Pharmacotherapy of end-stage renal disease

Effect of traditional Chinese medicine Bailing capsule on renal anemia in maintenance hemodialysis patients: A protocol for systematic review and meta-analysis

BACKGROUND

Renal anemia (RA) is one of the most common complications in patients with end-stage renal disease, and it is also one of the reasons for the decline of quality of life and functional status in patients with end-stage renal disease. Traditional treatment methods often fail to achieve satisfactory therapeutic effects, so it is very necessary to find effective adjuvant treatment methods. Bailing capsule (BLC), a traditional Chinese medicine, which has been widely used in the treatment of RA in maintenance hemodialysis patients, but a systematic review of the efficacy and safety of this drug is currently lacking. Therefore, this study used meta-analysis to evaluate the efficacy and safety of BLC in the treatment of RA, in order to provide guidance for finding effective auxiliary methods for the treatment of RA in maintenance hemodialysis patients (MHP).

METHODS

Using the computer to retrieve PubMed, EMbase, Cochrane Library, CNKI, VIP Database, WANFANG Database, SinoMed from 1990 to 2021 and collecting the clinical randomized controlled trial and retrospective cohort study of BLC in the treatment of RA in MHP. Two researchers independently read and screened the literature, followed by evaluating the retrospective cohort studies that met the selection criteria using the Newcastle-Ottawa Scale (NOS) scale. The randomized controlled trial used the Cochrane manual standards to assess the risk of bias, and the RevMan 5.3 software was used to conduct a meta-analysis of the result data.

RESULTS

This study will use the method of meta-analysis to evaluate the clinical efficacy and incidence of adverse reactions of BLC in the treatment of RA in MHP through the primary and secondary outcome indicators.

CONCLUSION

The results of this study will help clinicians find safe and effective adjuvant therapy in the treatment of RA in MHP.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/732KP (https://osf.io/732kp).

Effectiveness of self-management support in maintenance haemodialysis patients with hypertension: A pilot cluster randomized controlled trial

AIM

Uncontrolled hypertension is an independent risk factor for cardiovascular disease and is the leading cause of mortality in haemodialysis patients. The aim of this study was to examine the effectiveness of self-management support (SMS) for blood pressure (BP) control and health behaviours.

METHODS

We conducted a cluster randomized controlled trial (RCT) in which 90 adult haemodialysis patients were assigned to either an SMS or common intervention (CI) group. The SMS group received an intervention consisting of self-management education and motivational interviewing. The CI group received standard care and routine health education. The primary outcome was the BP monitored before each haemodialysis. Secondary outcomes included salt intake (measured using a balance formula), home BP monitoring (HBPM) (assessed using two self-administered questions), and medication adherence (measured using the Medication-taking Behavior Scale). Data were collected at baseline and at 1, 3 and 6 months post-intervention.

RESULTS

The SMS group showed continuous reductions in systolic BP from baseline: -9.2, -8.7, and -8.4 mmHg at 1, 3 and 6 months after the intervention, respectively (P < 0.01). Compared with the CI group, the SMS group had a greater decrease in systolic BP at 1 month: -5.9 mmHg (P = 0.0388), but no significant difference was found at 3 or 6 months (P > 0.05). SMS patients showed an improvement in health behaviours relative to baseline (less salt intake, more consistent HBPM, and greater medication adherence) (P < 0.05).

CONCLUSIONS

Self-management support obtained short-term success in improving salt restriction, regular performance of HBPM and medication adherence, which led to better BP control.

Decellularized Renal Matrix and Regenerative Medicine of the Kidney: A Different Point of View

Over the past years, extracellular matrix (ECM) obtained from whole organ decellularization has been investigated as a platform for organ engineering. The ECM is composed of fibrous and nonfibrous molecules providing structural and biochemical support to the surrounding cells. Multiple decellularization techniques, including ours, have been optimized to maintain the composition, microstructure, and biomechanical properties of the native renal ECM that are difficult to obtain during the generation of synthetic substrates. There are evidences suggesting that in vivo implanted renal ECM has the capacity to induce formation of vasculature-like structures, but long-term in vivo transplantation and filtration activity by these tissue-engineered constructs have not been investigated or reported. Therefore, even if the process of renal decellularization is possible, the repopulation of the renal matrix with functional renal cell types is still very challenging. This review aims to summarize the current reports on kidney tissue engineering with the use of decellularized matrices and addresses the challenges in creating functional kidney units. Finally, this review discusses how future studies investigating cell-matrix interaction may aid the generation of a functional renal unit that would be transplantable into patients one day.

