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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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Dobre MA, Ahlawat S, Schelling JR. Chronic kidney disease associated cardiomyopathy: recent advances and future perspectives. Curr Opin Nephrol Hypertens 2024; 33:203-211. [PMID: 38193308 PMCID: PMC10872957 DOI: 10.1097/mnh.0000000000000952] [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] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW Cardiomyopathy in chronic kidney disease (CKD) is a complex condition with multiple triggers and poor prognosis. This review provides an overview of recent advances in CKD-associated cardiomyopathy, with a focus on pathophysiology, newly discovered biomarkers and potential therapeutic targets. RECENT FINDINGS CKD is associated with a specific pattern of myocardial hypertrophy and fibrosis, resulting in diastolic and systolic dysfunction, and often triggered by nonatherosclerotic processes. Novel biomarkers, including amino-terminal type III procollagen peptide (PIIINP), carboxy-terminal type I procollagen peptide (PICP), FGF23, marinobufagenin, and several miRNAs, show promise for early detection and risk stratification. Treatment options for CKD-associated cardiomyopathy are limited. Sodium glucose cotransporter-2 inhibitors have been shown to reduce left ventricle hypertrophy and improve ejection fraction in individuals with diabetes and mild CKD, and are currently under investigation for more advanced stages of CKD. In hemodialysis patients calcimimetic etelcalcetide resulted in a significant reduction in left ventricular mass. SUMMARY CKD-associated cardiomyopathy is a common and severe complication in CKD. The identification of novel biomarkers may lead to future therapeutic targets. Randomized clinical trials in individuals with more advanced CKD would be well posed to expand treatment options for this debilitating condition.
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Affiliation(s)
- Mirela A Dobre
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center
- School of Medicine
| | - Shruti Ahlawat
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center
| | - Jeffrey R Schelling
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center
- School of Medicine
- Department of Physiology & Biophysics, Case Western Reserve University, Cleveland, Ohio, USA
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El Shamy O, Teakell J. In-Center Dialysis Versus Extended Home Hemodialysis: More Evidence to Support Extended Dialysis. Kidney Int Rep 2023; 8:2501-2503. [PMID: 38106600 PMCID: PMC10719643 DOI: 10.1016/j.ekir.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Affiliation(s)
- Osama El Shamy
- Vanderbilt University Medical Center, Department of Internal Medicine, Division of Nephrology and Hypertension, Nashville, Tennessee, USA
| | - Jade Teakell
- Division of Renal Diseases and Hypertension, McGovern Medical School at UTHealth Houston, Houston, Texas, USA
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Ok E, Demirci C, Asci G, Yuksel K, Kircelli F, Koc SK, Erten S, Mahsereci E, Odabas AR, Stuard S, Maddux FW, Raimann JG, Kotanko P, Kerr PG, Chan CT. Patient Survival With Extended Home Hemodialysis Compared to In-Center Conventional Hemodialysis. Kidney Int Rep 2023; 8:2603-2615. [PMID: 38106580 PMCID: PMC10719649 DOI: 10.1016/j.ekir.2023.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction More frequent and/or longer hemodialysis (HD) has been associated with improvements in numerous clinical outcomes in patients on dialysis. Home HD (HHD), which allows more frequent and/or longer dialysis with lower cost and flexibility in treatment planning, is not widely used worldwide. Although, retrospective studies have indicated better survival with HHD, this issue remains controversial. In this multicenter study, we compared thrice-weekly extended HHD with in-center conventional HD (ICHD) in a large patient population with a long-term follow-up. Methods We matched 349 patients starting HHD between 2010 and 2014 with 1047 concurrent patients on ICHD by using propensity scores. Patients were followed-up with from their respective baseline until September 30, 2018. The primary outcome was overall survival. Secondary outcomes were technique survival; hospitalization; and changes in clinical, laboratory, and medication parameters. Results The mean duration of dialysis session was 418 ± 54 minutes in HHD and 242 ± 10 minutes in patients on ICHD. All-cause mortality rate was 3.76 and 6.27 per 100 patient-years in the HHD and the ICHD groups, respectively. In the intention-to-treat analysis, HHD was associated with a 40% lower risk for all-cause mortality than ICHD (hazard ratio [HR] = 0.60; 95% confidence interval [CI] 0.45 to 0.80; P < 0.001). In HHD, the 5-year technical survival was 86.5%. HHD treatment provided better phosphate and blood pressure (BP) control, improvements in nutrition and inflammation, and reduction in hospitalization days and medication requirement. Conclusion These results indicate that extended HHD is associated with higher survival and better outcomes compared to ICHD.
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Sági B, Kun S, Jakabfi-Csepregi RK, Sulyok E, Csiky B. Acute Vascular Response to Hemodialysis as Measured by Serum Syndecan-1 and Endothelin-1 Levels as Well as Vascular Stiffness. J Clin Med 2023; 12:7384. [PMID: 38068435 PMCID: PMC10707344 DOI: 10.3390/jcm12237384] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 10/08/2024] Open
Abstract
Background: Chronic hemodialysis (HD) patients have a very high cardiovascular risk. Acute vascular changes during dialysis mediated by factors of the endothelium may have a crucial role in this. The aim of this article is to study the acute vascular changes during HD. Methods: In 29 consecutive chronic HD patients (age: 65.6 ± 10.4 years), their pre-, mid-, and post-HD plasma syndecan-1 (SDC-1) and endothelin-1 (ET-1) levels were measured. Applanation tonometry was performed before HD. Results: Their SDC-1 levels increased during HD (p = 0.004). Males had higher ET-1 levels. The patients were divided into two groups based on their pre-HD pulse wave velocity (PWV): PWV ≥ 12 m/s and PWV < 12 m/s. The pre-HD and mid-HD SDC-1 levels were higher in the group with a PWV ≥ 12 m/s (10.174 ± 2.568 vs. 7.928 ± 1.794 ng/mL, p = 0.013, and 10.319 ± 3.482 vs. 8.248 ± 1.793 ng/mL, p = 0.044, respectively). The post-HD ET-1 levels were higher in the patient group with a PWV ≥ 12 m/s (10.88 ± 3.00 vs. 8.05 ± 3.48 pg/l, p = 0.027). Patients with a PWV ≥ 12 m/s had higher pre-HD peripheral and aortic systolic blood pressures (p < 0.05). The total cholesterol correlated with the SDC-1 decrease during HD (r = 0.539; p = 0.008). The pre-, mid-, and post-HD SDC-1 correlated with ultrafiltration (r = 0.432, p = 0.019; r = 0.377, p = 0.044; and r = 0.401, p = 0.012, respectively). Conclusion: SDC-1 and ET-1 contribute to the vascular changes observed during HD, and they have correlations with some cardiovascular risk factors.
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Affiliation(s)
- Balázs Sági
- 2nd Department of Internal Medicine and Nephrology, Diabetes Center, Clinical Center, Medical School, University of Pécs, 7624 Pécs, Hungary; (B.S.)
- Fresenius Medical Care Dialysis Centers, 7624 Pécs, Hungary
| | - Szilárd Kun
- 2nd Department of Internal Medicine and Nephrology, Diabetes Center, Clinical Center, Medical School, University of Pécs, 7624 Pécs, Hungary; (B.S.)
| | | | - Endre Sulyok
- Doctoral School of Health Sciences, University of Pécs, 7624 Pécs, Hungary;
| | - Botond Csiky
- 2nd Department of Internal Medicine and Nephrology, Diabetes Center, Clinical Center, Medical School, University of Pécs, 7624 Pécs, Hungary; (B.S.)
- Fresenius Medical Care Dialysis Centers, 7624 Pécs, Hungary
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Quinn RR, Lam NN. Home Dialysis in North America: The Current State. Clin J Am Soc Nephrol 2023; 18:1351-1358. [PMID: 37523194 PMCID: PMC10578635 DOI: 10.2215/cjn.0000000000000273] [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: 02/21/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
There is widespread interest in expanding the uptake of home dialysis in North America. Although kidney transplantation should be the preferred option in eligible patients, home hemodialysis (HD) and peritoneal dialysis (PD) offer cost-effective options for KRT. In this review, the motivation for promoting home dialysis is presented, and the literature supporting it is critically reviewed. Randomized comparisons of home HD and PD with in-center HD have been challenging to conduct and provide only limited information. Nonrandomized studies are heterogeneous in their design and have often yielded conflicting results. They are prone to bias, and this must be carefully considered when evaluating this literature. Home modalities seem to have equivalent clinical outcomes and quality of life when compared with in-center HD. However, the cost of providing home therapies, particularly PD, is lower than conventional, in-center HD. Measures of home dialysis utilization, the philosophy behind their measurement, and important factors to consider when interpreting them are discussed. The importance of understanding measures of home dialysis utilization in the context of rates of kidney failure, the proportion of individuals who opt for conservative care, and rates of kidney transplantation is highlighted, and a framework for proposing targets is presented, using PD as an example.
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Affiliation(s)
- Robert R Quinn
- Cumming School of Medicine , University of Calgary , Calgary, Canada, and
- Department of Community Health Sciences , University of Calgary , Calgary, Canada
| | - Ngan N Lam
- Cumming School of Medicine , University of Calgary , Calgary, Canada, and
- Department of Community Health Sciences , University of Calgary , Calgary, Canada
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Natale P, Ju A, Strippoli GF, Craig JC, Saglimbene VM, Unruh ML, Stallone G, Jaure A. Interventions for fatigue in people with kidney failure requiring dialysis. Cochrane Database Syst Rev 2023; 8:CD013074. [PMID: 37651553 PMCID: PMC10468823 DOI: 10.1002/14651858.cd013074.pub2] [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] [Indexed: 09/02/2023]
Abstract
BACKGROUND Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD). OBJECTIVES We aimed to evaluate the effects of pharmacological and non-pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Studies evaluating pharmacological and non-pharmacological interventions affecting levels of fatigue or fatigue-related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue-related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered. DATA COLLECTION AND ANALYSIS Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Ninety-four studies involving 8191 randomised participants were eligible. Pharmacological and non-pharmacological interventions were compared either to placebo or control, or to another pharmacological or non-pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis-Related Fatigue scale score): SMD -1.18, 95% CI -2.04 to -0.31; I2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD -1.23, 95% CI -1.96 to -0.50; I2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD -1.06, 95% CI -1.47, -0.65; I2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD -0.64, 95% CI -1.03 to -0.25; I2 = 75%) in HD. A wide range of heterogenous interventions and fatigue-related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non-pharmacological interventions on fatigue or fatigue-related outcomes, including non-physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive-behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta-blockers, anabolic steroids, glucose-enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non-pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported. AUTHORS' CONCLUSIONS Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non-pharmacological interventions had uncertain effects on fatigue or fatigue-related outcomes in people receiving dialysis. Future adequately powered, high-quality studies are likely to change the estimated effects of interventions for fatigue and fatigue-related outcomes in people receiving dialysis.
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Affiliation(s)
- Patrizia Natale
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Angela Ju
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Giovanni Fm Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, 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
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Mark L Unruh
- University of New Mexico, Department of Internal Medicine, Albuquerque, New Mexico, USA
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Iatridi F, Theodorakopoulou MP, Papagianni A, Sarafidis P. Management of intradialytic hypertension: current evidence and future perspectives. J Hypertens 2022; 40:2120-2129. [PMID: 35950992 DOI: 10.1097/hjh.0000000000003247] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Intradialytic hypertension (IDH), that is, a paradoxical rise in blood pressure (BP) during or immediately after a hemodialysis session, affects approximately 10-15% of the hemodialysis population. It is currently recognized as a phenomenon of major clinical significance as recent studies have shown that BP elevation extends to the whole interdialytic interval and associates with increased cardiovascular and all-cause mortality. The pathophysiology of IDH is complex involving volume and sodium overload, endothelial dysfunction, excess renin-angiotensin-aldosterone system and sympathetic nervous system activation, and other mechanisms. For several years, there was a scarcity of studies regarding IDH treatment; recently, however, several attempts to examine the effect of nonpharmacological and pharmacological measures on BP levels in IDH are made. This review attempts to summarize this latest evidence in the field of management of IDH and discuss areas for future research.
