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Jin H, Lu R, Zhang L, Yao L, Shao G, Zuo L, Qin S, Zhang X, Zhang Q, Yu W, Luo Q, Ren Y, Peng H, Xiao J, Yang Q, Chen Q, Shi Y, Ni Z. Hyperkalemia burden and treatment patterns in Chinese patients on hemodialysis: final analysis of a prospective multicenter cohort study (PRECEDE-K). Ren Fail 2024; 46:2384585. [PMID: 39252179 PMCID: PMC11389625 DOI: 10.1080/0886022x.2024.2384585] [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: 03/14/2024] [Revised: 06/27/2024] [Accepted: 07/21/2024] [Indexed: 09/11/2024] Open
Abstract
OBJECTIVES Patients with end-stage renal disease (ESRD) on hemodialysis (HD) are at risk for hyperkalemia (HK), associated with cardiac arrhythmia and sudden death. Data on the burden of HK and management techniques among HD patients in China are still scarce. This study assessed the treatment modalities, recurrence, and prevalence of HK in Chinese HD patients. METHODS In this prospective cohort study conducted from May 2021 to July 2022, patients aged ≥18 years who had ESRD and were on HD were enrolled from 15 centers in China (up to 6 months). RESULTS Overall, 600 patients were enrolled. At the baseline visit, mean (± standard deviation) urea reduction ratio was 68.0% ± 9.70 and Kt/V was 1.45 ± 0.496. Over 6 months, 453 (75.5%) patients experienced HK, of whom 356 (78.6%) recurred. Within 1, 2, 3, 4, 5, and 6 months, 203 (44.8%), 262 (57.8%), 300 (66.2%), 326 (72.0%), 347 (76.6%), and 356 (78.6%) patients had at least one HK recurrence event, respectively. The proportions of patients with ≥1, 2, 3, 4, 5, or 6 HK recurrence events were 356 (78.6%), 306 (67.5%), 250 (55.2%), 208 (45.9%), 161 (35.5%), and 110 (24.3%), respectively. Among the 453 patients who experienced HK, only 24 (5.3%) were treated with potassium binders: seven (1.5%) with sodium polystyrene sulfonate, 13 (2.9%) with calcium polystyrene sulfonate, and six (1.3%) with sodium zirconium cyclosilicate. CONCLUSION Since HK is a chronic illness, long-term care is necessary. Patients on HD should have effective potassium management on non-dialysis days, yet our real-world population rarely used potassium binders. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT04799067.
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Affiliation(s)
- Haijiao Jin
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Renhua Lu
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lihong Zhang
- Department of Nephrology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Guojian Shao
- Department of Nephrology, Wenzhou Central Hospital, Wenzhou, Zhejiang, China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Shuguang Qin
- Department of Nephrology, Guangzhou First People's Hospital, Guangzhou, Guangdong, China
| | - Xinzhou Zhang
- Department of Nephrology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Qinghong Zhang
- Department of Nephrology, Taihe Hospital, Shiyan, Hubei, China
| | - Weimin Yu
- Department of Nephrology, Shanxi Bethune Hospital, Taiyuan, Shanxi, China
| | - Qun Luo
- Department of Nephrology, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Yuqing Ren
- Department of Nephrology, Yangquan Coal Industry (Group) General Hospital, Yangquan, Shanxi, China
| | - Hui Peng
- Department of Nephrology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jie Xiao
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qiongqiong Yang
- Department of Nephrology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qinkai Chen
- Department of Nephrology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yifan Shi
- Medical Affairs, AstraZeneca Investment China Co, Shanghai, China
| | - Zhaohui Ni
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Li C, Wen Q, Zhu G, Zhang Y, Wang Y, Luo D, Wu J. Association of the panimmune-inflammatory value (PIV) with all-cause and cardiovascular mortality in maintenance hemodialysis patients: a propensity score matching retrospective study. Int Urol Nephrol 2024:10.1007/s11255-024-04203-5. [PMID: 39254905 DOI: 10.1007/s11255-024-04203-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 09/03/2024] [Indexed: 09/11/2024]
Abstract
PURPOSE The panimmune-inflammatory value (PIV) is a novel inflammatory indicator. However, its role in maintenance hemodialysis (MHD) remains unclear. Our goal was to explore the predictive value of PIV for cardiovascular and all-cause mortality in MHD patients. METHODS In this retrospective cohort study, 507 patients receiving MHD between November 2017 and December 2022 were enrolled. The PIV value was calculated as follows: neutrophil count × monocyte count × platelet count/lymphocyte count. Patients were divided into two groups on the basis of the median PIV. Propensity score matching (PSM) was used to adjust for imbalances in baseline information between groups. Kaplan‒Meier curves, Cox regression, the Fine‒Gray competing risk model, and restricted cubic spline (RCS) curves were used to analyze the relationship between PIV and mortality. RESULTS By the end of follow-up, 126 deaths had occurred, 91 of which were due to cardiovascular disease. The Kaplan‒Meier curves demonstrated that MHD patients with higher PIV levels had a poorer prognosis for all-cause death (p = 0.019). PIV levels were linked to all-cause death in multivariate Cox proportional risk regression (HR = 1.76; 95% CI 1.14, 2.72; p = 0.011). The Fine‒Gray model revealed a greater cumulative incidence of cardiovascular death in the higher PIV group (p = 0.035). PIV levels were linked to cardiovascular mortality in the Fine‒Gray competing risk model (HR = 2.06; 95% CI 1.25, 3.42; p = 0.005). The RCS revealed a nonlinear relationship between PIV and mortality risk (p < 0.05). Using 63 years of age as the threshold, we observed a multiplicative interaction effect between age and PIV for all-cause mortality (p = 0.006). CONCLUSION In MHD patients, PIV is an independent hazard factor for cardiovascular-related mortality and all-cause mortality.
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Affiliation(s)
- Chunmin Li
- Department of Nephrology, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan University, 216 Guanshan Road, Wuhan, 430074, People's Republic of China
| | - Qian Wen
- Department of Nephrology, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan University, 216 Guanshan Road, Wuhan, 430074, People's Republic of China
| | - Geli Zhu
- Department of Nephrology, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan University, 216 Guanshan Road, Wuhan, 430074, People's Republic of China
| | - Yanxia Zhang
- Department of Nephrology, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan University, 216 Guanshan Road, Wuhan, 430074, People's Republic of China
| | - Yuan Wang
- Department of Nephrology, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan University, 216 Guanshan Road, Wuhan, 430074, People's Republic of China
| | - Dan Luo
- Department of Nephrology, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan University, 216 Guanshan Road, Wuhan, 430074, People's Republic of China
| | - Jun Wu
- Department of Nephrology, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan University, 216 Guanshan Road, Wuhan, 430074, People's Republic of China.
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Dilaver RG, Ikizler TA. Personalizing electrolytes in the dialysis prescription: what, why and how? Clin Kidney J 2024; 17:sfad210. [PMID: 38186873 PMCID: PMC10768751 DOI: 10.1093/ckj/sfad210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Indexed: 01/09/2024] Open
Abstract
Maintenance hemodialysis patients suffer from multiple comorbidities and treatment-related complications. A personalized approach to hemodialysis prescription could reduce some of these burdens by preventing complications such as excessive changes in blood pressure, arrhythmias, post-dialysis fatigue and decreased quality of life. A patient-centered approach to dialysate electrolyte concentrations represents one such opportunity. In addition to modifications in dialysate electrolyte concentrations, consideration of individual factors such as patients' serum concentrations, medication profiles, nutritional status and comorbidities is critical to tailoring hemodialysis prescriptions to optimize patient outcomes. The development of personalized dialysis treatment depends on the collection of comprehensive patient data, advances in technology, resource allocation and patient involvement in decision-making. This review discusses how the treatment of maintenance hemodialysis patients could benefit from individualized changes in certain dialysis fluid components.
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Affiliation(s)
- R Gulsah Dilaver
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Zhao X, Zuo L. Multicentre, observational, retrospective cohort of hyperkalaemia burden at haemodialysis facility-level in China: the Visualize-HD study protocol. BMJ Open 2023; 13:e066394. [PMID: 37734899 PMCID: PMC10514616 DOI: 10.1136/bmjopen-2022-066394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/13/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVES Hyperkalaemia is a potentially life-threatening disorder in patients undergoing haemodialysis (HD). Excess mortality and hospitalisation have been associated with hyperkalaemia (HK) after the long (2-day) interdialytic interval (LIDI) in patients on thrice a week HD compared with the short (1-day) interdialytic interval. Moreover, not much research has been conducted in China on the descriptive epidemiology and management of HK among different HD centres. The aim of this study is to address this evidence gap by investigating the risk factors associated with HK clinical burden at the HD facility level, current HD centres management patterns, serum potassium management patterns, as well as the risk factors associated with crude mortality in China. DESIGN Multicentre, observational, retrospective cohort study. SETTING This study plans to enrol 300 HD centres across China. Haemodialysis centres having ≥100 patients on maintenance HD within 3 years before study initiation, with participation willingness, routine blood collection post-LIDI and death records will be included. PARTICIPANTS Patients aged ≥18 years and on chronic HD for ≥3 months will be considered eligible. Summary data about serum potassium, characteristics of patients, facility practice patterns will be collected at HD facility level and death records will be at the patient level. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome will be to examine the association between suspected risk factors and HK prevalence at HD facility level. Suspected risk factors include dialysis prescriptions and serum potassium testing frequency, characteristics of patients and related medication usage. The secondary outcome will be to determine the HK prevalence, serum potassium management pattern and risk factors associated with crude mortality. The primary and secondary outcomes will be analysed using regression models. Exploratory outcomes will further investigate the risk factors associated with serum potassium ≥6.0 and ≥6.5 mmol/L. CONCLUSION The study is expected to provide insights to improve dialysis practice patterns and understand the clinical burden of HK. ETHICS AND DISSEMINATION This study protocol was reviewed and approved by the Institutional Review Boards and Ethics Committee of Peking University People's Hospital (Approval number: 2020PHB324-01). The results will be disseminated through national and international presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05020717.
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Affiliation(s)
- Xinju Zhao
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
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Ni Z, Jin H, Lu R, Zhang L, Yao L, Shao G, Zuo L, Qin S, Zhang X, Zhang Q, Yu W, Luo Q, Ren Y, Peng H, Xiao J, Yang Q, Chen Q, Shi Y. Hyperkalaemia prevalence and dialysis patterns in Chinese patients on haemodialysis: an interim analysis of a prospective cohort study (PRECEDE-K). BMC Nephrol 2023; 24:233. [PMID: 37559023 PMCID: PMC10411008 DOI: 10.1186/s12882-023-03261-8] [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: 01/31/2023] [Accepted: 06/30/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Hyperkalaemia is a known risk factor for cardiac arrhythmia and mortality in patients on haemodialysis. Despite standard adequate haemodialysis, hyperkalaemia is common in patients with end-stage renal disease (ESRD) at interdialytic intervals. Data on hyperkalaemia burden and its effects on dialysis patterns and serum potassium (sK) fluctuations in patients on haemodialysis in China remain limited. The prospective, observational cohort study (PRECEDE-K; NCT04799067) investigated the prevalence, recurrence, and treatment patterns of hyperkalaemia in Chinese patients with ESRD on haemodialysis. METHODS Six hundred adult patients were consecutively enrolled from 15 secondary and tertiary hospitals in China. In this interim analysis, we report the baseline characteristics of the cohort, the prevalence of predialysis hyperkalaemia (sK > 5.0 mmol/L), and the trends in serum-dialysate potassium gradient and intradialytic sK shift at Visit 1 (following a long interdialytic interval [LIDI]). RESULTS At baseline, most patients (85.6%) received three-times weekly dialysis; mean duration was 4.0 h. Mean urea reduction ratio was 68.0% and Kt/V was 1.45; 60.0% of patients had prior hyperkalaemia (previous 6 months). At Visit 1, mean predialysis sK was 4.83 mmol/L, and 39.6% of patients had hyperkalaemia. Most patients (97.7%) received a dialysate potassium concentration of 2.0 mmol/L. The serum-dialysate potassium gradient was greater than 3 mmol/L for over 40% of the cohort (1- < 2, 2- < 3, 3- < 4, and ≥ 4 mmol/L in 13.6%, 45.1%, 35.7%, and 5.2% of patients, respectively; mean: 2.8 mmol/L). The intradialytic sK reduction was 1- < 3 mmol/L for most patients (0- < 1, 1- < 2, 2- < 3, and ≥ 3 mmol/L in 24.2%, 62.2%, 12.8%, and 0.9% of patients, respectively; mean: 1.4 mmol/L). CONCLUSIONS Hyperkalaemia after a LIDI was common in this real-world cohort of Chinese patients despite standard adequate haemodialysis, and led to large serum-dialysate potassium gradients and intradialytic sK shifts. Previous studies have shown hyperkalaemia and sK fluctuations are highly correlated with poor prognosis. Effective potassium-lowering treatments should be evaluated for the improvement of long-term prognosis through the control of hyperkalaemia and sK fluctuations. TRIAL REGISTRATION ClinicalTrials.gov, NCT04799067.
