1
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Hamrahian SM, Vilayet S, Herberth J, Fülöp T. Prevention of Intradialytic Hypotension in Hemodialysis Patients: Current Challenges and Future Prospects. Int J Nephrol Renovasc Dis 2023; 16:173-181. [PMID: 37547077 PMCID: PMC10404053 DOI: 10.2147/ijnrd.s245621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023] Open
Abstract
Intradialytic hypotension, defined as rapid decrease in systolic blood pressure of greater than or equal to 20 mmHg or in mean arterial pressure of greater than or equal to 10 mmHg that results in end-organ ischemia and requires countermeasures such as ultrafiltration reduction or saline infusion to increase blood pressure to improve patient's symptoms, is a known complication of hemodialysis and is associated with several potential adverse outcomes. Its pathogenesis is complex and involves both patient-related factors such as age and comorbidities, as well as factors related to the dialysis prescription itself. Key factors include the need for volume removal during hemodialysis and a suboptimal vascular response which compromises the ability to compensate for acute intravascular volume loss. Inadequate vascular refill, incorrect assessment or unaccounted changes of target weight, acute illnesses and medication interference are further potential contributors. Intradialytic hypotension can lead to compromised tissue perfusion and end-organ damage, both acutely and over time, resulting in repetitive injuries. To address these problems, a careful assessment of subjective symptoms, minimizing interdialytic weight gains, individualizing dialysis prescription and adjusting the dialysis procedure based on patients' risk factors can mitigate negative outcomes.
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Affiliation(s)
| | - Salem Vilayet
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Johann Herberth
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Tibor Fülöp
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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2
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Gautam SC, Lim J, Jaar BG. Complications Associated with Continuous RRT. KIDNEY360 2022; 3:1980-1990. [PMID: 36514412 PMCID: PMC9717642 DOI: 10.34067/kid.0000792022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/06/2022] [Indexed: 01/12/2023]
Abstract
Continuous renal replacement therapy (CRRT) is a form of renal replacement therapy that is used in modern intensive care units (ICUs) to help manage acute kidney injury (AKI), end stage kidney disease (ESKD), poisonings, and some electrolyte disorders. CRRT has transformed the care of patients in the ICU over the past several decades. In this setting, it is important to recognize CRRT-associated complications but also up-to-date management of these complications. Some of these complications are minor, but others may be more significant and even life-threatening. Some CRRT complications may be related to dialysis factors and others to specific patient factors. Our overarching goal in this article is to review and discuss the most significant CRRT-related complications at the different stage of management of CRRT. With the advent of newer solutions, there have been newer complications as well.
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Affiliation(s)
- Samir C. Gautam
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathan Lim
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland,Nephrology Center of Maryland, Baltimore, Maryland
| | - Bernard G. Jaar
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland,Nephrology Center of Maryland, Baltimore, Maryland,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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3
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Wang Y, Miao X, Xiao G, Huang C, Sun J, Wang Y, Li P, You X. Clinical Prediction of Heart Failure in Hemodialysis Patients: Based on the Extreme Gradient Boosting Method. Front Genet 2022; 13:889378. [PMID: 35559036 PMCID: PMC9086166 DOI: 10.3389/fgene.2022.889378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Heart failure (HF) is the main cause of mortality in hemodialysis (HD) patients. However, it is still a challenge for the prediction of HF in HD patients. Therefore, we aimed to establish and validate a prediction model to predict HF events in HD patients. Methods: A total of 355 maintenance HD patients from two hospitals were included in this retrospective study. A total of 21 variables, including traditional demographic characteristics, medical history, and blood biochemical indicators, were used. Two classification models were established based on the extreme gradient boosting (XGBoost) algorithm and traditional linear logistic regression. The performance of the two models was evaluated based on calibration curves and area under the receiver operating characteristic curves (AUCs). Feature importance and SHapley Additive exPlanation (SHAP) were used to recognize risk factors from the variables. The Kaplan–Meier curve of each risk factor was constructed and compared with the log-rank test. Results: Compared with the traditional linear logistic regression, the XGBoost model had better performance in accuracy (78.5 vs. 74.8%), sensitivity (79.6 vs. 75.6%), specificity (78.1 vs. 74.4%), and AUC (0.814 vs. 0.722). The feature importance and SHAP value of XGBoost indicated that age, hypertension, platelet count (PLT), C-reactive protein (CRP), and white blood cell count (WBC) were risk factors of HF. These results were further confirmed by Kaplan–Meier curves. Conclusions: The HF prediction model based on XGBoost had a satisfactory performance in predicting HF events, which could prove to be a useful tool for the early prediction of HF in HD.