Medication beliefs are associated with phosphate binder non-adherence in hyperphosphatemic haemodialysis patients

OBJECTIVES

Patients with end-stage kidney disease receiving haemodialysis (HD) are at risk of cardiovascular disease and bone disorders related to high levels of serum phosphate. We studied the association between medication beliefs and depressive symptoms, with non-adherence to phosphate binding medication in a group of HD patients at risk of complications due to hyperphosphatemia.

DESIGN

Cross-sectional design.

METHODS

Baseline data from 112 patients participating in a randomized controlled trial, evaluating an adherence intervention, are presented. All patients had serum phosphate levels >1.6 mmol/l at baseline. Adherence was measured by (1) serum phosphate and (2) Medication Adherence Report Scales (MARS). Beliefs about Medicines (BMQ) and depressive symptoms (PHQ-9) were also evaluated.

RESULTS

Beliefs about Medicines Questionnaire necessity, but not concerns, beliefs were found to correlate with serum phosphate (r = -.23, p < .05) and self-reported adherence (r = .35, p < .01). In regression models, controlling for demographic, clinical and psychological variables, necessity beliefs explained the variance of serum phosphate (β = -.22, p = .01) and self-reported adherence (β = .30, p ≤ .01). Both BMQ concerns and depressive symptoms were not related to non-adherence.

CONCLUSION

Patients' beliefs about the necessity of their prescribed phosphate binding medications explain variation in non-adherence levels, measured both subjective and objectively. Dialysis patient's medication beliefs are potentially modifiable targets for future interventions.

Clindamycin-Associated Hyperphosphatemia in a Child with Renal Dysfunction

Objective:

To report a case of hyperphosphatemia associated with administration of intravenous clindamycin phosphate in a child with renal dysfunction.

Case Summary:

We describe the case of a 12-year-old boy who developed hyperphosphatemia while receiving intravenous clindamycin phosphate. The child had a history of asthma but was otherwise healthy. He was transferred to our facility for management of methicillin-resistant Staphylococcus aureus bacteremia, periorbital cellulitis, osteomyelitis, and necrotizing pneumonia. He received intravenous vancomycin and clindamycin 930 mg administered every 8 hours. Concurrently, he developed acute kidney injury. His baseline phosphorus concentration was within the normal range but increased as high as 11.7 mg/dL while he received clindamycin. Despite receiving oral phosphate binder therapy and a low phosphorus diet, he had little reduction in serum phosphorus values. Intravenous clindamycin was suspected as a potential cause for hyperphosphatemia, and a recommendation was made to switch from intravenous to oral clindamycin solution since it contains a different salt formulation. Given the severity of the child's disseminated infection and questions of whether he could absorb the enteral formulation, the decision was made to continue intravenous clindamycin and he was ultimately transferred to a rehabilitation facility for further care on intravenous clindamycin.

Discussion:

Excess oral or intravenous intake of phosphorus can result in hyperphosphatemia, as the body's plasma phosphate concentration exceeds the kidney's diminished filtration capacity. In this patient, use of the Naranjo probability scale indicated a possible adverse event associated with clindamycin. Phosphate intake from intravenous clindamycin and decreased glomerular filtration rate may have contributed to the child's hyperphosphatemia.

Conclusions:

While intravenous clindamycin was not the sole cause for this patient's hyperphosphatemia, health care professionals should be aware of the potential for increased phosphate load when administering this drug to a patient with renal dysfunction.

Appropriateness of anemia management in hemodialysis patients

The anemia of end stage renal disease (ESRD) is common and often severe complication that can be managed successfully by erythropoiesis-stimulating agents (ESA) administration.

AIMS

To investigate current practice of anemia management in hemodialysis patients and to assess the appropriateness of anemia management by comparing observed practice to the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommendations.

SETTINGS AND DESIGN

The study was conducted at two hemodialysis centers in Riyadh, Saudi Arabia. Data on anemia parameters, comorbidities, ESA dosing and iron supplementation were collected. The data were collected for 7 months retrospectively from April to the end of May 2008 and prospectively from June to October 2008. Patients who were over 18 years of age with ESRD undergoing hemodialysis were included. Patients were excluded if they have cancer or receiving chemotherapy or radiotherapy.

RESULTS

Data were collected from 87 patients. Mean Hgb value for those patients was 11.16 ± 0.97 g/dL. Thirty-nine patients (45%) had mean Hgb values between 11.0 and 12.0 g/dL the target range recommended by KDOQI guideline. The mean weekly prescribed dose of erythropoietin was 8099 ± 5946 IU/Week (135 ± 99 IU/kg/Week). Information on ferritin concentrations was available for 48 (55%) patients. The mean serum ferritin concentration for those patients was 693 ± 420.5 ng/mL. Fifty-two patients had transferrin saturation (TSAT) values recorded. The mean TSAT value was 38.5 ± 19.7%.

