residual renal function (RRF). The entire cohort was divided into 4 subgroups based on the daily urinary output (<=100mL per day, >100mL to <=500mL, >500mL to <=1000mL and >1000mL). Results The data show that the mortality rate was significantly higher in groups with lower RUO, which was caused mainly by cardiovascular events. Also, patients with higher RUO achieved better sodium, potassium, calcium, and phosphate balance. They were also less prone to overhydration and had a better nutritional status. Preserved RRF also had a positive impact on markers of cardiovascular damage, such as NT-proBNP as well as TnT. Conclusion In conclusion, preserving residual urine output in ESRD patients undergoing maintenance haemodialysis is invaluable in reducing their morbidity and mortality rates and enhancing other favourable parameters of those patients.
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Affiliation(s)
- Mikołaj Dopierała
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Schwermer
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Hoppe
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Małgorzata Kupczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Pawlaczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
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Okazaki M, Obi Y, Shafi T, Rhee CM, Kovesdy CP, Kalantar-Zadeh K. Residual Kidney Function and Cause-Specific Mortality Among Incident Hemodialysis Patients. Kidney Int Rep 2023; 8:1989-2000. [PMID: 37849997 PMCID: PMC10577493 DOI: 10.1016/j.ekir.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/16/2023] [Accepted: 07/24/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction The survival benefit of residual kidney function (RKF) in patients on hemodialysis is presumably due to enhanced fluid management and solute clearance. However, data are lacking on the association of renal urea clearance (CLurea) with specific causes of death. Methods We conducted a longitudinal cohort study of 39,623 adults initiating thrice-weekly in-center hemodialysis from 2007 to 2011 and had data on renal CLurea and urine volume. Multivariable cause-specific proportional hazards model was used to examine the associations between baseline RKF and cause-specific mortality, including sudden cardiac death (SCD), non-SCD cardiovascular death (CVD), and non-CVD. Restricted cubic splines were fitted for change in RKF over 6 months after initiating hemodialysis. Results Among 39,623 patients with data on baseline renal CLurea and urine volume, there was a significant trend toward a higher mortality risk across lower RKF levels, irrespective of cause of death in a case-mix adjustment model (Ptrend < 0.05). Adjustment for ultrafiltration rate (UFR) slightly attenuated the association between low renal CLurea and high cause-specific mortality, whereas adjustment for highest potassium did not have substantial effect. Among 12,169 patients with data on change in RKF, a 6-month decline in renal CLurea showed graded associations with SCD, non-SCD CVD, and non-CVD risk, whereas the graded associations between faster 6-month decline in urine output and higher death risk were clear only for SCD and non-CVD. Conclusion Lower RKF and loss of RKF were associated with higher cause-specific mortality among patients initiating thrice-weekly in-center hemodialysis.
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Affiliation(s)
- Masaki Okazaki
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshitsugu Obi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Tariq Shafi
- Division of Nephrology, Houston Methodist Hospital, Houston, Texas, USA
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine Medical Center, Orange, California, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
- Los Angeles County Harbor-UCLA Medical Center, and The Lundquist Institute, Torrance, California, USA
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
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Zhang Z, Wang Y. Management of Cardiovascular Diseases in Chronic Hemodialysis Patients. Rev Cardiovasc Med 2023; 24:185. [PMID: 39077004 PMCID: PMC11266462 DOI: 10.31083/j.rcm2407185] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 07/31/2024] Open
Abstract
Hemodialysis (HD) is the main treatment modality for patients with end-stage kidney disease. Cardiovascular diseases (CVD) are highly prevalent in HD patients and are the leading cause of death in this population, with the mortality from CVD approximately 20 times higher than that of the general population. Traditional and non-traditional cardiovascular risk factors accelerate progression of CVD and exacerbate the prognosis in HD patients. This review provides a brief overview of the characteristics of CVD in HD patients, and a description of advances in its management.
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Affiliation(s)
- Zhen Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, 200032 Shanghai, China
- Shanghai Medical Center for Kidney Disease, Shanghai Municipal Health Commission, 200032 Shanghai, China
- Shanghai Institute of Kidney and Dialysis, 200032 Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai Medical Quality Control Management Center, 200032 Shanghai, China
| | - Yaqiong Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, 200032 Shanghai, China
- Shanghai Medical Center for Kidney Disease, Shanghai Municipal Health Commission, 200032 Shanghai, China
- Shanghai Institute of Kidney and Dialysis, 200032 Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai Medical Quality Control Management Center, 200032 Shanghai, China
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20
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Alrowiyti IM, Bargman J. A Review of Residual Kidney Function in Peritoneal Dialysis Patients. Indian J Nephrol 2023; 33:239-246. [PMID: 37781547 PMCID: PMC10503572 DOI: 10.4103/ijn.ijn_242_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/28/2023] [Accepted: 07/14/2023] [Indexed: 10/03/2023] Open
Abstract
Residual kidney function (RKF) has been associated with better survival, less morbidity, and improved quality of life in peritoneal dialysis (PD) patients. Since higher peritoneal clearance does not lead to better outcomes, more emphasis should be put on preserving kidney function. Many other benefits have been reported, including better volume and blood pressure control, better nutritional status, lower rates of PD peritonitis, preserved erythropoietin and vitamin D production, middle molecule clearance, lower Left Ventricular Hypertrophy, and better serum phosphate level. The most practical method of assessing RKF is the mean of 24-h urinary urea and creatinine clearance. Incremental PD prescription is an ideal option to supplement RKF in PD patients, which also offers more flexibility to the patient and, possibly, improved adherence. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be used when possible in PD patients to preserve RKF. Loop diuretics are underutilized in PD patients despite providing an additional means of maintaining fluid balance and reducing the need for higher glucose-containing PD solutions. In this paper, we outline the importance of RKF in PD patients and the different strategies for its preservation.
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Affiliation(s)
- Ibrahim Mohammed Alrowiyti
- Department of Nephrology, University Health Network, University of Toronto, Toronto, Canada
- Department of Nephrology, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Joanne Bargman
- Department of Nephrology, University Health Network, University of Toronto, Toronto, Canada
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Andreoli MCC, Totoli C, Rocha DRD, Campagnaro LS. Diálise peritoneal: por que não? J Bras Nefrol 2023. [DOI: 10.1590/2175-8239-jbn-2023-e001pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023] Open
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22
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Corradi V, Samoni S, Mariotto A, Caprara C, Scalzotto E, Frigo AC, Martino FK, Giavarina D, Ronco C, Zanella M. Relationship between Residual Urine Output and Type of Dialysis with FGF23 Levels. J Clin Med 2022; 12:jcm12010222. [PMID: 36615023 PMCID: PMC9821742 DOI: 10.3390/jcm12010222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 12/13/2022] [Accepted: 12/21/2022] [Indexed: 12/30/2022] Open
Abstract
Several studies investigated the role of fibroblast growth factor 23 (FGF23) in the regulation of renal phosphate excretion in chronic kidney disease (CKD). However, patients with residual urine output (UO) seem to control their serum phosphorus levels better. Our aim was to determine whether FGF23 levels are influenced by dialysis modality and UO. We performed a cross-sectional study in hemodialysis (HD) and peritoneal dialysis (PD) patients. The C-terminal FGF23 (cFGF23) levels were determined in plasma with a two-site enzyme-linked immunosorbent assay. The UO collection referred to an mL/day measurement. All p values were two-sided, and the statistical significance was set at p < 0.05. We enrolled 133 patients (58 HD, 75 PD, UO 70%). The median cFGF23 was significantly higher in HD vs. PD patients (p = 0.0017) and not significantly higher in patients without UO (p = 0.12). We found a negative correlation between cFGF23 and the UO volume (p = 0.0250), but the correlation was not significant when considering the type of dialysis treatment. Phosphorus (ß = 0.21677; p = 0.0007), type of dialysis (ß = −0.68392; p = 0.0003), and creatinine (ß = 0.08130; p = 0.0133) were significant and independent predictors of cFGF23 levels. In conclusion, cFGF23 was significantly higher in HD than in PD patients. We found a significant negative correlation between cFGF23 and the residual UO volume, but the correlation was not significant considering the type of dialysis. Our study reveals that dialysis modality is an independent predictor of FGF23 levels. In particular, PD is associated with lower FGF23 levels than HD.