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Affiliation(s)
- Yanfeng Wang
- The School of Electrical and Information Engineering, Zhengzhou University of Light Industry, Zhengzhou, China
| | - Xisha Miao
- The School of Electrical and Information Engineering, Zhengzhou University of Light Industry, Zhengzhou, China
| | - Gang Xiao
- Department of Clinical Laboratory, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Chun Huang
- The School of Electrical and Information Engineering, Zhengzhou University of Light Industry, Zhengzhou, China
| | - Junwei Sun
- The School of Electrical and Information Engineering, Zhengzhou University of Light Industry, Zhengzhou, China
| | - Ying Wang
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Panlong Li
- The School of Electrical and Information Engineering, Zhengzhou University of Light Industry, Zhengzhou, China
| | - Xu You
- Department of Clinical Laboratory, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
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4
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Zsom L, Zsom M, Salim SA, Fülöp T. Estimated Glomerular Filtration Rate in Chronic Kidney Disease: A Critical Review of Estimate-Based Predictions of Individual Outcomes in Kidney Disease. Toxins (Basel) 2022; 14:toxins14020127. [PMID: 35202154 PMCID: PMC8875627 DOI: 10.3390/toxins14020127] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/04/2022] [Accepted: 02/04/2022] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is generally regarded as a final common pathway of several renal diseases, often leading to end-stage kidney disease (ESKD) and a need for renal replacement therapy. Estimated GFR (eGFR) has been used to predict this outcome recognizing its robust association with renal disease progression and the eventual need for dialysis in large, mainly cross-sectional epidemiological studies. However, GFR is implicitly limited as follows: (1) GFR reflects only one of the many physiological functions of the kidney; (2) it is dependent on several non-renal factors; (3) it has intrinsic variability that is a function of dietary intake, fluid and cardiovascular status, and blood pressure especially with impaired autoregulation or medication use; (4) it has been shown to change with age with a unique non-linear pattern; and (5) eGFR may not correlate with GFR in certain conditions and disease states. Yet, many clinicians, especially our non-nephrologist colleagues, tend to regard eGFR obtained from a simple laboratory test as both a valid reflection of renal function and a reliable diagnostic tool in establishing the diagnosis of CKD. What is the validity of these beliefs? This review will critically reassess the limitations of such single-focused attention, with a particular focus on inter-individual variability. What does science actually tell us about the usefulness of eGFR in diagnosing CKD?
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Affiliation(s)
- Lajos Zsom
- Fresenius Medical Care, Cegléd Dialysis Center, Törteli u 1-3, 2700 Cegléd, Hungary
- Correspondence: (L.Z.); (T.F.)
| | - Marianna Zsom
- Department of Medicine, St. Rókus Hospital, Rókus u 10, 6500 Baja, Hungary;
| | - Sohail Abdul Salim
- Department of Medicine, Division of Nephrology, University of Mississippi, 2500 N State St., Jackson, MS 39216, USA;
| | - Tibor Fülöp
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC 629, CSB 822, Charleston, SC 29425, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, 109 Bee St., Charleston, SC 29401, USA
- Correspondence: (L.Z.); (T.F.)