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Affiliation(s)
- Zhaohui Ni
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160, Pujian Road, Shanghai, 200127, China.
| | - Haijiao Jin
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160, Pujian Road, Shanghai, 200127, China
| | - Renhua Lu
- Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160, Pujian Road, Shanghai, 200127, China
| | - Lihong Zhang
- Department of Nephrology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Guojian Shao
- Department of Nephrology, Wenzhou Central Hospital, Wenzhou, Zhejiang, China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Shuguang Qin
- Department of Nephrology, Guangzhou First People's Hospital, Guangzhou, Guangdong, China
| | - Xinzhou Zhang
- Department of Nephrology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Qinghong Zhang
- Department of Nephrology, Taihe Hospital, Shiyan, Hubei, China
| | - Weimin Yu
- Department of Nephrology, Shanxi Bethune Hospital, Taiyuan, Shanxi, China
| | - Qun Luo
- Department of Nephrology, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Yuqing Ren
- Department of Nephrology, Yangquan Coal Industry (Group) General Hospital, Yangquan, Shanxi, China
| | - Hui Peng
- Department of Nephrology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jie Xiao
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qiongqiong Yang
- Department of Nephrology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qinkai Chen
- Department of Nephrology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yifan Shi
- Medical Affairs, AstraZeneca Investment China Co, Shanghai, China
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Ni Z, Lu R, Xu X, Bian X, Zhou Z, Yang J, Luo Q, Chen M, Chen C, Sun X, Yu L, He Q, Jiang H, Yuan W, Li Y, Zhou R, Wang J, Zhang X, Zuo L, Meng X, Chang Z, Zhao J, Wessman P, Xiang P. DIALIZE China: A Phase IIIb, Randomized, Placebo-Controlled Study to Reduce Predialysis Hyperkalemia With Sodium Zirconium Cyclosilicate in Chinese Patients. Clin Ther 2023; 45:633-642. [PMID: 37385905 DOI: 10.1016/j.clinthera.2023.04.014] [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: 01/13/2023] [Revised: 04/18/2023] [Accepted: 04/23/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE The DIALIZE China study (Reduce Incidence of Pre-Dialysis Hyperkalaemia With Sodium Zirconium Cyclosilicate in Chinese Subjects) (NCT04217590) evaluated sodium zirconium cyclosilicate (SZC) for the management of hyperkalemia in Chinese patients undergoing hemodialysis. METHODS In the double-blind, Phase IIIb DIALIZE China study, Chinese adults with kidney failure and predialysis hyperkalemia (predialysis serum potassium [sK+] concentration >5.4 mmol/L after the long interdialytic interval [LIDI] and >5.0 mmol/L after ≥1 short interdialytic interval) who were receiving hemodialysis 3 times weekly were randomized to placebo or SZC 5 g once daily on nondialysis days. Doses were titrated towards maintaining normokalemia for 4 weeks (titration period) in 5-g increments up to 15 g. Primary efficacy was the proportion of responders during the 4-week evaluation period following the titration period (ie, those with a predialysis sK+ of 4.0-5.0 mmol/L for at least 3 of 4 hemodialysis visits following the LIDI) who did not require urgent rescue therapy. FINDINGS Overall, 134 adults (mean [SD] age, 55 [11.3] years) were randomized to SZC or placebo (n = 67 each). There were significantly more responders with SZC (37.3%) versus placebo (10.4%; estimated odds ratio [OR] = 5.10; 95% CI, 1.90-15.12; P < 0.001). The probability of all predialysis sK+ concentrations being 3.5 to 5.5 mmol/L was significantly higher with SZC versus placebo (estimated OR = 6.41; 95% CI, 2.71-15.12; P < 0.001). A greater proportion of patients achieved an sK+ of 3.5 to 5.5 mmol/L on at least 3 of 4 LIDI visits during evaluation with SZC (73.1%) versus placebo (29.9%). Serious adverse events occurred in 9.1% and 11.9% of patients in the SZC and placebo groups, respectively. IMPLICATIONS SZC treatment for predialysis hyperkalemia is effective and well tolerated in Chinese patients with kidney failure receiving hemodialysis. CLINICALTRIALS gov identifier: NCT04217590.
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Affiliation(s)
- Zhaohui Ni
- Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Renhua Lu
- Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xudong Xu
- Central Hospital of Minhang District, Shanghai, China
| | | | - Zhihong Zhou
- The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junwei Yang
- The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qun Luo
- Ningbo Huamei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Menghua Chen
- General Hospital of Ningxia Medical University, Yinchuan, China
| | - Chaosheng Chen
- The First Affiliated Hospital of Wenzhou College, Wenzhou, China
| | - Xiuli Sun
- Baotou City Central Hospital, Baotou, China
| | - Lei Yu
- Inner Mongolia People's Hospital, Hohhot, China
| | - Qiang He
- Zhejiang Traditional Chinese Medicine Hospital, Hangzhou, China
| | - Hong Jiang
- People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
| | | | - Yi Li
- Dongguan People's Hospital, Dongguan, China
| | - Rong Zhou
- Shanghai Yangpu District Central Hospital, Shanghai, China
| | - Jianqin Wang
- Lanzhou University Second Hospital, Lanzhou, China
| | | | - Li Zuo
- Peking University People's Hospital, Beijing, China
| | | | | | - June Zhao
- BioPharmaceuticals Clinical, AstraZeneca R&D, Gaithersburg, Maryland
| | - Peter Wessman
- BioPharmaceuticals Clinical, AstraZeneca R&D, Gothenburg, Sweden
| | - Peng Xiang
- Global R&D (China), AstraZeneca, Shanghai, China
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Pun PH. Spironolactone and Cardiac Arrhythmias in Hemodialysis Patients: Helpful or Harmful? KIDNEY360 2023; 4:e429-e430. [PMID: 37103956 PMCID: PMC10278809 DOI: 10.34067/kid.0000000000000096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
- Patrick H. Pun
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham North Carolina
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Hu A, Liu S, Montez-Rath ME, Khairallah P, Niu J, Turakhia MP, Chang TI, Winkelmayer WC. Associations of Serum and Dialysate Potassium Concentrations With Incident Atrial Fibrillation in a Cohort Study of Older US Persons Initiating Hemodialysis for Kidney Failure. Kidney Int Rep 2023; 8:305-316. [PMID: 36815107 PMCID: PMC9939356 DOI: 10.1016/j.ekir.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/27/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Atrial fibrillation (AF) disproportionally affects persons on maintenance hemodialysis (HD). Associations of serum and dialysate potassium concentrations [K+] with AF incidence are poorly understood. Methods We conducted a cohort study using Medicare claims merged with clinical data from a dialysis provider to determine whether serum-[K+] and/or dialysate-[K+] independently associated with AF incidence. Persons insured by fee-for-service Medicare aged ≥67 years at dialysis initiation and free from diagnosed AF prior to day 120 of dialysis were eligible. Serum-[K+] and dialysate-[K+] were assessed in 30-day intervals and patients were followed-up with for AF incidence in subsequent 30-day intervals. Results During 2006 to 2011, 15,190 persons (mean age = 76.3 years) initiating HD had no prior AF diagnosis. Mean serum-[K+] was 4.5 mEq/l; dialysate-[K+] was 3 mEq/l in 34% and 2 mEq/l in 52% of patients. Followed-up over 21,907 person-years, 2869 persons had incident AF (incidence/100 person-years, 13.1 [95% confidence interval [CI], 12.6-13.6]). The multivariable-adjusted association of serum-[K+] with incident AF was J-shaped as follows: relative to a serum-[K+] of 4.5 mEq/l, lower serum-[K+] associated with increased AF risk, whereas confidence bands for higher serum-[K+] indicated no association. Dialysis against a dialysate-[K+] of 3 mEq/l versus 2 mEq/l independently associated with a 14% (95% CI, 5%-24%) lower incidence of AF. No effect modification between serum-[K+] and dialysate-[K+] was detected (P = 0.34). Conclusion Lower serum-[K+] was independently associated with incident AF whereas elevated serum-[K+] was not. The findings support adoption of dialysate solutions with a dialysate-[K+] of 3 mEq/l, regardless of patients' serum-[K+], and elimination of lower dialysate-[K+] solutions from practice. Clinical trials randomizing patients to different dialysate-[K+] are warranted to establish causality.
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Affiliation(s)
- Austin Hu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Maria E. Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Pascale Khairallah
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jingbo Niu
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Mintu P. Turakhia
- Cardiovascular Division, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tara I. Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Wolfgang C. Winkelmayer
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Li M, Li Y, Lv J, Xu H, Wu X, Wen W, Wang W, Yang H. The effects of glucose-free and glucose-containing dialysate during dialysis in MHD patients: a prospective cross-over study. Perfusion 2023; 38:178-185. [PMID: 34541941 DOI: 10.1177/02676591211042726] [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] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To investigate the effects of glucose-free and glucose-containing dialysates during dialysis in maintenance hemodialysis (MHD) patients by the prospective cross-over study, and detect glucose control methods in MHD patients. METHODS A total of 66 MHD 18-75 years old patients in our hospital from Nov. 2019 to Mar. 2020 were recruited. All patients underwent HD with 4 hours per time, three times per week. Glucose-free dialysate (glucose-free group) and then 5.55 mmol/L glucose-containing dialysate (glucose-5.55 group) were used alternately in dialysis. The demographics and parameters of pre- and post-dialysis were recorded. RESULTS A total of 60 patients were analyzed, and 28 patients among them had type 2 diabetes. Serum glucose pre and post dialysis were 8.64 ± 4.18 mmol/L versus 5.74 ± 1.82 mmol/L (p < 0.01) in glucose-free dialysate, and 9.31 ± 4.89 mmol/L versus 7.80 ± 2.59 mmol/L (p < 0.01) in glucose-5.55 dialysate. The post-dialysis blood glucose of glucose-free group was lower than glucose-5.55 group (5.74 ± 1.82 vs 7.80 ± 2.59, p < 0.01). About 18 (30.00%) patients in glucose-free group and 1 patient (1.67%) in glucose-5.55 group whose blood glucose was lower than 4.44 mmol/L (p < 0.01). About 29 patients (48.33%) in glucose-free group and 17 patients (28.33%; p = 0.02) in glucose-5.55 group have hunger feeling. Serum sodium level in the glucose-free group was higher than that in Glucose-5.55 group (137.92 ± 1.64 vs 136.70 ± 1.64, p < 0.01). Post-dialysis blood glucose had no significant differences between patients not using diabetes-related medication (13 patients) and patients using diabetes-related medication (15 patients) in glucose-free group (7.13 ± 1.78 mmol/L vs 6.08 ± 2.84 mmol/L, p = 0.23) and glucose-5.55 group (9.22 ± 2.59 mmol/L vs 9.35 ± 2.88 mmol/L, p = 0.90). CONCLUSIONS Glucose-free and glucose-5.55 dialysate both decrease the blood glucose post-dialysis. Dialysates containing 5.55 mmol/L glucose can reduce the incidence of hypoglycemia and lower serum sodium, but have no effect on blood pressure during dialysis. Stopping insulin and oral anti-diabetic drugs once before dialysis may not affect the control of blood glucose.