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Affiliation(s)
- Fotini Iatridi
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
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9
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Vô B, Anthonissen B, Verger C, Jadoul M, Morelle J, Goffin E. Characteristics, practices, and outcomes in a Belgian cohort of incident home hemodialysis patients: A 6-year experience. Hemodial Int 2022; 26:295-307. [PMID: 35441473 DOI: 10.1111/hdi.13014] [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: 12/03/2021] [Revised: 02/10/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Home hemodialysis (HHD) remains underused in patients with kidney failure. Current literature on HHD mostly originates from non-European countries, making generalization difficult. The present study describes patients' profile and practice patterns from a Belgian HHD center, and assesses patient and technique survival and complications associated with HHD. METHODS We analyzed data from all our incident patients during a 6-year period. The patient's characteristics were summarized using descriptive statistics. Transition to another therapeutic modality, estimated using a risk model with death and transplantation as competing events, episodes of respite cares and hospitalizations, and access complications were analyzed. RESULTS Eighty patients (mean age: 47 years; male: 64%) met the inclusion criteria. Fifty-one percent of patients initiated dialysis with a central venous catheter (CVC) and 96% were not assisted. Arterio-venous fistula (AVF) cannulation was performed using buttonhole technique. Standard-frequent HD (47%) and short-frequent low-flow dialysate HD (34%) were mostly used at HHD initiation. Cumulative incidences of technique failure and death were 15%, 24%, and 32% at 1, 2, and 5 years. Incidence rates for respite dialysis and hospitalizations were 2.39 and 0.54 per patient-year of HHD. In comparison with AVF, incidence rate ratios of overall access complications and access-related infections for CVC were 4.3 (95% CI: 3.1-6, p < 0.01) and 4.4 (95% CI: 2.1-10, p < 0.01), respectively. Buttonhole cannulation was complicated by 0.26 (95% CI: 0.15-0.46) infections per 1000 AVF-days. CONCLUSIONS This present study provides important information about patient's profile and practice patterns and safety in a cohort of 80 incident Belgian HHD patients, with encouraging techniques and patient survival.
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Affiliation(s)
- Bernard Vô
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Blaise Anthonissen
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Christian Verger
- Registre de Dialyse Péritonéale de Langue française (RDPLF), Pontoise, France
| | - Michel Jadoul
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Eric Goffin
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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10
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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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Murea M, Flythe JE, Anjay R, Emaad ARM, Gupta N, Kovach C, Vachharajani TJ, Kalantar-Zadeh K, Casino FG, Basile C. Kidney dysfunction requiring dialysis is a heterogeneous syndrome: we should treat it like one. Curr Opin Nephrol Hypertens 2022; 31:92-99. [PMID: 34846314 DOI: 10.1097/mnh.0000000000000754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Advanced kidney failure requiring dialysis, commonly labeled end-stage kidney disease or chronic kidney disease stage 5D, is a heterogeneous syndrome -a key reason that may explain why: treating advanced kidney dysfunction is challenging and many clinical trials involving patients on dialysis have failed, thus far. Treatment with dialytic techniques - of which maintenance thrice-weekly hemodialysis is most commonly used - is broadly named kidney 'replacement' therapy, a term that casts the perception of a priori abandonment of intrinsic kidney function and subsumes patients into a single, homogeneous group. RECENT FINDINGS Patients with advanced kidney failure necessitating dialytic therapy may have ongoing endogenous kidney function, and differ in their clinical manifestations and needs. Different terminology, for example, kidney dysfunction requiring dialysis (KDRD) with stages of progressive severity could better capture the range of phenotypes of patients who require kidney 'assistance' therapy. SUMMARY Classifying patients with KDRD based on objective, quantitative levels of endogenous kidney function, as well as patient-reported symptoms and quality of life, would facilitate hemodialysis prescriptions tailored to level of kidney dysfunction, clinical needs, and personal priorities. Such classification would encourage clinicians to move toward personalized, physiological, and adaptive approach to hemodialysis therapy.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Rastogi Anjay
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Abdel-Rahman M Emaad
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Nupur Gupta
- Indiana University Health, Indianapolis, Indiana
| | - 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, Ohio
| | - Tushar J Vachharajani
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti
- Dialysis Centre SM2, Policoro, Italy
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12
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Kusuzawa K, Suzuki K, Okada H, Suzuki K, Takada C, Nagaya S, Yasuda R, Okamoto H, Ishihara T, Tomita H, Kawasaki Y, Minamiyama T, Nishio A, Fukuda H, Shimada T, Tamaoki Y, Yoshida T, Nakashima Y, Chiba N, Yoshimura G, Kamidani R, Miura T, Oiwa H, Yamaji F, Mizuno Y, Miyake T, Kitagawa Y, Fukuta T, Doi T, Suzuki A, Yoshida T, Tetsuka N, Yoshida S, Ogura S. Measuring the Concentration of Serum Syndecan-1 to Assess Vascular Endothelial Glycocalyx Injury During Hemodialysis. Front Med (Lausanne) 2021; 8:791309. [PMID: 35004758 PMCID: PMC8733596 DOI: 10.3389/fmed.2021.791309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/07/2021] [Indexed: 11/13/2022] Open
Abstract
Glycocalyx is present on the surface of healthy endothelium, and the concentration of serum syndecan-1 can serve as an injury marker. This study aimed to assess endothelial injury using serum syndecan-1 as a marker of endothelial glycocalyx injury in patients who underwent hemodialysis. In this single-center, retrospective, observational study, 145 patients who underwent hemodialysis at the Gifu University Hospital between March 2017 and December 2019 were enrolled. The median dialysis period and time were 63 months and 3.7 h, respectively. The serum syndecan-1 concentration significantly increased from 124.6 ± 107.8 ng/ml before hemodialysis to 229.0 ± 138.1 ng/ml after hemodialysis (P < 0.001). Treatment with anticoagulant nafamostat mesylate inhibited hemodialysis-induced increase in the levels of serum syndecan-1 in comparison to unfractionated heparin. Dialysis time and the change in the syndecan-1 concentration were positively correlated. Conversely, the amount of body fluid removed and the changes in the syndecan-1 concentration were not significantly correlated. The reduction in the amount of body fluid removed and dialysis time inhibited the change in the syndecan-1 levels before and after hemodialysis. In conclusion, quantitative assessment of the endothelial glycocalyx injury during hemodialysis can be performed by measuring the serum syndecan-1 concentration, which may aid in the selection of appropriate anticoagulants, reduction of hemodialysis time, and the amount of body fluid removed.
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Affiliation(s)
- Keigo Kusuzawa
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Keiko Suzuki
- Department of Infection Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
- *Correspondence: Hideshi Okada
| | - Kodai Suzuki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Chihiro Takada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Soichiro Nagaya
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ryu Yasuda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Haruka Okamoto
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuki Kawasaki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Toru Minamiyama
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ayane Nishio
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hirotsugu Fukuda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takuto Shimada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuto Tamaoki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tomoki Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yusuke Nakashima
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Naokazu Chiba
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Genki Yoshimura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ryo Kamidani
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tomotaka Miura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
- Department of Infection Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hideaki Oiwa
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
- Abuse Prevention Center, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Fuminori Yamaji
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yosuke Mizuno
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takahito Miyake
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuichiro Kitagawa
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tetsuya Fukuta
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tomoaki Doi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Takahiro Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nobuyuki Tetsuka
- Department of Infection Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
- Abuse Prevention Center, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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13
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Pauly RP, Miller BW. Contextualizing the FHN Nocturnal Trial a Decade Later: How Nocturnal Home Hemodialysis Is Performed Matters to Outcomes. Clin J Am Soc Nephrol 2021; 16:966-968. [PMID: 33184091 PMCID: PMC8216607 DOI: 10.2215/cjn.09160620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Robert P. Pauly
- Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Brent W. Miller
- Division of Nephrology, Indiana University, Indianapolis, Indiana
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14
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Tennankore KK, Nadeau-Fredette AC, Vinson AJ. Survival comparisons in home hemodialysis: Understanding the present and looking to the future. Nephrol Ther 2021; 17S:S64-S70. [PMID: 33910701 DOI: 10.1016/j.nephro.2020.02.008] [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: 01/24/2020] [Accepted: 02/13/2020] [Indexed: 10/21/2022]
Abstract
A number of studies have compared relative survival for home hemodialysis patients (including longer hours/more frequent schedules) and other forms of renal replacement therapy. While informative, many of these studies have been limited by issues pertaining to their observational design including selection bias and residual confounding. Furthermore the few randomized controlled trials that have been conducted have been underpowered to detect a survival difference. Finally, in the face of a growing recognition of the value of patient-important outcomes beyond survival, the focus of comparisons between dialysis modalities may be changing. In this review, we will discuss the determinants of survival for patients receiving home hemodialysis and address the various studies that have compared relative survival for differing home hemodialysis schedules to each of in-center hemodialysis, peritoneal dialysis and transplantation. We will conclude this review by discussing whether there is an ongoing role for survival analyses in home hemodialysis.
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Affiliation(s)
- Karthik K Tennankore
- Dalhousie University/Nova Scotia Health Authority, 5082 Dickson Building, 5820, University Avenue, NS B3H 1V8 Halifax, Canada.
| | | | - Amanda J Vinson
- Dalhousie University/Nova Scotia Health Authority, 5082 Dickson Building, 5820, University Avenue, NS B3H 1V8 Halifax, Canada
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15
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Chanliau J, Durand PY. Lowering dialysis sessions duration may be dangerous. BULLETIN DE LA DIALYSE À DOMICILE 2021. [DOI: 10.25796/bdd.v4i1.60263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Dialysis session in less duration - either to give a better quality of life for the patient or to optimize the organization the dialysis institution - may have bad repercussions on the quality of the treatment and therefore the quality of life of the patient.
According to the result of the publications listed in this work, we conclude that it is necessary to perform either longer sessions or more frequent treatments to limit the interval time between two sessions.
As this is difficult to perform by the providers, we recommend to develop home dialysis to obtain the best result.
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16
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Elhassan EAE, Stoneman S, O'Kelly P, Francis V, Denton M, Magee C, de Freitas DG, O'Seaghdha CM, Donohoe J, Conlon PJ. Progressive survival improvement of incident dialysis patients in a tertiary center, Ireland. Ir J Med Sci 2021; 190:1597-1603. [PMID: 33443691 DOI: 10.1007/s11845-020-02481-3] [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: 09/21/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The survival of incident dialysis patients' end-stage kidney disease in some European and American has been reported to improve in modern era compared to earlier periods. However, in Ireland, this has not been well documented. AIM To investigate the survival outcomes of incident end-stage kidney failure dialysis patients in a tertiary center over a 24-year period, 1993-2017. METHODS A retrospective analysis was carried out utilizing the Beaumont Hospital Renal Database. Consecutive adults with incident dialysis were analyzed. Kaplan-Meier methods and the estimated mean survival times were used to evaluate survival at successive 4-year periods of time. RESULTS In total, 2106 patients were included, of whom 830 underwent subsequent renal transplantation during follow-up. During the study period, from 1993 up to 2017, the mean patients' age increased from 56.3 ± 17.4 in 1993-1996 to 60.6 ± 18.3 in 2014-2017. There was an overall decrement in mortality over successive time intervals which were mirrored by the improvements in median survival after commencement of dialysis treatment from 6.14 years during 1993-1996 to 8.01 years during 2009-2012. Patients' survival has steadily improved, with the 5-year survival has risen over time, by almost 15%. This positive signal persisted and became more pronounced after adjusting Kaplan-Meier curve to age, where the 5-year survival estimates were exceeding 80% in 2014-2017. CONCLUSION Survival rates among incident dialysis patients have improved progressively between 1993 and 2017 in Beaumont Hospital in Dublin, Ireland. The factors which led to this improvement are not entirely clear, but likely to be multifactorial.
