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Obi Y, Raimann JG, Kalantar-Zadeh K, Murea M. Residual Kidney Function in Hemodialysis: Its Importance and Contribution to Improved Patient Outcomes. Toxins (Basel) 2024; 16:298. [PMID: 39057938 PMCID: PMC11281084 DOI: 10.3390/toxins16070298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/27/2024] [Accepted: 06/11/2024] [Indexed: 07/28/2024] Open
Abstract
Individuals afflicted with advanced kidney dysfunction who require dialysis for medical management exhibit different degrees of native kidney function, called residual kidney function (RKF), ranging from nil to appreciable levels. The primary focus of this manuscript is to delve into the concept of RKF, a pivotal yet under-represented topic in nephrology. To begin, we unpack the definition and intrinsic nature of RKF. We then juxtapose the efficiency of RKF against that of hemodialysis in preserving homeostatic equilibrium and facilitating physiological functions. Given the complex interplay of RKF and overall patient health, we shed light on the extent of its influence on patient outcomes, particularly in those living with advanced kidney dysfunction and on dialysis. This manuscript subsequently presents methodologies and measures to assess RKF, concluding with the potential benefits of targeted interventions aimed at preserving RKF.
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Affiliation(s)
- Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, The University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Jochen G. Raimann
- Renal Research Institute, New York, NY 10065, USA;
- Katz School of Science and Health, Yeshiva University, New York, NY 10033, USA
| | - Kamyar Kalantar-Zadeh
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA;
- The Lundquist Institute at Harbor, UCLA Medical Center, Torrance, CA 90502, USA
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
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Ethier I, Hayat A, Pei J, Hawley CM, Johnson DW, Francis RS, Wong G, Craig JC, Viecelli AK, Htay H, Ng S, Leibowitz S, Cho Y. Peritoneal dialysis versus haemodialysis for people commencing dialysis. Cochrane Database Syst Rev 2024; 6:CD013800. [PMID: 38899545 PMCID: PMC11187793 DOI: 10.1002/14651858.cd013800.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Peritoneal dialysis (PD) and haemodialysis (HD) are two possible modalities for people with kidney failure commencing dialysis. Only a few randomised controlled trials (RCTs) have evaluated PD versus HD. The benefits and harms of the two modalities remain uncertain. This review includes both RCTs and non-randomised studies of interventions (NRSIs). OBJECTIVES To evaluate the benefits and harms of PD, compared to HD, in people with kidney failure initiating dialysis. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies from 2000 to June 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. MEDLINE and EMBASE were searched for NRSIs from 2000 until 28 March 2023. SELECTION CRITERIA RCTs and NRSIs evaluating PD compared to HD in people initiating dialysis were eligible. DATA COLLECTION AND ANALYSIS Two investigators independently assessed if the studies were eligible and then extracted data. Risk of bias was assessed using standard Cochrane methods, and relevant outcomes were extracted for each report. The primary outcome was residual kidney function (RKF). Secondary outcomes included all-cause, cardiovascular and infection-related death, infection, cardiovascular disease, hospitalisation, technique survival, life participation and fatigue. MAIN RESULTS A total of 153 reports of 84 studies (2 RCTs, 82 NRSIs) were included. Studies varied widely in design (small single-centre studies to international registry analyses) and in the included populations (broad inclusion criteria versus restricted to more specific participants). Additionally, treatment delivery (e.g. automated versus continuous ambulatory PD, HD with catheter versus arteriovenous fistula or graft, in-centre versus home HD) and duration of follow-up varied widely. The two included RCTs were deemed to be at high risk of bias in terms of blinding participants and personnel and blinding outcome assessment for outcomes pertaining to quality of life. However, most other criteria were assessed as low risk of bias for both studies. Although the risk of bias (Newcastle-Ottawa Scale) was generally low for most NRSIs, studies were at risk of selection bias and residual confounding due to the constraints of the observational study design. In children, there may be little or no difference between HD and PD on all-cause death (6 studies, 5752 participants: RR 0.81, 95% CI 0.62 to 1.07; I2 = 28%; low certainty) and cardiovascular death (3 studies, 7073 participants: RR 1.23, 95% CI 0.58 to 2.59; I2 = 29%; low certainty), and was unclear for infection-related death (4 studies, 7451 participants: RR 0.98, 95% CI 0.39 to 2.46; I2 = 56%; very low certainty). In adults, compared with HD, PD had an uncertain effect on RKF (mL/min/1.73 m2) at six months (2 studies, 146 participants: MD 0.90, 95% CI 0.23 to 3.60; I2 = 82%; very low certainty), 12 months (3 studies, 606 participants: MD 1.21, 95% CI -0.01 to 2.43; I2 = 81%; very low certainty) and 24 months (3 studies, 334 participants: MD 0.71, 95% CI -0.02 to 1.48; I2 = 72%; very low certainty). PD had uncertain effects on residual urine volume at 12 months (3 studies, 253 participants: MD 344.10 mL/day, 95% CI 168.70 to 519.49; I2 = 69%; very low certainty). PD may reduce the risk of RKF loss (3 studies, 2834 participants: RR 0.55, 95% CI 0.44 to 0.68; I2 = 17%; low certainty). Compared with HD, PD had uncertain effects on all-cause death (42 studies, 700,093 participants: RR 0.87, 95% CI 0.77 to 0.98; I2 = 99%; very low certainty). In an analysis restricted to RCTs, PD may reduce the risk of all-cause death (2 studies, 1120 participants: RR 0.53, 95% CI 0.32 to 0.86; I2 = 0%; moderate certainty). PD had uncertain effects on both cardiovascular (21 studies, 68,492 participants: RR 0.96, 95% CI 0.78 to 1.19; I2 = 92%) and infection-related death (17 studies, 116,333 participants: RR 0.90, 95% CI 0.57 to 1.42; I2 = 98%) (both very low certainty). Compared with HD, PD had uncertain effects on the number of patients experiencing bacteraemia/bloodstream infection (2 studies, 2582 participants: RR 0.34, 95% CI 0.10 to 1.18; I2 = 68%) and the number of patients experiencing infection episodes (3 studies, 277 participants: RR 1.23, 95% CI 0.93 to 1.62; I2 = 20%) (both very low certainty). PD may reduce the number of bacteraemia/bloodstream infection episodes (2 studies, 2637 participants: RR 0.44, 95% CI 0.27 to 0.71; I2 = 24%; low certainty). Compared with HD; It is uncertain whether PD reduces the risk of acute myocardial infarction (4 studies, 110,850 participants: RR 0.90, 95% CI 0.74 to 1.10; I2 = 55%), coronary artery disease (3 studies, 5826 participants: RR 0.95, 95% CI 0.46 to 1.97; I2 = 62%); ischaemic heart disease (2 studies, 58,374 participants: RR 0.86, 95% CI 0.57 to 1.28; I2 = 95%), congestive heart failure (3 studies, 49,511 participants: RR 1.10, 95% CI 0.54 to 2.21; I2 = 89%) and stroke (4 studies, 102,542 participants: RR 0.94, 95% CI 0.90 to 0.99; I2 = 0%) because of low to very low certainty evidence. Compared with HD, PD had uncertain effects on the number of patients experiencing hospitalisation (4 studies, 3282 participants: RR 0.90, 95% CI 0.62 to 1.30; I2 = 97%) and all-cause hospitalisation events (4 studies, 42,582 participants: RR 1.02, 95% CI 0.81 to 1.29; I2 = 91%) (very low certainty). None of the included studies reported specifically on life participation or fatigue. However, two studies evaluated employment. Compared with HD, PD had uncertain effects on employment at one year (2 studies, 593 participants: RR 0.83, 95% CI 0.20 to 3.43; I2 = 97%; very low certainty). AUTHORS' CONCLUSIONS The comparative effectiveness of PD and HD on the preservation of RKF, all-cause and cause-specific death risk, the incidence of bacteraemia, other vascular complications (e.g. stroke, cardiovascular events) and patient-reported outcomes (e.g. life participation and fatigue) are uncertain, based on data obtained mostly from NRSIs, as only two RCTs were included.
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Affiliation(s)
- Isabelle Ethier
- Department of Nephrology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Health innovation and evaluation hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Ashik Hayat
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Juan Pei
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Ross S Francis
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Germaine Wong
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Htay Htay
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Samantha Ng
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Saskia Leibowitz
- Department of Nephrology, Logan Hospital, Meadowbrook, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
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Butt U, Davenport A, Sridharan S, Farrington K, Vilar E. A practical approach to implementing incremental haemodialysis. J Nephrol 2024:10.1007/s40620-024-01939-2. [PMID: 38763995 DOI: 10.1007/s40620-024-01939-2] [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: 01/03/2024] [Accepted: 03/24/2024] [Indexed: 05/21/2024]
Abstract
The majority of end-stage kidney disease patients are treated with haemodialysis (HD). Starting HD can pose physical, social, and psychological challenges to patients, and mortality rates within the first 6 months are disproportionately high, with intensive HD regimens implicated as a potential factor. Starting HD with an incremental approach, taking residual kidney function (RKF) into account, potentially allows for a gentle start with reduced dialysis intensity. Dialysis intensity (session time or frequency) can then be proportionally increased as RKF reduces. This approach to starting HD has been reported in observational studies to result in better patient self-reported health quality of life and reduced costs, and now several definitive randomised controlled trials are underway comparing an incremental approach to the conventional thrice weekly paradigm. Physician concerns over the risk of inadequate dialysis, with consequent increased emergency admissions, and practical challenges of how to estimate RKF and implement incremental dialysis have impeded widespread adoption. Addressing these challenges is paramount to increasing the uptake of incremental HD. Careful patient selection lies at the heart of a successful incremental HD programme. Generally, patients with a residual urea clearance of > 3 ml/min/1.73 m2 can be considered suitable for starting with incremental HD provided they comply with fluid intake, salt and other dietary recommendations. Calculating RKF from regular interdialytic urine collections and appropriately adjusting sessional HD clearance targets are practical and conceptual challenges. In this report we aim to disentangle these complexities and provide a step-by-step guide for patient selection and adjusting dialysis sessional targets.
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Affiliation(s)
- Usama Butt
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK.
| | - A Davenport
- Royal Free Hospital, Royal Free London Foundation Trust, London, UK
- University College London, London, UK
| | - S Sridharan
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
| | - K Farrington
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
| | - E Vilar
- Renal Unit, Lister Hospital, East and North Herts NHS Trust, Hertfordshire, SG1 4AB, UK
- University of Hertfordshire, Hatfield, UK
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Samaan E, Nagah M, El Said G. Phosphate kinetic modeling as an estimate of daily ingested phosphate in hemodialysis patients with or without residual kidney function. Ther Apher Dial 2024; 28:42-50. [PMID: 37641162 DOI: 10.1111/1744-9987.14061] [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: 03/03/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND AND AIM Daugirdas suggested a 2-pool phosphate kinetic model based on his previously established urea kinetic model. The current study aims to assess the level of agreement between the modeled daily ingested phosphorus (DIP) values and the routine method of dietary recall calculations in hemodialysis patients. METHOD The study was conducted on 100 hemodialysis patients; 50 were anuric, and the others had residual kidney function (RKF). The level of correlation and agreement between the dietary calculated and modeled DIP were assessed in both study groups. RESULTS A statistically significant positive correlation existed between the calculated and modeled DIP (r = 0.79 for the anuric group, r = 0.84 for the RKF group, p < 0.001). There was a significant level of agreement between calculated and modeled DIP in RKF patients only. CONCLUSION These findings suggest that phosphate modeling can estimate phosphate intake in RKF patients and be cost-effective in their management.