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Affiliation(s)
- Minxia Li
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Yuehong Li
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Jiaxuan Lv
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Huiying Xu
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Xianglan Wu
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Wen Wen
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Wei Wang
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
| | - Hua Yang
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Changping District, Beijing, China
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10
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Edwards JC, Mosman A, Hauptman PJ, Lee T, Philipneri M, Farahmand F, Yn L, Brandon M, Buchanan PM. Arrhythmia in chronic hemodialysis as a function of predialysis electrolytes and interdialytic interval. Hemodial Int 2023; 27:45-54. [PMID: 36411729 DOI: 10.1111/hdi.13057] [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: 04/28/2022] [Revised: 10/19/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION People with end-stage renal disease on hemodialysis are at increased risk for death due to arrhythmia associated with the prolonged interdialytic interval that typically spans the weekend, with bradycardia being the arrhythmia most closely associated with sudden death. In this prospective observational study we assessed whether predialysis fluid and electrolytes values including hyperkalemia are risk factors for the arrhythmias associated with the prolonged interdialytic interval. METHODS Sixty patients on hemodialysis with a history of hyperkalemia underwent cardiac monitoring for 1 week. Arrhythmia frequency, average QTc interval, and average root mean square of successive differences (rMSSD) per 4-h period were reported. Predialysis electrolytes and electrocardiograms were collected prior to pre- and post-weekend dialysis sessions. Clinical variables were assessed for correlation with arrhythmias. FINDINGS Predialysis hyperkalemia occurred in 29 subjects and was more common at the post-weekend dialysis session. Bradycardia occurred in 11 subjects and increased before and during the post-weekend dialysis session, but was not correlated with any electrolyte or clinical parameter. Ventricular ectopy occurred in 50 subjects with diurnal variation unrelated to dialysis. Pre-dialysis prolonged QTc was common and not affected by interdialytic interval. Average QTc increased and rMSSD decreased during dialysis sessions and were not correlated with clinical parameters. DISCUSSION The results confirm that arrhythmias are prevalent in dialysis subjects with bradycardia particularly associated with the longer interdialytic interval; EKG markers of arrhythmia risk are increased during dialysis independent of interdialytic interval. Larger sample size and/or longer recording may be necessary to identify the clinical parameters responsible.
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Affiliation(s)
- John C Edwards
- Division of Nephrology, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, USA
| | - Amy Mosman
- Division of Nephrology, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, USA
| | - Paul J Hauptman
- Reno School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Taewoo Lee
- Division of Nephrology, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, USA
| | - Marie Philipneri
- Division of Nephrology, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, USA
| | - Firoozeh Farahmand
- Division of Nephrology, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, USA
| | - Louis Yn
- Division of Nephrology, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, USA
| | - Margaret Brandon
- Division of Nephrology, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, USA
| | - Paula M Buchanan
- AHEAD Institute, Department of Health and Clinical Outcomes Research Saint Louis University, Saint Louis, Missouri, USA
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11
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Igomu EM, Ige EO, Adesina OA. Coupled modeling and process optimization in a genetic-algorithm paradigm for reverse osmosis dialysate production plant. SOUTH AFRICAN JOURNAL OF CHEMICAL ENGINEERING 2022. [DOI: 10.1016/j.sajce.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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12
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Sarnowski A, Gama RM, Dawson A, Mason H, Banerjee D. Hyperkalemia in Chronic Kidney Disease: Links, Risks and Management. Int J Nephrol Renovasc Dis 2022; 15:215-228. [PMID: 35942480 PMCID: PMC9356601 DOI: 10.2147/ijnrd.s326464] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/22/2022] [Indexed: 12/21/2022] Open
Abstract
Hyperkalemia is a common clinical problem with potentially fatal consequences. The prevalence of hyperkalemia is increasing, partially due to wide-scale utilization of prognostically beneficial medications that inhibit the renin-angiotensin-aldosterone-system (RAASi). Chronic kidney disease (CKD) is one of the multitude of risk factors for and associations with hyperkalemia. Reductions in urinary potassium excretion that occur in CKD can lead to an inability to maintain potassium homeostasis. In CKD patients, there are a variety of strategies to tackle acute and chronic hyperkalemia, including protecting myocardium from arrhythmias, shifting potassium into cells, increasing potassium excretion from the body, addressing dietary intake and treating associated conditions, which may exacerbate problems such as metabolic acidosis. The evidence base is variable but has recently been supplemented with the discovery of novel oral potassium binders, which have shown promise and efficacy in studies. Their use is likely to become widespread and offers another tool to the clinician treating hyperkalemia. Our review article provides an overview of hyperkalemia in CKD patients, including an exploration of relevant guidelines and nuances around management.
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Affiliation(s)
- Alexander Sarnowski
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
| | - Rouvick M Gama
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
| | - Alec Dawson
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
| | - Hannah Mason
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
| | - Debasish Banerjee
- Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, London, UK
- Correspondence: Debasish Banerjee, Department of Renal Medicine and Transplantation, St George’s NHS University Hospitals NHS Foundation Trust, Blackshaw Road, SW170QT, London, United Kingdom, Tel +44 2087151673, Email
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13
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Course of Hyperkalemia in Patients on Hemodialysis. Int J Nephrol 2022; 2022:6304571. [PMID: 35531468 PMCID: PMC9071981 DOI: 10.1155/2022/6304571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
Abstract
Background Evidence of longitudinal serum potassium (sK+) concentrations in hyperkalemic hemodialysis patients is sparse. Objective These post hoc analyses of the placebo arm of the phase 3b DIALIZE study (NCT03303521) explored the course of hyperkalemia in hemodialysis patients receiving placebo. Methods In DIALIZE, 196 patients receiving hemodialysis three times weekly were randomized to placebo or sodium zirconium cyclosilicate 5 g starting dose once daily on nondialysis days for 8 weeks. In these post hoc analyses of placebo patients overall (n = 86) and by predialysis sK+ subgroups at randomization <5.5 mmol/L, 5.5 to <6.0 mmol/L, 6.0 to <6.5 mmol/L, and ≥6.5 mmol/L, we assessed mean predialysis sK+ concentration by visit and the proportions of patients with mean predialysis sK+ ranges of 4.0–5.0 and 4.0–5.5 mmol/L by visit. Results In placebo patients, the mean predialysis sK+ concentration at randomization was 5.9 mmol/L, and 5.8 mmol/L at the end of the study (day 57). For placebo patients overall and across all predialysis sK+ subgroups, the mean predialysis sK+ concentration remained ≥5.0 mmol/L for all visits over 8 weeks. Overall, 7–21% and 27–62% of placebo patients had predialysis sK+ ranges of 4.0–5.0 and 4.0–5.5 mmol/L, respectively, at any visit. The proportions of placebo patients with either predialysis sK+ range were greatest for those who were least hyperkalemic (<5.5 mmol/L) and generally decreased with increasing predialysis sK+ concentration. Conclusions Patients receiving placebo and hemodialysis maintained high predialysis sK+ concentrations over 8 weeks following a hyperkalemic event. Most placebo patients remained hyperkalemic and may be at continued risk of adverse events.
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14
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Shao G, Himmelfarb J, Hinds BJ. Strategies for optimizing urea removal to enable portable kidney dialysis: A reappraisal. Artif Organs 2022; 46:997-1011. [PMID: 35383963 DOI: 10.1111/aor.14185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/23/2021] [Accepted: 01/10/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Portable hemodialysis has the potential to improve health outcomes and quality of life for patients with kidney failure at reduced costs. Urea removal, required for dialysate regeneration, is a central function of any existing/potential portable dialysis device. Urea in the spent dialysate coexists with non-urea uremic toxins, nutrients, and electrolytes, all of which will interfere with the urea removal efficiency, regardless of whether the underlying urea removal mechanism is based on urease conversion, direct urea adsorption, or oxidation. The aim of the current review is to identify the amount of the most prevalent chemicals being removed during a single dialysis session and evaluate the potential benefits of an urea-selective membrane for portable dialysis. METHODS We have performed a literature search using Web of Science and PubMed databases to find available articles reporting (or be able to calculate from blood plasma concentration) > 5 mg of individually quantified solutes removed during thrice-weekly hemodialysis sessions. If multiple reports of the same solute were available, the reported values were averaged, and the geometric mean of standard deviations was taken. Further critical literature analysis of reported dialysate regeneration methods was performed using Web of Science and PubMed databases. RESULTS On average, 46.0 g uremic retention solutes are removed in a single conventional dialysis session, out of which urea is only 23.6 g. For both urease- and sorbent-based urea removal mechanisms, amino acids, with 7.7 g removal per session, could potentially interfere with urea removal efficiency. Additionally for the oxidation-based urea removal system, plentiful nutrients such as glucose (24.0 g) will interfere with urea removal by competition. Using a nanofiltration membrane between dialysate and oxidation unit with a molecular weight cutoff (MWCO) of ~200 Da, 67.6 g of non-electrolyte species will be removed in a single dialysis session, out of which 44.0 g are non-urea molecules. If the membrane MWCO is further decreased to 120 Da, the mass of non-electrolyte non-urea species will drop to 9.3 g. Reverse osmosis membranes have been shown to be both effective at blocking the transport of non-urea species (creatinine for example with ~90% rejection ratio), and permissive for urea transport (~20% rejection ratio), making them a promising urea selective membrane to increase the efficiency of the oxidative urea removal system. CONCLUSIONS Compiled are quantified solute removal amounts greater than 5 mg per session during conventional hemodialysis treatments, to act as a guide for portable dialysis system design. Analysis shows that multiple chemical species in the dialysate interfere with all proposed portable urea removal systems. This suggests the need for an additional protective dialysate loop coupled to urea removal system and an urea-selective membrane.
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Affiliation(s)
- Guozheng Shao
- Department of Materials Science & Engineering, University of Washington, Seattle, Washington, USA.,Center for Dialysis Innovation, University of Washington, Seattle, Washington, USA
| | - Jonathan Himmelfarb
- Center for Dialysis Innovation, University of Washington, Seattle, Washington, USA.,Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Bruce J Hinds
- Department of Materials Science & Engineering, University of Washington, Seattle, Washington, USA.,Center for Dialysis Innovation, University of Washington, Seattle, Washington, USA
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15
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Canaud B, Kooman JP, Selby NM, Taal M, Maierhofer A, Kopperschmidt P, Francis S, Collins A, Kotanko P. Hidden risks associated with conventional short intermittent hemodialysis: A call for action to mitigate cardiovascular risk and morbidity. World J Nephrol 2022; 11:39-57. [PMID: 35433339 PMCID: PMC8968472 DOI: 10.5527/wjn.v11.i2.39] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/30/2021] [Accepted: 03/23/2022] [Indexed: 02/06/2023] Open
Abstract
The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for patients. Conventional thrice weekly short HD is an imperfect treatment that only partially corrects uremic abnormalities, increases cardiovascular risk, and exacerbates disease burden. Altering cycles of fluid loading associated with cardiac stretching (interdialytic phase) and then fluid unloading (intradialytic phase) likely contribute to cardiac and vascular damage. This unphysiologic treatment profile combined with cyclic disturbances including osmotic and electrolytic shifts may contribute to morbidity in dialysis patients and augment the health burden of treatment. As such, HD patients are exposed to multiple stressors including cardiocirculatory, inflammatory, biologic, hypoxemic, and nutritional. This cascade of events can be termed the dialysis stress storm and sickness syndrome. Mitigating cardiovascular risk and morbidity associated with conventional intermittent HD appears to be a priority for improving patient experience and reducing disease burden. In this in-depth review, we summarize the hidden effects of intermittent HD therapy, and call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects.