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Affiliation(s)
| | - Sinead Stoneman
- Department of Nephrology & Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Nephrology & Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Veronica Francis
- Department of Nephrology & Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Mark Denton
- Department of Nephrology & Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Colm Magee
- Department of Nephrology & Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Declan G de Freitas
- Department of Nephrology & Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Conall M O'Seaghdha
- Department of Nephrology & Transplantation, Beaumont Hospital, Dublin, Ireland
| | - John Donohoe
- Department of Nephrology & Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Peter J Conlon
- Department of Nephrology & Transplantation, Beaumont Hospital, Dublin, Ireland.,Department of Medicine, Royal College of Surgeons, Dublin, Ireland
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17
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Fotheringham J, Latimer N, Froissart M, Kronenberg F, Stenvinkel P, Floege J, Eckardt KU, Wheeler DC. Survival on four compared with three times per week haemodialysis in high ultrafiltration patients: an observational study. Clin Kidney J 2020; 14:665-672. [PMID: 33623692 PMCID: PMC7886573 DOI: 10.1093/ckj/sfaa250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/26/2020] [Indexed: 12/26/2022] Open
Abstract
Background The harm caused by the long interdialytic interval in three-times-per-week haemodialysis regimens (3×WHD) may relate to fluid accumulation and associated high ultrafiltration rate (UFR). Four-times-per-week haemodialysis (4×WHD) may offer a solution, but its impact on mortality, hospitalization and vascular access complications is unknown. Methods From the AROii cohort of incident in-centre haemodialysis patients, 3×WHD patients with a UFR >10 mL/kg/h were identified. The hazard for the outcomes of mortality, hospitalization and vascular access complications in those who switched to 4×WHD compared with staying on 3×WHD was estimated using a marginal structural Cox proportional hazards model. Adjustment included baseline patient and treatment characteristics with inverse probability weighting used to adjust for time-varying UFR and cardiovascular comorbidities. Results From 10 637 European 3×WHD patients, 3842 (36%) exceeded a UFR >10 mL/kg/h. Of these, 288 (7.5%) started 4×WHD and at baseline were more comorbid. Event rates while receiving 4×WHD compared with 3×WHD were 12.6 compared with 10.8 per 100 patient years for mortality, 0.96 compared with 0.65 per year for hospitalization and 14.7 compared with 8.0 per 100 patient years for vascular access complications. Compared with 3×WHD, the unadjusted hazard ratio (HR) for mortality on 4×WHD was 1.05 [95% confidence interval (CI) 0.78–1.42]. Following adjustment for baseline demographics, time-varying treatment probability and censoring risks, this HR was 0.73 (95% CI 0.50–1.05; P = 0.095). Despite these adjustments on 4×WHD, the HR for hospitalization remained elevated and vascular access complications were similar to 3×WHD. Conclusions This observational study was not able to demonstrate a mortality benefit in patients switched to 4×WHD. To demonstrate the true benefits of 4×WHD requires a large, well-designed clinical trial. Our data may help in the design of such a study.
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Affiliation(s)
- James Fotheringham
- Sheffield Kidney Institute, Sheffield Teaching Hospitals, Sheffield, UK
- School of Health and Related Research, University of Sheffield, Sheffield, UK
- Correspondence to: James Fotheringham; E-mail:
| | - Nicholas Latimer
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Marc Froissart
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Stenvinkel
- Department of Renal Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Jürgen Floege
- Department of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin-Berlin, Berlin, Germany
| | - David C Wheeler
- Department of Renal Medicine, University College London, UK
- George Institute for Global Health, Sydney, New South Wales, Australia
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18
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Ethier I, Cho Y, Davies CE, Hawley CM, Campbell SB, Isbel NM, Pascoe EM, Polkinghorne KR, Roberts M, See EJ, Semple D, van Eps C, Viecelli AK, Johnson DW. Variability and trends over time and across centres in haemodialysis weekly duration in Australia and New Zealand. Nephrology (Carlton) 2020; 26:153-163. [PMID: 33094549 DOI: 10.1111/nep.13782] [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: 06/09/2020] [Revised: 07/27/2020] [Accepted: 08/28/2020] [Indexed: 11/28/2022]
Abstract
AIM Haemodialysis treatment prescription varies widely internationally. This study explored patient- and centre-level characteristics associated with weekly haemodialysis hours. METHODS Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data were analysed. Characteristics associated with weekly duration were evaluated using mixed-effects linear regression models with patient- and centre-level covariates as fixed effects, and dialysis centre and state as random effects using the 2017 prevalent in-centre haemodialysis (ICHD) and home haemodialysis (HHD) cohorts. Evaluation of patterns of weekly duration over time analysed the 2000 to 2017 incident ICHD and HHD cohorts. RESULTS Overall, 12 494 ICHD and 1493 HHD prevalent patients in 2017 were included. Median weekly treatment duration was 13.5 (interquartile range [IQR] 12-15) hours for ICHD and 16 (IQR 15-20) hours for HHD. Male sex, younger age, higher body mass index, arteriovenous fistula/graft use, Aboriginal and Torres Strait Islander ethnicity and longer dialysis vintage were associated with longer weekly duration for both ICHD and HHD. No centre characteristics were associated with duration. Variability in duration across centres was very limited in ICHD compared with HHD, with variation in HHD being associated with state. Duration did not vary significantly over time for ICHD, whereas longer weekly HHD treatments were reported between 2006 and 2012 compared with before and after this period. CONCLUSION This study in the Australian and New Zealand haemodialysis population showed that weekly duration was primarily associated with patient characteristics. No centre effect was demonstrated. Practice patterns seemed to differ across states/countries, with more variability in HHD than ICHD.
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Affiliation(s)
- Isabelle Ethier
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Christopher E Davies
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
| | - Scott B Campbell
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Nicole M Isbel
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Melbourne, Australia.,Department of Medicine, Monash University, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew Roberts
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Emily J See
- School of Medicine, University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Austin Health, Melbourne, Australia
| | - David Semple
- Department of Renal Medicine, Auckland District Health Board, Auckland, New Zealand.,School of Medicine, University of Auckland, Auckland, New Zealand
| | - Carolyn van Eps
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
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19
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Budhram B, Sinclair A, Komenda P, Severn M, Sood MM. A Comparison of Patient-Reported Outcome Measures of Quality of Life By Dialysis Modality in the Treatment of Kidney Failure: A Systematic Review. Can J Kidney Health Dis 2020; 7:2054358120957431. [PMID: 33149924 PMCID: PMC7580133 DOI: 10.1177/2054358120957431] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/15/2020] [Indexed: 12/19/2022] Open
Abstract
Background: There is an increasing demand to incorporate patient-reported outcome measures (PROMs) such as quality of life (QOL) in decision-making when selecting a chronic dialysis modality. Objective: To compare the change in QOL over time among similar patients on different dialysis modalities to provide unique and novel insights on the impact of dialysis modality on PROMs. Design: Systematic reviews, randomized controlled trials, and nonrandomized controlled trials were examined via a comprehensive search strategy incorporating multiple bibliographic databases. Setting: Data were extracted from relevant studies from January 1, 2000 to December 31, 2019 without limitations on country of study conduction. Patients: Eligible studies included adults (≥18 years) with end-stage kidney disease of any cause who were prescribed dialysis treatment (either as lifetime treatment or bridge to transplant). Measurements: The 5 comparisons were peritoneal dialysis (PD) vs in-center hemodialysis (ICHD), home hemodialysis (HHD) vs ICHD, HHD modalities compared with one another, HHD vs PD, and self-care ICHD vs traditional nurse-based ICHD. Methods: Included studies compared adults on different dialysis modalities with repeat measures within individuals to determine changes in QOL between dialysis modalities (in-center or home dialysis). Methodological quality was assessed by the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist. A narrative synthesis was conducted, synthesizing the direction and size of any observed effects across studies. Results: Two randomized controlled trials and 9 prospective cohort studies involving a combined total of 3711 participants were included. Comparing PD and ICHD, 5 out of 9 studies found significant differences (P < .05) favoring PD in the change of multiple QOL domains, including “physical component score,” “role of social component score,” “cognitive status,” “role limitation due to emotional function,” “role limitation due to physical function,” “bodily pain,” “burden of kidney disease,” “effects of kidney disease on daily life,” “symptoms/problems,” “sexual function,” “finance,” and “patient satisfaction.” Conversely, 3 of these studies demonstrated statistically significant differences (P < .05) favoring ICHD in the domains of “role limitation due to physical function,” “general health,” “support from staff,” “sleep quality,” “social support,” “health status,” “social interaction,” “body image,” and “overall health.” Comparing HHD and ICHD, significant differences (P < .05) favoring HHD for the QOL domains of “general health,” “burden of kidney disease,” and the visual analogue scale were reported. Limitations: Our study is constrained by the small sample sizes of included studies, as well as heterogeneity among both study populations and validated QOL scales, limiting inter-study comparison. Conclusions: We identified differences in specific QOL domains between dialysis modalities that may aid in patient decision-making based on individual priorities. Trial registration: PROSPERO Registration Number: CRD42016046980. Primary funding source: The original research for this study was derived from the Canadian Agency for Drugs and Technologies in Health (CADTH) 2017 optimal use report, titled “Dialysis Modalities for the Treatment of End-Stage Kidney Disease: A Health Technology Assessment.” The CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.
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Affiliation(s)
- Brandon Budhram
- The Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
| | - Alison Sinclair
- Canadian Agency for Drugs and Technologies in Health, Ottawa, ON, Canada
| | - Paul Komenda
- Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Melissa Severn
- Canadian Agency for Drugs and Technologies in Health, Ottawa, ON, Canada
| | - Manish M Sood
- The Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
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20
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Jansz TT, Noordzij M, Kramer A, Laruelle E, Couchoud C, Collart F, Cases A, Arici M, Helve J, Waldum-Grevbo B, Rydell H, Traynor JP, Zoccali C, Massy ZA, Jager KJ, van Jaarsveld BC. Survival of patients treated with extended-hours haemodialysis in Europe: an analysis of the ERA-EDTA Registry. Nephrol Dial Transplant 2020; 35:488-495. [PMID: 31740955 PMCID: PMC7056951 DOI: 10.1093/ndt/gfz208] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/13/2019] [Indexed: 01/16/2023] Open
Abstract
Background Previous US studies have indicated that haemodialysis with ≥6-h sessions [extended-hours haemodialysis (EHD)] may improve patient survival. However, patient characteristics and treatment practices vary between the USA and Europe. We therefore investigated the effect of EHD three times weekly on survival compared with conventional haemodialysis (CHD) among European patients. Methods We included patients who were treated with haemodialysis between 2010 and 2017 from eight countries providing data to the European Renal Association–European Dialysis and Transplant Association Registry. Haemodialysis session duration and frequency were recorded once every year or at every change of haemodialysis prescription and were categorized into three groups: CHD (three times weekly, 3.5–4 h/treatment), EHD (three times weekly, ≥6 h/treatment) or other. In the primary analyses we attributed death to the treatment at the time of death and in secondary analyses to EHD if ever initiated. We compared mortality risk for EHD to CHD with causal inference from marginal structural models, using Cox proportional hazards models weighted for the inverse probability of treatment and censoring and adjusted for potential confounders. Results From a total of 142 460 patients, 1338 patients were ever treated with EHD (three times, 7.1 ± 0.8 h/week) and 89 819 patients were treated exclusively with CHD (three times, 3.9 ± 0.2 h/week). Crude mortality rates were 6.0 and 13.5/100 person-years. In the primary analyses, patients treated with EHD had an adjusted hazard ratio (HR) of 0.73 [95% confidence interval (CI) 0.62–0.85] compared with patients treated with CHD. When we attributed all deaths to EHD after initiation, the HR for EHD was comparable to the primary analyses [HR 0.80 (95% CI 0.71–0.90)]. Conclusions EHD is associated with better survival in European patients treated with haemodialysis three times weekly.