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Affiliation(s)
- Emad Samaan
- Mansoura Nephrology and Dialysis Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohammed Nagah
- Hemodialysis Unit, Sherbin Central Hospital, Dakahlia, Egypt
| | - Ghada El Said
- Mansoura Nephrology and Dialysis Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Medaura JA, Zhou M, Ficociello LH, Anger MS, Sprague SM. Serum Phosphorus Management with Sucroferric Oxyhydroxide as a First-Line Phosphate Binder within the First Year of Hemodialysis. Am J Nephrol 2023; 55:127-135. [PMID: 38091973 PMCID: PMC10994597 DOI: 10.1159/000535754] [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: 10/06/2023] [Accepted: 12/03/2023] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Sucroferric oxyhydroxide (SO), a non-calcium, chewable, iron-based phosphate binder (PB), effectively lowers serum phosphorus (sP) concentrations while reducing pill burden relative to other PBs. To date, SO studies have largely examined treatment-experienced, prevalent hemodialysis populations. We aimed to explore the role of first-line SO initiated during the first year of dialysis. METHODS We retrospectively analyzed deidentified data from adults receiving in-center hemodialysis who were prescribed SO monotherapy within the first year of hemodialysis as part of routine clinical care. All patients continuing SO monotherapy for 12 months were included. Changes from baseline in sP, achievement of sP ≤5.5 and ≤4.5 mg/dL, and other laboratory parameters were analyzed quarterly for 1 year. RESULTS The overall cohort included 596 patients, 286 of whom had a dialysis vintage ≤3 months. In the 3 months preceding SO initiation, sP rapidly increased (mean increases of 1.02 and 1.65 mg/dL in the overall cohort and incident cohort, respectively). SO treatment was associated with significant decreases in quarterly sP (mean decreases of 0.26-0.36; p < 0.0001 for each quarter and overall). While receiving SO, 55-60% of patients achieved sP ≤5.5 mg/dL and 21-24% achieved sP ≤4.5 mg/dL (p < 0.0001 for each quarter and overall vs. baseline). Daily PB pill burden was approximately 4 pills. Serum calcium concentrations increased and intact parathyroid hormone concentrations decreased during SO treatment (p < 0.0001 vs. baseline). CONCLUSIONS Among patients on hemodialysis, initiating SO as a first-line PB resulted in significant reductions in sP while maintaining a relatively low PB pill burden.
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Affiliation(s)
- Juan A Medaura
- Touro Infirmary, LCMC Health, New Orleans, Louisiana, USA
| | - Meijiao Zhou
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA,
| | - Linda H Ficociello
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Michael S Anger
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University Health System-University of Chicago Pritzker School of Medicine, Evanston, Illinois, USA
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Yang S, Zeng Z, Yuan Q, Chen Q, Wang Z, Xie H, Liu J. Vascular calcification: from the perspective of crosstalk. MOLECULAR BIOMEDICINE 2023; 4:35. [PMID: 37851172 PMCID: PMC10584806 DOI: 10.1186/s43556-023-00146-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/20/2023] [Indexed: 10/19/2023] Open
Abstract
Vascular calcification (VC) is highly correlated with cardiovascular disease morbidity and mortality, but anti-VC treatment remains an area to be tackled due to the ill-defined molecular mechanisms. Regardless of the type of VC, it does not depend on a single cell but involves multi-cells/organs to form a complex cellular communication network through the vascular microenvironment to participate in the occurrence and development of VC. Therefore, focusing only on the direct effect of pathological factors on vascular smooth muscle cells (VSMCs) tends to overlook the combined effect of other cells and VSMCs, including VSMCs-VSMCs, ECs-VMSCs, Macrophages-VSMCs, etc. Extracellular vesicles (EVs) are a collective term for tiny vesicles with a membrane structure that are actively secreted by cells, and almost all cells secrete EVs. EVs docked on the surface of receptor cells can directly mediate signal transduction or transfer their contents into the cell to elicit a functional response from the receptor cells. They have been proven to participate in the VC process and have also shown attractive therapeutic prospects. Based on the advantages of EVs and the ability to be detected in body fluids, they may become a novel therapeutic agent, drug delivery vehicle, diagnostic and prognostic biomarker, and potential therapeutic target in the future. This review focuses on the new insight into VC molecular mechanisms from the perspective of crosstalk, summarizes how multi-cells/organs interactions communicate via EVs to regulate VC and the emerging potential of EVs as therapeutic methods in VC. We also summarize preclinical experiments on crosstalk-based and the current state of clinical studies on VC-related measures.
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Affiliation(s)
- Shiqi Yang
- Department of Metabolism and Endocrinology, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China
- Department of Clinical Laboratory Medicine, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China
| | - Zhaolin Zeng
- Department of Metabolism and Endocrinology, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China
| | - Qing Yuan
- Department of Metabolism and Endocrinology, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China
- Department of Clinical Laboratory Medicine, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China
| | - Qian Chen
- Department of Metabolism and Endocrinology, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China
| | - Zuo Wang
- Institute of Cardiovascular Disease, Key Lab for Arteriosclerology of Hunan Province, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Hui Xie
- Department of Orthopaedics, Movement System Injury and Repair Research Centre, Xiangya Hospital, Central South University, Changsha, Hunan Province, China.
| | - Jianghua Liu
- Department of Metabolism and Endocrinology, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, 421001, Hunan, China.
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Dopierała M, Schwermer K, Hoppe K, Kupczyk M, Pawlaczyk K. Benefits of Preserving Residual Urine Output in Patients Undergoing Maintenance Haemodialysis. Int J Nephrol Renovasc Dis 2023; 16:231-240. [PMID: 37868106 PMCID: PMC10590073 DOI: 10.2147/ijnrd.s421533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/01/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Chronic kidney disease is a widespread medical problem that leads to higher morbidity, mortality, and a decrease in the overall well-being of the general population. This is especially expressed in patients with end-stage renal disease (ESRD) undergoing maintenance haemodialysis. Several variables could be used to evaluate those patients' well-being and mortality risk. One of them is the presence of residual urine output. Materials and Methods The study was conducted on 485 patients treated with maintenance haemodialysis. After enrollment in the study, which consisted of medical history, physical examination, hydration assessment, and blood sampling, each patient was followed up for 24 months. We used residual urine output (RUO) as a measure of residual renal function (RRF). The entire cohort was divided into 4 subgroups based on the daily urinary output (<=100mL per day, >100mL to <=500mL, >500mL to <=1000mL and >1000mL). Results The data show that the mortality rate was significantly higher in groups with lower RUO, which was caused mainly by cardiovascular events. Also, patients with higher RUO achieved better sodium, potassium, calcium, and phosphate balance. They were also less prone to overhydration and had a better nutritional status. Preserved RRF also had a positive impact on markers of cardiovascular damage, such as NT-proBNP as well as TnT. Conclusion In conclusion, preserving residual urine output in ESRD patients undergoing maintenance haemodialysis is invaluable in reducing their morbidity and mortality rates and enhancing other favourable parameters of those patients.
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Affiliation(s)
- Mikołaj Dopierała
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Schwermer
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Hoppe
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Małgorzata Kupczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Pawlaczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
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8
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Hayat A, Cho Y, Hawley CM, Htay H, Krishnasamy R, Pascoe E, Teitelbaum I, Varnfield M, Johnson DW. Association of Incremental peritoneal dialysis with residual kidney function decline in patients on peritoneal dialysis: The balANZ trial. Perit Dial Int 2023; 43:374-382. [PMID: 37259236 DOI: 10.1177/08968608231175826] [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] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Incremental peritoneal dialysis (PD), defined as less than Full-dose PD prescription, has several possible merits, including better preservation of residual kidney function (RKF), lower peritoneal glucose exposure and reduced risk of peritonitis. The aims of this study were to analyse the association of Incremental and Full-dose PD strategy with RKF and urine volume (UV) decline in patients commencing PD. METHODS Incident PD patients who participated in the balANZ randomised controlled trial (RCT) (2004-2010) and had at least one post-baseline RKF and UV measurement was included in this study. Patients receiving <56 L/week and ≥56 L/week of PD fluid at PD commencement were classified as Incremental and Full-dose PD, respectively. An alternative cut-point of 42 L/week was used in a sensitivity analysis. The primary and secondary outcomes were changes in measured RKF and daily UV, respectively. RESULTS The study included 154 patients (mean age 57.9 ± 14.1 years, 44% female, 34% diabetic, mean follow-up 19.5 ± 6.6 months). Incremental and Full-dose PD was commenced by 45 (29.2%) and 109 (70.8%) participants, respectively. RKF declined in the Incremental group from 7.9 ± 3.2 mL/min/1.73 m2 at baseline to 3.2 ± 2.9 mL/min/1.73 m2 at 24 months (p < 0.001), and in the Full-dose PD group from 7.3 ± 2.7 mL/min/1.73 m2 at baseline to 3.4 ± 2.8 mL/min/1.73 m2 at 24 months (p < 0.001). There was no difference in the slope of RKF decline between Incremental and Full-dose PD (p = 0.78). UV declined from 1.81 ± 0.73 L/day at baseline to 0.64 ± 0.63 L/day at 24 months in the Incremental PD group (p < 0.001) and from 1.38 ± 0.61 L/day to 0.71 ± 0.46 L/day in the Full-dose PD group (p < 0.001). There was no difference in the slope of UV decline between Incremental and Full-dose PD (p = 0.18). CONCLUSIONS Compared with Full-dose PD start, Incremental PD start is associated with similar declines in RKF and UV.
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Affiliation(s)
- Ashik Hayat
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Yeoungjee Cho
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Carmel M Hawley
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Htay Htay
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Rathika Krishnasamy
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Sunshine Coast University Hospital, Queensland, Australia
| | - Elaine Pascoe
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Isaac Teitelbaum
- Division of Nephrology, Department of Medicine, University of Colorado, Aurora, USA
| | - Marliene Varnfield
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Australian e-Health Research Centre, CSIRO, Brisbane, Australia
| | - David W Johnson
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
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Wong G, Zimbudzi E, Kerr PG. Comparison of Residual Kidney Function Assessment Between the Hemodialysis 2-Day and 3-Day Interdialytic Interval. KIDNEY360 2023; 4:976-981. [PMID: 37289187 PMCID: PMC10371281 DOI: 10.34067/kid.0000000000000174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/25/2023] [Indexed: 06/09/2023]
Abstract
Key Points There was no detected difference in measured residual kidney function between the short and long interdialytic intervals. Sample collection for assessment of residual kidney function can occur at either interdialytic interval without concerns surrounding comparability of results. Background Residual kidney function (RKF) is a dynamic marker having been shown to demonstrate fluctuations over successive days of the interdialytic interval. This study compares measured RKF between the long interdialytic interval (LIDP) and short interdialytic interval (SIDP). Methods This was a prospective cohort study. Thirty-four clinically stable, ambulatory facility hemodialysis patients were recruited. Urine samples collected in the last 12 hours of each interdialytic interval were paired with a blood test at the conclusion of each 12-hour interval to evaluate measured RKF through a mean of urinary urea and creatinine clearances. The paired Student t test and the Wilcoxon matched pairs signed-ranks were used, respectively, to compare differences in assessed mean and median RKF. Results Although average serum creatinine (607±219 µ mol/L versus 547±192 µ mol/L, P = <0.01) and serum urea concentrations (25±15 mmol/L versus 19±5 mmol/L, P = 0.01) were higher in the LIDP compared with SIDP, there was no statistically significant difference in urine volume (630±460 ml versus 520±470 ml, P = 0.06), urine urea (116±49 mmol/L versus 118±90 mmol/L, P = 0.87), or urine creatinine (7816±3943 µ mol/L versus 8926±5752 µ mol/L, P = 0.06) concentrations. On the whole, there was no significant difference in assessed RKF between the LIDP and SIDP (mean 8±6 ml/min versus 6±4 ml/min, P = 0.24; median 6.3 [3.2–10.4] versus 5.8 [3.8–8.9], P = 0.13). Conclusions There was no statistically significant difference observed in assessed RKF between the LIDP and SIDP. Measured RKF through samples collected from the LIDP and SIDP is comparable.
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Affiliation(s)
| | - Edward Zimbudzi
- Department of Nephrology, Monash Medical Centre Clayton, Clayton, Victoria, Australia
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Peter G. Kerr
- Department of Nephrology, Monash Medical Centre Clayton, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
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10
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Zhang Z, Wang Y. Management of Cardiovascular Diseases in Chronic Hemodialysis Patients. Rev Cardiovasc Med 2023; 24:185. [PMID: 39077004 PMCID: PMC11266462 DOI: 10.31083/j.rcm2407185] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 07/31/2024] Open
Abstract
Hemodialysis (HD) is the main treatment modality for patients with end-stage kidney disease. Cardiovascular diseases (CVD) are highly prevalent in HD patients and are the leading cause of death in this population, with the mortality from CVD approximately 20 times higher than that of the general population. Traditional and non-traditional cardiovascular risk factors accelerate progression of CVD and exacerbate the prognosis in HD patients. This review provides a brief overview of the characteristics of CVD in HD patients, and a description of advances in its management.