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Affiliation(s)
- Valentina Corradi
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
- International Renal Research Institute of Vicenza and IRRIV Foundation for Research, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
- Correspondence: ; Tel.: +39-0444-753650
| | - Sara Samoni
- International Renal Research Institute of Vicenza and IRRIV Foundation for Research, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
- Department of Nephrology and Dialysis, S. Anna Hospital, ASST Lariana, 22077 Como, Italy
| | - Alice Mariotto
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
- International Renal Research Institute of Vicenza and IRRIV Foundation for Research, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
| | - Carlotta Caprara
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
- International Renal Research Institute of Vicenza and IRRIV Foundation for Research, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
| | - Elisa Scalzotto
- International Renal Research Institute of Vicenza and IRRIV Foundation for Research, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
| | - Anna Chiara Frigo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35122 Padua, Italy
| | - Francesca K. Martino
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
- International Renal Research Institute of Vicenza and IRRIV Foundation for Research, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
| | - Davide Giavarina
- Department of Laboratory Medicine, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza and IRRIV Foundation for Research, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
- University of Padova, 35122 Padua, Italy
| | - Monica Zanella
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
- International Renal Research Institute of Vicenza and IRRIV Foundation for Research, San Bortolo Hospital, AULSS 8 BERICA Vicenza, 36100 Vicenza, Italy
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Yang LJ, Chao YL, Kuo IC, Niu SW, Hung CC, Chiu YW, Chang JM. High Ultrafiltration Rate Is Associated with Increased All-Cause Mortality in Incident Hemodialysis Patients with a High Cardiothoracic Ratio. J Pers Med 2022; 12:jpm12122059. [PMID: 36556279 PMCID: PMC9786000 DOI: 10.3390/jpm12122059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/18/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022] Open
Abstract
A high ultrafiltration rate (UFR) is associated with increased mortality in hemodialysis patients. However, whether a high UFR itself or heart failure with fluid overload followed by a high UFR causes mortality remains unknown. In this study, 2615 incident hemodialysis patients were categorized according to their initial cardiothoracic ratios (CTRs) to assess whether UFR was associated with mortality in patients with high or low CTRs. In total, 1317 patients (50.4%) were women and 1261 (48.2%) were diabetic. During 2246 (1087−3596) days of follow-up, 1247 (47.7%) cases of all-cause mortality were noted. UFR quintiles 4 and 5 were associated with higher risks of all-cause mortality than UFR quintile 2 in fully adjusted Cox regression analysis. As the UFR increased by 1 mL/kg/h, the risk of all-cause mortality increased 1.6%. Subgroup analysis revealed that in UFR quintile 5, hazard ratios (HRs) for all-cause mortality were 1.91, 1.48, 1.22, and 1.10 for CTRs of >55%, 50−55%, 45−50%, and <45%, respectively. HRs for all-cause mortality were higher in women and patients with high body weight. Thus, high UFRs may be associated with increased all-cause mortality in incident hemodialysis patients with a high CTR, but not in those with a low CTR.
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Affiliation(s)
- Lii-Jia Yang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal CiJin Hospital, Kaohsiung 80544, Taiwan
| | - Yu-Lin Chao
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - I-Ching Kuo
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung 80145, Taiwan
| | - Sheng-Wen Niu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung 80145, Taiwan
| | - Chi-Chih Hung
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Correspondence:
| | - Yi-Wen Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Jer-Ming Chang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
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Tanriover C, Ucku D, Basile C, Tuttle KR, Kanbay M. On the importance of the interplay of residual renal function with clinical outcomes in end-stage kidney disease. J Nephrol 2022; 35:2191-2204. [PMID: 35819749 DOI: 10.1007/s40620-022-01388-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Abstract
Chronic kidney disease (CKD) is one of the most important public health concerns of the century, and is associated with high rates of morbidity, mortality and social costs. CKD evolving towards end-stage kidney disease (ESKD) is on the rise resulting in a greater number of patients requiring peritoneal dialysis (PD) and hemodialysis (HD). The aim of this manuscript is to review the current literature on the interplay of residual renal function (RRF) with clinical outcomes in ESKD. The persistence of RRF is one of the most important predictors of decreased morbidity, mortality, and better quality of life in both PD and HD patients. RRF contributes to the well-being of ESKD patients through various mechanisms including higher clearance of solutes, maintenance of fluid balance, removal of uremic toxins and control of electrolytes. Furthermore, RRF has beneficial effects on inflammation, anemia, malnutrition, diabetes mellitus, obesity, changes in the microbiota, and cardiac diseases. Several strategies have been proposed to preserve RRF, such as blockade of the renin-angiotensin-aldosterone system, better blood pressure control, incremental PD and HD. Several clinical trials investigating the issue of preservation of RRF are ongoing. They are needed to broaden our understanding of the interplay of RRF with clinical outcomes in ESKD.
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Affiliation(s)
- Cem Tanriover
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Duygu Ucku
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy.
| | - Katherine R Tuttle
- Division of Nephrology, University of Washington, Seattle, WA, USA.,Providence Medical Research Center, Providence Health Care, Washington, USA
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
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25
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Zhao C, Guo Y, Wang Y, Wang L, Yu L, Liang Y, Zhai Z, Tang L. The efficacy and safety of Sacubitril/Valsartan on pulmonary hypertension in hemodialysis patients. Front Med (Lausanne) 2022; 9:1055330. [PMID: 36523777 PMCID: PMC9745023 DOI: 10.3389/fmed.2022.1055330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/09/2022] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common complication of end-stage renal disease which is associated with adverse outcomes including all-cause mortality and cardiovascular events. Recent studies have demonstrated that Sacubitril/Valsartan (Sac/Val) as an enkephalinase inhibitor and angiotensin II receptor blocker could reduce pulmonary artery systolic pressure (PASP) and improve the prognosis of patients with heart failure. However, whether Sac/Val is effective in hemodialysis (HD) patients with PH is essentially unknown. In this retrospective study, we aimed to evaluate the efficacy and safety of Sac/Val in the treatment of PH in HD patients. METHODS A total of 122 HD patients with PH were divided into Sac/Val group (n = 71) and ARBs group (n = 51) based on the treatment regimen. The PASP, other cardiac parameters measured by echocardiography, and cardiac biomarkers including N-terminal fragment of BNP (NT-proBNP) and cardiac troponin I (cTnI) were observed at baseline and 3 months after treatment. RESULTS There were no significant differences in the baseline characteristics between the two groups. PASP decreased significantly from 45(38, 54) to 28(21, 40) mmHg in Sac/Val group (p < 0.001). PASP reduced from 41(37, 51) to 34(27, 44) mmHg in ARBs group (p < 0.001), and the decrease was more pronounced in the Sac/Val group (p < 0.001). In addition, improvements in the right atrial diameter (RAD), left ventricular diameter (LVD), left ventricular posterior wall thickness (LVPWT), left atrial diameter (LAD), pulmonary artery diameter (PAD), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), and fractional shortening (FS) were found in Sac/Val group (ps < 0.05). After 3 months, LVD, LAD, LVEDV, LVESV, LVEF, SV, and PASP were significantly improved in Sac/Val group compared with ARBs group (ps <0.05). Significant reduction in NT-proBNP [35,000 (15,000, 70,000) pg/ml vs. 7,042 (3,126, 29,060) pg/ml, p < 0.001] and cTnI [0.056(0.031, 0.085) ng/ml vs. 0.036 (0.012, 0.056) ng/ml, p < 0.001) were observed in Sac/Val group. No significant differences were observed in adverse events between the two groups (ps > 0.05). CONCLUSION Sac/Val seems to be an efficacious regimen in PH with favorable safety and has huge prospects for treating PH in HD patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Lin Tang
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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26
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Urine volume as an estimator of residual renal clearance and urinary removal of solutes in patients undergoing peritoneal dialysis. Sci Rep 2022; 12:18755. [PMID: 36335200 PMCID: PMC9637165 DOI: 10.1038/s41598-022-23093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 10/25/2022] [Indexed: 11/08/2022] Open
Abstract
In non-anuric patients undergoing peritoneal dialysis (PD), residual kidney function (RKF) is a main contributor to fluid and solute removal and an independent predictor of survival. We investigated if urine volume could be used to estimate renal clearances and removal of urea, creatinine, and phosphorus in PD patients. The observational, cross-sectional study included 93 non-anuric prevalent PD patients undergoing continuous ambulatory PD (CAPD; n = 34) or automated PD (APD; n = 59). Concentrations of urea, creatinine and phosphorus in serum and in 24-h collections of urine volume were measured to calculate weekly residual renal clearance (L/week) and removed solute mass (g/week). Median [interquartile range], 24-h urine output was 560 [330-950] mL and measured GFR (the mean of creatinine and urea clearances) was 3.24 [1.47-5.67] mL/min. For urea, creatinine and phosphorus, residual renal clearance was 20.60 [11.49-35.79], 43.02 [19.13-75.48] and 17.50 [8.34-33.58] L/week, respectively, with no significant differences between CAPD and APD. Urine volume correlated positively with removed solute masses (rho = 0.82, 0.67 and 0.74) and with weekly residual renal clearances (rho = 0.77, 0.62 and 0.72 for urea, creatinine, and phosphorus, respectively, all p < 0.001). Residual renal clearances and urinary mass removal rates for urea, creatinine, and phosphorus correlate strongly with 24-h urine volume suggesting that urine volume could serve as an estimator of typical values of residual solute removal indices in PD patients.