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Affiliation(s)
- Thijs T Jansz
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.,Dianet Dialysis Centres, Utrecht, The Netherlands
| | - Marlies Noordzij
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anneke Kramer
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric Laruelle
- AUB Sante Dialyse, Rennes, France.,Service de Nephrologie, CHU Rennes, Rennes, France
| | - Cécile Couchoud
- REIN Registry, Agence de la biomédecine, Saint-Denis La Plaine, France
| | | | - Aleix Cases
- Nephrology Unit, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.,Registre de Malalts Renals de Catalunya, Barcelona, Spain
| | - Mustafa Arici
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Jaako Helve
- Finnish Registry for Kidney Diseases, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Helena Rydell
- Department of Clinical Sciences Intervention and Technology, Karolinska Institutet, Huddinge, Sweden.,Swedish Renal Registry, Department of Internal Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - Jamie P Traynor
- Scottish Renal Registry Meridian Court, Information Services Division Scotland, Glasgow, UK
| | - Carmine Zoccali
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR-Institute of Clinical Physiology, Reggio Calabria, Italy
| | - Ziad A Massy
- Division of Nephrology, Ambroise-Paré University Hospital, APHP, University of Paris Ouest-Versailles-St-Quentin-en-Yvelines, Boulogne-Billancourt/Paris, France.,Institut National de la Santé et de la Recherche Médicale U1018, Team 5, CESP UVSQ, University Paris Saclay, Villejuif, France
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Brigit C van Jaarsveld
- Dianet Dialysis Centres, Utrecht, The Netherlands.,Department of Nephrology and Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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21
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Haroon S, Griva K, Davenport A. Factors affecting uptake of home hemodialysis among self-care dialysis unit patients. Hemodial Int 2020; 24:460-469. [PMID: 32856399 DOI: 10.1111/hdi.12862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 06/02/2020] [Accepted: 07/15/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Superior outcomes have been reported among hemodialysis (HD) patients who take active control over their dialysis treatment either at self-care satellite dialysis units or home compared to the regular in-center hemodialysis patient. Although the differences between the home hemodialysis (HHD) and self-care in-center HD (SCHD) are not well described, the growing literature on the superior outcomes of HHD suggests that HHD is the better option. METHODS We performed a cross-sectional study in a stand-alone self-care unit to examine the differences in patients that are keen to consider HHD and those who are not. FINDINGS A cross-sectional sample of 44 patients completed a structured interview and the distress thermometer score used to assess psychological stress. Only 68% of patients reported to have heard about the benefits of HHD despite the long-established history and availability of the modality in the unit. One of the more critical findings in our study was that the cohort of patients who were keen to consider HHD believed that self-care and HHD would improve their quality of life (P < 0.05). Specifically, the perceived benefits stated by those willing to consider HHD were the lack of need to travel, association with better outcomes and the possibility of having the treatment in the comfort of home (P < 0.05). DISCUSSION We surmise that the answers expressed in this survey likely reflect a difference in perceptions of self-care and beliefs about HHD; hence, the importance of introducing HHD education earlier in the course of their chronic kidney disease journey.
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Affiliation(s)
| | - Konstadina Griva
- Center for Population Health Sciences, Nanyang Technological University, Singapore
| | - Andrew Davenport
- Division of Nephrology, Department of Medicine, UCL Center for Nephrology, Royal Free Hospital, University College London, London, UK
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22
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Smyth B, Zuo L, Gray NA, Chan CT, de Zoysa JR, Hong D, Rogers K, Wang J, Cass A, Gallagher M, Perkovic V, Jardine M. No evidence of a legacy effect on survival following randomization to extended hours dialysis in the ACTIVE Dialysis trial. Nephrology (Carlton) 2020; 25:792-800. [PMID: 32500957 DOI: 10.1111/nep.13737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/01/2020] [Accepted: 05/15/2020] [Indexed: 11/28/2022]
Abstract
AIM Extended hours haemodialysis is associated with superior survival to standard hours. However, residual confounding limits the interpretation of this observation. We aimed to determine the effect of a period of extended hours dialysis on long-term survival among participants in the ACTIVE Dialysis trial. METHODS Two-hundred maintenance haemodialysis recipients were randomized to extended hours dialysis (median 24 h/wk) or standard hours dialysis (median 12 h/wk) for 12 months. Further pre-specified observational follow up occurred at 24, 36 and 60 months. Vital status and modality of renal replacement therapy were ascertained. RESULTS Over the 5 years, 38 participants died, 30 received a renal transplant, and 6 were lost to follow up. Total weekly dialysis hours did not differ between standard and extended groups during the follow-up period (14.1 hours [95%CI 13.4-14.8] vs 14.8 hours [95%CI 14.1-15.6]; P = .16). There was no difference in all-cause mortality (hazard ratio for extended hours 0.91 [95%CI 0.48-1.72]; P = .77). Similar results were obtained after censoring participants at transplantation, and after adjusting for potential confounding variables. Subgroup analysis did not reveal differences in treatment effect by region, dialysis setting or vintage (P-interaction .51, .54, .12, respectively). CONCLUSION Twelve months of extended hours dialysis did not improve long-term survival nor affect dialysis hours after the intervention period. An urgent need remains to further define the optimal dialysis intensity across the broad range of dialysis recipients.
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Affiliation(s)
- Brendan Smyth
- Renal and Metabolic Division, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia.,Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Nicholas A Gray
- Renal Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia.,Sunshine Coast Clinical School, University of Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Christopher T Chan
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Janak R de Zoysa
- Renal Services, North Shore Hospital, Auckland, New Zealand.,Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Daqing Hong
- Renal Department, Sichuan Provincial People's Hospital, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China Medical School, Chengdu, China
| | - Kris Rogers
- Renal and Metabolic Division, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia.,Graduate School of Health, University of Technology, Sydney, New South Wales, Australia
| | - Jia Wang
- School of Medicine, University of Electronic Science and Technology of China Medical School, Chengdu, China.,General Practice Department, Sichuan Provincial People's Hospital, Chengdu, China
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, North Territory, Australia
| | - Martin Gallagher
- Renal and Metabolic Division, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia.,Renal Unit, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Vlado Perkovic
- Renal and Metabolic Division, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
| | - Meg Jardine
- Renal and Metabolic Division, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia.,Renal Unit, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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23
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Marshall MR, Vandal AC, de Zoysa JR, Gabriel RS, Haloob IA, Hood CJ, Irvine JH, Matheson PJ, McGregor DOR, Rabindranath KS, Schollum JBW, Semple DJ, Xie Z, Ma TM, Sisk R, Dunlop JL. Effect of Low-Sodium versus Conventional Sodium Dialysate on Left Ventricular Mass in Home and Self-Care Satellite Facility Hemodialysis Patients: A Randomized Clinical Trial. J Am Soc Nephrol 2020; 31:1078-1091. [PMID: 32188697 PMCID: PMC7217404 DOI: 10.1681/asn.2019090877] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/19/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Fluid overload in patients undergoing hemodialysis contributes to cardiovascular morbidity and mortality. There is a global trend to lower dialysate sodium with the goal of reducing fluid overload. METHODS To investigate whether lower dialysate sodium during hemodialysis reduces left ventricular mass, we conducted a randomized trial in which patients received either low-sodium dialysate (135 mM) or conventional dialysate (140 mM) for 12 months. We included participants who were aged >18 years old, had a predialysis serum sodium ≥135 mM, and were receiving hemodialysis at home or a self-care satellite facility. Exclusion criteria included hemodialysis frequency >3.5 times per week and use of sodium profiling or hemodiafiltration. The main outcome was left ventricular mass index by cardiac magnetic resonance imaging. RESULTS The 99 participants had a median age of 51 years old; 67 were men, 31 had diabetes mellitus, and 59 had left ventricular hypertrophy. Over 12 months of follow-up, relative to control, a dialysate sodium concentration of 135 mmol/L did not change the left ventricular mass index, despite significant reductions at 6 and 12 months in interdialytic weight gain, in extracellular fluid volume, and in plasma B-type natriuretic peptide concentration (ratio of intervention to control). The intervention increased intradialytic hypotension (odds ratio [OR], 7.5; 95% confidence interval [95% CI], 1.1 to 49.8 at 6 months and OR, 3.6; 95% CI, 0.5 to 28.8 at 12 months). Five participants in the intervention arm could not complete the trial because of hypotension. We found no effect on health-related quality of life measures, perceived thirst or xerostomia, or dietary sodium intake. CONCLUSIONS Dialysate sodium of 135 mmol/L did not reduce left ventricular mass relative to control, despite improving fluid status. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER The Australian New Zealand Clinical Trials Registry, ACTRN12611000975998.
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Affiliation(s)
- Mark R Marshall
- Department of Renal Medicine, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand;
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Medical Affairs, Baxter Healthcare (Asia) Pte Ltd., Singapore
| | - Alain C Vandal
- Department of Statistics, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Janak R de Zoysa
- Department of Renal Medicine, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
- Waitemata Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ruvin S Gabriel
- Department of Cardiology, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Imad A Haloob
- Department of Renal Medicine, Bathurst Base Hospital, New South Wales, Bathurst, Australia
| | - Christopher J Hood
- Department of Renal Medicine, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - John H Irvine
- Department of Nephrology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Philip J Matheson
- Department of Nephrology, Wellington Hospital, Capital & Coast District Health Board, Wellington, New Zealand
| | - David O R McGregor
- Department of Nephrology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Kannaiyan S Rabindranath
- Department of Nephrology, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
| | - John B W Schollum
- Nephrology Service, Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand
| | - David J Semple
- Department of Renal Medicine, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Zhengxiu Xie
- Middlemore Clinical Trials, Auckland, New Zealand; and
| | - Tian Min Ma
- Department of Renal Medicine, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand;
| | - Rose Sisk
- Division of Informatics, Imaging & Data Sciences, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Joanna L Dunlop
- Department of Renal Medicine, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
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24
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William JH, Morales A, Rosas SE. When ESKD complicates the management of diabetes mellitus. Semin Dial 2020; 33:209-222. [PMID: 32274852 DOI: 10.1111/sdi.12873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Given the increased incidence and prevalence of ESKD (end-stage kidney disease) attributed to diabetes mellitus, it is important to consider the physiological and global sociodemographic factors that give rise to unique challenges in providing excellent care to this population. The individual with diabetes and ESKD faces alterations of glucose homeostasis that require close therapeutic attention, as well as the consideration of safe and effective means of maintaining glycemic control. Implementation of routine monitoring of blood glucose and thoughtful alteration of the individual's hypoglycemic drug regimen must be employed to reduce the risk of neurological, cardiovascular, and diabetes-specific complications that may arise as a result of ESKD. Titration of insulin therapy may become quite challenging, as kidney replacement therapy often significantly impacts insulin requirements. New medications have significantly improved the ability of the clinician to provide effective therapies for the management of diabetes, but have also raised an equal amount of uncertainty with respect to their safety and efficacy in the ESKD population. Additionally, the clinician must consider the challenges related to the delivery of kidney replacement therapy, and how inter-modality differences may impact glycemic control, diabetes, and ESKD-related complications, and issues surrounding dialysis vascular access creation.
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Affiliation(s)
- Jeffrey H William
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander Morales
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sylvia E Rosas
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Kidney and Hypertension Unit, Joslin Diabetes Center, Boston, MA, USA
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25
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Sarafidis P, Faitatzidou D, Papagianni A. Benefits and risks of frequent or longer haemodialysis: weighing the evidence. Nephrol Dial Transplant 2020; 36:gfaa023. [PMID: 32073626 DOI: 10.1093/ndt/gfaa023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Indexed: 12/28/2022] Open
Abstract
Although the ability of individuals with end-stage renal disease to maintain body homoeostasis is equally impaired during all weekdays, conventional haemodialysis (HD) treatment is scheduled thrice weekly, containing two short and one long interdialytic interval. This intermittent nature of HD and the consequent fluctuations in volume, metabolic parameters and electrolytes have long been hypothesized to predispose to complications. Large observational studies link the first weekday with an increased risk of cardiovascular morbidity and mortality. Several schemes of frequent and/or longer, home or in-centre HD have been introduced, aiming to alleviate the above risks by both increasing total dialysis duration and reducing the duration of interdialytic intervals. Observational studies in this field have non-uniform results, showing that enhanced frequency in home (but not in-centre) HD is associated with reduced mortality. Evidence from the randomized Daily and Nocturnal Trials of the Frequent HD Network suggest the opposite, showing mortality benefits with in-centre daily but not with home nocturnal dialysis. Secondary analyses of these trials indicate that daily and nocturnal schedules do not have equal effects on intermediate outcomes. Alternative schemes, such as thrice weekly in-centre nocturnal HD or every-other-day HD, seem to also offer improvements in several intermediate endpoints, but need further testing with randomized trials. This review summarizes the effects of frequent and/or longer HD methods on hard and intermediate outcomes, attempting to provide a balanced overview of the field.