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Affiliation(s)
- Zhen Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, 200032 Shanghai, China
- Shanghai Medical Center for Kidney Disease, Shanghai Municipal Health Commission, 200032 Shanghai, China
- Shanghai Institute of Kidney and Dialysis, 200032 Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai Medical Quality Control Management Center, 200032 Shanghai, China
| | - Yaqiong Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, 200032 Shanghai, China
- Shanghai Medical Center for Kidney Disease, Shanghai Municipal Health Commission, 200032 Shanghai, China
- Shanghai Institute of Kidney and Dialysis, 200032 Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai Medical Quality Control Management Center, 200032 Shanghai, China
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11
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Urine volume as an estimator of residual renal clearance and urinary removal of solutes in patients undergoing peritoneal dialysis. Sci Rep 2022; 12:18755. [PMID: 36335200 PMCID: PMC9637165 DOI: 10.1038/s41598-022-23093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 10/25/2022] [Indexed: 11/08/2022] Open
Abstract
In non-anuric patients undergoing peritoneal dialysis (PD), residual kidney function (RKF) is a main contributor to fluid and solute removal and an independent predictor of survival. We investigated if urine volume could be used to estimate renal clearances and removal of urea, creatinine, and phosphorus in PD patients. The observational, cross-sectional study included 93 non-anuric prevalent PD patients undergoing continuous ambulatory PD (CAPD; n = 34) or automated PD (APD; n = 59). Concentrations of urea, creatinine and phosphorus in serum and in 24-h collections of urine volume were measured to calculate weekly residual renal clearance (L/week) and removed solute mass (g/week). Median [interquartile range], 24-h urine output was 560 [330-950] mL and measured GFR (the mean of creatinine and urea clearances) was 3.24 [1.47-5.67] mL/min. For urea, creatinine and phosphorus, residual renal clearance was 20.60 [11.49-35.79], 43.02 [19.13-75.48] and 17.50 [8.34-33.58] L/week, respectively, with no significant differences between CAPD and APD. Urine volume correlated positively with removed solute masses (rho = 0.82, 0.67 and 0.74) and with weekly residual renal clearances (rho = 0.77, 0.62 and 0.72 for urea, creatinine, and phosphorus, respectively, all p < 0.001). Residual renal clearances and urinary mass removal rates for urea, creatinine, and phosphorus correlate strongly with 24-h urine volume suggesting that urine volume could serve as an estimator of typical values of residual solute removal indices in PD patients.
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12
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Roldão M, Gonçalves H, Ferrer F. Preditores de hiporresponsividade aos Agentes Estimulantes da Eritropoiese (AEE) em pacientes em diálise peritoneal: o papel da função renal residual. J Bras Nefrol 2022. [DOI: 10.1590/2175-8239-jbn-2022-0019pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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13
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Roldão M, Gonçalves H, Ferrer F. Predictors of hyporesponsiveness to ESAs in peritoneal dialysis patients: the role of residual renal function. J Bras Nefrol 2022; 45:131-133. [PMID: 35881844 PMCID: PMC10139711 DOI: 10.1590/2175-8239-jbn-2022-0019en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Marisa Roldão
- Centro Hospitalar do Médio Tejo, Serviço de Nefrologia, Torres Novas, Portugal
| | - Hernâni Gonçalves
- Centro Hospitalar do Médio Tejo, Serviço de Nefrologia, Torres Novas, Portugal
| | - Francisco Ferrer
- Centro Hospitalar do Médio Tejo, Serviço de Nefrologia, Torres Novas, Portugal
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14
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Soi V, Faber MD, Paul R. Incremental Hemodialysis: What We Know so Far. Int J Nephrol Renovasc Dis 2022; 15:161-172. [PMID: 35520631 PMCID: PMC9065374 DOI: 10.2147/ijnrd.s286947] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Traditionally, patients that develop progressive chronic kidney disease in need of kidney replacement therapy are prescribed thrice weekly in-center hemodialysis sessions at the beginning of therapy. This empiric prescription is based on historic trials that were comprised of mostly prevalent patients. Incremental hemodialysis is the process of performing <3 sessions of dialysis per week or limiting dialysis dose by duration at the initial onset of treatment to provide a more gradual transition, mimicking the progressive nature of kidney disease. Adding clearance contributions from residual kidney function is the standard of care with peritoneal dialysis but has not routinely been employed with hemodialysis. Accounting for residual kidney function accompanied by improvement in adjuvant pharmacotherapy, such as newer potassium binding agents and dietary modification, can augment dialytic clearances and allow for an incremental approach. Utilizing incremental dialysis has been associated with both preserving residual kidney function as well as improving patient quality of life. Barriers to this approach include concerns regarding patient acceptance of dialysis prescription changes, adherence to therapy, and provider factors that would require a restructuring of the current thrice weekly hemodialysis rubric. Candidacy for incremental therapy has shown the best outcomes when urea clearances exceed 3 mL/min and urine volumes are >500 mL/day, although these measures have been deemed conservative. A significant amount of retrospective and registry data has been supportive of initiating incremental hemodialysis and several pilot studies have shown the feasibility of implementing such an approach. Larger, randomized control trials are needed to fully evaluate safety and efficacy to allow for more widespread acceptance of this patient-centered approach to chronic kidney disease.
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Affiliation(s)
- Vivek Soi
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
- Wayne State University School of Medicine, Detroit, MI, USA
- Correspondence: Vivek Soi, Email
| | - Mark D Faber
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Ritika Paul
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
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15
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Murea M, Flythe JE, Anjay R, Emaad ARM, Gupta N, Kovach C, Vachharajani TJ, Kalantar-Zadeh K, Casino FG, Basile C. Kidney dysfunction requiring dialysis is a heterogeneous syndrome: we should treat it like one. Curr Opin Nephrol Hypertens 2022; 31:92-99. [PMID: 34846314 DOI: 10.1097/mnh.0000000000000754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Advanced kidney failure requiring dialysis, commonly labeled end-stage kidney disease or chronic kidney disease stage 5D, is a heterogeneous syndrome -a key reason that may explain why: treating advanced kidney dysfunction is challenging and many clinical trials involving patients on dialysis have failed, thus far. Treatment with dialytic techniques - of which maintenance thrice-weekly hemodialysis is most commonly used - is broadly named kidney 'replacement' therapy, a term that casts the perception of a priori abandonment of intrinsic kidney function and subsumes patients into a single, homogeneous group. RECENT FINDINGS Patients with advanced kidney failure necessitating dialytic therapy may have ongoing endogenous kidney function, and differ in their clinical manifestations and needs. Different terminology, for example, kidney dysfunction requiring dialysis (KDRD) with stages of progressive severity could better capture the range of phenotypes of patients who require kidney 'assistance' therapy. SUMMARY Classifying patients with KDRD based on objective, quantitative levels of endogenous kidney function, as well as patient-reported symptoms and quality of life, would facilitate hemodialysis prescriptions tailored to level of kidney dysfunction, clinical needs, and personal priorities. Such classification would encourage clinicians to move toward personalized, physiological, and adaptive approach to hemodialysis therapy.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Rastogi Anjay
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Abdel-Rahman M Emaad
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Nupur Gupta
- Indiana University Health, Indianapolis, Indiana
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Tushar J Vachharajani
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti
- Dialysis Centre SM2, Policoro, Italy
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16
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Torreggiani M, Fois A, Njandjo L, Longhitano E, Chatrenet A, Esposito C, Fessi H, Piccoli GB. Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis. Expert Rev Mol Diagn 2021; 21:1119-1137. [PMID: 34595991 DOI: 10.1080/14737159.2021.1987216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis. AREAS COVERED In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis. EXPERT OPINION In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.
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Affiliation(s)
| | - Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Linda Njandjo
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France.,Laboratory "Movement, Interactions, Performance" (EA 4334), Le Mans University, Le Mans, France
| | - Ciro Esposito
- Nephrology and Dialysis, ICS Maugeri S.p.A. Sb, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Hafedh Fessi
- Department of Nephrology, Hospital Tenon, Paris, France
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17
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He S, Xiong Q, Tian C, Li L, Zhao J, Lin X, Guo X, He Y, Liang W, Zuo X, Ying C. Inulin-type prebiotics reduce serum uric acid levels via gut microbiota modulation: a randomized, controlled crossover trial in peritoneal dialysis patients. Eur J Nutr 2021; 61:665-677. [PMID: 34491388 DOI: 10.1007/s00394-021-02669-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/31/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE Increased levels of uric acid (UA), which is mainly excreted through the kidneys, are independently associated with higher mortality in end-stage renal disease (ESRD) patients. The uricolysis of gut microbiota plays an important role in extrarenal excretion of UA. This study aimed to examine the effect of inulin-type prebiotics (a type of fermentable dietary fiber) on intestinal microbiota modulation and serum UA levels in ESRD patients. METHODS Continuous ambulatory peritoneal dialysis (CAPD) patients were recruited to a randomized, double-blind, placebo-controlled crossover trial of 12-week inulin-type prebiotics. Participants were visited before and after treatment with prebiotics or placebo. Serum UA levels, dietary purine intake, serum xanthine oxidase (XO) activity, daily "renal excretion" of UA, and fecal UA degradation capability were measured at each visit. Fecal metagenomic analysis was conducted to assess microbial composition and function. RESULTS Sixteen participants (mean age = 37 y; 10 men and 6 women) completed the trial, and 64 specimens were analyzed. The average concentration of serum UA decreased by approximately 10% in the prebiotic intervention group in comparison to the placebo group (p = 0.047) without an increase in daily "renal excretion" of UA via urine and dialysate. There were no significant changes in purine intake or activity of XO. Notably, enhanced fecal UA degradation was observed after prebiotic intervention (p = 0.041), and the ratio of Firmicutes/Bacteroidetes, which was positively associated with fecal UA degradation, increased in the prebiotic period (p = 0.032). Furthermore, prebiotics enriched purine-degrading species in the gut microbiota, including unclassified_o_Clostridiales, Clostridium sp. CAG:7, Clostridium sp. FS41, Clostridium citroniae, Anaerostipes caccae, and Clostridium botulinum. CONCLUSIONS Inulin-type prebiotics is a promising therapeutic candidate to reduce serum UA levels in renal failure patients, and this urate-lowering effect could possibly be attributed to intestinal microbial degradation of UA. TRIAL REGISTRY This study was registered at the Chinese Clinical Trials Registry ( http://www.chictr.org.cn/ ), registration ID: ChiCTR-INR-17013739, registration date: 6th Dec 2017.
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Affiliation(s)
- Shuiqing He
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, 430030, Hubei, China
| | - Qianqian Xiong
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, 430030, Hubei, China
| | - Chong Tian
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Li Li
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, 430030, Hubei, China
| | - Jing Zhao
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, 430030, Hubei, China
| | - Xuechun Lin
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, 430030, Hubei, China
| | - Xiaolei Guo
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, 430030, Hubei, China
| | - Yuqin He
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, 430030, Hubei, China
| | - Wangqun Liang
- Department of Nephrology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xuezhi Zuo
- Department of Clinical Nutrition, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, 430030, Hubei, China.
| | - Chenjiang Ying
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, 430030, Hubei, China.