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Affiliation(s)
- Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
- Department of Nephrology, Montpellier University, Montpellier 34000, France
| | - Jeroen P Kooman
- Department of Internal Medicine, Maastricht University, Maastricht 6229 HX, Netherlands
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Maarten Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Andreas Maierhofer
- Global Research Development, Fresenius Medical Care, Schweinfurt 97424, Germany
| | | | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
| | - Peter Kotanko
- Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10065, United States
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16
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Fishbane S, Ford M, Fukagawa M, McCafferty K, Rastogi A, Spinowitz B, Staroselskiy K, Vishnevskiy K, Lisovskaja V, Al-Shurbaji A, Guzman N, Bhandari S. Potassium responses to sodium zirconium cyclosilicate in hyperkalemic hemodialysis patients: post-hoc analysis of DIALIZE. BMC Nephrol 2022; 23:59. [PMID: 35135481 PMCID: PMC8826669 DOI: 10.1186/s12882-021-02569-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sodium zirconium cyclosilicate (SZC) is an effective and well-tolerated treatment for hyperkalemia in maintenance hemodialysis patients. In post-hoc analyses of the phase 3b DIALIZE study, we examined the spectrum of potassium responses to SZC. METHODS Post-hoc analyses with SZC and placebo included: the number of long interdialytic interval (LIDI) visits during the 4-week evaluation period where patients attained pre-dialysis serum potassium (sK+) concentrations of 4.0-5.0 and 4.0-5.5 mmol/L; potassium gradient (the difference between pre-dialysis sK+ and dialysate potassium) at days 36, 43, 50, and 57, and change from baseline to the end of treatment (EOT) using categories of potassium gradient (1 to < 2, 2 to < 3, 3 to < 4, and ≥ 4 mmol/L). RESULTS A greater proportion of patients achieved the ranges of pre-dialysis sK+ concentration with SZC versus placebo for ≥1, ≥ 2, ≥ 3, and 4 LIDI visits over 4 weeks; 23.7 and 48.5% of patients in the SZC group achieved pre-dialysis sK+ concentrations of 4.0-5.0 and 4.0-5.5 mmol/L, respectively, at all 4 LIDI visits. Baseline mean potassium gradient was similar with SZC and placebo. At day 57, mean (standard deviation) potassium gradient was 2.78 (0.08) mmol/L with SZC and 3.52 (0.08) mmol/L with placebo; mean difference (95% confidence interval) was - 0.74 mmol/L (- 0.97 to - 0.52). A greater reduction in potassium gradient category from baseline towards lower-risk categories at EOT was observed with SZC versus placebo. CONCLUSIONS These analyses expand our knowledge of the spectrum of potassium responses with SZC in hyperkalemic hemodialysis patients. TRIAL REGISTRATION NCT03303521 .
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Affiliation(s)
- Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, 100 Community Dr, Great Neck, NY, 11021, USA.
| | - Martin Ford
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | | | - Anjay Rastogi
- UCLA CORE Kidney Program, University of California Los Angeles, Los Angeles, CA, USA
| | - Bruce Spinowitz
- Department of Medicine, New York-Presbyterian Queens, Queens, NY, USA
| | | | - Konstantin Vishnevskiy
- Propedeutics of Internal Diseases Chair, First Pavlov State Medical University of St Petersburg, St Petersburg, Russia
| | - Vera Lisovskaja
- Biometrics and Information, AstraZeneca BioPharmaceuticals R&D Gothenburg, Mölndal, Sweden
| | - Ayman Al-Shurbaji
- Global Medicines Development, AstraZeneca BioPharmaceuticals R&D Gothenburg, Mölndal, Sweden
| | - Nicolas Guzman
- Global Medicines Development, AstraZeneca BioPharmaceuticals R&D, Gaithersburg, MD, USA
| | - Sunil Bhandari
- Department of Renal and Transplant Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK
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17
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Canaud B, Stuard S, Laukhuf F, Yan G, Canabal MIG, Lim PS, Kraus MA. Choices in hemodialysis therapies: variants, personalized therapy and application of evidence-based medicine. Clin Kidney J 2021; 14:i45-i58. [PMID: 34987785 PMCID: PMC8711767 DOI: 10.1093/ckj/sfab198] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/17/2022] Open
Abstract
The extent of removal of the uremic toxins in hemodialysis (HD) therapies depends primarily on the dialysis membrane characteristics and the solute transport mechanisms involved. While designation of ‘flux’ of membranes as well toxicity of compounds that need to be targeted for removal remain unresolved issues, the relative role, efficiency and utilization of solute removal principles to optimize HD treatment are better delineated. Through the combination and intensity of diffusive and convective removal forces, levels of concentrations of a broad spectrum of uremic toxins can be lowered significantly and successfully. Extended clinical experience as well as data from several clinical trials attest to the benefits of convection-based HD treatment modalities. However, the mode of delivery of HD can further enhance the effectiveness of therapies. Other than treatment time, frequency and location that offer clinical benefits and increase patient well-being, treatment- and patient-specific criteria may be tailored for the therapy delivered: electrolytic composition, dialysate buffer and concentration and choice of anticoagulating agent are crucial for dialysis tolerance and efficacy. Evidence-based medicine (EBM) relies on three tenets, i.e. clinical expertise (i.e. doctor), patient-centered values (i.e. patient) and relevant scientific evidence (i.e. science), that have deviated from their initial aim and summarized to scientific evidence, leading to tyranny of randomized controlled trials. One must recognize that practice patterns as shown by Dialysis Outcomes and Practice Patterns Study and personalization of HD care are the main driving force for improving outcomes. Based on a combination of the three pillars of EBM, and particularly on bedside patient–clinician interaction, we summarize what we have learned over the last 6 decades in terms of best practices to improve outcomes in HD patients. Management of initiation of dialysis, vascular access, preservation of kidney function, selection of biocompatible dialysers and use of dialysis fluids of high microbiological purity to restrict inflammation are just some of the approaches where clinical experience is vital in the absence of definitive scientific evidence. Further, HD adequacy needs to be considered as a broad and multitarget approach covering not just the dose of dialysis provided, but meeting individual patient needs (e.g. fluid volume, acid–base, blood pressure, bone disease metabolism control) through regular assessment—and adjustment—of a series of indicators of treatment efficiency. Finally, in whichever way new technologies (i.e. artificial intelligence, connected health) are embraced in the future to improve the delivery of dialysis, the human dimension of the patient–doctor interaction is irreplaceable. Kidney medicine should remain ‘an art’ and will never be just ‘a science’.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Stefano Stuard
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | - Frank Laukhuf
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | | | | | | | - Michael A Kraus
- Indiana University Medical School, Indianapolis, Indiana, USA
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts, USA
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18
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Ford M, Fishbane S, Spinowitz B, Rastogi A, Guzman N, McCafferty K. Effectiveness of Sodium Zirconium Cyclosilicate in Hemodialysis Patients With Severe Hyperkalemia. Kidney Int Rep 2021; 6:3074-3078. [PMID: 34901576 PMCID: PMC8640539 DOI: 10.1016/j.ekir.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Martin Ford
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Bruce Spinowitz
- Department of Medicine, New York-Presbyterian Queens, Queens, New York, USA
| | - Anjay Rastogi
- UCLA CORE Kidney Program, University of California Los Angeles, Los Angeles, California, USA
| | - Nicolas Guzman
- Global Medicines Development, AstraZeneca BioPharmaceuticals R&D, Gaithersburg, Maryland, USA
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19
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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20
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Morales Montoya A, Martínez Sánchez LM. Terapia de reemplazo renal, una alternativa para la calidad de vida de los pacientes. REPERTORIO DE MEDICINA Y CIRUGÍA 2021. [DOI: 10.31260/repertmedcir.01217372.1064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
La enfermedad renal crónica es una patología causada por la pérdida del funcionamiento del riñón con una filtración glomerular alterada por más de tres meses, por lo que es necesario recibir terapia de reemplazo renal consistente en la sustitución de esta función mediante la extracción de líquidos de la sangre y su filtración a través de membranas semipermeables, en especial para mantener la homeostasis mediante la eliminación de sustancias tóxicas nitrogenadas y desechos acumulados. Estos procedimientos y en particular la hemodiálisis pueden presentar diversas complicaciones debido a que son procesos invasivos. Cabe mencionar que los pacientes en terapia de reemplazo presentan una disminución de la calidad de vida sobre todo a nivel físico y psicológico, a costa de mantener una mejor condición de su salud renal.
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21
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Bozaci I, Tatar E. Prolongation of QTc interval at the beginning and during dialysis is associated with hypervolemia and calcium and magnesium change in the first 2 h. Int Urol Nephrol 2021; 54:1399-1408. [PMID: 34665413 DOI: 10.1007/s11255-021-03016-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 10/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS High rates of sudden cardiac death are mostly attributed to ventricular arrhythmias including QTc prolongation in hemodialysis patients. We aimed to investigate the correlation of electrolyte and volume changes with QTc interval prolongation in hemodialysis patients. STUDY DESIGN The present study is designed as a cross-sectional study. METHODS The study was conducted at the hemodialysis unit of a training and research hospital and its' satellite dialysis unit. Patients were divided into three groups. Group-1: with normal QTc interval both at the beginning and during dialysis session; group-2: with prolonged QTc interval at the beginning and remained prolonged during dialysis session; group-3: with normal QTc interval at the beginning but prolonged during the dialysis session. In addition, patients were evaluated in terms of QTc change between the beginning and 2nd hour (delta-QTc-1) and between 2nd hour and 4th hour (delta-QTc-2), respectively, and defined as 'patients with increased QTc interval' and 'patients without increased QTc interval'. RESULTS A total of 45 prevalent hemodialysis patients were enrolled in the study. 14 patients (31.1%) had normal QTc interval (group-1), 13 patients (28.9%) had prolonged QTc interval at the beginning and remained prolonged during dialysis session (group-2) and 18 patients (40%) had normal QTc interval at the beginning but prolonged during dialysis session (group-3). There was no statistically significant difference between groups in terms of baseline electrolyte levels. Calcium change in the first 2 h was lower in patients with QTc prolongation from the start or during the dialysis session (group-2 and group-3). In addition, systolic blood pressure (SBP) levels at the beginning of the session (118 ± 15 mmHg vs 124 ± 28 mmHg vs138 ± 24 mmHg; p = 0.04) and intradialytic ultrafiltration (UF) rate were higher (1.96 ± 0.6 L/4 h vs 2.6 ± 1.0 L/4 h vs 2.8 ± 0.9 L/4 h; p = 0.03) in group-2 and group-3 compared to patients in group-1. Increase in QTc interval was found higher in patients with less calcium increase (Rho: - 0.36; p = 0.01) and with greater magnesium decrease in the first 2 h (Rho: 0.31; p = 0.04). CONCLUSION QTc interval prolongation is common among hemodialysis patients. High intradialytic UF rates, change in serum magnesium and calcium levels in the first 2 h were found associated with QTc prolongation. However, QTc prolongation was found independently associated only with UF volume and calcium change in the first 2 h.
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Affiliation(s)
- I Bozaci
- Department of Nephrology, University of Health Sciences Bozyaka Training and Research Hospital, Saim Cikrikci Street, No:59Karabaglar, 35360, Izmir, Turkey.
| | - E Tatar
- Department of Nephrology, University of Health Sciences Bozyaka Training and Research Hospital, Saim Cikrikci Street, No:59Karabaglar, 35360, Izmir, Turkey
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22
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Shibata S, Uchida S. Hyperkalemia in patients undergoing hemodialysis: its pathophysiology and management. Ther Apher Dial 2021; 26:3-14. [PMID: 34378859 PMCID: PMC9291487 DOI: 10.1111/1744-9987.13721] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/01/2021] [Accepted: 08/09/2021] [Indexed: 11/28/2022]
Abstract
Potassium is a major intracellular cation in the body, regulating membrane potential of excitable cells, such as cardiomyocytes and skeletal muscle cells. Because the kidney plays a critical role in controlling potassium balance, the elevation in serum potassium levels is one of the most common complications in patients with maintenance hemodialysis (MHD). In addition to reduced renal potassium excretion, the alteration in body potassium distribution owing to comorbid conditions may also contribute to dyskalemia. Besides potassium elimination through hemodialysis in MHD patients, accumulating data indicate the potential importance of extra‐renal elimination involving the gastrointestinal system, which can be affected by the inhibitors of the renin‐angiotensin‐aldosterone system. In this article, the literature on potassium physiology in MHD patients is reviewed with an emphasis on the changes from individuals with normal kidney function. This article also summarizes the findings of recent studies on dietary control, dialysate prescription, and pharmacological therapy.