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Murea M, Highland BR, Yang W, Dressler E, Russell GB. Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis. BMC Nephrol 2022; 23:322. [PMID: 36167537 PMCID: PMC9513956 DOI: 10.1186/s12882-022-02946-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background Physical and emotional symptoms are prevalent in patients with kidney-dysfunction requiring dialysis (KDRD) and the rigors of thrice-weekly hemodialysis (HD) may contribute to deteriorated health-related quality of life. Less intensive HD schedules might be associated with lower symptom and/or emotional burden. Methods The TWOPLUS Pilot study was an individually-randomized trial conducted at 14 dialysis units, with the primary goal to assess feasibility and safety. Patients with incident KDRD and residual kidney function were assigned to incremental HD start (twice-weekly HD for 6 weeks followed by thrice-weekly HD) vs conventional HD (thrice-weekly HD). In exploratory analyses, we compared the two treatment groups with respect to three patient-reported outcomes measures. We analyzed the change from baseline in the score on Dialysis Symptom Index (DSI, range 0–150), Generalized Anxiety Disorder-7 (GAD-7, range 0–21), and Patient Health Questionnaire-9 (PHQ-9, range 0–27) at 6 (n = 20 in each treatment group) and 12 weeks (n = 21); with lower scores denoting lower symptom burden. Analyses were adjusted for age, race, gender, baseline urine volume, diabetes mellitus, and malignancy. Participants’ views on the intervention were sought using a Patient Feedback Questionnaire (n = 14 in incremental and n = 15 in conventional group). Results The change from baseline to week 6 in estimated mean score (standard error; P value) in the incremental and conventional group was − 9.7 (4.8; P = 0.05) and − 13.8 (5.0; P = 0.009) for DSI; − 1.9 (1.0; P = 0.07) and − 1.5 (1.4; P = 0.31) for GAD-7; and − 2.5 (1.1; P = 0.03) and − 3.5 (1.5; P = 0.02) for PHQ-9, respectively. Corresponding changes from week 6 to week 12 were − 3.1 (3.2; P = 0.34) and − 2.4 (5.5; P = 0.67) in DSI score; 0.5 (0.6; P = 0.46) and 0.1 (0.6; P = 0.87) in GAD-7 score; and − 0.3 (0.6; P = 0.70) and − 0.5 (0.6; P = 0.47) in PHQ-9 score, respectively. Majority of respondents felt their healthcare was not jeopardized and expressed their motivation for study participation was to help advance the care of patients with KDRD. Conclusions This study suggests a possible mitigating effect of twice-weekly HD start on symptoms of anxiety and depression at transition from pre-dialysis to KDRD. Larger clinical trials are required to rigorously test clinically-matched incrementally-prescribed HD across diverse organizations and patient populations. Trial registration Registered at ClinicalTrials.gov with study identifier NCT03740048, registration date 14/11/2018. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02946-w.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1053, USA.
| | - Benjamin R Highland
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Wesley Yang
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Emily Dressler
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gregory B Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Murea M, Patel A, Highland BR, Yang W, Fletcher AJ, Kalantar-Zadeh K, Dressler E, Russell GB. Twice-Weekly Hemodialysis With Adjuvant Pharmacotherapy and Transition to Thrice-Weekly Hemodialysis: A Pilot Study. Am J Kidney Dis 2022; 80:227-240.e1. [PMID: 34933066 DOI: 10.1053/j.ajkd.2021.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/04/2021] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Thrice-weekly hemodialysis (HD) is the most common treatment modality for kidney failure in the United States. We conducted a pilot study to assess the feasibility and safety of incremental-start HD in patients beginning maintenance HD. STUDY DESIGN Pilot study. SETTING & PARTICIPANTS Adults with estimated glomerular filtration rate (eGFR) ≥5 mL/min/1.73 m2 and urine volume ≥500 mL/d beginning maintenance HD at 14 outpatient dialysis units. EXPOSURE Randomized allocation (1:1 ratio) to twice-weekly HD and adjuvant pharmacologic therapy for 6 weeks followed by thrice-weekly HD (incremental HD group) or thrice-weekly HD (conventional HD group). OUTCOME The primary outcome was feasibility. Secondary outcomes included changes in urine volume and solute clearance. RESULTS Of 77 patients invited to participate, 51 consented to do so, representing 66% of eligible patients. We randomized 23 patients to the incremental HD group and 25 patients to the conventional HD group. Protocol-based loop diuretics, sodium bicarbonate, and patiromer were prescribed to 100%, 39%, and 17% of patients on twice-weekly HD, respectively. At a mean follow-up of 281.9 days, participant adherence was 96% to the HD schedule (22 of 23 and 24 of 25 in the incremental and conventional groups, respectively) and 100% in both groups to serial timed urine collection. The incidence rate ratio for all-cause hospitalization was 0.31 (95% CI, 0.08-1.17); and 7 deaths were recorded (1 in the incremental and 6 in the conventional group). At week 24, the incremental HD group had lower declines in urine volume (a difference of 51.0 [95% CI, -0.7 to 102.8] percentage points) and in the averaged urea and creatinine clearances (a difference of 57.9 [95% CI, -22.6 to 138.4] percentage points). LIMITATIONS Small sample size, time-limited twice-weekly HD. CONCLUSIONS It is feasible to enroll patients beginning maintenance HD into a randomized study of incremental-start HD with adjuvant pharmacotherapy who adhere to the study protocol during follow-up. Larger multicenter clinical trials are indicated to determine the efficacy and safety of incremental HD with longer twice-weekly HD periods. FUNDING Funding was provided by Vifor Inc. TRIAL REGISTRATION Registered at ClinicalTrials.gov, identifier NCT03740048.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
| | - Ashish Patel
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Benjamin R Highland
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Wesley Yang
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Alison J Fletcher
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology Hypertension, and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | - Emily Dressler
- Department of Biostatistics and Data Science, Division of Public Health Sciences, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Gregory B Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
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29
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Jaques DA, Ponte B, Haidar F, Dufey A, Carballo S, De Seigneux S, Saudan P. Outcomes of incident patients treated with incremental haemodialysis as compared with standard haemodialysis and peritoneal dialysis. Nephrol Dial Transplant 2022; 37:2514-2521. [PMID: 35731591 PMCID: PMC9681916 DOI: 10.1093/ndt/gfac205] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Residual kidney function is considered better preserved with incremental haemodialysis (I-HD) or peritoneal dialysis (PD) as compared with conventional thrice-weekly HD (TW-HD) and is associated with improved survival. We aimed to describe outcomes of patients initiating dialysis with I-HD, TW-HD or PD. METHODS We conducted a retrospective analysis of a prospectively assembled cohort in a single university centre including all adults initiating dialysis from January 2013 to December 2020. Primary and secondary endpoints were overall survival and hospitalization days at 1 year, respectively. RESULTS We included 313 patients with 234 starting on HD (166 TW-HD and 68 I-HD) and 79 on PD. At the end of the study, 10 were still on I-HD while 45 transitioned to TW-HD after a mean duration of 9.8 ± 9.1 months. Patients who stayed on I-HD were less frequently diabetics (P = .007). Mean follow-up was 33.1 ± 30.8 months during which 124 (39.6%) patients died. Compared with patients on TW-HD, those on I-HD had improved survival (hazard ratio 0.49, 95% confidence interval 0.26-0.93, P = .029), while those on PD had similar survival. Initial kidney replacement therapy modality was not significantly associated with hospitalization days at 1 year. CONCLUSIONS I-HD is suitable for selected patients starting dialysis and can be maintained for a significant amount of time before transition to TW-HD, with diabetes being a risk factor. Although hospitalization days at 1 year are similar, initiation with I-HD is associated with improved survival as compared with TW-HD or PD. Results of randomized controlled trials are awaited prior to large-scale implementation of I-HD programmes.
