The ABCs of personalized incremental dialysis start, Le Mans style

Thrice weekly hemodialysis (HD) is considered the standard of care for patients with end-stage chronic kidney disease (CKD) on extracorporeal renal replacement therapy. However, recent evidence has shown that up to one third of patients start dialysis with a residual kidney function that could allow a reduced frequency/dialysis dose. Interest towards HD schedules other than thrice weekly and the lessons learned from peritoneal dialysis, in addition to growing attention to patients' quality of life, have promoted renewed attention towards incremental HD (iHD). iHD comprises once and twice weekly schedules, makes it possible to soften the "dialysis shock" at the inception of therapy and is patient-friendly. Moreover, it might contribute to preserving residual kidney function longer. Nevertheless, iHD is performed differently in different settings and no guidelines exist on this subject. Taking advantage of the experience accrued with regard to the treatment of advanced CKD both in the outpatient clinic and in the dialysis unit in Le Mans, where two thirds of incident HD patients start in an incremental way, we aimed to present the practical aspects of iHD and discuss its advantages and drawbacks.

Nephrology pre-dialysis care affects the psychological adjustment, not only blood pressure, anemia, and phosphorus control

Several studies have suggested that pre-dialysis care is associated with clinical outcomes. However, little has been reported on the influence of pre-dialysis care on the psychological adjustment to dialysis. The purpose of this study was to evaluate the impact of pre-dialysis care on psychological adjustment to dialysis and clinical characteristics. In this cross-sectional study, we enrolled 52 patients who started hemodialysis at our hospital. They were divided into two groups according to the time of referral to our hospital: the early referral group (over 1 year prior to first dialysis: 19 patients, mean age 69.3 ± 11.1) and the late referral group (within 1 year prior to first dialysis: 33 patients, mean age 72.3 ± 8.9). We measured the clinical characteristics and evaluated the psychological adjustment to dialysis by Shontz's stage theory. Compared with the late referral group, the early referral group had a significantly better clinical characteristics concerning blood pressure (140.2 ± 23.7 vs. 156.9 ± 23.3 mmHg, P = 0.0150), hemoglobin (10.3 ± 1.5 vs. 9.4 ± 1.0 g/dL, P = 0.0078), and phosphorus (4.5 ± 1.5 vs. 5.5 ± 1.3 mg/dL, P = 0.0166). In addition, psychological adjustment to dialysis evaluated by Shontz's stage theory was significantly better in the early referral group (P = 0.017). Our results indicate that nephrology pre-dialysis care affects not only blood pressure, anemia, and phosphorus control but also the psychological adjustment to dialysis.

Lipid levels and renal function decline in pre-dialysis patients

Background

Little is known about the effect of low-density lipoprotein (LDL) cholesterol, triglyceride (TG), and high-density lipoprotein (HDL) cholesterol levels on renal function decline in patients receiving specialized pre-dialysis care.

Methods

In the prospective PREPARE-2 study, incident patients starting pre-dialysis care were included when referred to one of the 25 participating Dutch specialized pre-dialysis outpatient clinics (2004-2011). Clinical and laboratory data were collected every 6 months. A linear mixed model was used to compare renal function decline between patients with LDL cholesterol, TG, or HDL cholesterol levels above and below the target goals (LDL cholesterol: <2.50 mmol/l, TG: <2.25 mmol/l, and HDL cholesterol: ≥1.00 mmol/l). Additionally the HDL/LDL cholesterol ratio was investigated (≥0.4).

Results

In our study population (n = 306), the median age was 69 years and 70% were male. Patients with LDL cholesterol levels above the target of 2.50 mmol/l experienced an accelerated renal function decline compared to patients with levels below the target (crude additional decline: 0.10 ml/min/1.73 m²/month, 95% CI 0.00-0.20; p < 0.05). A similar trend was found for TG levels above the target of 2.25 mmol/l (0.05 ml/min/1.73 m²/month, 95% CI −0.06 to 0.16) and for a HDL/LDL cholesterol ratio below 0.4 (0.06 ml/min/1.73 m²/month, 95% CI −0.05 to 0.18). Adjustment for potential confounders resulted in similar results, and the exclusion of patients who were prescribed lipid-lowering medication (statin, fibrate, or cholesterol absorption inhibitor) resulted in a slightly larger estimated effect.

Conclusion

High levels of LDL cholesterol were associated with an accelerated renal function decline, independent of the prescription of lipid-lowering medication.