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18
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Meyer TW, Blanco IJ, Grimm JC, Leypoldt JK, Sirich TL. Barriers to Reducing Hemodialysis Time and Frequency in Patients with Residual Kidney Function. J Am Soc Nephrol 2021; 32:2112-2116. [PMID: 34465606 PMCID: PMC8729852 DOI: 10.1681/asn.2021030361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Timothy W. Meyer
- Department of Medicine, Stanford University, Stanford, California,Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Ignacio J. Blanco
- Department of Medicine, Stanford University, Stanford, California,Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - John C. Grimm
- Department of Medicine, Stanford University, Stanford, California,Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - John K. Leypoldt
- Nalecz Institute of Biocybernetics and Biomedical Engineering PAS, Warsaw, Poland
| | - Tammy L. Sirich
- Department of Medicine, Stanford University, Stanford, California,Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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19
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Vilar E, Kaja Kamal RM, Fotheringham J, Busby A, Berdeprado J, Kislowska E, Wellsted D, Alchi B, Burton JO, Davenport A, Farrington K. A multicenter feasibility randomized controlled trial to assess the impact of incremental versus conventional initiation of hemodialysis on residual kidney function. Kidney Int 2021; 101:615-625. [PMID: 34418414 DOI: 10.1016/j.kint.2021.07.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 06/11/2021] [Accepted: 07/15/2021] [Indexed: 12/13/2022]
Abstract
Twice-weekly hemodialysis, as part of incremental initiation, has reported benefits including preservation of residual kidney function (RKF). To explore this, we initiated a randomized controlled feasibility trial examining 55 incident hemodialysis patients with urea clearance of 3 ml/min/1.73 m2 or more across four centers in the United Kingdom randomized to standard or incremental schedules for 12 months. Incremental hemodialysis involved twice-weekly sessions, upwardly adjusting hemodialysis dose as RKF was lost, maintaining total (Dialysis+Renal) Std Kt/V above 2. Standard hemodialysis was thrice weekly for 3.5-4 hours, minimum Dialysis Std Kt/V of 2. Primary outcomes were feasibility parameters and effect size of group differences in rate of loss of RKF at six months. Health care cost impact and patient-reported outcomes were explored. Around one-third of patients met eligibility criteria. Half agreed to randomization; 26 received standard hemodialysis and 29 incremental. At 12 months, 21 incremental patients remained in the study vs 12 in the standard arm with no group differences in the urea clearance slope. Ninety-two percent of incremental and 75% of standard arm patients had a urea clearance of 2 ml/min/1.73 m2 or more at six months. Serious adverse events were less frequent in incremental patients (Incidence Rate Ratio 0.47, confidence interval 0.27-0.81). Serum bicarbonate was significantly lower in incremental patients indicating supplementation may be required. There were three deaths in each arm. Blood pressure, extracellular fluid and patient-reported outcomes were similar. There was no signal of benefit of incremental hemodialysis in terms of protection of RKF or Quality of Life score. Median incremental hemodialysis costs were significantly lower compared to standard hemodialysis. Thus, incremental hemodialysis appears safe and cost-saving in incident patients with adequate RKF, justifying a definitive trial.
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Affiliation(s)
- Enric Vilar
- Renal Unit, Lister Hospital, East and North Hertfordshire National Health Service (NHS) Trust, Stevenage, UK; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | - Raja M Kaja Kamal
- Renal Unit, Lister Hospital, East and North Hertfordshire National Health Service (NHS) Trust, Stevenage, UK; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, UK; Department of Renal Medicine, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Amanda Busby
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Jocelyn Berdeprado
- Renal Unit, Lister Hospital, East and North Hertfordshire National Health Service (NHS) Trust, Stevenage, UK
| | - Ewa Kislowska
- Renal Unit, Lister Hospital, East and North Hertfordshire National Health Service (NHS) Trust, Stevenage, UK
| | - David Wellsted
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Bassam Alchi
- Department of Renal Medicine, Royal Berkshire Hospital NHS Trust, Reading, UK
| | - James O Burton
- Department of Cardiovascular Science, University of Leicester, Leicester, UK; Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Andrew Davenport
- Department of Renal Medicine, University College London, Royal Free London NHS Foundation Trust, London, UK
| | - Ken Farrington
- Renal Unit, Lister Hospital, East and North Hertfordshire National Health Service (NHS) Trust, Stevenage, UK; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
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20
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Pınarbaşı AS, Dursun I, Günay N, Baatar B, Yel S, Dursun J, Balaban AG, Poyrazoğlu MH, Düşünsel R. Erythropoietin Resistance Index and the Affecting Factors in Children with Peritoneal Dialysis. Blood Purif 2021; 50:942-951. [PMID: 33784664 DOI: 10.1159/000514060] [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: 08/26/2020] [Accepted: 12/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) are used to treat anemia in CKD. Erythropoietin resistance index (ERI) is a useful tool used to evaluate the response to ESAs. In this study, we aimed to evaluate the causes of high ERI in children undergoing peritoneal dialysis (PD). METHOD Patients who had been on PD for at least 1 year were included in this retrospective study. Demographic characteristics, residual kidney function (RKF), adequacy of dialysis, peritoneal glucose exposure, the number and reason for hospitalization, and medications were recorded. Anemia and laboratory parameters that may affect anemia were noted by taking the average of laboratory values in the last follow-up year (time-averaged). The weekly ESA dose was proportioned to the annual average hemoglobin value and body weight to calculate the ERI in terms of U/kg/week/g/dL. RESULTS A total of 100 patients were included in the study. The mean ESA dose and ERI value were 119.8 ± 66.22 U/kg/week and 13.01 ± 7.52 U/kg/week/g/dL, respectively. It was determined that the patients <5 years of age have very high ERI value, and these patients need 2 times more ESA than those >10 years of age. Absence of RKF, large number of hospitalization, and ACEI use were also found to affect the ERI value negatively. CONCLUSION We demonstrate that the most important factor affecting ERI value is young age. We also reveal that absence of RKF, large number of hospitalization, and ACEI use are also important variables affecting the ERI value.
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Affiliation(s)
| | - Ismail Dursun
- Division of Pediatric Nephrology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Neslihan Günay
- Division of Pediatric Nephrology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Batsaikhan Baatar
- Medical Student, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Sibel Yel
- Division of Pediatric Nephrology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Jale Dursun
- Peritoneal Dialysis Nurse, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Aynur Gencer Balaban
- Division of Pediatric Nephrology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Muammer Hakan Poyrazoğlu
- Division of Pediatric Nephrology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ruhan Düşünsel
- Division of Pediatric Nephrology, Department of Pediatrics, Yeditepe Unıversity Faculty of Medicine, İstanbul, Turkey
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21
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Tantisattamo E, Hanna RM, Reddy UG, Ichii H, Dafoe DC, Danovitch GM, Kalantar-Zadeh K. Novel options for failing allograft in kidney transplanted patients to avoid or defer dialysis therapy. Curr Opin Nephrol Hypertens 2021; 29:80-91. [PMID: 31743241 DOI: 10.1097/mnh.0000000000000572] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Despite improvement in short-term renal allograft survival in recent years, renal transplant recipients (RTR) have poorer long-term allograft outcomes. Allograft function slowly declines with periods of stable function similar to natural progression of chronic kidney disease in nontransplant population. Nearly all RTR transitions to failing renal allograft (FRG) period and require transition to dialysis. Conservative chronic kidney disease management before transition to end-stage renal disease is an increasingly important topic; however, there is limited data in RTR regarding how to delay dialysis initiation with conservative management. RECENT FINDINGS Since immunological and nonimmunological factors unique to RTR contribute to decline in allograft function, therapies to slow progression of FRG should take both sets of factors into account. Renal replacement therapy either incremental dialysis or rekidney transplantation should be explored. This required taking benefits and risks of continuing immunosuppressive medications into account when allograft nephrectomy may be necessary. SUMMARY FRG may benefit from various interventions to slow progression of worsening allograft function. Until there are stronger evidence to guide interventions to preserve renal function, extrapolating evidence from nontransplant patients and clinical judgment are necessary. The goal is to provide individualized care for conservative management of RTR with FRG.
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Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange Nephrology Section, Department of Medicine, Veterans Affairs Long Beach Healthcare System, Long Beach, California Section of Nephrology, Department of Internal Medicine, Multi-Organ Transplant Center, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan Division of Kidney and Pancreas Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, California Division of Nephrology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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22
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Pei J, Ethier I, Hudson RE, Hawley CM, Johnson DW, Campbell SB, Francis RS, Wong G, Craig JC, Viecelli AK, Cho Y. Peritoneal dialysis versus haemodialysis for people commencing dialysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Juan Pei
- Department of Nephrology; The First Affiliated Hospital of Xiamen University; Xiamen China
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
| | - Isabelle Ethier
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Department of Nephrology; Centre hospitalier de l’Université de Montréal; Montréal Canada
| | - Rebecca E Hudson
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
| | - Carmel M Hawley
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Australia
- Translational Research Institute; Brisbane Australia
| | - David W Johnson
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Australia
- Translational Research Institute; Brisbane Australia
| | - Scott B Campbell
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
| | - Ross S Francis
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
| | - Germaine Wong
- School of Public Health; The University of Sydney; Sydney Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research; The Children's Hospital at Westmead; Westmead Australia
- College of Medicine and Public Health; Flinders University; Adelaide Australia
| | - Andrea K Viecelli
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Australia
- Translational Research Institute; Brisbane Australia
| | - Yeoungjee Cho
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Australia
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Australia
- Translational Research Institute; Brisbane Australia
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23
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Kimura H, Sy J, Okuda Y, Wenziger C, Hanna R, Obi Y, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Streja E. A faster decline of residual kidney function and erythropoietin stimulating agent hyporesponsiveness in incident hemodialysis patients. Hemodial Int 2020; 25:60-70. [PMID: 33034069 DOI: 10.1111/hdi.12877] [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: 04/06/2020] [Revised: 09/10/2020] [Accepted: 09/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Erythropoietin stimulating agents (ESA) hyporesposiveness has been associated with increased mortality in hemodialysis (HD) patients. However, the impact of decline of residual kidney function (RKF) on ESA hyporesposiveness has not been adequately elucidated among patients receiving HD. METHODS The associations of RKF decline with erythropoietin resistance index (ERI; average weekly ESA dose [units])/post-dialysis body weight [kg]/hemoglobin [g/dL]) were retrospectively examined across four strata of annual change in RKF (residual renal urea clearance [KRU] < -3.0, -3.0 to <-1.5, -1.5 to <0, ≥0 mL/min/1.73 m2 per year; urinary volume < -600, -600 to<-300, -300 to <0, ≥0 mL/day per year) using logistic regression models adjusted for clinical characteristics and laboratory variables in 5239 incident HD patients in a large US dialysis organization between 1 January 2007 and 31 December 2011. FINDINGS The median values of the annual change in KRU and urinary volume were -1.2 (interquartile range [IQR]: -2.8 to 0.1) mL/min/1.73 m2 per year and -250 (IQR: -600 to 100) mL/day per year. A faster KRU decline in the first year of HD was associated with higher odds for ESA hyporesponsiveness: KRU decline of <-3.0, -3.0 to <-1.5, and -1.5 to <0/min/1.73 m2 per year were associated with adjusted odds ratios (OR) of 2.07 (95% confidence interval [CI]: 1.66-2.58), 1.54 (95%CI: 1.28-1.85), and 1.26 (95%CI: 1.07-1.49), respectively (reference: ≥0 mL/min/1.73 m2 per year). These associations were consistent across strata of baseline KRU, age, sex, race, diabetes, congestive heart failure, hemoglobin, and serum albumin. Sensitivity analyses using urinary volume as another index of RKF showed consistent associations. DISCUSSION A faster RKF decline during the first year of dialysis was associated with ESA hyporesponsiveness and low hemoglobin levels among incident HD patients.
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Affiliation(s)
- Hiroshi Kimura
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - John Sy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, California, USA
| | - Yusuke Okuda
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Department of Pediatrics, Kitasato University School of Medicine
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Ramy Hanna
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Yoshitsugu Obi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA.,Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, California, USA
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24
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Factors affecting the relationship between ionized and corrected calcium levels in peritoneal dialysis patients: a retrospective cross-sectional study. BMC Nephrol 2020; 21:370. [PMID: 32847525 PMCID: PMC7448483 DOI: 10.1186/s12882-020-02033-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 08/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic kidney disease-mineral and bone disorder (CKD-MBD) management in patients with end-stage renal disease is important owing to the risk of cardiovascular diseases. In clinical practice, we manage patients not by monitoring the levels of biologically active ionized calcium (iCa) but by monitoring total serum calcium or corrected calcium (cCa). We previously reported that iCa/cCa ratio was different between patients with hemodialysis and those with peritoneal dialysis (PD). In PD patients, several factors are expected to affect iCa/cCa ratio. Therefore, modifying the strategy to achieve better CKD-MBD management might be necessary; however, no reports have studied this to date. Therefore, we investigated the factors influencing iCa/cCa ratio in PD patients. METHODS This retrospective cross-sectional study examined background and laboratory data, including iCa, collected at routine outpatient visits. The patients were divided into the first, second, and third tertile of iCa/cCa ratio groups to compare patient background and laboratory data. Multiple regression analysis was used to investigate the factors influencing iCa/cCa ratio. We used multiple imputation to deal with missing covariate data. RESULTS In total, 169 PD patients were enrolled. In PD patients with lower iCa/cCa ratio, PD duration was longer and pH was higher. Urine volume and weekly renal Kt/V were lower in the patients with lower iCa/cCa ratio than in those with higher iCa/cCa ratio. iCa/cCa ratio and weekly renal Kt/V were directly correlated (r = 0.41, p < 0.01), and weekly renal Kt/V and pH were independent factors affecting iCa/cCa ratio (t = 2.86, p < 0.01 and t = - 5.42, p < 0.01, respectively). CONCLUSIONS iCa levels were lower in PD patients with lower residual renal function (RRF) even though their cCa levels were equal to those with maintained RRF, warranting caution in the assessment and management of CKD-MBD in PD patients.