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Affiliation(s)
| | - Belen Ponte
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
| | - Fadi Haidar
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
| | - Anne Dufey
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
| | - Sebastian Carballo
- Division of Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Sophie De Seigneux
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
| | - Patrick Saudan
- Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
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Hladek MD, Zhu J, Crews DC, McAdams-DeMarco MA, Buta B, Varadhan R, Shafi T, Walston JD, Bandeen-Roche K. Physical Resilience Phenotype Trajectories in Incident Hemodialysis: Characterization and Mortality Risk Assessment. Kidney Int Rep 2022; 7:2006-2015. [PMID: 36090502 PMCID: PMC9459128 DOI: 10.1016/j.ekir.2022.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/13/2022] [Indexed: 12/19/2022] Open
Abstract
Introduction Methods Results Conclusion
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Soi V, Faber MD, Paul R. Incremental Hemodialysis: What We Know so Far. Int J Nephrol Renovasc Dis 2022; 15:161-172. [PMID: 35520631 PMCID: PMC9065374 DOI: 10.2147/ijnrd.s286947] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Traditionally, patients that develop progressive chronic kidney disease in need of kidney replacement therapy are prescribed thrice weekly in-center hemodialysis sessions at the beginning of therapy. This empiric prescription is based on historic trials that were comprised of mostly prevalent patients. Incremental hemodialysis is the process of performing <3 sessions of dialysis per week or limiting dialysis dose by duration at the initial onset of treatment to provide a more gradual transition, mimicking the progressive nature of kidney disease. Adding clearance contributions from residual kidney function is the standard of care with peritoneal dialysis but has not routinely been employed with hemodialysis. Accounting for residual kidney function accompanied by improvement in adjuvant pharmacotherapy, such as newer potassium binding agents and dietary modification, can augment dialytic clearances and allow for an incremental approach. Utilizing incremental dialysis has been associated with both preserving residual kidney function as well as improving patient quality of life. Barriers to this approach include concerns regarding patient acceptance of dialysis prescription changes, adherence to therapy, and provider factors that would require a restructuring of the current thrice weekly hemodialysis rubric. Candidacy for incremental therapy has shown the best outcomes when urea clearances exceed 3 mL/min and urine volumes are >500 mL/day, although these measures have been deemed conservative. A significant amount of retrospective and registry data has been supportive of initiating incremental hemodialysis and several pilot studies have shown the feasibility of implementing such an approach. Larger, randomized control trials are needed to fully evaluate safety and efficacy to allow for more widespread acceptance of this patient-centered approach to chronic kidney disease.
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Affiliation(s)
- Vivek Soi
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
- Wayne State University School of Medicine, Detroit, MI, USA
- Correspondence: Vivek Soi, Email
| | - Mark D Faber
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Ritika Paul
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
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Wu T, Qi Y, Ma S, Zhang L, Pu X, Chen K, Zhao Y, Sang S, Xiao J. Efficacy of Roxadustat on anemia and residual renal function in patients new to peritoneal dialysis. Ren Fail 2022; 44:529-540. [PMID: 35318873 PMCID: PMC8956311 DOI: 10.1080/0886022x.2022.2050754] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Both early correction of anemia and preserving residual renal function (RRF) are reported to improve patient survival. The aim of this study was to explore the efficacy and safety of Roxadustat for treatment of renal anemia in patients new to peritoneal dialysis (PD) and to assess its impact on RRF. Methods A retrospective analysis was performed on 60 initial peritoneal dialysis (PD) patients with renal anemia. Twenty-eight cases were treated with Roxadustat (Roxadustat group) and 32 with recombinant human erythropoietin (control group). Clinical characteristics, hemoglobin (Hb), C-reactive protein, blood lipids, iron metabolism, dialysis adequacy and RRF of the two groups were evaluated and adverse events were recorded. All patients were followed up for at least 40 weeks. Results After 40 weeks of treatment, mean Hb levels were significantly higher from baseline values in both groups, the mean Hb change in Roxadustat group was higher than control group (3.46 ± 1.59 g/dL vs. 2.28 ± 2.27 g/dL, p < 0.05). At 40 weeks, 92.9% patients met the target level of Hb in Roxadustat group and 84.4% in control group. Total iron binding was higher and ferritin was lower in Roxadustat group from baseline values and Roxadustat-induced Hb increases were independent of baseline C-reactive protein levels and history of rhuEPO administration. RRF decreased over time in both groups, the mean RRF change was lower in Roxadustat group than control group (1.15 ± 1.66 mL/min/1.73 m2 vs. 2.31 ± 1.46 mL/min/1.73 m2, p < 0.01). Compared with control group, patients in Roxadustat group had higher levels of total iron binding, 24 h urine volume, total weekly Ccr, and lower systolic pressure, ferritin, C-reactive protein, total cholesterol, LDL. No serious adverse reactions occurred in either group. Conclusion In patients new to PD, Roxadustat effectively and safely improved renal anemia and delay the decline of RRF.
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Affiliation(s)
- Tong Wu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanyuan Qi
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuang Ma
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijie Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinyu Pu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kui Chen
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Zhao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shenghua Sang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Xiao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Slabbert A, Chothia MY. The association between office blood pressure and fluid status using bioimpedance spectroscopy in stable continuous ambulatory peritoneal dialysis patients. Clin Hypertens 2022; 28:8. [PMID: 35287755 PMCID: PMC8922746 DOI: 10.1186/s40885-021-00192-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 12/14/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hypertension is common in continuous ambulatory peritoneal dialysis (CAPD) patients. It remains to be determined the extent to which fluid overload contributes to uncontrolled blood pressure (BP) in this population. The aim was to determine the association between fluid status as measured using bioimpedance spectroscopy (BIS) and BP in CAPD patients.
Methods
A cross-sectional study was performed involving 50 stable CAPD patients at a single center in Cape Town, South Africa. All participants were known to have hypertension and were divided into two groups based on office BP measurements: an uncontrolled BP group (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) and a controlled BP group. Fluid status was determined using BIS (Body Composition Monitor®, Fresenius Medical Care, Bad Homburg, Germany).