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Affiliation(s)
- Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Danai Faitatzidou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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26
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Wang M, Obi Y, Streja E, Rhee CM, Chen J, Hao C, Kovesdy CP, Kalantar-Zadeh K. Impact of residual kidney function on hemodialysis adequacy and patient survival. Nephrol Dial Transplant 2019; 33:1823-1831. [PMID: 29688442 DOI: 10.1093/ndt/gfy060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/21/2018] [Indexed: 11/14/2022] Open
Abstract
Background Both dialysis dose and residual kidney function (RKF) contribute to solute clearance and are associated with outcomes in hemodialysis patients. We hypothesized that the association between dialysis dose and mortality is attenuated with greater RKF. Methods Among 32 251 incident hemodialysis patients in a large US dialysis organization (2007-11), we examined the interaction between single-pool Kt/V (spKt/V) and renal urea clearance (rCLurea) levels in survival analyses using multivariable Cox proportional hazards regression model. Results The median rCLurea and mean baseline spKt/V were 3.06 [interquartile range (IQR) 1.74-4.85] mL/min/1.73 m2 and 1.32 ± 0.28, respectively. A total of 7444 (23%) patients died during the median follow-up of 1.2 years (IQR 0.5-2.2 years) with an incidence of 15.4 deaths per 100 patient-years. The Cox model with adjustment for case-mix and laboratory variables showed that rCLurea modified the association between spKt/V and mortality (Pinteraction = 0.03); lower spKt/V was associated with higher mortality among patients with low rCLurea (i.e. <3 mL/min/1.73 m2) but not among those with higher rCLurea. The adjusted mortality hazard ratios (aHRs) and 95% confidence intervals of the low (<1.2) versus high (≥1.2) spKt/V were 1.40 (1.12-1.74), 1.21 (1.10-1.33), 1.06 (0.98-1.14), and 1.00 (0.93-1.08) for patients with rCLurea of 0.0, 1.0, 3.0 and 6.0 mL/min/1.73 m2, respectively. Conclusions Incident hemodialysis patients with substantial RKF do not exhibit the expected better survival at higher hemodialysis doses. RKF levels should be taken into account when deciding on the dose of dialysis treatment among incident hemodialysis patients.
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Affiliation(s)
- Mengjing Wang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA.,Division of Nephrology, Department of Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Jing Chen
- Division of Nephrology, Department of Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Chuanming Hao
- Division of Nephrology, Department of Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA.,Fielding School of Public Health at UCLA, Los Angeles, CA, USA
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27
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Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Andrea Fox RN, Franklin G, Gardiner C, Martin Gerrish RN, Greenwood S, Hothi D, Khares A, Koufaki P, Levy J, Lindley E, Macdonald J, Mafrici B, Mooney A, Tattersall J, Tyerman K, Villar E, Wilkie M. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol 2019; 20:379. [PMID: 31623578 PMCID: PMC6798406 DOI: 10.1186/s12882-019-1527-3] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022] Open
Abstract
This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.
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Affiliation(s)
- Damien Ashby
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England.
| | - Natalie Borman
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | - James Burton
- University Hospitals of Leicester NHS Trust, Leicester, England
| | - Richard Corbett
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | | | - Ken Farrington
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Katey Flowers
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | | | - R N Andrea Fox
- School of Nursing and Midwifery, University of Sheffield, Sheffield, England
| | - Gail Franklin
- East & North Hertfordshire NHS Trust, Stevenage, England
| | | | | | - Sharlene Greenwood
- Renal and Exercise Rehabilitation, King's College Hospital, London, England
| | | | - Abdul Khares
- Haemodialysis Patient, c/o The Renal Association, Bristol, UK
| | - Pelagia Koufaki
- School of Health Sciences, Queen Margaret University, Edinburgh, Scotland
| | - Jeremy Levy
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Jamie Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Bruno Mafrici
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Kay Tyerman
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Enric Villar
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Martin Wilkie
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
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28
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Dias EC, Orcy R, Antunes MF, Kohn R, Rombaldi AJ, Ribeiro L, Oses JP, Ferreira GD, Araújo AM, Boff IF, Böhlke M. Intradialytic exercise with blood flow restriction: Something to add to hemodialysis adequacy? Findings from a crossover study. Hemodial Int 2019; 24:71-78. [PMID: 31612630 DOI: 10.1111/hdi.12793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Hemodialysis (HD) increases the lifespan of chronic kidney disease (CKD) patients. However, HD is only partially effective in replacing renal function. The aim of this study is to compare HD adequacy between sessions with intradialytic exercise with or without blood flow restriction (BFR) with sessions without exercise. METHODS A crossover study including 22 adult CKD patients on HD. The patients were assigned to BFR (n = 11) or exercise alone group (n = 11). Each patient was submitted to four HD sessions (two with exercise and two control sessions). HD adequacy was assessed by equilibrated Kt/V-urea (eKT/V), single-pool Kt/V-urea (sp-Kt/V), urea and phosphorus rebound, urea reduction ratio (URR) and removal of urea and phosphorus in dialysate. FINDINGS BFR exercise improved eKt/V and sp-Kt/V (1.32 ± 0.21 vs. 1.10 ± 0.16 for control, P < 0.001; 1.53 ± 0.26 vs. 1.27 ± 0.19 for control, P < 0.001, respectively) and URR (72.5 ± 5.4% vs. 66.1 ± 7.7% for control, P < 0.001). No difference in eKt/V, sp-Kt/V or URR could be detected between exercise alone and control HD sessions. Urea rebound was lower in BFR exercise vs. control sessions (-8.9 ± 9.1% vs. 30.7 ± 12.8%, P < 0.01) and exercise alone vs. control sessions (13.3 ± 29.0% vs. 42.4 ± 15.3%, P < 0.01). Phosphorus rebound was marginally lower in exercise vs. control sessions (14.4 ± 19.1% vs. 28.4 ± 22.1%, P = 0.18). Urea and phosphorus mass removal in dialysate were marginally higher in exercise vs. control sessions (42.2 ± 19.4 g vs. 35.7 ± 12.5 g, P = 0.24; 912.1 ± 360.9 mg vs. 778.6 ± 245.1 mg, P = 0.28). CONCLUSIONS Intradialytic exercise with BFR was more effective than standard exercise in increasing HD adequacy.
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Affiliation(s)
- Etiene C Dias
- Postgraduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil
| | - Rafael Orcy
- Physiology Department, Federal University of Pelotas, Pelotas, Brazil
| | - Maria F Antunes
- Postgraduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil
| | - Rodrigo Kohn
- Postgraduate Program in Physical Education, Federal University of Pelotas, Pelotas, Brazil
| | - Airton J Rombaldi
- Postgraduate Program in Physical Education, Federal University of Pelotas, Pelotas, Brazil
| | - Larissa Ribeiro
- Postgraduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil.,Dialysis and Renal Transplantation Unit, São Francisco de Paula University Hospital, Catholic University of Pelotas, Pelotas, Brazil
| | - Jean P Oses
- Postgraduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil
| | | | - Aline M Araújo
- Postgraduate Program in Physical Education, Federal University of Pelotas, Pelotas, Brazil
| | - Isis F Boff
- Postgraduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil
| | - Maristela Böhlke
- Postgraduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil.,Dialysis and Renal Transplantation Unit, São Francisco de Paula University Hospital, Catholic University of Pelotas, Pelotas, Brazil
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Fotheringham J, Sajjad A, Stel VS, McCullough K, Karaboyas A, Wilkie M, Bieber B, Robinson BM, Massy ZA, Jager KJ. The association between longer haemodialysis treatment times and hospitalization and mortality after the two-day break in individuals receiving three times a week haemodialysis. Nephrol Dial Transplant 2019; 34:1577-1584. [PMID: 30820580 PMCID: PMC6735689 DOI: 10.1093/ndt/gfz007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND On the first haemodialysis (HD) day after the 2-day break in three times a week (3×W) in-centre HD, mortality and hospitalization are higher. If longer HD sessions prescribed 3×W is associated with a reduction in these events is unknown. METHODS HD session length in 19 557 prevalent European in-centre 3×W HD patients participating in the Dialysis Outcomes and Practice Patterns Study (1998-2011) were categorized into <200, 200-225, 226-250 or >250 min. Standardized event rates on the first (HD1) versus the second (HD2) HD day after the 2-day break, with supporting Cox proportional hazards models adjusted for patient and dialysis characteristics, were generated for all-cause mortality, all-cause hospitalization, out-of-hospital death and fluid overload hospitalization. RESULTS By comparing HD1 with HD2, increased rates of all endpoints were observed (all P < 0.002). As HD session lengthened across the four groups, all-cause mortality per 100 patient-years on the HD1 (23.0, 20.4, 16.4 and 14.6) and HD2 (26.1, 13.3, 13.4 and 12.1) reduced. Similar improvements were observed for out-of-hospital death but were less marked for hospitalization endpoints. However, even patients dialysing >250 min were at significantly greater risk on HD1 when compared with their HD2 for out-of-hospital death [hazard ratio (HR) = 2.1, 95% CI 1.0-4.3], all-cause hospitalization (HR = 1.3, 95% CI 1.2-1.4) and fluid overload hospitalization (HR = 3.2, 95% CI 1.8-6.0). CONCLUSIONS Despite the association between reduced mortality across all dialysis days in patients performing longer sessions, elevated risk on the first dialysis day relative to the second persists even in patients dialysing 4.5 h 3×W.
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Affiliation(s)
- James Fotheringham
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, UK
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ayesha Sajjad
- European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Vianda S Stel
- European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | | | | | - Martin Wilkie
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, UK
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Ziad A Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, University of Versailles-Saint-Quentin-en-Yvelines, Boulogne-Billancourt, France
- INSERM Unit 1018, CESP, University Paris-Saclay, University of Versailles-Saint-Quentin-en-Yvelines, Université Paris Sud, Villejuif, France
| | - Kitty J Jager
- European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Vinson AJ, Perl J, Tennankore KK. Survival Comparisons of Home Dialysis Versus In-Center Hemodialysis: A Narrative Review. Can J Kidney Health Dis 2019; 6:2054358119861941. [PMID: 31321065 PMCID: PMC6628511 DOI: 10.1177/2054358119861941] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/28/2019] [Indexed: 12/22/2022] Open
Abstract
Purpose of review: Many observational studies have demonstrated a survival benefit with home dialysis compared with in-center dialysis; however, results have been conflicting. The purpose of this review was to identify pitfalls and limitations in existing literature and examine the challenges of studying home and in-center dialysis populations. Sources of information: Original research articles were identified from MEDLINE using search terms “in-center hemodialysis,” “home hemodialysis,” “conventional hemodialysis,” “nocturnal hemodialysis,” and “short daily hemodialysis.” Methods: A focused review and critical appraisal of existing home versus in-center hemodialysis survival literature was conducted to identify potential causes for variability in the observed survival outcomes. Key findings: The controversy in existing literature stems from the challenges of randomizing patients to home versus in-center hemodialysis modalities, and therefore a reliance on observational comparisons for study. In many cases, these observational analyses have been limited by selection bias (variabilities in populations included, inclusion of both incident and prevalent cohorts, and variabilities in dialysis intensity), as well as residual confounding. Furthermore, the studies that do exist lack generalizability in many cases. Limitations: There are few randomized controlled trials examining the survival benefit of home versus in-center hemodialysis and existing observational studies are often limited by bias and reduced generalizability. These limitations comprise the body of this review. Implications: This review examines challenges surrounding survival comparisons with home versus in-center hemodialysis and identify important directions for future study.