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Affiliation(s)
- Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Shunya Uchida
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan.,Department of Health Care, Teikyo Heisei University, Tokyo, Japan
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23
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Fishbane S, Charytan DM, Chertow GM, Ford M, Kovesdy CP, Pergola PE, Pollock C, Spinowitz B. Consensus-Based Recommendations for the Management of Hyperkalemia in the Hemodialysis Setting. J Ren Nutr 2021; 32:e1-e14. [PMID: 34364782 DOI: 10.1053/j.jrn.2021.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/04/2021] [Accepted: 06/02/2021] [Indexed: 12/26/2022] Open
Abstract
Hyperkalemia (serum K+ >5.0 mmol/L) is commonly observed among patients receiving maintenance hemodialysis and associated with increased risk of cardiac arrhythmias. Current international guidelines may not reflect the latest evidence on managing hyperkalemia in patients undergoing hemodialysis, and there is a lack of high-quality published studies in this area. This consensus guideline aims to provide recommendations in relation to clinical practice. Available published evidence was evaluated through a systematic literature review, and the nominal group technique was used to develop consensus recommendations from a panel of experienced nephrologists, covering monitoring, dietary restrictions, prescription of K+ binders, and concomitant prescription of renin-angiotensin-aldosterone system inhibitors. Recent studies have shown that K+ binders reduce the incidence of hyperkalemia, but further evidence is needed in areas including whether reduced-K+ diets or treatment with K+ binders improve patient-centered outcomes. Treatment of hyperkalemia in the hemodialysis setting is complex, and decisions need to be tailored for individual patients.
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Affiliation(s)
- Steven Fishbane
- Zucker School of Medicine at Hofstra/Northwell, New York, New York.
| | - David M Charytan
- NYU Langone Medical Center and New York University Grossman School of Medicine, New York, New York
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Martin Ford
- Department of Renal Medicine, King's College Hospital NHS Foundation Trust and Kings College London, London, UK
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Carol Pollock
- The University of Sydney, Sydney, New South Wales, Australia
| | - Bruce Spinowitz
- Division of Nephrology, Department of Medicine, New York Presbyterian Queens, Flushing, New York
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24
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Karaboyas A, Robinson BM, James G, Hedman K, Moreno Quinn CP, De Sequera P, Nitta K, Pecoits-Filho R. Hyperkalemia excursions are associated with an increased risk of mortality and hospitalizations in hemodialysis patients. Clin Kidney J 2021; 14:1760-1769. [PMID: 34221383 PMCID: PMC8243282 DOI: 10.1093/ckj/sfaa208] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/31/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hyperkalemia is common among hemodialysis (HD) patients and has been associated with adverse clinical outcomes. Previous studies considered a single serum potassium (K) measurement or time-averaged values, but serum K excursions out of the target range may be more reflective of true hyperkalemia events. We assessed whether hyperkalemia excursions lead to an elevated risk of adverse clinical outcomes. METHODS Using data from 21 countries in Phases 4-6 (2009-18) of the Dialysis Outcomes and Practice Patterns Study (DOPPS), we investigated the associations between peak serum K level, measured monthly predialysis, over a 4-month period ('peak K') and clinical outcomes over the subsequent 4 months using Cox regression, adjusted for potential confounders. RESULTS The analysis included 62 070 patients contributing a median of 3 (interquartile range 2-6) 4-month periods. The prevalence of hyperkalemia based on peak K was 58% for >5.0, 30% for >5.5 and 12% for >6.0 mEq/L. The all-cause mortality hazard ratio for peak K (reference ≤5.0 mEq/L) was 1.15 [95% confidence interval (CI) 1.09, 1.21] for 5.1-5.5 mEq/L, 1.19 (1.12, 1.26) for 5.6-6.0 mEq/L and 1.33 (1.23, 1.43) for >6.0 mEq/L. Results were qualitatively consistent when analyzing hospitalizations and a cardiovascular composite outcome. CONCLUSIONS Among HD patients, we identified a lower K threshold (peak K 5.1-5.5 mEq/L) than previously reported for increased risk of hospitalization and mortality, with the implication that a greater proportion (>50%) of the HD population may be at risk. A reassessment of hyperkalemia severity ranges is needed, as well as an exploration of new strategies for effective management of chronic hyperkalemia.
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Affiliation(s)
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Glen James
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Katarina Hedman
- BioPharmaceuticals Business Unit, AstraZeneca, Gothenburg, Sweden
| | | | | | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
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25
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Palmieri F, Gomis P, Ruiz JE, Ferreira D, Martín-Yebra A, Pueyo E, Martínez JP, Ramírez J, Laguna P. ECG-based monitoring of blood potassium concentration: Periodic versus principal component as lead transformation for biomarker robustness. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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26
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Vida C, Carracedo J, de Sequera P, Bodega G, Pérez R, Alique M, Ramírez R. A high magnesium concentration in citrate dialysate prevents oxidative stress and damage in human monocytes in vitro. Clin Kidney J 2021; 14:1403-1411. [PMID: 33959268 PMCID: PMC8087128 DOI: 10.1093/ckj/sfaa131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of dialysis fluids (DFs) during haemodialysis has been associated with increased oxidative stress and reduced serum magnesium (Mg) levels, contributing to chronic inflammation. Since the role of Mg in modulating immune function and reducing oxidative stress has been demonstrated, the aim of this study was to characterize in vitro whether increasing the Mg concentration in DFs could protect immune cells from oxidative stress and damage. METHODS The effect of citrate [citrate dialysis fluid (CDF), 1 mM] or acetate [acetate dialysis fluid (ADF), 3 mM] dialysates with low (0.5 mM; routinely used) or high (1 mM, 1.25 mM and 2 mM) Mg concentrations was assessed in THP-1 human monocytes. The levels of reactive oxygen species (ROS), malondialdehyde (MDA) and oxidized/reduced (GSSG/GSH) glutathione were quantified under basal and inflammatory conditions (stimulation with lipopolysaccharide, LPS). RESULTS The increase of Mg in CDF resulted in a significant reduction of ROS production under basal and inflammatory conditions (extremely marked in 2 mM Mg; P < 0.001). These effects were not observed in ADF. Interestingly, in a dose-dependent manner, high Mg doses in CDF reduced oxidative stress in monocytes under both basal and inflammatory conditions. In fact, 2 mM Mg significantly decreased the levels of GSH, GSSG and MDA and the GSSG/GSH ratio in relation to 0.5 mM Mg. CONCLUSIONS CDF produces lower oxidative stress than ADF. The increase of Mg content in DFs, especially in CDF, could have a positive and protective effect in reducing oxidative stress and damage in immune cells, especially under inflammatory conditions.
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Affiliation(s)
- Carmen Vida
- Dpto de Biología de Sistemas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Julia Carracedo
- Dpto Genética, Fisiología y Microbiología (Sección Fisiología), Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Patricia de Sequera
- Sección de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
- Dpto de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Guillermo Bodega
- Dpto de Biomedicina y Biotecnología, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Rafael Pérez
- Sección de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Matilde Alique
- Dpto de Biología de Sistemas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria, (IRYCIS), Madrid, Spain
| | - Rafael Ramírez
- Dpto de Biología de Sistemas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria, (IRYCIS), Madrid, Spain
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27
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Kula AJ, Bansal N. Magnesium and Cardiovascular Disease in CKD: The Mysteries of a Humble Divalent Cation. Kidney Med 2021; 3:162-164. [PMID: 33851109 PMCID: PMC8039415 DOI: 10.1016/j.xkme.2021.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alexander J. Kula
- Division of Pediatric Nephrology, Seattle Children’s Hospital, Seattle, WA
| | - Nisha Bansal
- Division of Nephrology, University of Washington, Seattle, WA
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28
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Monardo P, Lacquaniti A, Campo S, Bucca M, Casuscelli di Tocco T, Rovito S, Ragusa A, Santoro A. Updates on hemodialysis techniques with a common denominator: The personalization of the dialytic therapy. Semin Dial 2021; 34:183-195. [PMID: 33592133 DOI: 10.1111/sdi.12956] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/02/2020] [Indexed: 12/14/2022]
Abstract
Hemodialysis (HD) is a life-saving therapy for patients with end-stage renal disease. In dialyzed patients, the prevalence of multi-morbidity is rising driven by various factors, such as the population aging, the incomplete correction of uremia, and the side effects of the dialysis therapy itself. Each dialyzed patient has their own specific clinical and biochemical problems. It is therefore unthinkable that the same dialysis procedure can be able to meet the needs of every patient on chronic dialysis. We have very sophisticated dialysis machines and different dialysis techniques and procedures beyond conventional HD, such as hemodiafiltration (HDF) with pre- and post-dilution, acetate-free biofiltration (AFB), hemofiltration (HF), and expanded HD. Each of these techniques has its own specific characteristics. To solve some intradialytic clinical issues, such as arterial hypotension and arrhythmias, we have biofeedback systems with automatic regulation of the blood volume, body temperature, arterial pressure, as well as potassium profiling techniques in the dialysis bath. New technical innovations, such as citrate-containing dialysate or heparin-coated membranes, could reduce the risk of bleeding. To better address to patient needs, the strengths and weaknesses of each of these systems must be well-known, in order to have a personalized dialysis prescription for each patient.
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Affiliation(s)
- Paolo Monardo
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | | | - Susanna Campo
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | - Maurizio Bucca
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | | | - Stefania Rovito
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | - Antonino Ragusa
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | - Antonio Santoro
- Department of Organ Failures and Transplantations, Policlinico S.Orsola-Malpighi- Bologna, Italy
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29
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Palmieri F, Gomis P, Ferreira D, Ruiz JE, Bergasa B, Martín-Yebra A, Bukhari HA, Pueyo E, Martínez JP, Ramírez J, Laguna P. Monitoring blood potassium concentration in hemodialysis patients by quantifying T-wave morphology dynamics. Sci Rep 2021; 11:3883. [PMID: 33594135 PMCID: PMC7887245 DOI: 10.1038/s41598-021-82935-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/27/2021] [Indexed: 12/29/2022] Open
Abstract
We investigated the ability of time-warping-based ECG-derived markers of T-wave morphology changes in time ([Formula: see text]) and amplitude ([Formula: see text]), as well as their non-linear components ([Formula: see text] and [Formula: see text]), and the heart rate corrected counterpart ([Formula: see text]), to monitor potassium concentration ([Formula: see text]) changes ([Formula: see text]) in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD). We compared the performance of the proposed time-warping markers, together with other previously proposed [Formula: see text] markers, such as T-wave width ([Formula: see text]) and T-wave slope-to-amplitude ratio ([Formula: see text]), when computed from standard ECG leads as well as from principal component analysis (PCA)-based leads. 48-hour ECG recordings and a set of hourly-collected blood samples from 29 ESRD-HD patients were acquired. Values of [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text] and [Formula: see text] were calculated by comparing the morphology of the mean warped T-waves (MWTWs) derived at each hour along the HD with that from a reference MWTW, measured at the end of the HD. From the same MWTWs [Formula: see text] and [Formula: see text] were also extracted. Similarly, [Formula: see text] was calculated as the difference between the [Formula: see text] values at each hour and the [Formula: see text] reference level at the end of the HD session. We found that [Formula: see text] and [Formula: see text] showed higher correlation coefficients with [Formula: see text] than [Formula: see text]-Spearman's ([Formula: see text]) and Pearson's (r)-and [Formula: see text]-Spearman's ([Formula: see text])-in both SL and PCA approaches being the intra-patient median [Formula: see text] and [Formula: see text] in SL and [Formula: see text] and [Formula: see text] in PCA respectively. Our findings would point at [Formula: see text] and [Formula: see text] as the most suitable surrogate of [Formula: see text], suggesting that they could be potentially useful for non-invasive monitoring of ESRD-HD patients in hospital, as well as in ambulatory settings. Therefore, the tracking of T-wave morphology variations by means of time-warping analysis could improve continuous and remote [Formula: see text] monitoring of ESRD-HD patients and flagging risk of [Formula: see text]-related cardiovascular events.