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25
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How do Uremic Toxins Affect the Endothelium? Toxins (Basel) 2020; 12:toxins12060412. [PMID: 32575762 PMCID: PMC7354502 DOI: 10.3390/toxins12060412] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/15/2020] [Accepted: 06/19/2020] [Indexed: 12/11/2022] Open
Abstract
Uremic toxins can induce endothelial dysfunction in patients with chronic kidney disease (CKD). Indeed, the structure of the endothelial monolayer is damaged in CKD, and studies have shown that the uremic toxins contribute to the loss of cell–cell junctions, increasing permeability. Membrane proteins, such as transporters and receptors, can mediate the interaction between uremic toxins and endothelial cells. In these cells, uremic toxins induce oxidative stress and activation of signaling pathways, including the aryl hydrocarbon receptor (AhR), nuclear factor kappa B (NF-κB), and mitogen-activated protein kinase (MAPK) pathways. The activation of these pathways leads to overexpression of proinflammatory (e.g., monocyte chemoattractant protein-1, E-selectin) and prothrombotic (e.g., tissue factor) proteins. Uremic toxins also induce the formation of endothelial microparticles (EMPs), which can lead to the activation and dysfunction of other cells, and modulate the expression of microRNAs that have an important role in the regulation of cellular processes. The resulting endothelial dysfunction contributes to the pathogenesis of cardiovascular diseases, such as atherosclerosis and thrombotic events. Therefore, uremic toxins as well as the pathways they modulated may be potential targets for therapies in order to improve treatment for patients with CKD.
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26
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Almeida LLSD, Sette LHBC, Fonseca FLA, Bezerra LSVDS, Oliveira Júnior FH, Bérgamo RR. Metabolic and volume status evaluation of hemodialysis patients with and without residual renal function in the long interdialytic interval. ACTA ACUST UNITED AC 2020; 41:481-491. [PMID: 30620775 PMCID: PMC6979571 DOI: 10.1590/2175-8239-jbn-2018-0171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 10/14/2018] [Indexed: 11/22/2022]
Abstract
Introduction: It is unclear whether residual renal function (RRF) in dialysis patients can
attenuate the metabolic impact of the long 68-hour interdialytic interval,
in which water, acid, and electrolyte accumulation occurs. Objective: to evaluate serum electrolyte levels, water balance, and acid-base status in
dialytic patients with and without RRF over the long interdialytic interval
(LII). Methodology: this was a single-center, cross-sectional, and analytical study that compared
patients with and without RRF, defined by diuresis above 200 mL in 24 hours.
Patients were weighed and serum samples were collected for biochemical and
gasometric analysis at the beginning and at the end of the LII. Results: 27 and 24 patients with and without RRF were evaluated, respectively.
Patients without RRF had a higher increase in serum potassium during the LII
(2.67 x 1.14 mEq/L, p < 0.001), reaching higher values
at the end of the study (6.8 x 5.72 mEq/L, p < 0.001)
and lower pH value at the beginning of the interval (7.40 x 7.43,
p = 0.018). More patients with serum bicarbonate <
18 mEq/L (50 x 14.8%, p = 0.007) and mixed acid-base
disorder (57.7 x 29.2%, p = 0.042), as well as greater
interdialytic weight gain (14.67 x 8.87 mL/kg/h, p <
0.001) and lower natremia (137 x 139 mEq/L, p = 0.02) at
the end of the interval. Calcemia and phosphatemia were not different
between the groups. Conclusion: Patients with RRF had better control of serum potassium, sodium, acid-base
status, and volemia throughout the LII.
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27
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Kaja Kamal RM, Farrington K, Busby AD, Wellsted D, Chandna H, Mawer LJ, Sridharan S, Vilar E. Initiating haemodialysis twice-weekly as part of an incremental programme may protect residual kidney function. Nephrol Dial Transplant 2020; 34:1017-1025. [PMID: 30357360 DOI: 10.1093/ndt/gfy321] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Initiating twice-weekly haemodialysis (2×HD) in patients who retain significant residual kidney function (RKF) may have benefits. We aimed to determine differences between patients initiated on twice- and thrice-weekly regimes, with respect to loss of kidney function, survival and other safety parameters. METHODS We conducted a single-centre retrospective study of patients initiating dialysis with a residual urea clearance (KRU) of ≥3 mL/min, over a 20-year period. Patients who had 2×HD for ≥3 months during the 12 months following initiation of 2×HD were identified for comparison with those dialysed thrice-weekly (3×HD). RESULTS The 2×HD group consisted of 154 patients, and the 3×HD group 411 patients. The 2×HD patients were younger (59 ± 15 versus 62 ± 15 years: P = 0.014) and weighed less (70 ± 16 versus 80 ± 18 kg: P < 0.001). More were females (34% versus 27%: P = 0.004). Fewer had diabetes (25% versus 34%: P = 0.04) and peripheral vascular disease (PVD) (13% versus 23%: P = 0.008). Baseline KRU was similar in both groups (5.3 ± 2.4 for 2 × HD versus 5.1 ± 2.8 mL/min for 3 × HD: P = 0.507). In a mixed effects model correcting for between-group differences in comorbidities and demographics, 3×HD was associated with increased rate of loss of KRU and separation of KRU. In separate mixed effects models, group (2×HD versus 3×HD) was not associated with differences in serum potassium or phosphate, and the groups did not differ with respect to total standard Kt/V. Survival, adjusted for age, gender, weight, baseline KRU and comorbidity (prevalence of diabetes, cardiac disease, PVD and malignancy) was greater in the 2×HD group (hazard ratio 0.755: P = 0.044). In sub-analyses, the survival benefit was confined to women, and those of less than median bodyweight. CONCLUSION 2×HD initiation as part of an incremental programme with regular monthly monitoring of KRU was safe and associated with a reduced rate of loss of RKF early after dialysis initiation and improved survival. Randomized controlled trials of this approach are indicated.
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Affiliation(s)
- Raja Mohammed Kaja Kamal
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Ken Farrington
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Amanda D Busby
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - David Wellsted
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Humza Chandna
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Laura J Mawer
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Sivakumar Sridharan
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Enric Vilar
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
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28
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Residual kidney function in nocturnal vs conventional haemodialysis patients: a prospective observational study. Int Urol Nephrol 2020; 52:757-764. [DOI: 10.1007/s11255-020-02419-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
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29
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Kong JH, Davies MRP, Mount PF. Relationship between residual kidney function and symptom burden in haemodialysis patients. Intern Med J 2020; 51:52-61. [PMID: 32043691 DOI: 10.1111/imj.14775] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/02/2020] [Accepted: 02/05/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Residual kidney function (RKF) has been associated with improved solute clearance and survival in haemodialysis (HD) patients. However, whether RKF impacts symptom burden in HD patients is unknown. AIMS To determine the prevalence of RKF in HD patients and to explore associations between higher levels of RKF with symptom burden, as well as clinical and biochemical parameters. METHODS This is a single-centre, retrospective, observational study. RKF was assessed as urea clearance (KRU) by interdialytic urine collection. Symptom burden was measured using the palliative care outcome scale renal questionnaire. RESULTS A total of 90 maintenance HD patients was recruited; 31.9% had KRU ≥1 mL/min/1.73 m2 . Patients with KRU ≥1 mL/min/1.73 m2 reported fewer symptoms (5.3 ± 3.5 vs 7.7 ± 3.8) (P = 0.011), including less shortness of breath (15% vs 55%) (P = 0.0013) and vomiting (0% vs 30%) (P = 0.0016). Higher RKF was associated with lower β2 -microglobilin (P < 0.0001), and lower serum potassium (P = 0.02), but no difference in phosphate, haemoglobin, C-reactive protein or serum albumin. CONCLUSION Higher RKF was significantly associated with fewer symptoms, and lower serum β2 -microglobulin and potassium, suggesting that strategies to preserve RKF may be beneficial.
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Affiliation(s)
- Jessica H Kong
- Dentistry and Health Sciences, Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Peter F Mount
- Dentistry and Health Sciences, Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Nephrology, Austin Health, Melbourne, Victoria, Australia
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30
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Lee YJ, Okuda Y, Sy J, Obi Y, Kang DH, Nguyen S, Hsiung JT, Park C, Rhee CM, Kovesdy CP, Streja E, Kalantar-Zadeh K. Association of Mineral Bone Disorder With Decline in Residual Kidney Function in Incident Hemodialysis Patients. J Bone Miner Res 2020; 35:317-325. [PMID: 31610040 DOI: 10.1002/jbmr.3893] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/15/2019] [Accepted: 09/11/2019] [Indexed: 01/17/2023]
Abstract
Abnormalities of mineral bone disorder (MBD) parameters have been suggested to be associated with poor renal outcome in predialysis patients. However, the impact of those parameters on decline in residual kidney function (RKF) is uncertain among incident hemodialysis (HD) patients. We performed a retrospective cohort study in 13,772 patients who initiated conventional HD during 2007 to 2011 and survived 6 months of dialysis. We examined the association of baseline serum phosphorus, calcium, intact parathyroid hormone (PTH), and alkaline phosphatase (ALP) with a decline in RKF. Decline in RKF was assessed by estimated slope of renal urea clearance (KRU) over 6 months from HD initiation. Our cohort had a mean ± SD age of 62 ± 15 years; 64% were men, 57% were white, 65% had diabetes, and 51% had hypertension. The median (interquartile range [IQR]) baseline KRU level was 3.4 (2.0, 5.2) mL/min/1.73 m2 . The median (IQR) estimated 6-month KRU slope was -1.47 (-2.24, -0.63) mL/min/1.73 m2 per 6 months. In linear regression models, higher phosphorus categories were associated with a steeper 6-month KRU slope compared with the reference category (phosphorus 4.0 to <4.5 mg/dL). Lower calcium and higher intact PTH and ALP categories were also associated with a steeper 6-month KRU slope compared with their respective reference groups (calcium 9.2 to <9.5 mg/dL; intact PTH 150 to <250 pg/mL; ALP <60 U/L). The increased number of parameter abnormalities had an additive effect on decline in RKF. Abnormalities of MBD parameters including higher phosphorus, intact PTH, ALP and lower calcium levels were independently associated with decline in RKF in incident HD patients. © 2019 American Society for Bone and Mineral Research. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Yu-Ji Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Division of Nephrology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Yusuke Okuda
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - John Sy
- Nephrology Section, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Duk-Hee Kang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Division of Nephrology, Department of Internal Medicine, Ewha Womans University College of Medicine, Ewha Medical Research Center, Seoul, Korea
| | - Steven Nguyen
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Jui Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
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31
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Predicting Residual Function in Hemodialysis and Hemodiafiltration-A Population Kinetic, Decision Analytic Approach. J Clin Med 2019; 8:jcm8122080. [PMID: 31795401 PMCID: PMC6947429 DOI: 10.3390/jcm8122080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/16/2019] [Accepted: 11/18/2019] [Indexed: 01/16/2023] Open
Abstract
In this study, we introduce a novel framework for the estimation of residual renal function (RRF), based on the population compartmental kinetic behavior of beta 2 microglobulin (B2M) and its dialytic removal. Using this model, we simulated a large cohort of patients with various levels of RRF receiving either conventional high-flux hemodialysis or on-line hemodiafiltration. These simulations were used to estimate a novel population kinetic (PK) equation for RRF (PK-RRF) that was validated in an external public dataset of real patients. We assessed the performance of the resulting equation(s) against their ability to estimate urea clearance using cross-validation. Our equations were derived entirely from computer simulations and advanced statistical modeling and had extremely high discrimination (Area Under the Curve, AUC 0.888–0.909) when applied to a human dataset of measurements of RRF. A clearance-based equation that utilized predialysis and postdialysis B2M measurements, patient weight, treatment duration and ultrafiltration had higher discrimination than an equation previously derived in humans. Furthermore, the derived equations appeared to have higher clinical usefulness as assessed by Decision Curve Analysis, potentially supporting decisions for individualizing dialysis prescriptions in patients with preserved RRF.