Results
There was a statistically significant difference in overhydration (OH) between the uncontrolled BP group and the controlled BP group (3.0 ± 2.3 L vs. 1.4 ± 1.6 L, respectively, P = 0.01). The uncontrolled BP group was older (37.7 ± 9.5 years vs. 32.0 ± 8.0 years, P = 0.04) and had a shorter dialysis vintage (15 [IQR, 7–22] months vs. 31 [IQR, 12–39] months, P = 0.02). Significant correlations were found between OH and the extracellular water (ECW) (r = 0.557, P < 0.01) and ECW to total body water (TBW) ratio (r = 0.474, P < 0.01). Mixed ancestry, presence of residual kidney function, ECW, and ECW to TBW ratio were identified as predictors of OH on multivariable linear regression.
Conclusions
We found that stable CAPD patients with uncontrolled BP had higher OH compared to patients whose BP was controlled.
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Does delivering more dialysis improve clinical outcomes? What randomized controlled trials have shown. J Nephrol 2022; 35:1315-1327. [PMID: 35041196 DOI: 10.1007/s40620-022-01246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/01/2022] [Indexed: 10/19/2022]
Abstract
Some randomized controlled trials (RCTs) have sought to determine whether different dialysis techniques, dialysis doses and frequencies of treatment are able to improve clinical outcomes in end-stage kidney disease (ESKD). Virtually all of these RCTs were enacted on the premise that 'more' haemodialysis might improve clinical outcomes compared to 'conventional' haemodialysis. Aim of the present narrative review was to analyse these landmark RCTs by posing the following question: were their intervention strategies (i.e., earlier dialysis start, higher haemodialysis dose, intensive haemodialysis, increase in convective transport, starting haemodialysis with three sessions per week) able to improve clinical outcomes? The answer is no. There are at least two main reasons why many RCTs have failed to demonstrate the expected benefits thus far: (1) in general, RCTs included relatively small cohorts and short follow-ups, thus producing low event rates and limited statistical power; (2) the designs of these studies did not take into account that ESKD does not result from a single disease entity: it is a collection of different diseases and subtypes of kidney dysfunction. Patients with advanced kidney failure requiring dialysis treatment differ on a multitude of levels including residual kidney function, biochemical parameters (e.g., acid base balance, serum electrolytes, mineral and bone disorder), and volume overload. In conclusion, the different intervention strategies of the RCTs herein reviewed were not able to improve clinical outcomes of ESKD patients. Higher quality studies are needed to guide patients and clinicians in the decision-making process. Future RCTs should account for the heterogeneity of patients when considering inclusion/exclusion criteria and study design, and should a priori consider subgroup analyses to highlight specific subgroups that can benefit most from a particular intervention.
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Jung HK, Lai TH, Lai JN, Lin JG, Kao ST. Preserving residual renal function: Is interdialytic acupuncture an add-on option? A case series report. Explore (NY) 2022; 18:710-713. [DOI: 10.1016/j.explore.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/06/2022] [Indexed: 11/04/2022]
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Schaeffner E. Smoothing transition to dialysis to improve early outcomes after dialysis initiation among old and frail adults-a narrative review. Nephrol Dial Transplant 2021; 37:2307-2313. [PMID: 34865111 PMCID: PMC9681923 DOI: 10.1093/ndt/gfab342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Indexed: 12/31/2022] Open
Abstract
The number of patients ≥65 years of age suffering from advanced chronic kidney disease and transitioning to end-stage kidney disease (ESKD) is increasing. However, elderly patients often have poor outcomes once haemodialysis is initiated, including high mortality within the first year as well as fast cognitive and functional decline and diminished quality of life. The question is how we can smooth this transition to ESKD in older patients who also exhibit much higher proportions of frailty when compared with community-dwelling non-dialysis older adults and who are generally more vulnerable to invasive treatment such as kidney replacement therapy. To avoid early death and poor quality of life, a carefully prepared smooth transition should precede the initiation of treatment. This involves pre-dialysis physical and educational care, as well as mental and psychosocial preparedness of the patient to enable an informed and shared decision about the individual choice of treatment modality. Communication between a healthcare professional and patient plays a pivotal role but can be challenging given the high rate of cognitive impairment in this particular population. In order to practise patient-centred care, adapting treatment tailored to the individual patient should include comprehensive conservative care. However, structured treatment pathways including multidisciplinary teams for such conservative care are still rare and may be difficult to establish outside of large cities. Generally, geriatric nephrology misses data on the comparative effectiveness of different treatment modalities in this population of old and very old age on which to base recommendations and decisions.
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Bernier-Jean A, Wong G, Saglimbene V, Ruospo M, Palmer SC, Natale P, Garcia-Larsen V, Johnson DW, Tonelli M, Hegbrant J, Craig JC, Teixeira-Pinto A, Strippoli GF. Dietary Potassium Intake and All-Cause Mortality in Adults Treated with Hemodialysis. Clin J Am Soc Nephrol 2021; 16:1851-1861. [PMID: 34853064 PMCID: PMC8729497 DOI: 10.2215/cjn.08360621] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/08/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Dietary potassium restriction in people receiving maintenance hemodialysis is standard practice and is recommended in guidelines, despite a lack of evidence. We aimed to assess the association between dietary potassium intake and mortality and whether hyperkalemia mediates this association. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 8043 adults undergoing maintenance hemodialysis in Europe and South America were included in the DIETary intake, death and hospitalization in adults with end-stage kidney disease treated with HemoDialysis (DIET-HD) study. We measured baseline potassium intake from the Global Allergy and Asthma European Network food frequency questionnaire and performed time-to-event and mediation analyses. RESULTS The median potassium intake at baseline was 3.5 (interquartile range, 2.5-5.0) g/d. During a median follow-up of 4.0 years (25,890 person-years), we observed 2921 (36%) deaths. After adjusting for baseline characteristics, including cardiac disease and food groups, dietary potassium intake was not associated with all-cause mortality (per 1 g/d higher dietary potassium intake: hazard ratio, 1.00; 95% confidence interval [95% CI], 0.95 to 1.05). A mediation analysis showed no association of potassium intake with mortality, either through or independent of serum potassium (hazard ratio, 1.00; 95% CI, 1.00 to 1.00 and hazard ratio, 1.01; 95% CI, 0.96 to 1.06, respectively). Potassium intake was not significantly associated with serum levels (0.03; 95% CI, -0.01 to 0.07 mEq/L per 1 g/d higher dietary potassium intake) or the prevalence of hyperkalemia (≥6.0 mEq/L) at baseline (odds ratio, 1.11; 95% CI, 0.89 to 1.37 per 1 g/d higher dietary potassium intake). Hyperkalemia was associated with cardiovascular death (hazard ratio, 1.23; 95% CI, 1.03 to 1.48). CONCLUSIONS Higher dietary intake of potassium is not associated with hyperkalemia or death in patients treated with hemodialysis.
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Affiliation(s)
- Amelie Bernier-Jean
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Germaine Wong
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Valeria Saglimbene
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Patrizia Natale
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Vanessa Garcia-Larsen
- Program in Human Nutrition, Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David W. Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | | | | | - Jonathan C. Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Armando Teixeira-Pinto
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Giovanni F.M. Strippoli
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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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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Yeter HH, Akcay OF. YouTube as a platform for knowledge and awareness of peritoneal dialysis: A content analysis. Perit Dial Int 2021; 42:489-496. [PMID: 34369832 DOI: 10.1177/08968608211035947] [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: 11/15/2022] Open
Abstract
BACKGROUND One of the main barriers to choosing peritoneal dialysis (PD) is the lack of awareness and PD knowledge. There is an increasing trend in the use of the internet as a search tool for health-related information. This study aims to determine how useful YouTube videos are to get information about PD. METHODS YouTube videos were evaluated independently by two nephrologists. The videos' quality was assessed with DISCERN scoring system, global quality score (GQS) and the Journal of the American Medical Association (JAMA) scoring system. We determined the quartile (Q) of the videos as follows: most reliable top 25% videos Q1 and others Q2-4. RESULTS A total of 295 videos were evaluated. University or society-sourced videos made up 15% (n = 43) of all videos, and healthcare providers were the primary target audience compared to patients (p < 0.001). JAMA, GQS and DISCERN scores were significantly higher for the videos that were targeted healthcare providers compared to the patients (p < 0.001, for all). A total of 34% of the videos in Q1 were obtained from the university or society. Nevertheless, only 17% of the videos prepared for the patients were among the Q1. A small number of videos mentioned that PD maintains the residual kidney function (RKF) longer compared to haemodialysis. CONCLUSIONS Universities and societies should upload videos to provide easy-to-understand information on PD. Also, the important benefits of PD, like the preservation of RKF, should be further highlighted in these videos. It may increase the PD penetrance by increasing patients' awareness.