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5
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Lin L, Xie Q, Zheng M, Zhou X, Dekkers IA, Tao Q, Lamb HJ. Identification of cardiovascular abnormalities by multiparametric magnetic resonance imaging in end-stage renal disease patients with preserved left ventricular ejection fraction. Eur Radiol 2021; 31:7098-7109. [PMID: 33629157 DOI: 10.1007/s00330-021-07752-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 01/07/2021] [Accepted: 02/04/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Our study aimed to evaluate myocardial strain and tissue characteristics by multiparametric cardiovascular magnetic resonance (CMR) imaging in end-stage renal disease (ESRD) patients on peritoneal dialysis with preserved left ventricular ejection fraction (LVEF). METHODS ESRD patients on peritoneal dialysis with echocardiographic LVEF > 50% and age- and sex-matched healthy volunteers underwent multiparametric CMR at 3 T. LV function, LV myocardial native T1 and T2, and biventricular strain were measured and compared between the patients and controls. Associations of LV myocardial mass index (LVMI) with tissue characterization and strain were evaluated by multiple linear regression. RESULTS A total of 65 subjects (42 healthy volunteers and 23 ESRD patients) were enrolled. ESRD group demonstrated larger LVMI, higher native T1 and T2 (1301.9 ± 30.6 ms, 44.6 ± 2.6 ms) than those of the control group (1255.8 ± 45.2 ms, 40.5 ± 1.6 ms; both p < 0.001). Decreased LV strain and increased right ventricular circumferential strain were observed in the ESRD group. In ESRD patients with normal diastolic function on echocardiography, native T1 and T2 values were higher than those of the control group (p = 0.006, p = 0.001). Increased LVMI was associated with increased native T1 (p = 0.001) and T2 value (p < 0.001) after adjusting for age and sex. Increased myocardial native T1 value was associated with reduced LV strain after adjusting age, sex, and LVMI. CONCLUSIONS ESRD patients on peritoneal dialysis with preserved LVEF demonstrated higher myocardial mass, higher native T1 and T2 values, decreased LV strain, and increased RVGCS compared with healthy controls. Increased myocardial T1 and T2 were found in ESRD even when no systolic or diastolic dysfunction was detected by routine echocardiography. KEY POINTS • Even with preserved LVEF and no known cardiovascular diseases, ESRD patients on peritoneal dialysis demonstrated elevated myocardial T1 and T2 values and decreased left ventricular strain. • Subclinical changes in myocardial tissue composition may exist in ESRD patients on peritoneal dialysis even when no systolic or diastolic dysfunction was detected by routine echocardiography based on ejection fraction, left atrium size, and tissue Doppler. • Right ventricular free wall strain could be enhanced in response to subclinical LV systolic dysfunction in ESRD patients on peritoneal dialysis with preserved LVEF at an early stage.
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Affiliation(s)
- Ling Lin
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Qiuxia Xie
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shennan Middle Road 3025, Shenzhen, China
| | - Mei Zheng
- Department of Ultrasonography, Guangzhou Women and Children's Medical Center, Jinsui Road 9, Guangzhou, China
| | - Xuhui Zhou
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shennan Middle Road 3025, Shenzhen, China.
| | - Ilona A Dekkers
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Qian Tao
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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6
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Tantisattamo E, Hanna RM, Reddy UG, Ichii H, Dafoe DC, Danovitch GM, Kalantar-Zadeh K. Novel options for failing allograft in kidney transplanted patients to avoid or defer dialysis therapy. Curr Opin Nephrol Hypertens 2021; 29:80-91. [PMID: 31743241 DOI: 10.1097/mnh.0000000000000572] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Despite improvement in short-term renal allograft survival in recent years, renal transplant recipients (RTR) have poorer long-term allograft outcomes. Allograft function slowly declines with periods of stable function similar to natural progression of chronic kidney disease in nontransplant population. Nearly all RTR transitions to failing renal allograft (FRG) period and require transition to dialysis. Conservative chronic kidney disease management before transition to end-stage renal disease is an increasingly important topic; however, there is limited data in RTR regarding how to delay dialysis initiation with conservative management. RECENT FINDINGS Since immunological and nonimmunological factors unique to RTR contribute to decline in allograft function, therapies to slow progression of FRG should take both sets of factors into account. Renal replacement therapy either incremental dialysis or rekidney transplantation should be explored. This required taking benefits and risks of continuing immunosuppressive medications into account when allograft nephrectomy may be necessary. SUMMARY FRG may benefit from various interventions to slow progression of worsening allograft function. Until there are stronger evidence to guide interventions to preserve renal function, extrapolating evidence from nontransplant patients and clinical judgment are necessary. The goal is to provide individualized care for conservative management of RTR with FRG.
