Peritoneal clearance of homocysteine with icodextrin or standard glucose solution exchange

Reduction of protein-bound uraemic toxins in plasma of chronic renal failure patients: A systematic review

BACKGROUND

Protein-bound uraemic toxins (PBUTs) accumulate in patients with chronic kidney disease and impose detrimental effects on the vascular system. However, a unanimous consensus on the most optimum approach for the reduction of plasma PBUTs is still lacking.

METHODS

In this systematic review, we aimed to identify the most efficient clinically available plasma PBUT reduction method reported in the literature between 1980 and 2020. The literature was screened for clinical studies describing approaches to reduce the plasma concentration of known uraemic toxins. There were no limits on the number of patients studied or on the duration or design of the studies.

RESULTS

Out of 1274 identified publications, 101 studies describing therapeutic options aiming at the reduction of PBUTs in CKD patients were included in this review. We stratified the studies by the PBUTs and the duration of the analysis into acute (data from a single procedure) and longitudinal (several treatment interventions) trials. Reduction ratio (RR) was used as the measure of plasma PBUTs lowering efficiency. For indoxyl sulphate and p-cresyl sulphate, the highest RR in the acute studies was demonstrated for fractionated plasma separation, adsorption and dialysis system. In the longitudinal trials, supplementation of haemodialysis patients with AST-120 (Kremezin®) adsorbent showed the highest RR. However, no superior method for the reduction of all types of PBUTs was identified based on the published studies.

CONCLUSIONS

Our study shows that there is presently no technique universally suitable for optimum reduction of all PBUTs. There is a clear need for further research in this field.

Assessing Plasma Total Homocysteine in Patients with End-Stage Renal Disease

Elevated plasma total homocysteine (tHcy) is a risk factor for cardiovascular disease; however, in light of several recent randomized trials, the issue of causality has been cast into doubt. Patients with end-stage renal disease are particularly interesting as they consistently have elevated tHcy and their leading causes of morbidity and mortality are related to cardiovascular disease. In the present article, we review the early evidence for the homocysteine theory of atherosclerosis, homocysteine metabolism, mechanisms of toxicity, and pertinent available clinical investigations. Where appropriate, the sparse evidence of homocysteine in peritoneal dialysis is reviewed. We conclude by addressing the difficulties associated with lowering plasma tHcy in patients with end-stage renal disease and suggest some novel methods for lowering tHcy in this resistant population. Finally, to address the issue of causality, we recommend that clinicians and scientists await the results of the FAVORIT trial before abandoning homocysteine as a modifiable risk factor for cardiovascular disease, as this study has recruited patients from a population with consistently elevated plasma tHcy who are known to respond to vitamin therapy.

Icodextrin is associated with a lower risk of atrial fibrillation in peritoneal dialysis patients

AIM

Dialysis patients with atrial fibrillation (AF) are at 1.72-fold increased mortality risk. This study investigated whether peritoneal dialysis (PD) patients using icodextrin were at a reduced risk of AF.

METHODS

From the Taiwan National Health Insurance database, we identified 4040 icodextrin users and 3517 non-users among 7557 patients newly diagnosed with end-stage renal disease undergoing PD from 2005 to 2011. The incidence of AF was compared between PD patients with and without icodextrin treatment by the end of 2011, with the hazard ratio (HR) of AF measured using Cox proportional hazards regression models.

RESULTS

The incidence of AF was 50% lower in icodextrin users than in non-users (2.14 vs 4.24 per 1000 person-years) with an adjusted HR of 0.49 (95% confidence interval (CI) = 0.28-0.85). The protective effect was greater for PD patients with diabetes (adjusted HR = 0.39, 95% CI = 0.17-0.86) than those without diabetes (adjusted HR = 0.57, 95% CI = 0.28-1.18). The beneficial effect of icodextrin treatment remained after controlling for the competing risk of deaths, with an adjusted sub-HR of 0.35 (95% CI = 0.16-0.75) for those with diabetes and 0.50 (95% CI = 0.26-0.99) for those without diabetes.

CONCLUSION

The use of icodextrin solution is associated with a lower risk of new-onset AF in PD patients. The protective effectiveness was greater for those with diabetes.