-
Seminars in Dialysis Jul 2018Since the advent of maintenance dialysis therapy, our interpretation of what adequate dialysis really is has broadened and become more controversial. This is not only... (Review)
Review
Since the advent of maintenance dialysis therapy, our interpretation of what adequate dialysis really is has broadened and become more controversial. This is not only due to our changing and aging dialysis population but also to our evolving knowledge base. As nephrologists, we strive to achieve both quality and (often) quantity of life for our patients and we feel reassured when we have a quantifiable marker to show for our efforts. However, we suggest that adequate dialysis reaches far beyond the realms of attaining a particular biochemical result. Dialysis adequacy should encompass a more comprehensive assessment of patient well-being. This metric could comprise quality of life and patient-specified goals, sufficient small solute and middle molecule clearance, optimal blood pressure control, and effective bone-mineral balance, all in the context of minimizing mortality and morbidity, and a livable dialysis regimen for the patient.
Topics: Dialysis Solutions; Goals; Humans; Kidney Function Tests; Outcome Assessment, Health Care; Quality of Life; Renal Dialysis; Renal Insufficiency, Chronic; Urea
PubMed: 29573025
DOI: 10.1111/sdi.12684 -
Contributions To Nephrology 2018Most hemodialysis (HD) in Japan is based on the central dialysis fluid delivery system (CDDS). With CDDS, there is an improvement in work efficiency, reduction in cost,... (Review)
Review
Most hemodialysis (HD) in Japan is based on the central dialysis fluid delivery system (CDDS). With CDDS, there is an improvement in work efficiency, reduction in cost, and a reduction in regional and institutional differences in dialysis conditions. This has resulted in an improvement in the survival rate throughout Japan. However, as the number of cases with various complications increases, it is necessary to select the optimal dialysis prescription (including hours and frequency) for each individual in order to further improve survival rates. To perform intensive HD, home HD is essential, and various prescriptions have been tried. However, several challenges remain before widespread implementation of home HD can occur.
Topics: Dialysis Solutions; Hemodialysis, Home; Humans; Japan; Renal Dialysis; Survival Rate
PubMed: 30041223
DOI: 10.1159/000485718 -
The Cochrane Database of Systematic... Jul 2014The high mortality rate among critically ill patients with acute kidney injury (AKI) remains an unsolved problem in intensive care medicine, despite the use of renal... (Review)
Review
BACKGROUND
The high mortality rate among critically ill patients with acute kidney injury (AKI) remains an unsolved problem in intensive care medicine, despite the use of renal replacement therapy (RRT). Increasing evidence from clinical studies in adults and children suggests that the new peritoneal dialysis (PD) fluids may allow for better long-term preservation of peritoneal morphology and function. Formation of glucose degradation products (GDPs) can be reduced and even avoided with the use of newer "biocompatible" solutions. However, it is still unclear if there are any differences in using conventional (lactate) solutions compared with low GDP (bicarbonate) solutions for acute PD.
OBJECTIVES
To look at the benefits and harms of bicarbonate versus lactate solutions in acute PD.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1966), EMBASE (from 1980), Latin American and Caribbean Health Sciences Literature Database LILACS (from 1982), and reference lists of articles.Date of last search: 6 May 2014.
SELECTION CRITERIA
Randomised controlled trials (RCTs) comparing bicarbonate to lactate solution for acute PD.
DATA COLLECTION AND ANALYSIS
Two authors independently assess the methodological quality of studies. One author abstracted data onto a standard form, and a second author checked data extraction. We used the random-effects model and expressed the results as relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).
MAIN RESULTS
We included one study (20 patients) in this review. In shock patients, bicarbonate did not differ from lactate with respect to mortality (RR 0.50, 95% CI 0.06 to 3.91); however there were significant differences in blood lactate (MD -1.60 mmol/L, 95% CI -2.04 to -1.16), serum bicarbonate (MD 5.00 mmol/L, 95% CI 3.26 to 6.74) and blood pH (MD 0.12, 95% CI 0.06 to 0.18). In non-shock patients there was a significance difference in blood lactate (MD -0.60 mmol/L, 95% CI -0.85 to -0.35) but not in serum bicarbonate (MD 1.10 mmol/L, 95% CI -0.27 to 2.47) or blood pH (MD -0.02, 95% CI -0.02 to -0.06). Other outcomes could not be analysed because of the limited data available.