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Affiliation(s)
- Flavio Palmieri
- Centre de Recerca en Enginyeria Biomèdica, Universitat Politècnica de Catalunya, Barcelona, Spain.
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain.
- Laboratorios Rubió, Castellbisbal, Barcelona, Spain.
| | - Pedro Gomis
- Centre de Recerca en Enginyeria Biomèdica, Universitat Politècnica de Catalunya, Barcelona, Spain
- Valencian International University, Valencia, Spain
| | | | - José Esteban Ruiz
- Nephrology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Beatriz Bergasa
- Nephrology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Alba Martín-Yebra
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Hassaan A Bukhari
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Esther Pueyo
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Juan Pablo Martínez
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Julia Ramírez
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pablo Laguna
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
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30
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Vareesangthip K, Yincharoen P, Winijkul A, Chanchairujira T. Cardiac arrhythmia during early-week and mid-week dialysis in hemodialysis patients. Ther Apher Dial 2021; 25:890-898. [PMID: 33470546 DOI: 10.1111/1744-9987.13622] [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: 10/15/2020] [Revised: 12/17/2020] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Abstract
Data on cardiac arrhythmia and electrolyte changes during the dialysis cycle have been limited. Fifty-two hemodialysis (HD) patients underwent 48-h Holter monitoring during early-week and mid-week HD sessions. Pre-HD and post-HD blood samples were collected in both HD sessions. The 48-h Holter data were divided into five phases: (1) 4-h during the early-week HD (HD1), (2) 12-h post-HD1, (3) 16-h period between Phases 2 and 4 (used as the patient's baseline electrocardiography [ECG]), (4) 12-h pre-HD2 phase, and (5) 4-h during the mid-week HD (HD2). The patients' mean age was 68.54 ± 13.37 years. We found that the dialysate-to-serum[K] gradient and changes of S[K] were significantly higher in HD1 than in HD2, as well as changes of S[Mg]. There were no significant ECG changes during the 4-h HD1 and HD2 when compared with the baseline ECG. Phase 2 of Holter ECG was the most common phase that showed significant changes (increased QT interval dispersion (QTD), increased ventricular events, increased number of premature ventricular contractions, ST elevation and ST depression), which was contributed from the dialysate[K] 2 mmol/L subgroup, but not the dialysate[K] 3 mmol/L subgroup. In the subgroup of patients with a high ultrafiltration rate (UFR; mean UFR ≥10 mL/kg/h), there were significantly increased ventricular events and ST-segment changes in Phase 2. In conclusion, ECG changes were associated with the dialysis cycle, significantly in the 12-h after early-week HD sessions. These may be associated with low dialysate[K] or high dialysate-to-S[K] gradient, high ultrafiltration rate and duration of the interdialytic interval.
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Affiliation(s)
- Kornchanok Vareesangthip
- Renal Division, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Picha Yincharoen
- Renal Division, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Arjbordin Winijkul
- Cardiology Division, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thawee Chanchairujira
- Renal Division, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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31
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Wouda RD, Vogt L, Hoorn EJ. Personalizing potassium management in patients on haemodialysis. Nephrol Dial Transplant 2021; 36:13-18. [PMID: 33089313 PMCID: PMC7771972 DOI: 10.1093/ndt/gfaa213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/27/2020] [Indexed: 12/29/2022] Open
Affiliation(s)
- Rosa D Wouda
- Department of Internal Medicine, Division of Nephrology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Division of Nephrology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
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32
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Timofte D, Tanasescu MD, Balcangiu-Stroescu AE, Balan DG, Tulin A, Stiru O, Vacaroiu IA, Mihai A, Constantin PC, Cosconel CI, Enyedi M, Miricescu D, Ionescu D. Dyselectrolytemia-management and implications in hemodialysis (Review). Exp Ther Med 2021; 21:102. [PMID: 33363613 PMCID: PMC7725007 DOI: 10.3892/etm.2020.9534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/11/2020] [Indexed: 12/27/2022] Open
Abstract
Hemodialysis is a method for the renal replacement therapy followed by series of acute and chronic complications. Dyselectrolytemia appears in patients undergoing dialysis through mechanisms related to the chronic kidney disease and/or to the dialysis therapy and for this group of patients it is associated with an increase of morbidity and mortality. The dialysate has a standard composition, which can be modified according to the patient's characteristics. During hemodialysis patients are exposed to 18,000-36.000 litres of water/year, and the water purity along with the biochemical composition of the dialysate are essential. The individualization of the dialysis prescription is recommended for each patient and it has an important role in preventing the occurrence of dyselectrolyemia. The individualization of the treatment prescription according to the blood constants of each patient is the prerogative of the nephrologist and the association of the electrolyte imbalances with the patients cardiovascular mortality explains the importance of paying special attention to them.
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Affiliation(s)
- Delia Timofte
- Department of Dialysis, Emergency University Hospital, 050098 Bucharest, Romania
| | - Maria-Daniela Tanasescu
- Department of Medical Semiology, Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Nephrology, Emergency University Hospital, 050098 Bucharest, Romania
| | - Andra-Elena Balcangiu-Stroescu
- Department of Dialysis, Emergency University Hospital, 050098 Bucharest, Romania
- Discipline of Physiology, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Daniela Gabriela Balan
- Discipline of Physiology, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Adrian Tulin
- Department of Anatomy, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of General Surgery, ‘Prof. Dr. Agrippa Ionescu’ Clinical Emergency Hospital, 011356 Bucharest, Romania
| | - Ovidiu Stiru
- Department of Cardiovascular Surgery, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Cardiovascular Surgery, ‘Prof. Dr. C.C. Iliescu’ Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Ileana Adela Vacaroiu
- Department of Nephrology and Dialysis, St. Ioan Emergency Clinical Hospital, 042122 Bucharest, Romania
- Department of Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Andrada Mihai
- Discipline of Diabetes, ‘Prof. N. Paulescu’ National Institute of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Second Department of Diabetes, ‘Prof. N. Paulescu’ National Institute of Diabetes, Nutrition and Metabolic Diseases, 020474 Bucharest, Romania
| | - Popa Cristian Constantin
- Department of Surgery, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Surgery, Emergency University Hospital, 050098 Bucharest, Romania
| | - Cristina-Ileana Cosconel
- Discipline of Foreign Languages, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihaly Enyedi
- Department of Anatomy, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Radiology, ‘Victor Babes’ Private Medical Clinic, 030303 Bucharest, Romania
| | - Daniela Miricescu
- Discipline of Biochemistry, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Dorin Ionescu
- Department of Medical Semiology, Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Nephrology, Emergency University Hospital, 050098 Bucharest, Romania
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Canaud B, Kooman JP, Selby NM, Taal MW, Francis S, Maierhofer A, Kopperschmidt P, Collins A, Kotanko P. Dialysis-Induced Cardiovascular and Multiorgan Morbidity. Kidney Int Rep 2020; 5:1856-1869. [PMID: 33163709 PMCID: PMC7609914 DOI: 10.1016/j.ekir.2020.08.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Hemodialysis has saved many lives, albeit with significant residual mortality. Although poor outcomes may reflect advanced age and comorbid conditions, hemodialysis per se may harm patients, contributing to morbidity and perhaps mortality. Systemic circulatory "stress" resulting from hemodialysis treatment schedule may act as a disease modifier, resulting in a multiorgan injury superimposed on preexistent comorbidities. New functional intradialytic imaging (i.e., echocardiography, cardiac magnetic resonance imaging [MRI]) and kinetic of specific cardiac biomarkers (i.e., Troponin I) have clearly documented this additional source of end-organ damage. In this context, several factors resulting from patient-hemodialysis interaction and/or patient management have been identified. Intradialytic hypovolemia, hypotensive episodes, hypoxemia, solutes, and electrolyte fluxes as well as cardiac arrhythmias are among the contributing factors to systemic circulatory stress that are induced by hemodialysis. Additionally, these factors contribute to patients' symptom burden, impair cognitive function, and finally have a negative impact on patients' perception and quality of life. In this review, we summarize the adverse systemic effects of current intermittent hemodialysis therapy, their pathophysiologic consequences, review the evidence for interventions that are cardioprotective, and explore new approaches that may further reduce the systemic burden of hemodialysis. These include improved biocompatible materials, smart dialysis machines that automatically may control the fluxes of solutes and electrolytes, volume and hemodynamic control, health trackers, and potentially disruptive technologies facilitating a more personalized medicine approach.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- GMO, FMC, Bad Homburg, Germany
| | - Jeroen P. Kooman
- Maastricht University Medical Centre, Department of Internal Medicine, Maastricht, Netherlands
| | - Nicholas M. Selby
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, UK
| | - Maarten W. Taal
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, UK
| | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK
| | | | | | | | - Peter Kotanko
- Renal Research Institute, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Varghese A, Lacson E, Sontrop JM, Acedillo RR, Al-Jaishi AA, Anderson S, Bagga A, Bain KL, Bennett LL, Bohm C, Brown PA, Chan CT, Cote B, Dev V, Field B, Harris C, Kalatharan S, Kiaii M, Molnar AO, Oliver MJ, Parmar MS, Schorr M, Shah N, Silver SA, Smith DM, Sood MM, St Louis I, Tennankore KK, Thompson S, Tonelli M, Vorster H, Waldvogel B, Zacharias J, Garg AX. A Higher Concentration of Dialysate Magnesium to Reduce the Frequency of Muscle Cramps: A Narrative Review. Can J Kidney Health Dis 2020; 7:2054358120964078. [PMID: 33149925 PMCID: PMC7585892 DOI: 10.1177/2054358120964078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/28/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose of review: Strategies to mitigate muscle cramps are a top research priority for patients receiving hemodialysis. As hypomagnesemia is a possible risk factor for cramping, we reviewed the literature to better understand the physiology of cramping as well as the epidemiology of hypomagnesemia and muscle cramps. We also sought to review the evidence from interventional studies on the effect of oral and dialysate magnesium-based therapies on muscle cramps. Sources of information: Peer-reviewed articles. Methods: We searched for relevant articles in major bibliographic databases including MEDLINE and EMBASE. The methodological quality of interventional studies was assessed using a modified version of the Downs and Blacks criteria checklist. Key findings: The etiology of muscle cramps in patients receiving hemodialysis is poorly understood and there are no clear evidence-based prevention or treatment strategies. Several factors may play a role including a low concentration of serum magnesium. The prevalence of hypomagnesemia (concentration of <0.7 mmol/L) in patients receiving hemodialysis ranges from 10% to 20%. Causes of hypomagnesemia include a low dietary intake of magnesium, use of medications that inhibit magnesium absorption (eg, proton pump inhibitors), increased magnesium excretion (eg, high-dose loop diuretics), and a low concentration of dialysate magnesium. Dialysate magnesium concentrations of ≤0.5 mmol/L may be associated with a decrease in serum magnesium concentration over time. Preliminary evidence from observational and interventional studies suggests a higher dialysate magnesium concentration will raise serum magnesium concentrations and may reduce the frequency and severity of muscle cramps. However, the quality of evidence supporting this benefit is limited, and larger, multicenter clinical trials are needed to further determine if magnesium-based therapy can reduce muscle cramps in patients receiving hemodialysis. In studies conducted to date, increasing the concentration of dialysate magnesium appears to be well-tolerated and is associated with a low risk of symptomatic hypermagnesemia. Limitations: Few interventional studies have examined the effect of magnesium-based therapy on muscle cramps in patients receiving hemodialysis and most were nonrandomized, pre-post study designs.