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32
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Zhan X, Yang Y, Chen Y, Wei X, Xiao J, Zhang L, Yan C, Qiu P, Liu S, Hu Q, Chen Q, Wang Y. Serum alkaline phosphatase levels correlate with long-term mortality solely in peritoneal dialysis patients with residual renal function. Ren Fail 2019; 41:718-725. [PMID: 31409217 PMCID: PMC6713195 DOI: 10.1080/0886022x.2019.1646662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/13/2019] [Accepted: 07/14/2019] [Indexed: 12/23/2022] Open
Abstract
Introduction: Increased serum alkaline phosphatase (ALP) is predictive of a higher mortality in patients with end-stage renal disease. However, it remains unknown whether residual renal function (RRF) influences the outcome-association of serum ALP among peritoneal dialysis (PD) patients. Methods: A total of 650 incident PD patients receiving PD catheter implantation in an institute between 1 November 2005 and 28 February 2017 were retrospectively enrolled. These patients were divided into groups with and without RRF (RRF and non-RRF groups) and those with serum ALP levels in tertiles. The Kaplan-Meier method and multivariate Cox proportional hazard models were used to analyze their outcomes based on RRF and serum ALP levels. Results: These 650 patients had a mean age of 49.4 ± 14.0 years old, their median ALP level was 74 U/L (interquartile range (IQR): 59-98). After 28-month (IQR: 14-41) follow-up, 80 patients in RRF group and 40 patients in non-RRF group died. PD patients with the highest serum ALP tertile had significant lower survival (p = .014), when compared to other patients in the RRF group. However, this relationship was not observed in patients in the non-RRF group. After multivariate adjustment, in the RRF group, patients with the highest ALP tertile had a significantly higher risk of mortality (hazard ratio (HR): 2.26, 95% confidence interval (CI): 1.06-4.82, p = .034). Each 10-U/L increase in ALP level was associated with a 4% (HR: 1.04, 95% CI: 1.00-1.08, p = .045) higher mortality risk. Conclusions: Higher serum ALP level is associated with increased mortality solely in PD patients with RRF.
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Affiliation(s)
- Xiaojiang Zhan
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuting Yang
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yanbing Chen
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xin Wei
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Xiao
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Li Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Caixia Yan
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Panlin Qiu
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Siyi Liu
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qinglan Hu
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qinkai Chen
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yu Wang
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Chin AI, Sheth V, Kim J, Bang H. Estimating Residual Native Kidney Urea Clearance in Hemodialysis Patients with and without 24-Hour Urine Volume. Kidney Med 2019; 1:376-382. [PMID: 32462139 PMCID: PMC7252258 DOI: 10.1016/j.xkme.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Rationale & Objective Quantification of residual native kidney function is rarely performed in patients receiving hemodialysis. Methods of estimating residual kidney urea clearance that use commonly available laboratory and clinical data, with or without urine volume information, may be useful tools. Study Design Retrospective, predictive modeling and model validation. Setting & Participants Initial timed urine collections in 604 incident in-center hemodialysis patients on thrice-weekly treatments from a single academic center in which residual kidney urea clearance is measured in usual care. Predictors Models using a combination of serum creatinine and urea levels, age, weight, height, sex, race, fluid weight gains, and with and without 24-hour urine volume. Outcomes Residual kidney urea clearance. Analytic Approach Generalized linear model was used for model development for residual kidney urea clearance using the first urine collection in 604 patients, as both a continuous and binary outcome (for >2.5 mL/min). Model validation was done by bootstrap resampling of the development cohort and with 1,093 follow-up measurements. Results Urine volume alone was the strongest predictor of residual kidney urea clearance. The model that included 24-hour urine volume with common clinical data had high diagnostic accuracy for residual kidney urea clearance > 2.5 mL/min (area under the curve, 0.91 in both development and bootstrap validation) and R2 of 0.56 with outcome as a continuous residual kidney urea clearance value. Our model that did not use urine volume performed less well (eg, area under the curve, 0.75). Analyses of follow-up urine collections in these same participants yielded comparable or improved performance. Limitations Data were retrospective from a single center, no external validation, not validated in 2- or 4-times-weekly hemodialysis patients. Conclusions Estimation equations for residual kidney urea clearance that use commonly available data in dialysis clinics, with and without urine volume, may be useful tools for evaluation of hemodialysis patients who still have residual kidney function for individualization of dialysis prescriptions.
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Affiliation(s)
- Andrew I Chin
- Division of Nephrology, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Vishwa Sheth
- Division of Nephrology, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Jeehyoung Kim
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis School of Medicine, Davis, CA, USA
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Barreto FC, Barreto DV, Massy ZA, Drüeke TB. Strategies for Phosphate Control in Patients With CKD. Kidney Int Rep 2019; 4:1043-1056. [PMID: 31440695 PMCID: PMC6698320 DOI: 10.1016/j.ekir.2019.06.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/27/2019] [Accepted: 06/03/2019] [Indexed: 02/08/2023] Open
Abstract
Hyperphosphatemia is a common complication in patients with chronic kidney disease (CKD), particularly in those requiring renal replacement therapy. The importance of controlling serum phosphate has long been recognized based on observational epidemiological studies that linked increased phosphate levels to adverse outcomes and higher mortality risk. Experimental data further supported the role of phosphate in the development of bone and cardiovascular diseases. Recent advances in our understanding of the mechanisms involved in phosphate homeostasis have made it clear that the serum phosphate concentration depends on a complex interplay among the kidneys, intestinal tract, and bone, and is tightly regulated by a complex endocrine system. Moreover, the source of dietary phosphate and the use of phosphate-based additives in industrialized foods are additional factors that are of particular importance in CKD. Not surprisingly, the management of hyperphosphatemia is difficult, and, despite a multifaceted approach, it remains unsuccessful in many patients. An additional issue is the fact that the supposedly beneficial effect of phosphate lowering on hard clinical outcomes in interventional trials is a matter of ongoing debate. In this review, we discuss currently available treatment approaches for controlling hyperphosphatemia, including dietary phosphate restriction, reduction of intestinal phosphate absorption, phosphate removal by dialysis, and management of renal osteodystrophy, with particular focus on practical challenges and limitations, and on potential benefits and harms.
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Affiliation(s)
- Fellype Carvalho Barreto
- Service of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Daniela Veit Barreto
- Service of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Ziad A. Massy
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France
- Division of Nephrology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt/Paris, France
| | - Tilman B. Drüeke
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France
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Tao X, Zhang H, Yang Y, Zhang C, Wang M. Daily dietary phosphorus intake variability and hemodialysis patient adherence to phosphate binder therapy. Hemodial Int 2019; 23:458-465. [PMID: 31328873 DOI: 10.1111/hdi.12769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/08/2019] [Accepted: 06/13/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Xingjuan Tao
- School of NursingShanghai Jiao Tong University Shanghai China
| | - Haifen Zhang
- Department of Nephrology, Renji Hospital, School of MedicineShanghai Jiao Tong University Shanghai China
| | - Yan Yang
- Department of Nephrology, Renji Hospital, School of MedicineShanghai Jiao Tong University Shanghai China
| | - Caihong Zhang
- Department of Nephrology, Renji Hospital, School of MedicineShanghai Jiao Tong University Shanghai China
| | - Min Wang
- Department of Nephrology, Renji Hospital, School of MedicineShanghai Jiao Tong University Shanghai China
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Kong J, Davies M, Mount P. The importance of residual kidney function in haemodialysis patients. Nephrology (Carlton) 2018; 23:1073-1080. [DOI: 10.1111/nep.13427] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Jessica Kong
- Department of Nephrology; Austin Health; Melbourne Victoria Australia
| | - Matthew Davies
- Department of Nephrology; Austin Health; Melbourne Victoria Australia
| | - Peter Mount
- Department of Nephrology; Austin Health; Melbourne Victoria Australia
- Department of Medicine (Austin Health), Faculty of Medicine, Dentistry and Health Sciences; University of Melbourne; Melbourne Victoria Australia
- Institute of Breathing and Sleep (Kidney Laboratory); Austin Health; Melbourne Victoria Australia
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Lu W, Ren C, Han X, Yang X, Cao Y, Huang B. The protective effect of different dialysis types on residual renal function in patients with maintenance hemodialysis: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12325. [PMID: 30212979 PMCID: PMC6156018 DOI: 10.1097/md.0000000000012325] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Residual renal function (RRF) is an important determinant of mortality and morbidity in patients undergoing hemodialysis. Different dialysis types may have different effects on RRF. We therefore conducted this meta-analysis to examine the RRF protective effect of different dialysis types for hemodialysis patients. METHODS A systematic search was performed on PubMed, EMbase, Web of Science, Chinese Biomedical Literature Database, Wanfang database, and China National Knowledge Infrastructure for randomized controlled trials and cohort studies. Dialysis types included low-flux hemodialysis (LFHD), high-flux hemodialysis (HFHD), hemodiafiltration (HDF), and hemodialysis and hemoperfusion (HD+HP). The mean of endogenous creatinine clearance rate (CCR) and urea clearance rate (Curea), or urine volume was used to estimate RRF [95% confidence interval (95% CI), 6.05-16.80]. RESULTS There were 12 articles involving 1224 patients, including 11 random controlled trials and 1 cohort study. Meta-analysis showed that the RRF protective effect of HFHD [mean difference (MD) = 1.48, 95% CI (2.11 to 0.86), P < .01] and HD+HP [MD = 0.41, 95% CI (0.69 to 0.12), P = .005] was better than that of LFHD, and the RRF decline rate was the lowest in HFHD group [MD = 0.13, 95% CI (0.17 to 0.09), P < .01]. Descriptive analysis showed that HDF could better protect RRF when compared with LFHD. However, there was no consistency among other interventions when removing LFHD due to limited data. CONCLUSION For patients undergoing maintenance hemodialysis, the HFHD, HD+HP and HDF may better protect RRF, compared with LFHD.
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Mathew AT, Obi Y, Rhee CM, Chou JA, Kalantar-Zadeh K. Incremental dialysis for preserving residual kidney function-Does one size fit all when initiating dialysis? Semin Dial 2018; 31:343-352. [PMID: 29737013 PMCID: PMC6035086 DOI: 10.1111/sdi.12701] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
While many patients have substantial residual kidney function (RKF) when initiating hemodialysis (HD), most patients with end stage renal disease in the United States are initiated on 3-times per week conventional HD regimen, with little regard to RKF or patient preference. RKF is associated with many benefits including survival, volume control, solute clearance, and reduced inflammation. Several strategies have been recommended to preserve RKF after HD initiation, including an incremental approach to HD initiation. Incremental HD prescriptions are personalized to achieve adequate volume control and solute clearance with consideration to a patient's endogenous renal function. This allows the initial use of less frequent and/or shorter HD treatment sessions. Regular measurement of RKF is important because HD frequency needs to be increased as RKF inevitably declines. We narratively review the results of 12 observational cohort studies of twice-weekly compared to thrice-weekly HD. Incremental HD is associated with several benefits including preservation of RKF as well as extending the event-free life of arteriovenous fistulas and grafts. Patient survival and quality of life, however, has been variably associated with incremental HD. Serious risks must also be considered, including increased hospitalization and mortality perhaps related to fluid and electrolyte shifts after a long interdialytic interval. On the basis of the above literature review, and our clinical experience, we suggest patient characteristics which may predict favorable outcomes with an incremental approach to HD. These include substantial RKF, adequate volume control, lack of significant anemia/electrolyte imbalance, satisfactory health-related quality of life, low comorbid disease burden, and good nutritional status without evidence of hypercatabolism. Clinicians should engage patients in on-going conversations to prepare for incremental HD initiation and to ensure a smooth transition to thrice-weekly HD when needed.