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Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange Nephrology Section, Department of Medicine, Veterans Affairs Long Beach Healthcare System, Long Beach, California Section of Nephrology, Department of Internal Medicine, Multi-Organ Transplant Center, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan Division of Kidney and Pancreas Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, California Division of Nephrology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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7
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Kuo PY, Saran R, Argentina M, Heung M, Bragg-Gresham J, Krein S, Gillespie BW, Zheng K, Veinot TC. Cramping, crashing, cannulating, and clotting: a qualitative study of patients' definitions of a "bad run" on hemodialysis. BMC Nephrol 2020; 21:67. [PMID: 32103726 PMCID: PMC7045425 DOI: 10.1186/s12882-020-01726-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 02/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemodialysis sessions frequently become unstable from complications such as intradialytic hypotension and untoward symptoms. Previous patient safety initiatives promote prevention of treatment complications; yet, they have placed little specific focus on avoidable session instability. A patient-centered definition of session instability grounded in patient experiences, and an understanding of patient perceptions of causes and solutions to instability, may enable such efforts. METHODS Twenty-five participants participated in three focus groups and/or a survey. They were purposively sampled for variation in region of residence, and sensitivity to patient well-being. Focus group recordings were analyzed using descriptive coding, in vivo coding, and thematic analysis. RESULTS Patients define unstable sessions ("bad runs") as those in which they experience severe discomfort or unanticipated events that interfere with their ability to receive therapy. Bad runs were characterized primarily by cramping, low blood pressure ("crashing"), cannulation-related difficulties ("bad sticks"), and clotting of the dialysis circuit or vascular access. Patients believed that cramping and crashing could be explained by both patient and clinician behavior: patient fluid consumption and providers' fluid removal goals. Patients felt that the responsibility for cannulation-related problems lay with dialysis staff, and they asked for different staff or self-cannulated as solutions. Clotting was viewed as an idiosyncratic issue with one's body, and perceived solutions were clinician-driven. Patients expressed concern about "bad runs" on their ability to achieve fluid balance. CONCLUSIONS Findings point to novel priorities for efforts to enhance hemodialysis session stability, and areas in which patients can be supported to become involved in such efforts.
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Affiliation(s)
- Pei-Yi Kuo
- School of information, University of Michigan, 4314 North Quad, 105 S. State St, Ann Arbor, MI, 48109-1285, USA.,Institute of Service Science, National Tsing Hua University, HsinChu, Taiwan
| | - Rajiv Saran
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, USA
| | | | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer Bragg-Gresham
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, USA
| | - Sarah Krein
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health Services Research & Development Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Brenda W Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kai Zheng
- School of Information and Computer Sciences, University of California, Irvine, CA, USA
| | - Tiffany C Veinot
- School of information, University of Michigan, 4314 North Quad, 105 S. State St, Ann Arbor, MI, 48109-1285, USA. .,School of Public Health, University of Michigan, 4314 North Quad, 105 S. State St, Ann Arbor, MI, 48109-1285, USA.
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8
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Marants R, Qirjazi E, Grant CJ, Lee TY, McIntyre CW. Renal Perfusion during Hemodialysis: Intradialytic Blood Flow Decline and Effects of Dialysate Cooling. J Am Soc Nephrol 2019; 30:1086-1095. [PMID: 31053638 DOI: 10.1681/asn.2018121194] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/05/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Residual renal function (RRF) confers survival in patients with ESRD but declines after initiating hemodialysis. Previous research shows that dialysate cooling reduces hemodialysis-induced circulatory stress and protects the brain and heart from ischemic injury. Whether hemodialysis-induced circulatory stress affects renal perfusion, and if it can be ameliorated with dialysate cooling to potentially reduce RRF loss, is unknown. METHODS We used renal computed tomography perfusion imaging to scan 29 patients undergoing continuous dialysis under standard (36.5°C dialysate temperature) conditions; we also scanned another 15 patients under both standard and cooled (35.0°C) conditions. Imaging was performed immediately before, 3 hours into, and 15 minutes after hemodialysis sessions. We used perfusion maps to quantify renal perfusion. To provide a reference to another organ vulnerable to hemodialysis-induced ischemic injury, we also used echocardiography to assess intradialytic myocardial stunning. RESULTS During standard hemodialysis, renal perfusion decreased 18.4% (P<0.005) and correlated with myocardial injury (r=-0.33; P<0.05). During sessions with dialysis cooling, patients experienced a 10.6% decrease in perfusion (not significantly different from the decline with standard hemodialysis), and ten of the 15 patients showed improved or no effect on myocardial stunning. CONCLUSIONS This study shows an acute decrease in renal perfusion during hemodialysis, a first step toward pathophysiologic characterization of hemodialysis-mediated RRF decline. Dialysate cooling ameliorated this decline but this effect did not reach statistical significance. Further study is needed to explore the potential of dialysate cooling as a therapeutic approach to slow RRF decline.