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Affiliation(s)
- Akshay Varghese
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Eduardo Lacson
- Division of Nephrology, Tufts University School of Medicine, Boston, MA, USA
| | - Jessica M Sontrop
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Rey R Acedillo
- Department of Medicine, Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
| | - Ahmed A Al-Jaishi
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Sierra Anderson
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Amit Bagga
- Division of Nephrology, Department of Medicine, Windsor Regional Hospital, ON, Canada
| | - Katie L Bain
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | | | - Clara Bohm
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Pierre A Brown
- Department of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Christopher T Chan
- Division of Nephrology, University Health Network, University of Toronto, ON, Canada
| | - Brenden Cote
- Patient Partner, London Health Sciences Centre, London, ON, Canada
| | - Varun Dev
- Department of Nephrology, Humber River Hospital, Toronto, ON, Canada
| | - Bonnie Field
- Patient Partner, Patient and Family Advisory Council, London Health Sciences Centre, London, ON, Canada
| | - Claire Harris
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | | | - Mercedeh Kiaii
- Division of Nephrology, Department of Medicine, St Paul's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Malvinder S Parmar
- Department of Medicine, Timmins & District Hospital, Timmins, ON, Canada
| | - Melissa Schorr
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Nikhil Shah
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Samuel A Silver
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - D Michael Smith
- Patient Partner, Patient and Family Advisory Council, London Health Sciences Centre, London, ON, Canada
| | - Manish M Sood
- Department of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Irina St Louis
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Karthik K Tennankore
- Division of Nephrology, Department of Medicine, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Stephanie Thompson
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marcello Tonelli
- Division of Nephrology, Department of Medicine, Health Sciences Centre, University of Calgary, Calgary, AB, Canada
| | | | - Blair Waldvogel
- Patient Partner, Home Hemodialysis Department, Health Sciences Centre, Winnipeg, MB, Canada
| | - James Zacharias
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London, ON, Canada.,ICES Western, London, ON, Canada
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Schüttler D, Schönermarck U, Wenner F, Toepfer M, Rizas KD, Bauer A, Brunner S, Hamm W. Large potassium shifts during dialysis enhance cardiac repolarization instability. J Nephrol 2020; 34:1301-1305. [PMID: 33058038 PMCID: PMC8357640 DOI: 10.1007/s40620-020-00880-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/27/2020] [Indexed: 12/01/2022]
Abstract
Background Patients with end-stage kidney disease are at high risk for the development of arrhythmias and sudden cardiac death (SCD). This has been especially attributed to large potassium shifts during hemodialysis (HD), and malignant arrhythmias are closely linked to dysfunction of the autonomic nervous system. Nevertheless, there is still a lack of methods for risk stratification in these patients. Methods In the present pilot study we investigated changes of the novel ECG-based biomarker periodic repolarization dynamics (PRD) mirroring the effect of efferent sympathetic nervous activity on the ventricular myocardium in 18 patients undergoing routine hemodialysis. High-resolution ECGs were recorded throughout the dialysis and PRD values were calculated out of 30 min intervals at the start and the end of dialysis. Results We detected a clear correlation between the intradialytic potassium shift and the increase in PRD levels (Spearman correlation coefficient R = 0.62, p = 0.006). Patients with a potassium shift > 1 mmol/l showed significantly increased levels of PRD at the end of dialysis when compared to patients with potassium shifts ≤ 1.0 mmol/l [delta PRD 2.82 (IQR 2.13) vs. − 2.08 (IQR 3.60), p = 0.006]. Spearman analysis showed no significant correlation between PRD changes and fluid removal (R = − 0.23, p = 0.36). Conclusions We provide evidence that large potassium shifts during HD enhance sympathetic activity-associated repolarization instability. This could facilitate the occurrence of malignant arrhythmias, and PRD measurements might serve as a non-invasive monitoring tool in HD patients in future.
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Affiliation(s)
- Dominik Schüttler
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany. .,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany. .,Walter Brendel Centre of Experimental Medicine, Ludwig-Maximilians University Munich (LMU), Munich, Germany.
| | - Ulf Schönermarck
- Nephrology Division, Medizinische Klinik Und Poliklinik IV, Klinikum der Universität München - Campus Großhadern, Munich, Germany
| | - Felix Wenner
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany
| | | | - Konstantinos D Rizas
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany
| | - Axel Bauer
- DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany.,University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Stefan Brunner
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany
| | - Wolfgang Hamm
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany
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36
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Pietribiasi M, Waniewski J, Załuska W, Wójcik-Załuska A, Leypoldt JK. Comparison of two single-solute models of potassium kinetics during hemodialysis. Biocybern Biomed Eng 2020. [DOI: 10.1016/j.bbe.2020.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Mc Causland FR, Tumlin JA, Roy-Chaudhury P, Koplan BA, Costea AI, Kher V, Williamson D, Pokhariyal S, Charytan DM. Intradialytic Hypotension and Cardiac Arrhythmias in Patients Undergoing Maintenance Hemodialysis: Results from the Monitoring in Dialysis Study. Clin J Am Soc Nephrol 2020; 15:805-812. [PMID: 32381584 PMCID: PMC7274298 DOI: 10.2215/cjn.06810619] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 02/27/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients receiving maintenance hemodialysis (HD) have a high incidence of cardiac events, including arrhythmia and sudden death. Intradialytic hypotension (IDH) is a common complication of HD and is associated with development of reduced myocardial perfusion, a potential risk factor for arrhythmia. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We analyzed data from the Monitoring in Dialysis study, which used implantable loop recorders to detect and continuously monitor electrocardiographic data from patients on maintenance HD (n=66 from the United States and India) over a 6-month period (n=4720 sessions). Negative binomial mixed effects regression was used to test the association of IDH20 (decline in systolic BP >20 mm Hg from predialysis systolic BP) and IDH0-20 (decline in systolic BP 0-20 mm Hg from predialysis systolic BP) with clinically significant arrhythmia (bradycardia≤40 bpm for ≥6 seconds, asystole≥3 seconds, ventricular tachycardia ≥130 bpm for ≥30 seconds, or patient-marked events) during HD. RESULTS The median age of participants was 58 (25th-75th percentile, 49-66) years; 70% were male; and 65% were from the United States. IDH occurred in 2251 (48%) of the 4720 HD sessions analyzed, whereas IDH0-20 occurred during 1773 sessions (38%). The number of sessions complicated by least one intradialytic clinically significant arrhythmia was 27 (1.2%) where IDH20 occurred and 15 (0.8%) where IDH0-20 occurred. Participants who experienced IDH20 (versus not) had a nine-fold greater rate of developing an intradialytic clinically significant arrhythmia (incidence rate ratio, 9.4; 95% confidence interval, 3.0 to 29.4), whereas IDH0-20 was associated with a seven-fold higher rate (incidence rate ratio, 7.2; 95% confidence interval, 2.1 to 25.4). CONCLUSIONS IDH is common in patients on maintenance HD and is associated with a greater risk of developing intradialytic clinically significant arrhythmia.
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Affiliation(s)
- Finnian R Mc Causland
- Renal Division and Brigham and Women's Hospital, Boston, Massachusetts .,Harvard Medical School, Boston, Massachusetts
| | - Jim A Tumlin
- NephroNet Clinical Research Consortium, Atlanta, Georgia
| | - Prabir Roy-Chaudhury
- UNC Kidney Center, Chapel Hill, North Carolina.,WG (Bill) Hefner VA Medical Center, Salisbury, North Carolina
| | - Bruce A Koplan
- Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Vijay Kher
- Medanta Kidney and Urology Institute, Medanta, India
| | - Don Williamson
- Southeastern Clinical Research Institute, Augusta, Georgia
| | | | - David M Charytan
- New York University School of Medicine and NYU Langone Medical Center, New York, New York
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38
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Increasing the Magnesium Concentration in Various Dialysate Solutions Differentially Modulates Oxidative Stress in a Human Monocyte Cell Line. Antioxidants (Basel) 2020; 9:antiox9040319. [PMID: 32326605 PMCID: PMC7222382 DOI: 10.3390/antiox9040319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/01/2020] [Accepted: 04/14/2020] [Indexed: 12/14/2022] Open
Abstract
Oxidative stress is exacerbated in hemodialysis patients by several factors, including the uremic environment and the use of dialysis fluids (DFs). Since magnesium (Mg) plays a key role in modulating immune function and in reducing oxidative stress, we aimed to evaluate whether increasing the Mg concentration in different DFs could protect against oxidative stress in immunocompetent cells in vitro. Effect of ADF (acetate 3 mM), CDF (citrate 1 mM), and ACDF (citrate 0.8 mM + acetate 0.3 mM) dialysates with Mg at standard (0.5 mM) or higher (1, 1.25, and 2 mM) concentrations were assessed in THP-1 monocyte cultures. Reactive oxygen species (ROS) and malondialdehyde (MDA) levels were quantified under basal and uremic conditions (indoxyl sulfate (IS) treatment). Under uremic conditions, the three DFs with 0.5 mM Mg promoted higher ROS production and lipid damage than the control solution. However, CDF and ACDF induced lower levels of ROS and MDA, compared to that induced by ADF. High Mg concentration (1.25 and/or 2 mM) in CDF and ACDF protected against oxidative stress, indicated by reduced ROS and MDA levels compared to respective DFs with standard concentration of Mg. Increasing Mg concentrations in ADF promoted high ROS production and MDA content. Thus, an increase in Mg content in DFs has differential effects on the oxidative stress in IS-treated THP-1 cells depending on the dialysate used.
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Canaud B, Collins A, Maddux F. The renal replacement therapy landscape in 2030: reducing the global cardiovascular burden in dialysis patients. Nephrol Dial Transplant 2020; 35:ii51-ii57. [PMID: 32162663 PMCID: PMC7066547 DOI: 10.1093/ndt/gfaa005] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Indexed: 12/15/2022] Open
Abstract
Despite the significant progress made in understanding chronic kidney disease and uraemic pathophysiology, use of advanced technology and implementation of new strategies in renal replacement therapy, the clinical outcomes of chronic kidney disease 5 dialysis patients remain suboptimal. Considering residual suboptimal medical needs of short intermittent dialysis, it is our medical duty to revisit standards of dialysis practice and propose new therapeutic options for improving the overall effectiveness of dialysis sessions and reduce the burden of stress induced by the therapy. Several themes arise to address the modifiable components of the therapy that are aimed at mitigating some of the cardiovascular risks in patients with end-stage kidney disease. Among them, five are of utmost importance and include: (i) enhancement of treatment efficiency and continuous monitoring of dialysis performances; (ii) prevention of dialysis-induced stress; (iii) precise handling of sodium and fluid balance; (iv) moving towards heparin-free dialysis; and (v) customizing electrolyte prescriptions. In summary, haemodialysis treatment in 2030 will be substantially more personalized to the patient, with a clear focus on cardioprotection, volume management, arrhythmia surveillance, avoidance of anticoagulation and the development of more dynamic systems to align the fluid and electrolyte needs of the patient on the day of the treatment to their particular circumstances.
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Affiliation(s)
- Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
- School of Medicine, Montpellier University, Montpellier, France
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | - Frank Maddux
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
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40
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Bansal S, Pergola PE. Current Management of Hyperkalemia in Patients on Dialysis. Kidney Int Rep 2020; 5:779-789. [PMID: 32518860 PMCID: PMC7270720 DOI: 10.1016/j.ekir.2020.02.1028] [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: 12/04/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with end-stage renal disease (ESRD) on maintenance dialysis have a high risk of developing hyperkalemia, generally defined as serum potassium (K+) concentrations of >5.0 mmol/l, particularly those undergoing maintenance hemodialysis. Currently, the key approaches to the management of hyperkalemia in patients with ESRD are dialysis, dietary K+ restriction, and avoidance of medications that increase hyperkalemia risk. In this review, we highlight the issues and challenges associated with effective management of hyperkalemia in patients undergoing maintenance dialysis using an illustrative case presentation. In addition, we examine the potential nondialysis options for the management of these patients, including use of the newer K+ binder agents patiromer and sodium zirconium cyclosilicate, which may reduce the need for the highly restrictive dialysis diet, with its own implication on nutritional status in patients with ESRD, as well as reducing the risk of potentially life-threatening hyperkalemia.