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Affiliation(s)
- Hasan Haci Yeter
- Department of Nephrology, Sivas Numune State Hospital, Sivas, Turkey
| | - Omer Faruk Akcay
- Department of Nephrology Dialysis and Transplantation, Faculty of Medicine, 64001Gazi University, Ankara, Turkey
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Cupisti A, Bolasco P, D’Alessandro C, Giannese D, Sabatino A, Fiaccadori E. Protection of Residual Renal Function and Nutritional Treatment: First Step Strategy for Reduction of Uremic Toxins in End-Stage Kidney Disease Patients. Toxins (Basel) 2021; 13:toxins13040289. [PMID: 33921862 PMCID: PMC8073165 DOI: 10.3390/toxins13040289] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 02/06/2023] Open
Abstract
The retention of uremic toxins and their pathological effects occurs in the advanced phases of chronic kidney disease (CKD), mainly in stage 5, when the implementation of conventional thrice-weekly hemodialysis is the prevalent and life-saving treatment. However, the start of hemodialysis is associated with both an acceleration of the loss of residual kidney function (RKF) and the shift to an increased intake of proteins, which are precursors of uremic toxins. In this phase, hemodialysis treatment is the only way to remove toxins from the body, but it can be largely inefficient in the case of high molecular weight and/or protein-bound molecules. Instead, even very low levels of RKF are crucial for uremic toxins excretion, which in most cases are protein-derived waste products generated by the intestinal microbiota. Protection of RKF can be obtained even in patients with end-stage kidney disease (ESKD) by a gradual and soft shift to kidney replacement therapy (KRT), for example by combining a once-a-week hemodialysis program with a low or very low-protein diet on the extra-dialysis days. This approach could represent a tailored strategy aimed at limiting the retention of both inorganic and organic toxins. In this paper, we discuss the combination of upstream (i.e., reduced production) and downstream (i.e., increased removal) strategies to reduce the concentration of uremic toxins in patients with ESKD during the transition phase from pure conservative management to full hemodialysis treatment.
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Affiliation(s)
- Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (C.D.); (D.G.)
- “Conservative Treatment of Chronic Kidney Disease” Project Group of the Italian Society of Nephrology, 00185 Rome, Italy;
- Correspondence:
| | - Piergiorgio Bolasco
- “Conservative Treatment of Chronic Kidney Disease” Project Group of the Italian Society of Nephrology, 00185 Rome, Italy;
| | - Claudia D’Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (C.D.); (D.G.)
- “Conservative Treatment of Chronic Kidney Disease” Project Group of the Italian Society of Nephrology, 00185 Rome, Italy;
| | - Domenico Giannese
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (C.D.); (D.G.)
| | - Alice Sabatino
- Department of Medicine and Surgery, University of Parma, Nephrology Unit, Parma University Hospital, 43121 Parma, Italy; (A.S.); (E.F.)
| | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, Nephrology Unit, Parma University Hospital, 43121 Parma, Italy; (A.S.); (E.F.)
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Grzegorzewska AE, Adamska P, Iwańczyk-Skalska E, Ostromecka K, Niepolski L, Marcinkowski W, Mostowska A, Warchoł W, Żaba C, Jagodziński PP. Paraoxonase 1 concerning dyslipidaemia, cardiovascular diseases, and mortality in haemodialysis patients. Sci Rep 2021; 11:6773. [PMID: 33762698 PMCID: PMC7990965 DOI: 10.1038/s41598-021-86231-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/23/2021] [Indexed: 01/31/2023] Open
Abstract
Paraoxonase 1 (PON1) is known for preventing atherosclerosis through lipid-modifying features, antioxidant activity, anti-inflammatory, anti-apoptosis, anti-thrombosis, and anti-adhesion properties. Uremic patients requiring haemodialysis (HD) are especially prone to atherosclerosis and its complications. We analysed the PON1 gene (PON1) polymorphisms and serum PON1 (paraoxonase) activity concerning dyslipidaemia and related cardiovascular diseases and mortality to show how they associate under uremic conditions modified by maintenance HD treatment. The rs662 AA + AG (OR 1.76, 95%CI 1.10-2.80, P = 0.018), rs854560 TT (OR 1.48, 95%CI 1.04-2.11, P = 0.031), and rs854560 AT + TT (OR 1.28, 95%CI 1.01-1.63, P = 0.040) contributed to the prevalence of atherogenic dyslipidaemia diagnosed by the triglyceride (TG)/HDL-cholesterol ratio ≥ 3.8. The normalized serum PON1 activity positively correlated with atherogenic dyslipidaemia (ẞ 0.67 ± 0.25, P = 0.008). The PON1 rs854560 allele T was involved in the higher prevalence of ischemic cerebral stroke (OR 1.38, 1.02-1.85, P = 0.034). The PON1 rs705379 TT genotype contributed to cardiovascular (HR 1.27, 95% CI 1.03-1.57, P = 0.025) and cardiac (HR 1.34, 95% CI 1.05-1.71, P = 0.018) mortality. All P-values were obtained in multiple regression analyses, including clinical variables. Multifaceted associations of PON1 with dyslipidaemia, ischemic cerebral stroke, and cardiovascular mortality in HD patients provide arguments for the consideration of PON1 and its protein product as therapeutic targets in the prevention of atherosclerosis and its complications in uremic patients.
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Affiliation(s)
- Alicja E. Grzegorzewska
- grid.22254.330000 0001 2205 0971Department of Nephrology, Transplantology and Internal Diseases, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355 Poznań, Poland
| | - Paulina Adamska
- grid.22254.330000 0001 2205 0971Department of Nephrology, Transplantology and Internal Diseases, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355 Poznań, Poland
| | - Ewa Iwańczyk-Skalska
- grid.22254.330000 0001 2205 0971Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, 60-781 Poznań, Poland
| | - Kamila Ostromecka
- grid.22254.330000 0001 2205 0971Nephrology Research Group, Department of Nephrology, Transplantology and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland
| | - Leszek Niepolski
- B. Braun Avitum Poland, Dialysis Center, 64-300 Nowy Tomyśl, Poland
| | | | - Adrianna Mostowska
- grid.22254.330000 0001 2205 0971Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, 60-781 Poznań, Poland
| | - Wojciech Warchoł
- grid.22254.330000 0001 2205 0971Department of Ophthalmology and Optometry, Poznan University of Medical Sciences, 60-806 Poznań, Poland
| | - Czesław Żaba
- grid.22254.330000 0001 2205 0971Department of Forensic Medicine, Poznan University of Medical Sciences, 60-781 Poznań, Poland
| | - Paweł P. Jagodziński
- grid.22254.330000 0001 2205 0971Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, 60-781 Poznań, Poland
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Gupta A, Zimmerman D. Complications and challenges of home hemodialysis: A historical review. Semin Dial 2021; 34:269-274. [PMID: 33609415 DOI: 10.1111/sdi.12960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Home hemodialysis (HHD) has evolved as a preferred and safe kidney replacement modality over the past six decades. Despite advances in technological aspects of HHD, potential complications still pose a challenge to health care givers, patients, and their families. In this narrative review, we describe vascular access and cannulation, anticoagulation, nutritional, residual kidney function, psychosocial, technique failure, and machine/procedural-related complications. Addressing these problems is essential for favorable patient outcomes.