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Affiliation(s)
- Raanan Marants
- Department of Medical Biophysics, Western University, London, Canada.,Robarts Research Institute, Western University, London, Canada
| | - Elena Qirjazi
- The Lilibeth Caberto Kidney Clinical Research Unit and
| | - Claire J Grant
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, Western University, London, Canada.,Robarts Research Institute, Western University, London, Canada.,Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Christopher W McIntyre
- Department of Medical Biophysics, Western University, London, Canada; .,The Lilibeth Caberto Kidney Clinical Research Unit and.,Lawson Health Research Institute, London Health Sciences Centre, London, Canada.,Division of Nephrology, London Health Sciences Centre, London, Canada; and
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9
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Mathew AT, Obi Y, Rhee CM, Chou JA, Kalantar-Zadeh K. Incremental dialysis for preserving residual kidney function-Does one size fit all when initiating dialysis? Semin Dial 2018; 31:343-352. [PMID: 29737013 PMCID: PMC6035086 DOI: 10.1111/sdi.12701] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
While many patients have substantial residual kidney function (RKF) when initiating hemodialysis (HD), most patients with end stage renal disease in the United States are initiated on 3-times per week conventional HD regimen, with little regard to RKF or patient preference. RKF is associated with many benefits including survival, volume control, solute clearance, and reduced inflammation. Several strategies have been recommended to preserve RKF after HD initiation, including an incremental approach to HD initiation. Incremental HD prescriptions are personalized to achieve adequate volume control and solute clearance with consideration to a patient's endogenous renal function. This allows the initial use of less frequent and/or shorter HD treatment sessions. Regular measurement of RKF is important because HD frequency needs to be increased as RKF inevitably declines. We narratively review the results of 12 observational cohort studies of twice-weekly compared to thrice-weekly HD. Incremental HD is associated with several benefits including preservation of RKF as well as extending the event-free life of arteriovenous fistulas and grafts. Patient survival and quality of life, however, has been variably associated with incremental HD. Serious risks must also be considered, including increased hospitalization and mortality perhaps related to fluid and electrolyte shifts after a long interdialytic interval. On the basis of the above literature review, and our clinical experience, we suggest patient characteristics which may predict favorable outcomes with an incremental approach to HD. These include substantial RKF, adequate volume control, lack of significant anemia/electrolyte imbalance, satisfactory health-related quality of life, low comorbid disease burden, and good nutritional status without evidence of hypercatabolism. Clinicians should engage patients in on-going conversations to prepare for incremental HD initiation and to ensure a smooth transition to thrice-weekly HD when needed.
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Affiliation(s)
- Anna T Mathew
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Yoshitsugu Obi
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Connie M Rhee
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Jason A Chou
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, California
- Fielding School of Public Health at UCLA, Los Angeles, California
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
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10
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Abstract
PURPOSE OF REVIEW Volume management in hemodialysis patients is often challenging. Assessing volume status and deciding how much fluid to remove during hemodialysis, the so-called ultrafiltration rate (UFR), has remained a conundrum. RECENT FINDINGS To date there is no objective assessment tool to determine the needed UFR during each hemodialysis session. Higher volume overload or higher UFR is associated with poor outcomes including worse mortality and unfavorable clinical outcomes. We suggest combined use of the following criteria to determine UFR or post-dialysis target dry weight: pre-hemodialysis blood pressure and its intradialytic changes, muscle cramps, dyspnea from pulmonary vascular congestion, peripheral edema, tachycardia or palpitation, headache or lightheadedness, perspiration, and post-dialysis fatigue. Restricting fluid and salt intake-and high-dose loop diuretic use in cases of residual kidney function-can be helpful in controlling fluid gains. More frequent and more severe hypotensive episodes are associated with poor outcomes including higher death risk.
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Affiliation(s)
- Jason A Chou
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Division of Nephrology, Department of Medicine, University of California, Irvine, School of Medicine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.
- Division of Nephrology, Department of Medicine, University of California, Irvine, School of Medicine, Orange, CA, USA.
- Fielding School of Public Health at UCLA, Los Angeles, CA, USA.
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA.
- Harold Simmons Center for Kidney Disease Research & Epidemiology, Division of Nephrology & Hypertension, University of California Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400-ZOT: 4088, Orange, CA, 92868-3217, USA.