AUTHORS' CONCLUSIONS
There is no strong evidence that any clinical advantage for patients requiring acute PD for AKI when comparing conventional (lactate) with low GDP dialysis solutions (bicarbonate).
Topics: Acute Kidney Injury; Adult; Bicarbonates; Dialysis Solutions; Humans; Lactic Acid; Peritoneal Dialysis; Randomized Controlled Trials as Topic
PubMed: 24992903
DOI: 10.1002/14651858.CD007034.pub3 -
Biomedicine & Pharmacotherapy =... Sep 2023Peritoneal dialysis is an efficient renal replacement therapy for patients with end-stage kidney disease. However, continuous exposure of the peritoneal membrane to... (Review)
Review
Peritoneal dialysis is an efficient renal replacement therapy for patients with end-stage kidney disease. However, continuous exposure of the peritoneal membrane to dialysate frequently leads to peritoneal fibrosis, which alters the function of the peritoneal membrane and results in withdrawal from peritoneal dialysis in patients. Among others, high glucose dialysate is considered as a predisposing factor for peritoneal fibrosis in patients on peritoneal dialysis. Glucose-induced inflammation, metabolism disturbance, activation of the renin-angiotensin-aldosterone system, angiogenesis and noninflammation-induced reactive oxygen species are implicated in the pathogenesis of high glucose dialysate-induced peritoneal fibrosis. Specifically, high glucose causes chronic inflammation and recurrent peritonitis, which could cause migration and polarization of inflammatory cells, as well as release of cytokines and fibrosis. High glucose also interferes with lipid metabolism and glycolysis by activating the sterol-regulatory element-binding protein-2/cleavage-activating protein pathway and increasing hypoxia inducible factor-1α expression, leading to angiogenesis and peritoneal fibrosis. Activation of the renin-angiotensin-aldosterone system and Ras-mitogen activated protein kinase signaling pathway is another contributing factor in high glucose dialysate-induced fibrosis. Ultimately, activation of the transforming growth factor-β1/Smad pathway is involved in mesothelial-mesenchymal transition or epithelial-mesenchymal transition, which leads to the development of fibrosis. Although possible intervention strategies for peritoneal dialysate-induced fibrosis by targeting the transforming growth factor-β1/Smad pathway have occasionally been proposed, lack of laboratory evidence renders clinical decision-making difficult. We therefore aim to revisit the upstream pathways of transforming growth factor-beta1/Smad and propose potential therapeutic targets for high glucose-induced peritoneal fibrosis.
Topics: Humans; Peritoneal Fibrosis; Dialysis Solutions; Transforming Growth Factor beta1; Peritoneum; Fibrosis; Inflammation; Glucose
PubMed: 37523983
DOI: 10.1016/j.biopha.2023.115246 -
Clinical and Experimental Nephrology Sep 2023Encapsulating peritoneal sclerosis (EPS), a condition with a high mortality rate, is a serious complication of peritoneal dialysis (PD). In Japan, EPS became a central... (Review)
Review
Encapsulating peritoneal sclerosis (EPS), a condition with a high mortality rate, is a serious complication of peritoneal dialysis (PD). In Japan, EPS became a central issue in the clinical setting during the mid-90s and the beginning of this century. However, following the introduction of biocompatible neutral PD solutions containing lower levels of glucose degradation products, the incidence and clinical severity of EPS has been greatly lessened. During the past three decades, the etiology of EPS has been elucidated by findings obtained by peritoneal biopsy, laparoscopy, and surgical intervention. Accumulating findings suggest the need for a paradigm change on the nature of EPS pathophysiology; notably, EPS appears not to reflect peritoneal sclerosis per se, but rather the formation of a neo-membrane as a biological reaction to peritoneal injury. This narrative review looks back on the history of EPS in Japan, and discusses EPS pathophysiology, the impact of neutral PD solution on peritoneal protection, and a future novel diagnostic approach, ultra-fine endoscope, for the identification of patients at high risk of EPS.