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Affiliation(s)
- Amanda J Vinson
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Canada
| | - Jeffrey Perl
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Karthik K Tennankore
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Canada
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Emmett CJ, Macintyre K, Kitsos A, McKercher CM, Jose M, Bettiol S. Independent effect of haemodialysis session frequency and duration on survival in non-indigenous Australians on haemodialysis. Nephrology (Carlton) 2019; 25:323-331. [PMID: 31112321 DOI: 10.1111/nep.13607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND End-stage kidney disease patients have increased mortality compared to the general population. Haemodialysis (HD) of more frequent and of longer duration has been proposed to improve survival but it remains unclear if this is attributed to increased frequency, duration, or both. We aimed to examine the independent effects of session frequency and duration on mortality in incident HD patients. METHODS A retrospective cohort study was performed using data from the Australian and New Zealand Dialysis and Transplant Registry examining non-Indigenous patients aged ≥18 years who initiated HD of ≥3 sessions/week in Australia from 2001 to 2015. Initial dialysis prescription was categorized as session duration >5 h/session compared to ≤5 h/session and session frequency as >3 sessions/week compared to 3 sessions/week. Survival analysis was performed using Cox regression analysis, with multivariable analysis controlling for available covariates. RESULTS We examined 16 944 patients of whom 757 (4.5%) received >3 sessions/week and 518 (3.1%) received >5 h/session. After controlling for frequency, patients initiated on HD sessions >5 h had a significantly reduced risk of mortality compared with patients with HD session ≤5 h (adjusted hazard ratio (HR) = 0.57; 95% confidence interval (CI) = 0.44-0.74). In contrast, patients initiated on >3 sessions/week of HD had a similar risk of death when compared with patients on 3 sessions/week of HD (adjusted HR = 0.97; 95% CI = 0.84-1.13), after controlling for duration. Limitations include potential residual confounding and changes in exposure over time. CONCLUSION Longer duration rather than increased frequency of treatment appears to reduce mortality in HD patients. This has implications for management and requires further study.
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Affiliation(s)
- Christopher J Emmett
- College of Health and Medicine, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Kate Macintyre
- College of Health and Medicine, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Alex Kitsos
- Health Services Innovation Tasmania, College of Health and Medicine, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Charlotte M McKercher
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Precinct, Hobart, Tasmania, Australia
| | - Matthew Jose
- College of Health and Medicine, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Medical Science Precinct, Hobart, Tasmania, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Adelaide, South Australia, Australia
| | - Silvana Bettiol
- College of Health and Medicine, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Abstract
Dialyzer clearance of urea multiplied by dialysis time and normalized for urea distribution volume (Kt/Vurea or simply Kt/V) has been used as an index of dialysis adequacy since more than 30 years. This article reviews the flaws of Kt/V, starting with a lack of proof of concept in three randomized controlled hard outcome trials (RCTs), and continuing with a long list of conditions where the concept of Kt/V was shown to be flawed. This information leaves little room for any conclusion other than that Kt/V, as an indicator of dialysis adequacy, is obsolete. The dialysis patient might benefit more if, instead, the nephrology community concentrates in the future on pursuing the optimal dialysis dose that conforms with adequate quality of life and on factors that are likely to affect outcomes more than Kt/V. These include residual renal function, volume status, dialysis length, ultrafiltration rate, the number of intra-dialytic hypotensive episodes, interdialytic blood pressure, serum potassium and phosphate, serum albumin, and C reactive protein.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
| | - Norbert Lameire
- Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
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33
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Dhruve M, Faratro R, D'Gama C, Fung S, Arustei D, Wong E, Chan CT. The use of nurse-administered vascular access audit in home hemodialysis patients: A quality initiative. Hemodial Int 2019; 23:133-138. [PMID: 30734988 DOI: 10.1111/hdi.12708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 08/08/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Vascular access complications are associated with increased morbidity and mortality in home hemodialysis (HHD). Nurse-administered vascular access checklist is a feasible quality improvement strategy aimed to lower HHD access errors. METHODS We conducted a prospective quality improvement initiative for consecutive HHD patients between April 2013 and December 2016 at the Toronto General Hospital. Vascular access audits were administered every 6 months during clinic visits and during retraining sessions after an infection. We aimed to (1) determine whether prospective serial administration of vascular audit will decrease in the number of errors performed by the patient and (2) to determine whether there is an association between the number of errors and vascular access related infection. FINDINGS A total of 370 audits were performed on 122 patients with a mean HHD vintage of 6.7 (0.8-19.5) years. The mean number of errors per patient decreased from 1.24 ± 1.75 (baseline) to 0.33 ± 0.49 (last follow-up), P < 0.001. Among patients who had serial vascular access audits performed, there was a significant decrease in median number of errors (baseline median 1, [0-2] end of study median 0, [0-1] P = 0.01). Patients performing buttonhole cannulation made most proportion of errors as compared to CVC, 54% vs. 40% (P = 0.01) respectively; and as compared to rope ladder cannulation 54% vs. 37% (P = 0.008). We were unable to demonstrate an association between the change in patient reported errors and vascular access related infection. DISCUSSION Vascular access audit is a feasible quality initiative, which leads to a decrease in the number of patient reported errors in vascular access. The longitudinal clinical sequelae of this strategy warrants further examination.
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Affiliation(s)
- Miten Dhruve
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rose Faratro
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Celine D'Gama
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Stella Fung
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Daniela Arustei
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Elizabeth Wong
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christopher T Chan
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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34
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Deira J, Suárez MA, López F, García-Cabrera E, Gascón A, Torregrosa E, García GE, Huertas J, de la Flor JC, Puello S, Gómez-Raja J, Grande J, Lerma JL, Corradino C, Musso C, Ramos M, Martín J, Basile C, Casino FG. IHDIP: a controlled randomized trial to assess the security and effectiveness of the incremental hemodialysis in incident patients. BMC Nephrol 2019; 20:8. [PMID: 30626347 PMCID: PMC6325813 DOI: 10.1186/s12882-018-1189-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 12/17/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Most people who make the transition to renal replacement therapy (RRT) are treated with a fixed dose thrice-weekly hemodialysis réegimen, without considering their residual kidney function (RKF). Recent papers inform us that incremental hemodialysis is associated with preservation of RKF, whenever compared with conventional hemodialysis. The objective of the present controlled randomized trial (RCT) is to determine if start HD with one sessions per week (1-Wk/HD), it is associated with better patient survival and other safety parameters. METHODS/DESIGN IHDIP is a multicenter RCT experimental open trial. It is randomized in a 1:1 ratio and controlled through usual clinical practice, with a low intervention level and non-commercial. It includes 152 incident patients older than 18 years, with a RRF of ≥4 ml/min/1.73 m2, measured by renal clearance of urea (KrU). The intervention group includes 76 patients who will start with incremental HD (1-Wk/HD). The control group includes 76 patients who will start with thrice-weekly hemodialysis régimen. The primary outcome is assessing the survival rate, while the secondary outcomes are the morbidity rate, the clinical parameters, the quality of life and the efficiency. DISCUSSION This study will enable to know the number of sessions a patient should receive when starting HD, depending on his RRF. The potentially important clinical and financial implications of incremental hemodialysis warrant this RCT. TRIAL REGISTRATION U.S. National Institutes of Health, ClinicalTrials.gov . Number: NCT03239808 , completed 13/04/2017. SPONSOR Foundation for Training and Research of Health Professionals of Extremadura.
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Affiliation(s)
- Javier Deira
- Hospital San Pedro de Alcantara, Cáceres, Spain.
| | | | | | | | | | | | | | - Jorge Huertas
- Hospital de Especialidades de las Fuerzas Armadas, Quito, Ecuador
| | | | - Suleya Puello
- Hospital Clínico Universitario, Santiago de Compostela, Spain
| | | | | | - José L Lerma
- Complejo Asistencial Universitario, Salamanca, Spain
| | | | - Carlos Musso
- Hospital Durand de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Carlo Basile
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Bari, Italy.,Dialysis Centre SM2, Potenza, Italy
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35
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Liew A. Perspectives in renal replacement therapy: Haemodialysis. Nephrology (Carlton) 2019; 23 Suppl 4:95-99. [PMID: 30298645 DOI: 10.1111/nep.13449] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 11/30/2022]
Abstract
Haemodialysis (HD) was the first procedure that had demonstrated the ability to partially replace renal function, and became the most widely utilized treatment for patients with end-stage renal disease (ESRD). In a great majority of countries around the world, conventional in-centre HD had become the predominant renal replacement therapy, being touted as able to achieve better solute clearance and more successful in attaining euvolemia than patients on peritoneal dialysis. This is despite the antecedent hemodynamic risks, more rapid loss of residual renal function, greater infectious perils, excessive erythropoietin requirements and higher infrastructure costs. In addition, quality of life had been suggested to be worse among patients on HD, though this had been challenged repeatedly. Consequently, the concept of integrated ESRD care over the last few decades had placed HD, as a complementary rather than a competitive treatment modality to the entire armamentarium of renal replacement therapies. Incorporating HD as part of integrated care into health-care policies and national resource planning will become an essential strategy in improving access and outcome to care among the ESRD population. The improvement in technologies and innovation in prescription had brought forth enhanced dialyzer membrane and machine upgrades, and expanded modalities including more frequent HD and haemodiafiltration. While boasting of controversial improvement in outcomes, many of these therapies remain expensive and insurmountable for widespread utility in many countries. In addition, the results of these new technologies had been conflicting across studies, with some even suggesting that they could be detrimental. Therefore, judicial consideration has to be undertaken to appropriate their use in clinical practice.
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Affiliation(s)
- Adrian Liew
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore, Singapore
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36
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Suárez MA, García-Cabrera E, Gascón A, López F, Torregrosa E, García GE, Huertas J, de la Flor JC, Puello S, Gómez-Raja J, Grande J, Lerma JL, Corradino C, Ramos M, Martín J, Basile C, Casino FG, Deira J. Rationale and design of DiPPI: A randomized controlled trial to evaluate the safety and effectiveness of progressive hemodialysis in incident patients. Nefrologia 2018; 38:630-638. [PMID: 30344012 DOI: 10.1016/j.nefro.2018.07.010] [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: 09/26/2017] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Progressive haemodialysis (HD) is a starting regime for renal replacement therapy (RRT) adapted to each patient's necessities. It is mainly conditioned by the residual renal function (RRF). The frequency of sessions with which patients start HD (one or two sessions per week), is lower than that for conventional HD (three times per week). Such frequency is increased (from one to two sessions, and from two to three sessions) as the RRF declines. METHODOLOGY/DESIGN IHDIP is a multicentre randomised experimental open trial. It is randomised in a 1:1 ratio and controlled through usual clinical practice, with a low intervention level and non-commercial. It includes 152 patients older than 18 years with chronic renal disease stage 5 and start HD as RRT, with an RRF of ≥4ml/min/1.73m2, measured by renal clearance of urea (KrU). The intervention group includes 76 patients who will start with one session of HD per week (progressive HD). The control group includes 76 patients who will start with three sessions per week (conventional HD). The primary purpose is assessing the survival rate, while the secondary purposes are the morbidity rate (hospital admissions), the clinical parameters, the quality of life and the efficiency. DISCUSSION This study will enable us to know, with the highest level of scientific evidence, the number of sessions a patient should receive when starting the HD treatment, depending on his/her RRF. TRIAL REGISTRATION Registered at the U.S. National Institutes of Health, ClinicalTrials.gov under the number NCT03239808.