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Affiliation(s)
- Anna T Mathew
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Yoshitsugu Obi
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Connie M Rhee
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Jason A Chou
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, California
- Fielding School of Public Health at UCLA, Los Angeles, California
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
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Nevo A, Armaly Z, Abd El Kadir A, Douvdevani A, Tovbin D. Elevated Neutrophil Gelatinase Lipocalin Levels Are Associated With Increased Oxidative Stress in Hemodialysis Patients. J Clin Med Res 2018; 10:461-465. [PMID: 29707087 PMCID: PMC5916534 DOI: 10.14740/jocmr3360w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 01/29/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Administration of intravenous iron is an essential treatment of anemia in hemodialysis patients, but it may lead to oxidative stress and increased morbidity and mortality. There is evidence that neutrophil gelatinase-associated lipocalin (NGAL) is protective against oxidative stress and thus the aim of the present study was to investigate the relationship between plasma NGAL and advanced oxidative protein products (AOPP) in hemodialysis patients treated with intravenous iron. METHODS In a prospective study, 47 hemodialysis patients (mean age 63 years, SD = 13.6; 40% women) were enrolled from two separate hospitals. Oxidative stress was induced by an intravenous administration of 100 mg iron saccharate 0.5 h after the start of dialysis. Blood samples were drawn at the beginning of the dialysis, 0.5 h after iron administration and at the end of dialysis. NGAL levels were measured from the first blood sample, AOPP levels were measured from all blood samples. RESULTS Our results showed that higher NGAL and AOPP levels at the beginning of the dialysis, prior to iron administration, significantly predicted higher levels of AOPP toward the end of dialysis, (β = 0.355, SE = 0.054, P = 0.035; β = 0.297, SE = 0.159, P = 0.043, respectively). CONCLUSIONS Our results suggest that higher level of NGAL is a risk factor for oxidative stress, as measured by AOPP levels, in dialysis patients receiving intravenous iron. Our findings could identify dialysis patients who are at higher risk from iron supplementation via measurement of NGAL levels.
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Affiliation(s)
- Adam Nevo
- Cardiothoracic Division, Department of Surgery, Duke University Medical Center, Durham, NC, USA
- These authors contributed equally to this manuscript
| | - Zaher Armaly
- Department of Nephrology, EMMS Nazareth -The Nazareth Hospital, Nazareth, Galilee Medical School-Bar Ilan University, Safed, Israel
- These authors contributed equally to this manuscript
| | - Amir Abd El Kadir
- Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Amos Douvdevani
- Department of Nephrology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - David Tovbin
- Department of Nephrology, Haemek Medical Center, Afula, Israel
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Leypoldt JK, Agar BU, Akonur A, Gellens ME, Culleton BF. Steady State Phosphorus Mass Balance Model during Hemodialysis Based on a Pseudo One-Compartment Kinetic Model. Int J Artif Organs 2018. [DOI: 10.1177/039139881203501102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John K. Leypoldt
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Baris U. Agar
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Alp Akonur
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Mary E. Gellens
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
| | - Bruce F. Culleton
- Medical Products (Renal), Baxter Healthcare Corporation, McGaw Park, IL - USA
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Yamashita K, Mizuiri S, Nishizawa Y, Kenichiro S, Doi S, Masaki T. Oral iron supplementation with sodium ferrous citrate reduces the serum intact and c-terminal fibroblast growth factor 23 levels of maintenance haemodialysis patients. Nephrology (Carlton) 2017; 22:947-953. [PMID: 27558654 PMCID: PMC5725691 DOI: 10.1111/nep.12909] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/07/2016] [Accepted: 08/16/2016] [Indexed: 12/15/2022]
Abstract
AIM Iron deficiency stimulates fibroblast growth factor 23 (FGF23) transcription. This study aimed to determine whether oral ferrous iron (Fe2+ ) reduces the serum FGF23 levels of iron-deficient maintenance haemodialysis (MHD) patients in the same way as oral ferric iron (Fe3+ ) METHODS: Thirty-one MHD patients with iron deficiency were enrolled in this prospective study. Patients who had taken iron supplements during the 8 weeks before the study were excluded. The patients' iron stores and their serum FGF23, phosphate, intact parathyroid hormone (iPTH), albumin, C-reactive protein (CRP), and albumin-adjusted calcium (Ca) levels were examined at the baseline and after 3 months' treatment with sodium ferrous citrate (Fe2+ ). RESULTS The patients' transferrin saturation values and serum iron and ferritin levels were significantly increased after 3 months' treatment (P < 0.01), as were their serum albumin levels (P < 0.05). Conversely, their serum intact FGF23 (iFGF23) [1820 (342-4370) vs 1240 (214-2940) pg/mL, P < 0.05], C-terminal FGF23 (cFGF23) [309 (120-1211) vs 259 (99-600) pg/mL, P < 0.05)], and CRP levels (P < 0.01) were significantly reduced after 3 months' treatment. No changes were detected in the patients' serum iFGF23:cFGF23 ratios or their serum phosphate, Ca, or iPTH levels. The changes in the patients' serum iFGF23 and cFGF23 levels induced by sodium ferrous citrate supplementation were shown to be attributable to changes in their serum ferritin levels (P < 0.05). CONCLUSION Short-term oral iron supplementation with sodium ferrous citrate replenished the iron stores and reduced the serum iFGF23 and cFGF23 levels of MHD patients with iron deficiency without affecting their serum phosphate, Ca, or iPTH levels.
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Affiliation(s)
- Kazuomi Yamashita
- Department of NephrologyHiroshima University HospitalHiroshimaJapan
- Department of NephrologyIchiyokai Harada HospitalHiroshimaJapan
| | - Sonoo Mizuiri
- Department of NephrologyIchiyokai Harada HospitalHiroshimaJapan
| | | | | | - Shigehiro Doi
- Department of NephrologyHiroshima University HospitalHiroshimaJapan
| | - Takao Masaki
- Department of NephrologyHiroshima University HospitalHiroshimaJapan
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Louw EH, Chothia MY. Residual renal function in chronic dialysis is not associated with reduced erythropoietin-stimulating agent dose requirements: a cross-sectional study. BMC Nephrol 2017; 18:336. [PMID: 29178879 PMCID: PMC5702117 DOI: 10.1186/s12882-017-0752-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 11/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anaemia is a very common problem in patients with end-stage kidney disease (ESKD) and the use of erythropoietin-stimulating agents (ESA) has revolutionised its treatment. Residual renal function (RRF) is associated with a reduction in ESA resistance and mortality in chronic dialysis. The primary aim was to establish whether RRF has an association with ESA dose requirements in ESKD patients receiving chronic dialysis. METHODS A single center, cross-sectional study involving 100 chronic dialysis patients was conducted from December 2015 to May 2016. Participants were divided into two groups depending on presence of RRF, which was defined as a 24-h urine sample volume of ≥ 100 ml. Erythropoietin resistance index [ERI = total weekly ESA dose (IU)/weight (kg)/haemoglobin concentration (g/dL] was used as a measure of ESA dose requirements. RESULTS There was no difference in ERI between those with RRF as compared to those without (9.5 versus 11.0, respectively; P = 0.45). Also, ERI did not differ between those receiving haemodialysis as compared with peritoneal dialysis (10.8 versus 10.2, respectively; P = 0.84) or in those using renin-angiotensin system (RAS) blockers as compared with no RAS blocker use (11.6 versus 9.2, respectively; P = 0.10). Lower ERI was evident for those with cystic kidney disease as compared to those with other causes of ESKD (6.9 versus 16.5, respectively; P = 0.32) although this did not reach statistical significance. Higher ERI was found in those with evidence of systemic inflammation as compared to those without (16.5 versus 9.5, respectively; P = 0.003). CONCLUSIONS There was no association between RRF and ESA dose requirements, irrespective of dialysis modality, RAS blocker use, primary renal disease or hyperparathyroidism.
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Affiliation(s)
- Elizabeth Helene Louw
- Divisions of General Medicine and Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, 7505, South Africa
| | - Mogamat-Yazied Chothia
- Divisions of General Medicine and Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, 7505, South Africa.
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Tsuruya K, Torisu K, Yoshida H, Yamada S, Tanaka S, Tsuchimoto A, Eriguchi M, Fujisaki K, Masutani K, Kitazono T. Positive association of residual kidney function with hemoglobin level in patients on peritoneal dialysis independent of endogenous erythropoietin concentration. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0126-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Vascular calcification and cardiac function according to residual renal function in patients on hemodialysis with urination. PLoS One 2017; 12:e0185296. [PMID: 28953969 PMCID: PMC5617191 DOI: 10.1371/journal.pone.0185296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/08/2017] [Indexed: 12/26/2022] Open
Abstract
Background Vascular calcification is common and may affect cardiac function in patients with end-stage renal disease (ESRD). However, little is known about the effect of residual renal function on vascular calcification and cardiac function in patients on hemodialysis. Methods This study was conducted between January 2014 and January 2017. One hundred six patients with residual renal function on maintenance hemodialysis for 3 months were recruited. We used residual renal urea clearance (KRU) to measure residual renal function. First, abdominal aortic calcification score (AACS) and brachial-ankle pulse wave velocity (baPWV) were measured in patients on hemodialysis. Second, we performed echocardiography and investigated new cardiovascular events after study enrollment. Results The median KRU was 0.9 (0.3–2.5) mL/min/1.73m2. AACS (4.0 [1.0–10.0] vs. 3.0 [0.0–8.0], p = 0.05) and baPWV (1836.1 ± 250.4 vs. 1676.8 ± 311.0 cm/s, p = 0.01) were significantly higher in patients with a KRU < 0.9 mL/min/1.73m2 than a KRU ≥ 0.9 mL/min/1.73m2. Log-KRU significantly negatively correlated with log-AACS (ß = -0.29, p = 0.002) and baPWV (ß = -0.19, P = 0.05) after factor adjustment. The proportion of left ventricular diastolic dysfunction was significantly higher in patients with a KRU < 0.9 mL/min/1.73m2 than with a KRU ≥ 0.9 mL/min/1.73m2 (67.9% vs. 49.1%, p = 0.05). Patients with a KRU < 0.9 mL/min/1.73m2 showed a higher tendency of cumulative cardiovascular events compared to those with a KRU ≥ 0.9 ml/min/1.73m2 (P = 0.08). Conclusions Residual renal function was significantly associated with vascular calcification and left ventricular diastolic dysfunction in patients on hemodialysis.
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Chin AI, Appasamy S, Carey RJ, Madan N. Feasibility of Incremental 2-Times Weekly Hemodialysis in Incident Patients With Residual Kidney Function. Kidney Int Rep 2017; 2:933-942. [PMID: 29270499 PMCID: PMC5733820 DOI: 10.1016/j.ekir.2017.06.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/09/2017] [Accepted: 06/14/2017] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION We hypothesized that at least half of incident hemodialysis (HD) patients on 3-times weekly dialysis could safely start on an incremental, 2-times weekly HD schedule if residual kidney function (RKF) had been considered. METHODS RKF is assessed in all our HD patients. This single-center, retrospective cohort study of incident adult HD patients, who survived ≥6 months on a 3-times weekly HD regimen and had a timed urine collection within 3 months of starting HD, assessed each patient's theoretical ability to achieve adequate urea clearance, ultrafiltration rate, and hemodynamic stability if on 2-times weekly HD. RESULTS Of the 410 patients in the cohort, we found that 112 (27%) could have optimally and 107 (26%) could have been appropriately considered for 2-times weekly incremental HD. In general, diuretics were underutilized in >50% of subjects who had adequate RKF urea clearance. The optimal 2-times weekly patients had better potassium and phosphorus control. The correlation coefficient of calculated residual kidney urea clearance with 24-hour urine volume and with kinetic model residual kidney clearance was 0.68 and 0.99, respectively. DISCUSSION More than 50% of incident HD patients with RKF have adequate kidney urea clearance to be considered for 2-times weekly HD. When additionally ultrafiltration volume and blood pressure stability are taken into account, more than one-fourth of the total cohort could optimally start HD in an incremental fashion.