Topics: Humans; Peritoneal Fibrosis; Japan; Peritoneal Dialysis; Peritoneum; Dialysis Solutions; Sclerosis
PubMed: 37278945
DOI: 10.1007/s10157-023-02360-y -
Seminars in Dialysis Mar 2021For three-weekly hemodialysis, a single-pool Kt/V target of at least 1.4 together with a minimal dialysis dose Kt at 45 L for men and 40 L for women per each session is... (Review)
Review
For three-weekly hemodialysis, a single-pool Kt/V target of at least 1.4 together with a minimal dialysis dose Kt at 45 L for men and 40 L for women per each session is currently recommended. Fully automatic online calculation of Kt and Kt/V from conductivity or UV-absorbance measurements in the dialysate is standardly implemented on some hemodialysis monitors and makes it possible to estimate the dialysis dose without the need for blood or dialysate samples. Monitoring the UV-absorbance of the spent dialysate is the most direct method for estimating Kt/V as it does not require an estimate of V. Calculation of ionic dialysance from conductivity measurements is the most direct method for estimating Kt and BSA-scaled dialysis dose. Both ionic dialysance monitoring and UV-absorbance monitoring may help detect a change in urea clearance occurring during the session, but this change must be interpreted differently depending on the monitoring being considered. An abrupt decrease in urea clearance results in a decrease in ionic dialysance but, paradoxically, a sudden increase in estimated urea clearance provided by dialysate UV-absorbance monitoring. Healthcare teams who monitor both ionic dialysance and UV-absorbance in their hemodialysis units must be clearly informed of this difficulty.
Topics: Blood Urea Nitrogen; Dialysis Solutions; Female; Humans; Ions; Male; Monitoring, Physiologic; Renal Dialysis; Urea
PubMed: 33529406
DOI: 10.1111/sdi.12949 -
Blood Purification 2015Hemodiafiltration (HDF) seems to represent the gold standard in the field of replacement of renal function by dialysis. High convective fluxes have been correlated with... (Review)
Review
Hemodiafiltration (HDF) seems to represent the gold standard in the field of replacement of renal function by dialysis. High convective fluxes have been correlated with better clinical outcomes. Sometimes, however, there are technical barriers to the achievement of high blood flows adequate to perform effective convective therapies. In spite of optimized procedures, the progressive increase in transmembrane pressure (TMP), the blood viscosity due to hemoconcentration and blood path resistance sometimes becomes inevitable. We propose two possible solutions that can be operated automatically via specific software in the dialysis machine: predilution on demand and backflush on demand. Predilution on demand consists in an automatic feedback of the machine, diverting part of the filtered dialysate into a predilution mode with an infusion of 200 ml in 30 s while the ultrafiltration pump stops. This produces a sudden hemodilution with a return of the parameters to acceptable values. The performance of the filter improves, and the pressure alterations are mitigated. Backflush on demand consists in an automatic feedback of the machine triggered by the TMP control, producing a positive pressure in the dialysate compartment due to a stop of filtration and rapid infusion of at least 100 ml of ultrapure dialysate into the hollow fiber. This not only produces a significant hemodilution, but also backflushes the membrane pores detaching protein layers and improving membrane permeability. These are two examples of how technology will permit to overcome technical barriers to a widespread diffusion of HDF and adequate convective dose delivery.
Topics: Dialysis Solutions; Diffusion; Hemodiafiltration; Humans; Kidney Failure, Chronic; Pressure; Rheology; Software; Vascular Resistance
PubMed: 26344507
DOI: 10.1159/000437403 -
Nephrology, Dialysis, Transplantation :... Jan 2024Peritoneal dialysis (PD) solutions containing low levels of glucose degradation products (GDPs) are associated with attenuation of peritoneal membrane injury and...