CONCLUSIONS

There is an opportunity to improve anemia management in hemodialysis patients particularly thorough evaluation of causes of inadequate response rate and better monitoring and management of iron status.

Cinacalcet: a pharmacoeconomic review of its use in secondary hyperparathyroidism in end-stage renal disease

This article provides an overview of the clinical profile of the calcimimetic agent cinacalcet (Mimpara®, Sensipar®) in the treatment of patients with secondary hyperparathyroidism (SHPT) undergoing dialysis for end-stage renal disease (ESRD), followed by a comprehensive review of pharmacoeconomic analyses with cinacalcet in this patient population. Most patients with ESRD undergoing dialysis develop SHPT, which is associated with disturbances in bone mineral metabolism and the development of fractures, cardiovascular disease and other clinical events. Standard treatment of SHPT includes phosphate binders and active vitamin D derivatives. However, standard treatment alone seldom achieves recommended target plasma or serum levels of parathyroid hormone (PTH), calcium and phosphorous. The addition of cinacalcet to standard therapy in patients with SHPT undergoing dialysis for ESRD improves the likelihood of achieving target biochemical levels compared with standard therapy alone. On the basis of association studies, improvements in these intermediate endpoints are likely to reduce the risk of clinical events, such as fractures and cardiovascular disease. Therefore, part of the acquisition cost of cinacalcet is likely to be offset by reductions in other healthcare resource use, such as reductions in costs associated with a lower likelihood of clinical events, as well as potential reductions in dosages of standard treatment. A number of pharmacoeconomic analyses across various country settings indicate that cinacalcet plus standard therapy is cost effective relative to standard therapy alone if dialysis costs are excluded, or that early initiation of cinacalcet is cost effective compared with delaying cinacalcet treatment until PTH levels become very uncontrolled. However, across analyses with cinacalcet, results were variable and not always favourable. This wide range of results stems from differences in selection of data sources used to populate the models, regional differences in healthcare resource use and costs, as well as other factors. Future cost-effectiveness analyses with cinacalcet should incorporate data on hard clinical outcomes from the EVOLVE study once this information becomes available.

Cardiac ventricular repolarization reserve: a principle for understanding drug-related proarrhythmic risk

Cardiac repolarization abnormalities can be caused by a wide range of cardiac and non-cardiac compounds and may lead to the development of life-threatening Torsades de Pointes (TdP) ventricular arrhythmias. Drug-induced torsades de pointes is associated with unexpected and unexplained sudden cardiac deaths resulting in the withdrawal of several compounds in the past. To better understand the mechanism of such unexpected sudden cardiac deaths, the concept of repolarization reserve has recently emerged. According to this concept, pharmacological, congenital or acquired impairment of one type of transmembrane ion channel does not necessarily result in excessive repolarization changes because other repolarizing currents can take over and compensate. In this review, the major factors contributing to repolarization reserve are discussed in the context of their clinical significance in physiological and pathophysiological conditions including drug administration, genetic defects, heart failure, diabetes mellitus, gender, renal failure, hypokalaemia, hypothyroidism and athletes' sudden deaths. In addition, pharmacological support of repolarization reserve as a possible therapeutic option is discussed. Some methods for the quantitative estimation of repolarization reserve are also recommended. It is concluded that repolarization reserve should be considered by safety pharmacologists to better understand, predict and prevent previously unexplained drug-induced sudden cardiac deaths.

Choosing not to take phosphate binders: the role of dialysis patients' medication beliefs

OBJECTIVE

Patients with end-stage renal disease (ESRD) receiving haemodialysis are at risk of cardiovascular disease and bone disorders related to high levels of serum phosphate (PO(4)). Phosphate binders are an important treatment; however, non-adherence remains a significant issue. This study investigates whether patients' beliefs about medicines predict intentional non-adherence to phosphate binders.

METHOD

This was a cross-sectional study of ESRD patients (n = 76). Non-adherence was measured in two ways: (1) the self-report Medication Adherence Questionnaire (MAQ) and (2) 3-month average level of serum phosphate. The Beliefs about Medicines questionnaire was used to assess general and specific beliefs towards phosphate medicines.

RESULTS

Eleven (14.5% of 76) patients reported being intentionally non-adherent to phosphate binders. Patients' beliefs that phosphate binders were less necessary were significantly associated with intentional self-reported non- adherence. Furthermore, patients with greater concerns about phosphate binders had higher serum phosphate levels.

CONCLUSION

Assessing patient beliefs about medicines is a reliable indicator of intentional non-adherence to treatment with phosphate binders. These findings may help in identifying ways in which adherence rates to phosphate binders can be improved.