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Affiliation(s)
- Andrew I. Chin
- Department of Internal Medicine, Division of Nephrology, University of California, Davis School of Medicine, Sacramento, California, USA
- Division of Nephrology, Sacramento VA Medical Center, VA Northern California Health Care Systems, Mather Field, California, USA
| | - Suresh Appasamy
- Department of Internal Medicine, Division of Nephrology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Robert J. Carey
- Department of Internal Medicine, Division of Nephrology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Niti Madan
- Department of Internal Medicine, Division of Nephrology, University of California, Davis School of Medicine, Sacramento, California, USA
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Rroji M, Spahia N, Seferi S, Barbullushi M, Spasovski G. Influence of Residual Renal Function in Carotid Modeling as a Marker of Early Atherosclerosis in Dialysis Patients. Ther Apher Dial 2017; 21:451-458. [PMID: 28714271 DOI: 10.1111/1744-9987.12548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 01/19/2017] [Indexed: 11/27/2022]
Abstract
Atherosclerosis is frequently present in patients with chronic kidney disease (CKD) treated with dialysis. We evaluated the association between residual renal function (RRF), phosphate level, inflammation and other risk factors in carotid modeling as a marker of early atherosclerosis in peritoneal dialysis (PD) compared with hemodialysis (HD) patients. We studied 39 stable PD and 53 HD patients on renal replacement therapy (RRT) for 3 to 36 months duration. B-mode ultrasonography was used to determine carotid artery intima media thickness (CIMT). We classified patients with atherosclerosis if they have CIMT >10 mm and or presence of plaque. Out of our total dialysis population studied of 92 patients, 16.3% were diabetics and 57.6% were on hemodialysis. Expectedly, PD patients had a higher RRF (P < 0.001), 24 h urine volume (P < 0.001); C-reactive protein (P = 0.047), and a lower serum phosphate (P = 0.01), PTH (P < 0.05), alkaline phosphatase (P < 0.05), and albumin levels (P < 0.001) compared to hemodialysis patients. Atherosclerosis was found in 66.3% of patients and in 100% of a diabetic population. There was no significant difference in the presence of atherosclerosis between PD and HD patients [56.4 vs 73.6% HD, respectively]. Multiple regression analysis showed age, diabetes, HD modality, RRF, phosphate, PTH and pulse pressure as independent parameters associated with atherosclerosis. Apart from the traditional risk factors like age and diabetes, our study showed a link of atherosclerosis with metabolic abnormalities secondary to renal failure. We demonstrated a novel, independent association between RRF and atherosclerosis, underlining the importance of preservation of the RRF in dialysis patients.
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Affiliation(s)
- Merita Rroji
- Department of Nephrology-Dialysis, UHC "Mother Teresa", Tirana, Albania
| | - Nereida Spahia
- Department of Nephrology-Dialysis, UHC "Mother Teresa", Tirana, Albania
| | - Saimir Seferi
- Department of Nephrology-Dialysis, UHC "Mother Teresa", Tirana, Albania
| | | | - Goce Spasovski
- University Department of Nephrology, Medical Faculty, University of Skopje, Skopje, Macedonia
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Wang M, Obi Y, Streja E, Rhee CM, Lau WL, Chen J, Hao C, Hamano T, Kovesdy CP, Kalantar-Zadeh K. Association of Parameters of Mineral Bone Disorder with Mortality in Patients on Hemodialysis according to Level of Residual Kidney Function. Clin J Am Soc Nephrol 2017; 12:1118-1127. [PMID: 28487345 PMCID: PMC5498357 DOI: 10.2215/cjn.11931116] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The relationship between mineral and bone disorders and survival according to residual kidney function status has not been previously studied in patients on hemodialysis. We hypothesized that residual kidney function, defined by renal urea clearance, modifies the association between mineral and bone disorder parameters and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The associations of serum phosphorus, albumin-corrected calcium, intact parathyroid hormone, and alkaline phosphatase with all-cause mortality were examined across three strata (<1.5, 1.5 to <3.0, and ≥3.0 ml/min per 1.73 m2) of baseline residual renal urea clearance using Cox models adjusted for clinical characteristics and laboratory measurements in 35,114 incident hemodialysis patients from a large United States dialysis organization over the period of 2007-2011. RESULTS A total of 8102 (23%) patients died during the median follow-up of 1.3 years (interquartile range, 0.6-2.3 years). There was an incremental mortality risk across higher serum phosphorus concentrations, which was pronounced among patients with higher residual renal urea clearance (Pinteraction=0.001). Lower concentrations of serum intact parathyroid hormone were associated with higher mortality among patients with low residual renal urea clearance (i.e., <1.5 ml/min per 1.73 m2), whereas higher concentrations showed a higher mortality risk among patients with greater residual renal urea clearance (i.e., ≥1.5 ml/min per 1.73 m2; Pinteraction<0.001). Higher serum corrected total calcium and higher alkaline phosphatase concentrations consistently showed higher mortality risk (Ptrend<0.001 for both) irrespective of residual renal urea clearance strata (Pinteraction=0.34 and Pinteraction=0.53, respectively). CONCLUSIONS Residual kidney function modified the mortality risk associated with serum phosphorus and intact parathyroid hormone among incident hemodialysis patients. Future studies are needed to examine whether taking account for residual kidney function into the assessment of mortality risk associated with serum phosphorus and intact parathyroid hormone improves patient management and clinical outcomes in the hemodialysis population.
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Affiliation(s)
- Mengjing Wang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chuanming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Department of Epidemiology, Fielding School of Public Health at University of California, Los Angeles, Los Angeles, California; and
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
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Is incremental hemodialysis ready to return on the scene? From empiricism to kinetic modelling. J Nephrol 2017; 30:521-529. [PMID: 28337715 DOI: 10.1007/s40620-017-0391-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/14/2017] [Indexed: 11/27/2022]
Abstract
Most people who make the transition to maintenance dialysis therapy are treated with a fixed dose thrice-weekly hemodialysis regimen without considering their residual kidney function (RKF). The RKF provides effective and naturally continuous clearance of both small and middle molecules, plays a major role in metabolic homeostasis, nutritional status, and cardiovascular health, and aids in fluid management. The RKF is associated with better patient survival and greater health-related quality of life, although these effects may be confounded by patient comorbidities. Preservation of the RKF requires a careful approach, including regular monitoring, avoidance of nephrotoxins, gentle control of blood pressure to avoid intradialytic hypotension, and an individualized dialysis prescription including the consideration of incremental hemodialysis. There is currently no standardized method for applying incremental hemodialysis in practice. Infrequent (once- to twice-weekly) hemodialysis regimens are often used arbitrarily, without knowing which patients would benefit the most from them or how to escalate the dialysis dose as RKF declines over time. The recently heightened interest in incremental hemodialysis has been hindered by the current limitations of the urea kinetic models (UKM) which tend to overestimate the dialysis dose required in the presence of substantial RKF. This is due to an erroneous extrapolation of the equivalence between renal urea clearance (Kru) and dialyser urea clearance (Kd), correctly assumed by the UKM, to the clinical domain. In this context, each ml/min of Kd clears the urea from the blood just as 1 ml/min of Kru does. By no means should such kinetic equivalence imply that 1 ml/min of Kd is clinically equivalent to 1 ml/min of urea clearance provided by the native kidneys. A recent paper by Casino and Basile suggested a variable target model (VTM) as opposed to the fixed model, because the VTM gives more clinical weight to the RKF and allows less frequent hemodialysis treatments at lower RKF. The potentially important clinical and financial implications of incremental hemodialysis render it highly promising and warrant randomized controlled trials.
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Lee MJ, Park JT, Park KS, Kwon YE, Oh HJ, Yoo TH, Kim YL, Kim YS, Yang CW, Kim NH, Kang SW, Han SH. Prognostic Value of Residual Urine Volume, GFR by 24-hour Urine Collection, and eGFR in Patients Receiving Dialysis. Clin J Am Soc Nephrol 2017; 12:426-434. [PMID: 28228465 PMCID: PMC5338702 DOI: 10.2215/cjn.05520516] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 12/07/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Residual kidney function can be assessed by simply measuring urine volume, calculating GFR using 24-hour urine collection, or estimating GFR using the proposed equation (eGFR). We aimed to investigate the relative prognostic value of these residual kidney function parameters in patients on dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using the database from a nationwide prospective cohort study, we compared differential implications of the residual kidney function indices in 1946 patients on dialysis at 36 dialysis centers in Korea between August 1, 2008 and December 31, 2014. Residual GFR calculated using 24-hour urine collection was determined by an average of renal urea and creatinine clearance on the basis of 24-hour urine collection. eGFR-urea, creatinine and eGFR β2-microglobulin were calculated from the equations using serum urea and creatinine and β2-microglobulin, respectively. The primary outcome was all-cause death. RESULTS During a mean follow-up of 42 months, 385 (19.8%) patients died. In multivariable Cox analyses, residual urine volume (hazard ratio, 0.96 per 0.1-L/d higher volume; 95% confidence interval, 0.94 to 0.98) and GFR calculated using 24-hour urine collection (hazard ratio, 0.98; 95% confidence interval, 0.95 to 0.99) were independently associated with all-cause mortality. In 1640 patients who had eGFR β2-microglobulin data, eGFR β2-microglobulin (hazard ratio, 0.98; 95% confidence interval, 0.96 to 0.99) was also significantly associated with all-cause mortality as well as residual urine volume (hazard ratio, 0.96 per 0.1-L/d higher volume; 95% confidence interval, 0.94 to 0.98) and GFR calculated using 24-hour urine collection (hazard ratio, 0.97; 95% confidence interval, 0.95 to 0.99). When each residual kidney function index was added to the base model, only urine volume improved the predictability for all-cause mortality (net reclassification index =0.11, P=0.01; integrated discrimination improvement =0.01, P=0.01). CONCLUSIONS Higher residual urine volume was significantly associated with a lower risk of death and exhibited a stronger association with mortality than GFR calculated using 24-hour urine collection and eGFR-urea, creatinine. These results suggest that determining residual urine volume may be beneficial to predict patient survival in patients on dialysis.
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Affiliation(s)
- Mi Jung Lee
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnamsi, Korea
| | - Jung Tak Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyoung Sook Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Eun Kwon
- Department of Internal Medicine, Myongji Hospital, Seonam University College of Medicine, Goyangsi, Korea
| | - Hyung Jung Oh
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
- Clinical Research Center for End-Stage Renal Disease, Daegu, Korea
| | - Yon Su Kim
- Clinical Research Center for End-Stage Renal Disease, Daegu, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chul Woo Yang
- Clinical Research Center for End-Stage Renal Disease, Daegu, Korea
- Department of Internal Medicine, Catholic University of Korea College of Medicine, Seoul, Korea; and
| | - Nam-Ho Kim
- Clinical Research Center for End-Stage Renal Disease, Daegu, Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Clinical Research Center for End-Stage Renal Disease, Daegu, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Comparative Study on Trace Element Excretions between Nonanuric and Anuric Patients Undergoing Continuous Ambulatory Peritoneal Dialysis. Nutrients 2016; 8:nu8120826. [PMID: 27999390 PMCID: PMC5188479 DOI: 10.3390/nu8120826] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 11/26/2016] [Accepted: 12/15/2016] [Indexed: 01/08/2023] Open
Abstract
Few studies have been reported on alterations of trace elements (TE) in peritoneal dialysis patients. Our objective was to investigate and assess the characteristics of daily TE excretions in continuous ambulatory peritoneal dialysis (CAPD) patients. This cross-sectional study included 61 CAPD patients (nonanuric/anuric: 45/16) and 11 healthy subjects in Wuhan, China between 2013 and 2014. The dialysate and urine of patients and urine of healthy subjects were collected. The concentrations of copper (Cu), zinc (Zn), selenium (Se), molybdenum (Mo), and arsenic (As) in dialysate and urine were determined using inductively coupled plasma mass spectrometer (ICP-MS). Various clinical variables were obtained from automatic biochemical analyzer. Daily Cu, Zn, Se, and Mo excretions in nonanuric patients were higher than healthy subjects, while arsenic excretion in anuric patients was lower. A strong and positive correlation was observed between Se and Mo excretion in both dialysate (β = 0.869, p < 0.010) and urine (β = 0.968, p < 0.010). Furthermore, the clinical variables associated with Se excretion were found to be correlated with Mo excretion. Our findings indicated that nonanuric CAPD patients may suffer from deficiency of some essential TEs, while anuric patients are at risk of arsenic accumulation. A close association between Se and Mo excretion was also found.
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