BACKGROUND
Peritoneal dialysis (PD) solutions containing low levels of glucose degradation products (GDPs) are associated with attenuation of peritoneal membrane injury and vascular complications. However, clinical benefits associated with neutral-pH, low-GDP (N-pH/L-GDP) solutions remain unclear.
METHODS
Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the associations between N-pH/L-GDP solutions and all-cause mortality, cause-specific mortality, transfer to haemodialysis (HD) for ≥30 days and PD peritonitis in adult incident PD patients in Australia and New Zealand between 1 January 2005 and 31 December 2020 using adjusted Cox regression analyses.
RESULTS
Of 12 814 incident PD patients, 2282 (18%) were on N-pH/L-GDP solutions. The proportion of patients on N-pH/L-GDP solutions each year increased from 11% in 2005 to 33% in 2017. During the study period, 5330 (42%) patients died, 4977 (39%) experienced transfer to HD and 5502 (43%) experienced PD peritonitis. Compared with the use of conventional solutions only, the use of any form of N-pH/L-GDP solution was associated with reduced risks of all-cause mortality {adjusted hazard ratio [aHR] 0.67 [95% confidence interval (CI) 0.61-0.74]}, cardiovascular mortality [aHR 0.65 (95% CI 0.56-0.77)], infection-related mortality [aHR 0.62 (95% CI 0.47-0.83)] and transfer to HD [aHR 0.79 (95% CI 0.72-0.86)] but an increased risk of PD peritonitis [aHR 1.16 (95% CI 1.07-1.26)].
CONCLUSIONS
Patients who received N-pH/L-GDP solutions had decreased risks of all-cause and cause-specific mortality despite an increased risk of PD peritonitis. Studies assessing the causal relationships are warranted to determine the clinical benefits of N-pH/L-GDP solutions.
Topics: Adult; Humans; Renal Dialysis; Peritoneal Dialysis; Dialysis Solutions; Peritonitis; Hydrogen-Ion Concentration
PubMed: 37429598
DOI: 10.1093/ndt/gfad153 -
American Journal of Physiology. Heart... Apr 2022
Topics: Bicarbonates; Dialysis Solutions
PubMed: 35324335
DOI: 10.1152/ajpheart.00057.2022 -
The Pan African Medical Journal 2020Peritoneal dialysis is a form of renal replacement therapy that is both effective and relatively affordable. Peritoneal dialysis (PD) was first used in Nigeria as a...
INTRODUCTION
Peritoneal dialysis is a form of renal replacement therapy that is both effective and relatively affordable. Peritoneal dialysis (PD) was first used in Nigeria as a treatment option for renal failure. Its use was first reported in Nigeria in 1969 and became more widespread in the 80s and 90s. Haemodialysis, which is capital intensive to set up and requires infrastructures and facilities such as electricity, intense water consumption and buildings, seems to have upstaged peritoneal dialysis both in demand and supply.
METHODS
This cross-sectional study is a convenient survey of nephrologists, renal technicians and nurses in Nigeria. We used a structured, self-administered questionnaire on a cross-section of members and associate members attending a national nephrology association meeting.
RESULTS
There were 68(54.4%) doctors, 43(27.2%) nurses, and 14(11.2%) renal technicians, all from medical institutions with renal treatment programs who participated in the study. The most common problems encountered with PD use are financial constraints (51.7%), inadequate fluid supply (50%), frequent line blockage (22.4%) and frequent infections (17.2%). Reasons attributed to the stoppage of PD in the centres included lack of PD fluids (50.8%), unavailability of PD catheters (22.8%), lack of expert personnel to train (15.8%).
CONCLUSION
Main challenges to peritoneal dialysis use in Nigeria include limited experience and training and availability and cost of consumables. Effort to overcome the factors militating against its use should be positively pursued so that peritoneal dialysis will be re-integrated into the mainstream of renal replacement therapy once more.
Topics: Cross-Sectional Studies; Dialysis Solutions; Humans; Nigeria; Peritoneal Dialysis; Renal Insufficiency; Surveys and Questionnaires
PubMed: 32655752
DOI: 10.11604/pamj.2020.35.138.21066