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Affiliation(s)
- Miguel A Suárez
- Unidad de Nefrología, Hospital Virgen del Puerto, Plasencia, España.
| | | | - Antonio Gascón
- Unidad de Nefrología, Hospital Obispo Polanco, Teruel, España
| | - Francisca López
- Unidad de Nefrología, Hospital Costa del Sol, Marbella, España
| | | | | | - Jorge Huertas
- Unidad de Nefrología, Hospital de Especialidades de las Fuerzas Armadas, Quito, Ecuador
| | - José C de la Flor
- Unidad de Nefrología, Hospital Central de la Defensa Gómez Ulla, Madrid, España
| | - Suleyka Puello
- Unidad de Nefrología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, España
| | | | - Jesús Grande
- Unidad de Nefrología, Hospital Virgen de la Concha, Zamora, España
| | - José L Lerma
- Unidad de Nefrología, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | | | - Manuel Ramos
- Unidad de Nefrología, Hospital de Jerez, Jerez de la Frontera, España
| | - Jesús Martín
- Unidad de Nefrología, Hospital Nuestra Sra. de Sonsoles, Ávila, España
| | - Carlo Basile
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italia
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italia; Dialysis Centre SM2, Potenza, Italia
| | - Javier Deira
- Unidad de Nefrología, Hospital San Pedro de Alcántara, Cáceres, España
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Cruz LGD, Zanetti HR, Andaki ACR, Mota GRD, Barbosa Neto O, Mendes EL. Intradialytic aerobic training improves inflammatory markers in patients with chronic kidney disease: a randomized clinical trial. MOTRIZ: REVISTA DE EDUCACAO FISICA 2018. [DOI: 10.1590/s1980-657420180003e017517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Lucas Gonçalves da Cruz
- Universidade Federal do Triângulo Mineiro, Brazil; Universidade Federal de Uberlândia, Brazil
| | | | | | - Gustavo Ribeiro da Mota
- Universidade Federal do Triângulo Mineiro, Brazil; Universidade Federal do Triângulo Mineiro, Brazil
| | - Octávio Barbosa Neto
- Universidade Federal do Triângulo Mineiro, Brazil; Universidade Federal do Triângulo Mineiro, Brazil
| | - Edmar Lacerda Mendes
- Universidade Federal do Triângulo Mineiro, Brazil; Universidade Federal do Triângulo Mineiro, Brazil
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Health-related quality of life compared between kidney transplantation and nocturnal hemodialysis. PLoS One 2018; 13:e0204405. [PMID: 30235331 PMCID: PMC6147724 DOI: 10.1371/journal.pone.0204405] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background Health-related quality of life (HRQOL) is an important outcome measure in patients with end-stage renal disease. HRQOL is assumed to improve with kidney transplantation and also with nocturnal hemodialysis compared to conventional hemodialysis. However, there is no evidence regarding HRQOL to support the optimal treatment choice for patients on nocturnal hemodialysis who hesitate opting for transplantation. We therefore compared HRQOL between patients who were treated with kidney transplantation or nocturnal hemodialysis for one year. Methods We assessed HQROL using the Kidney Disease Quality of Life–Short Form questionnaire in a cross-sectional sample of patients who were treated with kidney transplantation (n = 41) or nocturnal hemodialysis (n = 31) for one year. All patients on nocturnal hemodialysis were transplantation candidates. Using linear regression, we compared HRQOL between kidney transplantation and nocturnal hemodialysis, and adjusted for age, sex, dialysis duration, cardiovascular disease, and presence of residual urine production. Results At one year follow-up, mean age of the study population was 54 ±13 years, and median dialysis duration was 3.2 (IQR 2.1–5.0) years. Kidney transplantation was associated with significantly higher HRQOL on the domain “effects” compared to nocturnal hemodialysis (adjusted difference 12.0 points, 95% CI 3.9; 20.1). There were potentially clinically relevant differences between kidney transplantation and nocturnal hemodialysis on the domains “burden” (adjusted difference 11.1 points, 95% CI -2.6; 24.8), “social support” (adjusted difference 6.2, 95% CI -6.6; 19.1), and the physical composite score (adjusted difference 3.0, 95% CI -2.0; 8.1), but these were not significant. Conclusions After kidney transplantation, HRQOL is especially higher on the domain “effects of kidney disease” compared to nocturnal hemodialysis. This can be useful when counseling patients on nocturnal hemodialysis who may opt for transplantation.
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Jones CB, Bargman JM. Should we look beyond Kt/V urea in assessing dialysis adequacy? Semin Dial 2018; 31:420-429. [PMID: 29573025 DOI: 10.1111/sdi.12684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Since the advent of maintenance dialysis therapy, our interpretation of what adequate dialysis really is has broadened and become more controversial. This is not only due to our changing and aging dialysis population but also to our evolving knowledge base. As nephrologists, we strive to achieve both quality and (often) quantity of life for our patients and we feel reassured when we have a quantifiable marker to show for our efforts. However, we suggest that adequate dialysis reaches far beyond the realms of attaining a particular biochemical result. Dialysis adequacy should encompass a more comprehensive assessment of patient well-being. This metric could comprise quality of life and patient-specified goals, sufficient small solute and middle molecule clearance, optimal blood pressure control, and effective bone-mineral balance, all in the context of minimizing mortality and morbidity, and a livable dialysis regimen for the patient.
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Affiliation(s)
- Clare B Jones
- Division of Nephrology, University Health Network, Toronto, Canada
| | - Joanne M Bargman
- Division of Nephrology, University Health Network, Toronto, Canada
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40
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Tattersall J, Farrington K, Gentile G, Kooman J, Macias Núñez JF, Nistor I, Van Biesen W, Covic A. Is Kt/V useful in elderly dialysis patients? Pro and Con arguments. Nephrol Dial Transplant 2018; 33:742-750. [DOI: 10.1093/ndt/gfy042] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 02/04/2018] [Indexed: 01/06/2023] Open
Affiliation(s)
- James Tattersall
- Renal Unit, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ken Farrington
- Renal Unit, Lister Hospital, Stevenage, Hertfordshire, UK
- Centre for Health Services and Clinical Research, University of Hertfordshire, Hatfield, UK
| | - Giorgio Gentile
- Department of Renal Medicine, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Jeroen Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Ionut Nistor
- Department of Nephrology “Dr CI Parhon” Hospital, Iasi, Romania
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Adrian Covic
- Department of Nephrology “Dr CI Parhon” Hospital, Iasi, Romania
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41
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Abstract
The use of frequent hemodialysis (HD) is growing, with the hope of improving outcomes in end-stage renal disease. We narratively review the three randomized trials, 15 comparative cohort studies, and several case series of frequent HD that empirically demonstrate the potential efficacy and adverse effects of these regimens. Taken together, the randomized studies suggest frequent HD may result in left ventricular mass regression. This effect is most pronounced when left ventricular mass is abnormal, but attenuated by significant residual urine output. Both frequent short and long HD consistently improved blood pressure control and reduced antihypertensive use, despite greater weekly interdialytic weight gains. Serum phosphate was lowered. Frequent short daytime HD improved health-related quality of life, while frequent long overnight HD did not. Regarding adverse effects, frequent HD patients underwent significantly more procedures to salvage arteriovenous vascular accesses. An absolute increase in hypotensive episodes was observed with frequent short HD, while frequent long HD accelerated residual renal function loss and increased perceived caregiver burden. The effect of frequent HD on mortality is controversial, due to conflicting results and limitations of published studies. Finally, pregnancy outcomes may be substantially better with frequent long HD. On the basis of these data, we suggest frequent HD is most likely to benefit patients with left ventricular hypertrophy particularly if there is minimal urine output, those unable to attain dry weight on a thrice weekly schedule, and pregnant women. All patients receiving frequent HD should be advised of and monitored for potential risks.
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Affiliation(s)
- Rita S Suri
- Department of Medicine, University of Montreal, Montreal, Canada
| | - Alan S Kliger
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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42
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Jansz TT, Özyilmaz A, Grooteman MPC, Hoekstra T, Romijn M, Blankestijn PJ, Bots ML, van Jaarsveld BC. Long-term clinical parameters after switching to nocturnal haemodialysis: a Dutch propensity-score-matched cohort study comparing patients on nocturnal haemodialysis with patients on three-times-a-week haemodialysis/haemodiafiltration. BMJ Open 2018. [PMID: 29523566 PMCID: PMC5855195 DOI: 10.1136/bmjopen-2017-019900] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Nocturnal haemodialysis (NHD), characterised by 8-hour sessions ≥3 times a week, is known to improve clinical parameters in the short term compared with conventional-schedule haemodialysis (HD), generally 3×3.5-4 hours a week. We studied long-term effects of NHD and used patients on conventional HD/haemodiafiltration (HDF) as controls. DESIGN Four-year prospective follow-up of patients who switched to NHD; we compared patients with patients on HD/HDF using propensity score matching. SETTING 28 Dutch dialysis centres. PARTICIPANTS We included 159 patients starting with NHD any time since 2004, aged 56.7±12.9 years, with median dialysis vintage 2.3 (0.9-5.1) years. We propensity-score matched 100 patients on NHD to 100 on HD/HDF. PRIMARY AND SECONDARY OUTCOME MEASURES Control of hypertension (predialysis blood pressure, number of antihypertensives), phosphate (phosphate, number of phosphate binders), nutritional status and inflammation (albumin, C reactive protein and postdialysis weight) and anaemia (erythropoiesis-stimulating agent (ESA) resistance). RESULTS Switching to NHD was associated with a non-significant reduction of antihypertensives compared with HD/HDF (OR <2 types 2.17, 95% CI 0.86 to 5.50, P=0.11); and a prolonged lower need for phosphate binders (OR <2 types 1.83, 95% CI 1.10 to 3.03, P=0.02). NHD was not associated with significant changes in blood pressure or phosphate. NHD was associated with significantly higher albumin over time compared with HD/HDF (0.70 g/L/year, 95% CI 0.10 to 1.30, P=0.02). ESA resistance decreased significantly in NHD compared with HD/HDF, resulting in a 33% lower ESA dose in the long term. CONCLUSIONS After switching to NHD, the lower need for antihypertensives, phosphate binders and ESA persists for at least 4 years. These sustained improvements in NHD contrast significantly with the course of these parameters during continued treatment with conventional-schedule HD and HDF. NHD provides an optimal form of dialysis, also suitable for patients expected to have a long waiting time for transplantation or those convicted to indefinite dialysis.
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Affiliation(s)
- Thijs Thomas Jansz
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Akin Özyilmaz
- Dialysis Centre Groningen, Groningen, The Netherlands
- Division of Nephrology, Department of Internal Medicine, University Medical Centre, Groningen, The Netherlands
| | - Muriel P C Grooteman
- Department of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Tiny Hoekstra
- Department of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Marieke Romijn
- Department of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Michael L Bots
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Brigit C van Jaarsveld
- Department of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands
- Diapriva Dialysis Centre, Amsterdam, The Netherlands
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43
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Kalim S, Wald R, Yan AT, Goldstein MB, Kiaii M, Xu D, Berg AH, Clish C, Thadhani R, Rhee EP, Perl J. Extended Duration Nocturnal Hemodialysis and Changes in Plasma Metabolite Profiles. Clin J Am Soc Nephrol 2018; 13:436-444. [PMID: 29444900 PMCID: PMC5967674 DOI: 10.2215/cjn.08790817] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/08/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES In-center, extended duration nocturnal hemodialysis has been associated with variable clinical benefits, but the effect of extended duration hemodialysis on many established uremic solutes and other components of the metabolome is unknown. We determined the magnitude of change in metabolite profiles for patients on extended duration nocturnal hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a 52-week prospective, observational study, we followed 33 patients receiving conventional thrice weekly hemodialysis who converted to nocturnal hemodialysis (7-8 hours per session, three times per week). A separate group of 20 patients who remained on conventional hemodialysis (3-4 hours per session, three times per week) served as a control group. For both groups, we applied liquid chromatography-mass spectrometry-based metabolite profiling on stored plasma samples collected from all participants at baseline and after 1 year. We examined longitudinal changes in 164 metabolites among those who remained on conventional hemodialysis and those who converted to nocturnal hemodialysis using Wilcoxon rank sum tests adjusted for multiple comparisons (false discovery rate <0.05). RESULTS On average, the nocturnal group had 9.6 hours more dialysis per week than the conventional group. Among 164 metabolites, none changed significantly from baseline to study end in the conventional group. Twenty-nine metabolites changed in the nocturnal group, 21 of which increased from baseline to study end (including all branched-chain amino acids). Eight metabolites decreased after conversion to nocturnal dialysis, including l-carnitine and acetylcarnitine. By contrast, several established uremic retention solutes, including p-cresol sulfate, indoxyl sulfate, and trimethylamine N-oxide, did not change with extended dialysis. CONCLUSIONS Across a wide array of metabolites examined, extended duration hemodialysis was associated with modest changes in the plasma metabolome, with most differences relating to metabolite increases, despite increased dialysis time. Few metabolites showed reduction with more dialysis, and no change in several established uremic toxins was observed.