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11
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Y-Hassan S. Acute, repetitive and chronic Takotsubo syndrome in patients with chronic kidney disease: Sympathetic reno-cardial syndrome. Int J Cardiol 2016; 222:874-880. [PMID: 27522391 DOI: 10.1016/j.ijcard.2016.07.278] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/18/2016] [Accepted: 07/30/2016] [Indexed: 02/07/2023]
Abstract
Heart failure and cardiovascular death are common in patients with chronic kidney disease (CKD) and extremely prevalent in patients undergoing dialysis. It has been shown that the excess of cardiovascular mortality in this patient population is not fully accounted for by the traditional cardiovascular risk factors. Substantial evidence exists for the presence of sympathetic over-activity in patients with dialytic and non-dialytic CKD. Several studies have also been reported on reversible segmental left ventricular wall motion abnormality consistent with myocardial stunning in association with dialysis especially hemodialysis. In the literature, the most acceptable underpinning hypothesis for the myocardial stunning in CKD is "demand myocardial ischemia". However, the occurrence of cardiac sympathetic over-activation-disruption and repeated reversible myocardial stunning in patients with CKD can be compared to that occurring in acute Takotsubo syndrome where local cardiac sympathetic disruption may cause acute regional circumferential pattern of myocardial stunning. In this manuscript, converging evidences suggestive for the fact that acute, repetitive, and chronic TS may be one of the important causes of cardiac morbidity including myocardial stunning and heart failure and mortality in patients with CKD are provided.
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Affiliation(s)
- Shams Y-Hassan
- Karolinska University Hospital, Huddinge, Department of Cardiology, S-141 86 Stockholm, Sweden.
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12
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Mathew AT, Fishbane S, Obi Y, Kalantar-Zadeh K. Preservation of residual kidney function in hemodialysis patients: reviving an old concept. Kidney Int 2016; 90:262-271. [PMID: 27182000 PMCID: PMC5798008 DOI: 10.1016/j.kint.2016.02.037] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/18/2016] [Accepted: 02/24/2016] [Indexed: 12/30/2022]
Abstract
Residual kidney function (RKF) may confer a variety of benefits to patients on maintenance dialysis. RKF provides continuous clearance of middle molecules and protein-bound solutes. Whereas the definition of RKF varies across studies, interdialytic urine volume may emerge as a pragmatic alternative to more cumbersome calculations. RKF preservation is associated with better patient outcomes including survival and quality of life and is a clinical parameter and research focus in peritoneal dialysis. We propose the following practical considerations to preserve RKF, especially in newly transitioned (incident) hemodialysis patients: (1) periodic monitoring of RKF in hemodialysis patients through urine volume and including residual urea clearance with dialysis adequacy and outcome markers such as anemia, fluid gains, minerals and electrolytes, nutritional, status and quality of life; (2) avoidance of nephrotoxic agents such as radiocontrast dye, nonsteroidal anti-inflammatory drugs, and aminoglycosides; (3) more rigorous hypertension control and minimizing intradialytic hypotensive episodes; (4) individualizing the initial dialysis prescription with consideration of an incremental/infrequent approach to hemodialysis initiation (e.g., twice weekly) or peritoneal dialysis; and (5) considering a lower protein diet, especially on nondialysis days. Because RKF appears to be associated with better patient outcomes, it requires more clinical and research focus in the care of hemodialysis and peritoneal dialysis patients.
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Affiliation(s)
- Anna T Mathew
- Hofstra Northwell School of Medicine, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, New York, USA
| | - Steven Fishbane
- Hofstra Northwell School of Medicine, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, New York, USA.
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA; Fielding School of Public Health at UCLA, Los Angeles, California, USA; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California, USA
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Astan R, Ozeke O. Theories and Controversies on Mechanism of Electrocardiographic Changes during Hemodialysis: Reply to Christov et al. Ann Noninvasive Electrocardiol 2016; 21:215-6. [PMID: 27296906 DOI: 10.1111/anec.12341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 11/12/2015] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ramazan Astan
- Department of Cardiology, Batman Regional State Hospital, Batman, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, Türkiye Yüksek Ihtisas Education and Research Hospital, Ankara, Turkey
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Wang IK, Lu CY, Lin CL, Liang CC, Yen TH, Liu YL, Sung FC. Comparison of the risk of de novo cardiovascular disease between hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Int J Cardiol 2016; 218:219-224. [PMID: 27236118 DOI: 10.1016/j.ijcard.2016.05.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND The purpose of the study was to compare the risk of de novo cardiovascular disease (CVD) between hemodialysis (HD) and peritoneal dialysis (PD) in patients with incident end-stage renal disease (ESRD). METHODS From a Taiwanese universal insurance claims database, we identified 45309 incident ESRD patients without preexisting CVD from 2000 to 2010. Using the propensity score matching method, we included 6516 patients in HD and PD groups, respectively. All patients were followed up until the end of 2011. The Cox proportional hazards regression model was employed to calculate the impact of dialysis modality on the risk of new onset cardiovascular events including ischemic heart disease, and congestive heart failure (CHF). RESULTS No difference was observed in the overall risk of de novo ischemic heart disease between the propensity score-matched HD and PD groups (HD versus PD, adjusted hazard ratio [HR]: 1.03, 95% confidence interval [CI]: 0.86-1.22). However, HD was associated with a higher risk of de novo CHF (adjusted HR: 1.29, 95% CI: 1.13-1.47) than PD was. The risk of de novo CHF was particularly high in the first year under dialysis treatment for propensity score-matched HD patients, compared to PD patients. CONCLUSIONS No difference was observed in the overall risk of de novo major ischemic heart events between HD and PD patients. However, HD was associated with a higher risk of de novo CHF than PD in the first year under dialysis treatment.