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Affiliation(s)
- Shweta Bansal
- Division of Nephrology, UT Health at San Antonio, San Antonio, Texas, USA
| | - Pablo E Pergola
- Division of Nephrology, UT Health at San Antonio, San Antonio, Texas, USA.,Renal Associates, P.A., San Antonio, Texas, USA
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41
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Palmer BF. Potassium Binders for Hyperkalemia in Chronic Kidney Disease-Diet, Renin-Angiotensin-Aldosterone System Inhibitor Therapy, and Hemodialysis. Mayo Clin Proc 2020; 95:339-354. [PMID: 31668450 DOI: 10.1016/j.mayocp.2019.05.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/14/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023]
Abstract
Hyperkalemia is a potentially life-threatening complication of chronic kidney disease (CKD). The management of CKD requires balancing the benefits of specific treatments, which may exacerbate the potential for hyperkalemia, with the risks of hyperkalemia itself. Renin-angiotensin-aldosterone system (RAAS) inhibitors, which slow CKD progression and improve cardiovascular outcomes, are often discontinued if hyperkalemia develops. Patients with hyperkalemia are frequently advised to restrict dietary potassium (K+), depriving these patients of many heart-healthy foods. Patients receiving hemodialysis are particularly susceptible to hyperkalemia during long interdialytic intervals, and managing this risk without causing hypokalemia can be challenging. Recently, 2 K+-binding agents were approved for the treatment of hyperkalemia: sodium zirconium cyclosilicate and patiromer. These agents offer alternatives to sodium polystyrene sulfonate, which is associated with serious gastrointestinal adverse effects. For this review, PubMed was searched for English-language articles published in 2014-2018 using the terms patiromer, sodium zirconium cyclosilicate, sodium polystyrene sulfonate, hyperkalemia, renin-angiotensin-aldosterone, diet, and dialysis. In randomized controlled studies of patients with hyperkalemia, sodium zirconium cyclosilicate and patiromer effectively reduced serum K+ and were generally well tolerated. Furthermore, patients in these studies could maintain RAAS inhibitor therapy and, in some studies, were not required to limit dietary K+. There may also be a role for these agents in preventing hyperkalemia in patients receiving hemodialysis. Thus, K+-binding agents may allow patients with CKD at risk for hyperkalemia to optimize RAAS inhibitor therapy, receive benefits of a K+-rich diet, and experience improved hemodialysis outcomes. Additional long-term studies are necessary to confirm these effects.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
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42
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Association between Blood Potassium Level and Recovery of Postoperative Gastrointestinal Motility during Continuous Renal Replacement Therapy in Patient Undergoing Open Abdominal Surgery. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6392751. [PMID: 31355273 PMCID: PMC6634123 DOI: 10.1155/2019/6392751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/04/2019] [Accepted: 06/16/2019] [Indexed: 11/18/2022]
Abstract
Background The aim of this study was to identify the blood potassium level beneficial to the postoperative recovery of gastrointestinal motility during continuous renal replacement therapy (CRRT) in patient undergoing open abdominal surgery. Materials and Methods 538 critically ill patients after open abdominal surgery and receiving CRRT were retrospectively recruited as the study cohort. Demographic and clinical data were recorded along with an evaluation of the postoperative gastrointestinal motility. Results Correlation analysis was used to assess the correlation coefficient, and then the variables with correlation coefficient value less than 0.5 were included in the binary logistic regression model. Binary logistic regression model indicated that the postoperative blood potassium level was independently associated with the recovery of gastrointestinal motility (OR=0.109, 95% CI= 0.063 to 0.190, p<0.001). Based on the normal range of blood potassium level, we selected the cut-off point of blood potassium level via Weight of Evidence analysis, which was 4.00 mmol/L. Compared with the patients with insufficient blood potassium levels (plasma potassium concentration < 4.00 mmol/L), those with sufficient blood potassium levels (plasma potassium concentration≥ 4.00 mmol/L) conferred an increase in the rate of 4-day postoperative recovery of gastrointestinal motility (OR= 4.425, 95% CI = 2.933 to 6.667, p<0.001). Conclusions Maintaining the blood potassium concentrations at a relatively high level of the normal blood potassium range during CRRT would be beneficial to postoperative recovery of gastrointestinal motility.
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Abstract
In the United States, end-stage renal disease patients receiving hemodialysis have an exceedingly high risk of sudden cardiac death (SCD), accounting for 29% of death events, likely relating to their uremic milieu, recurring exposure to fluid and electrolyte fluxes, and underlying cardiovascular pathology. Furthermore, epidemiologic studies have shown that SCD events, as well as mortality and hospitalizations, occur most frequently on the first dialysis day after the long interdialytic gap, suggesting that abrupt fluctuations in the accumulation and removal of electrolytes, fluid, and uremic toxins over the dialysis cycle may be contributory. Some population-based observational studies have suggested that lower dialysate potassium concentrations appear to be associated with a heightened risk of postdialysis cardiac arrest in hemodialysis patients, although the optimal serum-to-dialysate potassium gradient remains unclear. Some observational studies have suggested that low dialysate calcium concentrations and high serum-to-dialysate calcium gradients may predispose patients to SCD. There is ongoing controversy about an association between higher dialysate bicarbonate concentrations and higher risk of cardiac arrest, likely owing to confounding by indication. Some observational studies also have shown that large interdialytic weight gains, fluid retention, and high ultrafiltration rates are linked with higher risk of SCD and mortality. However, there remains considerable controversy regarding the pros and cons of designating a specific upper ultrafiltration limit with extended treatment times as a clinical practice measure, and further studies are needed to define the optimal tools, metrics, targets, and implementation measures for volume control in the hemodialysis population. In this review, we highlight the epidemiology and pathophysiology of how specific aspects of the hemodialysis procedure may relate to the risk of SCD, as well as preventative strategies and future research directions that can address this risk.
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Abstract
Chronic kidney disease mineral and bone disorder (MBD) encompasses changes in mineral ion and vitamin D metabolism that are widespread in the setting of chronic kidney disease and end-stage renal disease. MBD components associate with cardiovascular disease in many epidemiologic studies. Through impacts on hypertension, activation of the renin-angiotensin-aldosterone system, vascular calcification, endothelial function, and cardiac remodeling and conduction, MBD may be a direct and targetable cause of cardiovascular disease. However, assessment and treatment of MBD is rife with challenges owing to biological tensions between its many components, such as calcium and phosphorus with their regulatory hormones fibroblast growth factor 23 and parathyroid hormone; fibroblast growth factor 23 with its co-receptor klotho; and vitamin D with control of calcium and phosphorus. These complex interactions between MBD components hinder the simple translation to clinical trials, which ultimately are needed to prove the benefits of treating MBD. Deeper investigation using precision medicine tools and principles, including genomics and individualized risk assessment and therapy, may help move the field closer toward clinical applications. This review provides a high-level overview of conventional and precision epidemiology in MBD, potential mechanisms of cardiovascular disease pathogenesis, and guiding therapeutic principles for established and emerging treatments.
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Affiliation(s)
- Joseph Lunyera
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC.
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Affiliation(s)
- Jürgen Floege
- Division of Nephrology, Medizinische Klinik II, RWTH University Hospital Aachen, Aachen, Germany
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46
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Edmonston D, Morris JD, Middleton JP. Working Toward an Improved Understanding of Chronic Cardiorenal Syndrome Type 4. Adv Chronic Kidney Dis 2018; 25:454-467. [PMID: 30309463 DOI: 10.1053/j.ackd.2018.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/09/2018] [Accepted: 08/15/2018] [Indexed: 12/17/2022]
Abstract
Chronic diseases of the heart and of the kidneys commonly coexist in individuals. Certainly combined and persistent heart and kidney failure can arise from a common pathologic insult, for example, as a consequence of poorly controlled hypertension or of severe diffuse arterial disease. However, strong evidence is emerging to suggest that cross talk exists between the heart and the kidney. Independent processes are set in motion when kidney function is chronically diminished, and these processes can have distinct adverse effects on the heart. The complex chronic heart condition that results from chronic kidney disease (CKD) has been termed cardiorenal syndrome type 4. This review will include an updated description of the cardiac morphology in patients who have CKD, an overview of the most likely CKD-sourced culprits for these cardiac changes, and the potential therapeutic strategies to limit cardiac complications in patients who have CKD.
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Pun PH. Dialysate potassium concentration: Should mass balance trump electrophysiology? Semin Dial 2018; 31:569-575. [PMID: 30027592 DOI: 10.1111/sdi.12738] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Nephrologists are faced with a difficult dilemma in choosing the ideal dialysis prescription to maintain neutral potassium mass balance. Should potassium mass balance goals prioritize the normalization of serum potassium levels using low potassium dialysate at the expense of provoking intradialytic arrhythmias, or should mass balance goals favor permissive hyperkalemia using higher dialysate potassium to avoid rapid intradialytic fluxes at the risk of more interdialytic arrhythmias? This review examines the factors that determine potassium mass balance among HD patients, the relationships between serum and dialysate potassium levels and outcomes, and concludes by examining currently available approaches to reducing risk of arrhythmias while managing potassium mass balance.
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Affiliation(s)
- Patrick H Pun
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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Ferrey A, You AS, Kovesdy CP, Nakata T, Veliz M, Nguyen DV, Kalantar-Zadeh K, Rhee CM. Dialysate Potassium and Mortality in a Prospective Hemodialysis Cohort. Am J Nephrol 2018; 47:415-423. [PMID: 29879714 DOI: 10.1159/000489961] [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: 01/15/2018] [Accepted: 05/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studies examining the association of dialysate potassium concentration and mortality in hemodialysis patients show conflicting findings. We hypothesized that low dialysate potassium concentrations are associated with higher mortality, particularly in patients with high pre-dialysis serum potassium concentrations. METHODS We evaluated 624 hemodialysis patients from the prospective Malnutrition, Diet, and Racial Disparities in Kidney Disease study recruited from 16 outpatient dialysis facilities over 2011-2015 who underwent protocolized collection of dialysis treatment characteristics every 6 months. We examined the association of dialysate potassium concentration, categorized as 1, 2, and 3 mEq/L, with all-cause mortality risk in the -overall cohort, and stratified by pre-dialysis serum potassium (< 5 vs. ≥5 mEq/L) using case-mix adjusted Cox models. RESULTS In baseline analyses, dialysate potassium concentrations of 1 mEq/L were associated with higher mortality, whereas concentrations of 3 mEq/L were associated with similar mortality in the overall cohort (reference: 2 mEq/L): adjusted hazard ratios (aHRs; 95% CI) 1.70 (1.01-2.88) and 0.95 (0.64-1.39), respectively. In analyses stratified by serum potassium, baseline dialysate potassium concentrations of 1 mEq/L were associated with higher mortality in patients with serum potassium ≥5 mEq/L but not in those with serum potassium < 5 mEq/L: aHRs (95% CI) 2.87 (1.51-5.46) and 0.74 (0.27-2.07), respectively (p interaction = 0.04). These findings were robust with incremental adjustment for serum potassium, potassium-binding resins, and potassium-modifying medications. CONCLUSION Low (1 mEq/L) dialysate potassium -concentrations were associated with higher mortality, particularly in hemodialysis patients with high pre-dialysis serum potassium. Further studies are needed to identify therapeutic strategies that mitigate inter-dialytic serum potassium accumulation and subsequent high dialysate serum potassium gradients in this population.
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Affiliation(s)
- Antoney Ferrey
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Amy S You
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Tracy Nakata
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Mary Veliz
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Danh V Nguyen
- Department of General Internal Medicine, 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, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
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