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Affiliation(s)
- Ankur Gupta
- Department of Medicine, Whakatane Hospital, Whakatane, New Zealand
| | - Deborah Zimmerman
- Division of Nephrology, The Ottawa Hospital, University of Ottawa, Ottawa, Canada
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Tantisattamo E, Hanna RM, Reddy UG, Ichii H, Dafoe DC, Danovitch GM, Kalantar-Zadeh K. Novel options for failing allograft in kidney transplanted patients to avoid or defer dialysis therapy. Curr Opin Nephrol Hypertens 2021; 29:80-91. [PMID: 31743241 DOI: 10.1097/mnh.0000000000000572] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Despite improvement in short-term renal allograft survival in recent years, renal transplant recipients (RTR) have poorer long-term allograft outcomes. Allograft function slowly declines with periods of stable function similar to natural progression of chronic kidney disease in nontransplant population. Nearly all RTR transitions to failing renal allograft (FRG) period and require transition to dialysis. Conservative chronic kidney disease management before transition to end-stage renal disease is an increasingly important topic; however, there is limited data in RTR regarding how to delay dialysis initiation with conservative management. RECENT FINDINGS Since immunological and nonimmunological factors unique to RTR contribute to decline in allograft function, therapies to slow progression of FRG should take both sets of factors into account. Renal replacement therapy either incremental dialysis or rekidney transplantation should be explored. This required taking benefits and risks of continuing immunosuppressive medications into account when allograft nephrectomy may be necessary. SUMMARY FRG may benefit from various interventions to slow progression of worsening allograft function. Until there are stronger evidence to guide interventions to preserve renal function, extrapolating evidence from nontransplant patients and clinical judgment are necessary. The goal is to provide individualized care for conservative management of RTR with FRG.
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Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange Nephrology Section, Department of Medicine, Veterans Affairs Long Beach Healthcare System, Long Beach, California Section of Nephrology, Department of Internal Medicine, Multi-Organ Transplant Center, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan Division of Kidney and Pancreas Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, California Division of Nephrology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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Furaz Czerpak K, Gruss Vergara E, Barril Cuadrado G, Pérez Fernández E, Benavides N, de la Flor J, Mendez Á, Martín R. Usefulness of ABPM and bioimpedance for the treatment and control of hypertension in patients on chronic haemodialysis. Nefrologia 2021; 41:17-26. [PMID: 36165357 DOI: 10.1016/j.nefroe.2020.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/11/2020] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Hypertension is very common in haemodialysis (HD) patients, and is associated with increased morbidity and mortality rates. The goals of our research were to: 1. Measure blood pressure (BP) during HD sessions; 2. Study BP in between HD sessions with 44-h Ambulatory Blood Pressure Monitoring (ABPM); 3. Evaluate changes in treatment after the ABPM; 4. Perform bioimpedance spectroscopy (BIS) on all patients and, in those hyper-hydrated or hypertensive according to ABPM, assess for changes in BP after adjusting the dry weight; 5. Identify factors associated with average systolic and diastolic BP measured by ABPM. MATERIAL AND METHODS Prospective observational study, which included 100 patients from our dialysis unit. We measured BP before and after the HD sessions for two weeks and then, mid-week, we attached the ABPM device to the patients for 44 h. Before starting the following dialysis session, we performed BIS. A second ABPM was performed on hyper-hydrated patients and patients hypertensive according to ABPM to evaluate changes in BP values. RESULTS According to the ABPM, 65% of patients had daytime BP > 135/85 mmHg, 90% night-time BP > 120/70 mmHg and 76% average BP > 130/80 mmHg; 11% had a dipper pattern, 51% non-dipper and 38% riser. The average systolic and diastolic BP readings were 4.7 mmHg (3.8%) and 1.1 mmHg (1.64%) higher on the second day. The dose of antihypertensive medication had to be lowered in 6% of patients, 9% had to stop taking it, 28% needed increased doses and 17% had to add a new drug. The pre-HD diastolic BP best matched the ABPM. After performing the bioimpedance and adjusting dry weight, there was a statistically significant decrease in all BP values. The univariate analysis showed that the average systolic BP was higher in patients with a high-calcium dialysis bath, more antihypertensive drugs and higher doses of EPO. The multivariate analysis showed significant association for EPO and number of drugs (p < 0.01). The average diastolic BP was higher in younger patients and patients with lower Charlson index, lower body mass index and less diuresis, those on higher doses of EPO and non-diabetics. The linear regression study showed age (p < 0.005), body mass index (p < 0.03) and EPO (p < 0.03) as significant variables. CONCLUSIONS Our study shows: 1. The variability of hypertension criteria according to use of BP values from during the HD session or ABPM; 2. The variability of BP in the interdialysis period; 3. That the pre-dialysis diastolic BP best corresponds with the ABPM. 4. That the use of both BIS and ABPM improves the control of BP; 5. That the dose of EPO is the most important factor associated with hypertension in our patients.
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Affiliation(s)
- Karina Furaz Czerpak
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain.
| | | | | | - Elia Pérez Fernández
- Departamento de Estadística, Hospital Universitario Fundación de Alcorcón, Madrid, Spain
| | - Nardeth Benavides
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain
| | - José de la Flor
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain
| | - Ángel Mendez
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain
| | - Roberto Martín
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain
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Zarantonello D, Rhee CM, Kalantar-Zadeh K, Brunori G. Novel conservative management of chronic kidney disease via dialysis-free interventions. Curr Opin Nephrol Hypertens 2021; 30:97-107. [PMID: 33186220 DOI: 10.1097/mnh.0000000000000670] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW In advanced chronic kidney disease (CKD) patients with progressive uremia, dialysis has traditionally been the dominant treatment paradigm. However, there is increasing interest in conservative and preservative management of kidney function as alternative patient-centered treatment approaches in this population. RECENT FINDINGS The primary objectives of conservative nondialytic management include optimization of quality of life and treating symptoms of end-stage renal disease (ESRD). Dietetic-nutritional therapy can be a cornerstone in the conservative management of CKD by reducing glomerular hyperfiltration, uremic toxin generation, metabolic acidosis, and phosphorus burden. Given the high symptom burden of advanced CKD patients, routine symptom assessment using validated tools should be an integral component of their treatment. As dialysis has variable effects in ameliorating symptoms, palliative care may be needed to manage symptoms such as pain, fatigue/lethargy, anorexia, and anxiety/depression. There are also emerging treatments that utilize intestinal (e.g., diarrhea induction, colonic dialysis, oral sorbents, gut microbiota modulation) and dermatologic pathways (e.g., perspiration reduction) to reduce uremic toxin burden. SUMMARY As dialysis may not confer better survival nor improved patient-centered outcomes in certain patients, conservative management is a viable treatment option in the advanced CKD population.