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Affiliation(s)
- I-Kuan Wang
- Graduate Institute of Clinical Medical Science, China Medical University College of Medicine, Taichung, Taiwan; Department of Internal Medicine, China Medical University College of Medicine, Taichung, Taiwan; Division of Nephrology, China Medical University Hospital, Taichung, Taiwan
| | - Chi-Yu Lu
- Department of Biochemistry, College of Medicine Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Chia Liang
- Division of Nephrology, China Medical University Hospital, Taichung, Taiwan
| | - Tzung-Hai Yen
- Division of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yao-Lung Liu
- Division of Nephrology, China Medical University Hospital, Taichung, Taiwan
| | - Fung-Chang Sung
- Graduate Institute of Clinical Medical Science, China Medical University College of Medicine, Taichung, Taiwan; Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.
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Suthar SD, Middleton JP. Clinical Outcomes in Dialysis Patients: Prospects for Improvement with Aldosterone Receptor Antagonists. Semin Dial 2015; 29:52-61. [DOI: 10.1111/sdi.12421] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Samantha Dias Suthar
- Division of Nephrology; Department of Medicine; Duke University School of Medicine; Durham North Carolina
| | - John P. Middleton
- Division of Nephrology; Department of Medicine; Duke University School of Medicine; Durham North Carolina
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16
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Mácsai E, Németh I, Benke A, Dávid G. [Effect of diabetes on the relation between troponin T and inflammatory markers in patients on hemodialysis]. Orv Hetil 2014; 155:627-33. [PMID: 24733105 DOI: 10.1556/oh.2014.29872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Cardiac troponin T in renal failure is used for the assessment of cardiovascular risk and mortality. Elevated cardiac troponin T levels correlate with subclinical myocardial necrosis, coronary heart disease, several echocardiographic parameters, metastatic calcification, as well as the presence of diabetes and uremic toxins. AIM The aim of the authors was to examine the impact of factors, mainly the independent effects of inflammatory laboratory parameters, which may influence hypersensitive troponin T levels in hemodialysed patient groups with and without diabetes. METHOD Hemodialysed patient groups with (n = 44) and without diabetes (n = 76) were studied. Difference in serum hypersensitive troponin T values before and after dialysis were analysed by paired Wilcoxon test. Factors possibly affecting the level of hypersensitive troponin T (especially inflammatory markers) were evaluated by multiregression analysis. RESULTS Hypersensitive troponin T levels in patients without diabetes (p = 0.0003) and those with diabetes (p = 0.0032) significantly increased during hemodialysis. In patients without diabetes several factors had significant effect on hypersensitive troponin T including age (p = 0.025), duration of hemodialysis (p = 0.0002), presence of cardiovascular complications (p = 0.0002), high sensitivity C-reactive protein (p = 0.0021), white blood cell count (p = 0.038), and the monocyte ratio (p = 0.0202). However, in patients with diabetes only high sensitivity C-reactive protein (p = 0.0024) showed association with hypersensitive troponin T levels. CONCLUSIONS In hemodyalised patients with and without diabetes the hypersensitive troponin T levels are differently influenced by clinical and inflammatory laboratory parameters, which should be taken into consideration during clinical judgement.