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Affiliation(s)
| | | | - Andrew T. Yan
- Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Mercedeh Kiaii
- Division of Nephrology, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | | | - Anders H. Berg
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | | | | | - Eugene P. Rhee
- Nephrology Division and
- Endocrinology Unit, Massachusetts General Hospital, Boston, Massachusetts
- Broad Institute, Cambridge, Massachusetts
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Miller BW, Himmele R, Sawin DA, Kim J, Kossmann RJ. Choosing Home Hemodialysis: A Critical Review of Patient Outcomes. Blood Purif 2018; 45:224-229. [PMID: 29478056 DOI: 10.1159/000485159] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM Home hemodialysis (HHD) has been associated with improved clinical outcomes vs. in-center HD (ICHD). The prevalence of HHD in the United States is still very low at 1.8%. This critical review compares HHD and ICHD outcomes for survival, hospitalization, cardiovascular (CV), nutrition, and quality of life (QoL). METHODS Of 545 publications identified, 44 were not selected after applying exclusion criteria. A systematic review of the identified publications was conducted to compare HHD to ICHD outcomes for survival, hospitalization, CV outcomes, nutrition, and QoL. RESULTS Regarding mortality, 10 of 13 trials reported 13-52% reduction; three trials found no differences. According to 6 studies, blood pressure and left ventricular size measurements were generally lower in HHD patients compared to similar measurements in ICHD patients. Regarding nutritional status, conflicting results were reported (8 studies); some found improved muscle mass, total protein, and body mass index in HHD vs. ICHD patients, while others found no significant differences. There were no significant differences in the rate of hospitalization between HHD and ICHD in the 6 articles reviewed. Seven studies on QoL demonstrated positive trends in HHD vs. ICHD populations. CONCLUSIONS Despite limitations in the current data, 66% of the publications reviewed (29/44) demonstrated improved clinical outcomes in patients who chose HHD. These include improved survival, CV, nutritional, and QoL parameters. Even though HHD may not be preferred in all patients, a review of the literature suggests that HHD should be provided as a modality choice for substantially more than the current 1.8% of HHD patients in the United States.
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45
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Mathew A, McLeggon JA, Mehta N, Leung S, Barta V, McGinn T, Nesrallah G. Mortality and Hospitalizations in Intensive Dialysis: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2018; 5:2054358117749531. [PMID: 29348924 PMCID: PMC5768251 DOI: 10.1177/2054358117749531] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/30/2017] [Indexed: 11/15/2022] Open
Abstract
Background: Survival and hospitalization are critically important outcomes considered when choosing between intensive hemodialysis (HD), conventional HD, and peritoneal dialysis (PD). However, the comparative effectiveness of these modalities is unclear. Objective: We had the following aims: (1) to compare the association of mortality and hospitalization in patients undergoing intensive HD, compared with conventional HD or PD and (2) to appraise the methodological quality of the supporting evidence. Data Sources: MEDLINE, Embase, ISI Web of Science, CENTRAL, and nephrology conference abstracts. Study Eligibility, Participants, and Interventions: We included cohort studies with comparator arm, and randomized controlled trials (RCTs) with >50% of adult patients (≥18 years) comparing any form of intensive HD (>4 sessions/wk or >5.5 h/session) with any form of chronic dialysis (PD, HD ≤4 sessions/wk or ≤5.5 h/session), that reported at least 1 predefined outcome (mortality or hospitalization). Methods: We used the GRADE approach to systematic reviews and quality appraisal. Two reviewers screened citations and full-text articles, and extracted study-level data independently, with discrepancies resolved by consensus. We pooled effect estimates of randomized and observational studies separately using generic inverse variance with random effects models, and used fixed-effects models when only 2 studies were available for pooling. Predefined subgroups for the intensive HD cohorts were classified by nocturnal versus short daily HD and home versus in-center HD. Results: Twenty-three studies with a total of 70 506 patients were included. Of the observational studies, compared with PD, intensive HD had a significantly lower mortality risk (hazard ratio [HR]: 0.67; 95% confidence interval [CI]: 0.53-0.84; I2 = 91%). Compared with conventional HD, home nocturnal (HR: 0.46; 95% CI: 0.38-0.55; I2 = 0%), in-center nocturnal (HR: 0.73; 95% CI: 0.60-0.90; I2 = 57%) and home short daily (HR: 0.54; 95% CI: 0.31-0.95; I2 = 82%) intensive regimens had lower mortality. Of the 2 RCTs assessing mortality, in-center short daily HD had lower mortality (HR: 0.54; 95% CI: 0.31-0.93), while home nocturnal HD had higher mortality (HR: 3.88; 95% CI: 1.27-11.79) in long-term observational follow-up. Hospitalization days per patient-year (mean difference: –1.98; 95% CI: –2.37 to −1.59; I2 = 6%) were lower in nocturnal compared with conventional HD. Quality of evidence was similarly low or very low in RCTs (due to imprecision) and observational studies (due to residual confounding and selection bias). Limitations: The overall quality of evidence was low or very low for critical outcomes. Outcomes such as quality of life, transplantation, and vascular access outcomes were not included in our review. Conclusions: Intensive HD regimens may be associated with reduced mortality and hospitalization compared with conventional HD or PD. As the quality of supporting evidence is low, patients who place a high value on survival must be adequately advised and counseled of risks and benefits when choosing intensive dialysis. Practice guidelines that promote shared decision-making are likely to be helpful.
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Affiliation(s)
- Anna Mathew
- McMaster University, Hamilton, Ontario, Canada
| | - Jody-Ann McLeggon
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Nirav Mehta
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Samuel Leung
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Valerie Barta
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Thomas McGinn
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Gihad Nesrallah
- Department of Nephrology, Humber River Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Ontario, Canada
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46
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Tennankore KK, Na Y, Wald R, Chan CT, Perl J. Short daily-, nocturnal- and conventional-home hemodialysis have similar patient and treatment survival. Kidney Int 2018; 93:188-194. [DOI: 10.1016/j.kint.2017.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/26/2017] [Accepted: 06/08/2017] [Indexed: 10/19/2022]
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47
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Zhang ZH, Mao JR, Chen H, Su W, Zhang Y, Zhang L, Chen DQ, Zhao YY, Vaziri ND. Removal of uremic retention products by hemodialysis is coupled with indiscriminate loss of vital metabolites. Clin Biochem 2017; 50:1078-1086. [DOI: 10.1016/j.clinbiochem.2017.09.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 12/11/2022]
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48
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Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). J Hypertens 2017; 35:657-676. [PMID: 28157814 DOI: 10.1097/hjh.0000000000001283] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In patients with end-stage renal disease treated with hemodialysis or peritoneal dialysis, hypertension is very common and often poorly controlled. Blood pressure (BP) recordings obtained before or after hemodialysis display a J-shaped or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar hemodynamic setting related with dialysis treatment. Elevated BP by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnea and the use of erythropoietin-stimulating agents may also be involved. Nonpharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium-volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
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49
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Wang M, Obi Y, Streja E, Rhee CM, Lau WL, Chen J, Hao C, Hamano T, Kovesdy CP, Kalantar-Zadeh K. Association of Parameters of Mineral Bone Disorder with Mortality in Patients on Hemodialysis according to Level of Residual Kidney Function. Clin J Am Soc Nephrol 2017; 12:1118-1127. [PMID: 28487345 PMCID: PMC5498357 DOI: 10.2215/cjn.11931116] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The relationship between mineral and bone disorders and survival according to residual kidney function status has not been previously studied in patients on hemodialysis. We hypothesized that residual kidney function, defined by renal urea clearance, modifies the association between mineral and bone disorder parameters and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The associations of serum phosphorus, albumin-corrected calcium, intact parathyroid hormone, and alkaline phosphatase with all-cause mortality were examined across three strata (<1.5, 1.5 to <3.0, and ≥3.0 ml/min per 1.73 m2) of baseline residual renal urea clearance using Cox models adjusted for clinical characteristics and laboratory measurements in 35,114 incident hemodialysis patients from a large United States dialysis organization over the period of 2007-2011. RESULTS A total of 8102 (23%) patients died during the median follow-up of 1.3 years (interquartile range, 0.6-2.3 years). There was an incremental mortality risk across higher serum phosphorus concentrations, which was pronounced among patients with higher residual renal urea clearance (Pinteraction=0.001). Lower concentrations of serum intact parathyroid hormone were associated with higher mortality among patients with low residual renal urea clearance (i.e., <1.5 ml/min per 1.73 m2), whereas higher concentrations showed a higher mortality risk among patients with greater residual renal urea clearance (i.e., ≥1.5 ml/min per 1.73 m2; Pinteraction<0.001). Higher serum corrected total calcium and higher alkaline phosphatase concentrations consistently showed higher mortality risk (Ptrend<0.001 for both) irrespective of residual renal urea clearance strata (Pinteraction=0.34 and Pinteraction=0.53, respectively). CONCLUSIONS Residual kidney function modified the mortality risk associated with serum phosphorus and intact parathyroid hormone among incident hemodialysis patients. Future studies are needed to examine whether taking account for residual kidney function into the assessment of mortality risk associated with serum phosphorus and intact parathyroid hormone improves patient management and clinical outcomes in the hemodialysis population.
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Affiliation(s)
- Mengjing Wang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chuanming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Department of Epidemiology, Fielding School of Public Health at University of California, Los Angeles, Los Angeles, California; and
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
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50
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Sarafidis PA, Persu A, Agarwal R, Burnier M, de Leeuw P, Ferro CJ, Halimi JM, Heine GH, Jadoul M, Jarraya F, Kanbay M, Mallamaci F, Mark PB, Ortiz A, Parati G, Pontremoli R, Rossignol P, Ruilope L, Van der Niepen P, Vanholder R, Verhaar MC, Wiecek A, Wuerzner G, London GM, Zoccali C. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). Nephrol Dial Transplant 2017; 32:620-640. [PMID: 28340239 DOI: 10.1093/ndt/gfw433] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 11/14/2016] [Indexed: 01/07/2023] Open
Abstract
In patients with end-stage renal disease (ESRD) treated with haemodialysis or peritoneal dialysis, hypertension is common and often poorly controlled. Blood pressure (BP) recordings obtained before or after haemodialysis display a J- or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar haemodynamic setting related to dialysis treatment. Elevated BP detected by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnoea and the use of erythropoietin-stimulating agents may also be involved. Non-pharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium and volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
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Affiliation(s)
- Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - Michel Burnier
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | - Peter de Leeuw
- Department of Medicine, Maastricht University Medical Center, Maastricht and Zuyderland Medical Center, Geleen/Heerlen, The Netherlands
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jean-Michel Halimi
- Service de Néphrologie-Immunologie Clinique, Hôpital Bretonneau, François-Rabelais University, Tours, France
| | - Gunnar H Heine
- Saarland University Medical Center, Internal Medicine IV-Nephrology and Hypertension, Homburg, Germany
| | - Michel Jadoul
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Faical Jarraya
- Department of Nephrology, Sfax University Hospital and Research Unit, Faculty of Medicine, Sfax University, Sfax, Tunisia
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
| | - Gianfranco Parati
- Department of Cardiovascular, Neural, and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano and Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Roberto Pontremoli
- Università degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genova, Italy
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, and Association Lorraine de Traitement de l'Insuffisance Rénale, Nancy, France
| | - Luis Ruilope
- Hypertension Unit & Institute of Research i?+?12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel - VUB, Brussels, Belgium
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, The Netherlands
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Katowice, Poland
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
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