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Affiliation(s)
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
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Pei J, Ethier I, Hudson RE, Hawley CM, Johnson DW, Campbell SB, Francis RS, Wong G, Craig JC, Viecelli AK, Cho Y. Peritoneal dialysis versus haemodialysis for people commencing dialysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Juan Pei
- Department of Nephrology; The First Affiliated Hospital of Xiamen University; Xiamen China
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
| | - Isabelle Ethier
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Department of Nephrology; Centre hospitalier de l’Université de Montréal; Montréal Canada
| | - Rebecca E Hudson
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
| | - Carmel M Hawley
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Australia
- Translational Research Institute; Brisbane Australia
| | - David W Johnson
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Australia
- Translational Research Institute; Brisbane Australia
| | - Scott B Campbell
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
| | - Ross S Francis
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
| | - Germaine Wong
- School of Public Health; The University of Sydney; Sydney Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research; The Children's Hospital at Westmead; Westmead Australia
- College of Medicine and Public Health; Flinders University; Adelaide Australia
| | - Andrea K Viecelli
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Australia
- Translational Research Institute; Brisbane Australia
| | - Yeoungjee Cho
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Australia
- Translational Research Institute; Brisbane Australia
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47
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Toth-Manikowski SM, Sirich TL, Meyer TW, Hostetter TH, Hwang S, Plummer NS, Hai X, Coresh J, Powe NR, Shafi T. Contribution of 'clinically negligible' residual kidney function to clearance of uremic solutes. Nephrol Dial Transplant 2020; 35:846-853. [PMID: 30879076 DOI: 10.1093/ndt/gfz042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 02/03/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Residual kidney function (RKF) is thought to exert beneficial effects through clearance of uremic toxins. However, the level of native kidney function where clearance becomes negligible is not known. METHODS We aimed to assess whether levels of nonurea solutes differed among patients with 'clinically negligible' RKF compared with those with no RKF. The hemodialysis study excluded patients with urinary urea clearance >1.5 mL/min, below which RKF was considered to be 'clinically negligible'. We measured eight nonurea solutes from 1280 patients participating in this study and calculated the relative difference in solute levels among patients with and without RKF based on measured urinary urea clearance. RESULTS The mean age of the participants was 57 years and 57% were female. At baseline, 34% of the included participants had clinically negligible RKF (mean 0.7 ± 0.4 mL/min) and 66% had no RKF. Seven of the eight nonurea solute levels measured were significantly lower in patients with RKF than in those without RKF, ranging from -24% [95% confidence interval (CI) -31 to -16] for hippurate, -7% (-14 to -1) for trimethylamine-N-oxide and -4% (-6 to -1) for asymmetric dimethylarginine. The effect of RKF on plasma levels was comparable or more pronounced than that achieved with a 31% higher dialysis dose (spKt/Vurea 1.7 versus 1.3). Preserved RKF at 1-year follow-up was associated with a lower risk of cardiac death and first cardiovascular event. CONCLUSIONS Even at very low levels, RKF is not 'negligible', as it continues to provide nonurea solute clearance. Management of patients with RKF should consider these differences.
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Affiliation(s)
| | - Tammy L Sirich
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Timothy W Meyer
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Thomas H Hostetter
- Department of Medicine, Palo Alto Veterans Affairs Health Care System, Stanford University, Palo Alto, CA, USA
| | - Seungyoung Hwang
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Natalie S Plummer
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Xin Hai
- Department of Medicine, Palo Alto Veterans Affairs Health Care System, Stanford University, Palo Alto, CA, USA
| | - Josef Coresh
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Neil R Powe
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tariq Shafi
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
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48
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Momciu B, Chan CT. Evaluating dialysis adequacy: Origins, evolution, and future directions. Semin Dial 2020; 33:468-474. [PMID: 33063393 DOI: 10.1111/sdi.12926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The expansion and transformation over time of dialysis therapies have been inexorably linked to the concept of adequacy. While initially the goal of dialysis was simple survival of patients until their next treatment, this changed with the publication of the National Cooperative Dialysis Study. It brought about a focus on defining adequate dialysis through measurements of the removal of small solutes, in particular urea. This spurred significant improvements in patient outcomes by standardizing therapy and providing benchmarks for each center to achieve. Over time, however, further research has found this narrow definition of adequacy to be insufficient to encompass the complexities of dialysis therapies. Factors such as residual kidney function (RKF), nutritional and volume status, and cardiovascular control all contribute to the outcomes for dialysis patients. We propose that an optimal definition of adequacy should not only focus on one factor but rather the interconnection and contribution to our patient's individual specific goals and their overall quality of life.
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Affiliation(s)
- Bogdan Momciu
- Division of Nephrology, University Health Network, Toronto, Canada
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49
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Kimura H, Sy J, Okuda Y, Wenziger C, Hanna R, Obi Y, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Streja E. A faster decline of residual kidney function and erythropoietin stimulating agent hyporesponsiveness in incident hemodialysis patients. Hemodial Int 2020; 25:60-70. [PMID: 33034069 DOI: 10.1111/hdi.12877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/10/2020] [Accepted: 09/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Erythropoietin stimulating agents (ESA) hyporesposiveness has been associated with increased mortality in hemodialysis (HD) patients. However, the impact of decline of residual kidney function (RKF) on ESA hyporesposiveness has not been adequately elucidated among patients receiving HD. METHODS The associations of RKF decline with erythropoietin resistance index (ERI; average weekly ESA dose [units])/post-dialysis body weight [kg]/hemoglobin [g/dL]) were retrospectively examined across four strata of annual change in RKF (residual renal urea clearance [KRU] < -3.0, -3.0 to <-1.5, -1.5 to <0, ≥0 mL/min/1.73 m2 per year; urinary volume < -600, -600 to<-300, -300 to <0, ≥0 mL/day per year) using logistic regression models adjusted for clinical characteristics and laboratory variables in 5239 incident HD patients in a large US dialysis organization between 1 January 2007 and 31 December 2011. FINDINGS The median values of the annual change in KRU and urinary volume were -1.2 (interquartile range [IQR]: -2.8 to 0.1) mL/min/1.73 m2 per year and -250 (IQR: -600 to 100) mL/day per year. A faster KRU decline in the first year of HD was associated with higher odds for ESA hyporesponsiveness: KRU decline of <-3.0, -3.0 to <-1.5, and -1.5 to <0/min/1.73 m2 per year were associated with adjusted odds ratios (OR) of 2.07 (95% confidence interval [CI]: 1.66-2.58), 1.54 (95%CI: 1.28-1.85), and 1.26 (95%CI: 1.07-1.49), respectively (reference: ≥0 mL/min/1.73 m2 per year). These associations were consistent across strata of baseline KRU, age, sex, race, diabetes, congestive heart failure, hemoglobin, and serum albumin. Sensitivity analyses using urinary volume as another index of RKF showed consistent associations. DISCUSSION A faster RKF decline during the first year of dialysis was associated with ESA hyporesponsiveness and low hemoglobin levels among incident HD patients.
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Affiliation(s)
- Hiroshi Kimura
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - John Sy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, California, USA
| | - Yusuke Okuda
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Department of Pediatrics, Kitasato University School of Medicine
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Ramy Hanna
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Yoshitsugu Obi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA.,Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, California, USA
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50
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Pinter J, Chazot C, Stuard S, Moissl U, Canaud B. Sodium, volume and pressure control in haemodialysis patients for improved cardiovascular outcomes. Nephrol Dial Transplant 2020; 35:ii23-ii30. [PMID: 32162668 PMCID: PMC7066545 DOI: 10.1093/ndt/gfaa017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Indexed: 12/12/2022] Open
Abstract
Chronic volume overload is pervasive in patients on chronic haemodialysis and substantially increases the risk of cardiovascular death. The rediscovery of the three-compartment model in sodium metabolism revolutionizes our understanding of sodium (patho-)physiology and is an effect modifier that still needs to be understood in the context of hypertension and end-stage kidney disease. Assessment of fluid overload in haemodialysis patients is central yet difficult to achieve, because traditional clinical signs of volume overload lack sensitivity and specificity. The highest all-cause mortality risk may be found in haemodialysis patients presenting with high fluid overload but low blood pressure before haemodialysis treatment. The second highest risk may be found in patients with both high blood pressure and fluid overload, while high blood pressure but normal fluid overload may only relate to moderate risk. Optimization of fluid overload in haemodialysis patients should be guided by combining the traditional clinical evaluation with objective measurements such as bioimpedance spectroscopy in assessing the risk of fluid overload. To overcome the tide of extracellular fluid, the concept of time-averaged fluid overload during the interdialytic period has been established and requires possible readjustment of a negative target post-dialysis weight. 23Na-magnetic resonance imaging studies will help to quantitate sodium accumulation and keep prescribed haemodialytic sodium mass balance on the radar. Cluster-randomization trials (e.g. on sodium removal) are underway to improve our therapeutic approach to cardioprotective haemodialysis management.
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Affiliation(s)
- Jule Pinter
- Renal Division, University Hospital of Würzburg, Würzburg, Germany
| | | | - Stefano Stuard
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Ulrich Moissl
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
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