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Affiliation(s)
- Emília Mácsai
- Csolnoky Ferenc Oktatókórház Veszprém Kórház u. 1. 8200 BBRAUN 3 Dialíziscentrum Veszprém
| | - Ilona Németh
- Csolnoky Ferenc Oktatókórház Veszprém Kórház u. 1. 8200
| | | | - Gyula Dávid
- Csolnoky Ferenc Oktatókórház Veszprém Kórház u. 1. 8200
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Alhaj E, Alhaj N, Rahman I, Niazi TO, Berkowitz R, Klapholz M. Uremic Cardiomyopathy: An Underdiagnosed Disease. ACTA ACUST UNITED AC 2013; 19:E40-5. [DOI: 10.1111/chf.12030] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 03/04/2013] [Accepted: 03/05/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Eyad Alhaj
- Department of Cardiology; UMDNJ; New Jersey Medical School, Newark; NJ
| | - Nehad Alhaj
- Department of Cardiology; UMDNJ; New Jersey Medical School, Newark; NJ
| | - Ifad Rahman
- Department of Cardiology; UMDNJ; New Jersey Medical School, Newark; NJ
| | - Tariq O. Niazi
- Department of Cardiology; UMDNJ; New Jersey Medical School, Newark; NJ
| | - Robert Berkowitz
- Department of Cardiology; UMDNJ; New Jersey Medical School, Newark; NJ
| | - Marc Klapholz
- Department of Cardiology; UMDNJ; New Jersey Medical School, Newark; NJ
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Reyes-Bahamonde J, Raimann JG, Thijssen S, Levin NW, Kotanko P. Fluid overload and inflammation--a vicious cycle. Semin Dial 2012; 26:31-5. [PMID: 23043638 DOI: 10.1111/sdi.12024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Zuidema MY, Dellsperger KC. Myocardial Stunning with Hemodialysis: Clinical Challenges of the Cardiorenal Patient. Cardiorenal Med 2012; 2:125-133. [PMID: 22851961 DOI: 10.1159/000337476] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We discuss the current state of knowledge related to the pathogenesis of myocardial stunning as well as the potential mechanisms responsible for the clinical presentation of myocardial stunning in hemodialysis patients. We suggest future research areas for this critical and clinically important condition in this high-risk patient population. In consideration of acute and chronic changes secondary to dialysis, especially in patients with risk for coronary artery disease, the prevalence of myocardial stunning and its role in the natural history of these patients' disease progression is considered. We propose a paradigm: that the majority of the pathophysiologic mechanisms by which hemodialysis may induce myocardial stunning falls into two categories with (1) vascular and/or (2) metabolic contributions. In order to prevent eventual myocardial hibernation, myocardial remodeling, scarring, and loss of contractile function with aberrant electrical conductivity that could lead to sudden death, it is imperative to identify the risk factors associated with myocardial stunning during hemodialysis. Further understanding of these mechanisms may lead to novel clinical interventions and pharmacologic therapeutic agents.
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Affiliation(s)
- Mozow Y Zuidema
- Division of Cardiovascular Medicine, Department of Internal Medicine, Columbia, Mo., USA
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Covic A, Voroneanu L, Locatelli F. Uraemic toxins versus volume and water as the major factor that matters with dialysis. Nephrol Dial Transplant 2012; 27:58-62. [DOI: 10.1093/ndt/gfr636] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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21
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Cotovio P, Rocha A, Rodrigues A. Peritoneal dialysis in diabetics: there is room for more. Int J Nephrol 2011; 2011:914849. [PMID: 22013524 PMCID: PMC3195540 DOI: 10.4061/2011/914849] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Revised: 07/05/2011] [Accepted: 08/15/2011] [Indexed: 12/21/2022] Open
Abstract
End stage renal disease diabetic patients suffer from worse clinical outcomes under dialysis-independently of modality. Peritoneal dialysis offers them the advantages of home therapy while sparing their frail vascular capital and preserving residual renal function. Other benefits and potential risks deserve discussion. Predialysis intervention with early nephrology referral, patient education, and multidisciplinary support are recommended. Skilled and updated peritoneal dialysis protocols must be prescribed to assure better survival. Optimized volume control, glucose-sparing peritoneal dialysis regimens, and elective use of icodextrin are key therapy strategies. Nutritional evaluation and support, preferential use of low-glucose degradation products solutions, and prescription of renin-angiotensin-aldosterone system acting drugs should also be part of the panel to improve diabetic care under peritoneal dialysis.
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Affiliation(s)
- P Cotovio
- Nephrology Department, Centro Hospitalar de Coimbra (CHC), Quinta dos Vales, 3041-801 S. Martinho do Bispo, Portugal
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