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Clinical Journal of the American... Aug 2023Sodium-glucose cotransporter 2 (SGLT2) inhibitors attenuate incident cardiovascular outcomes, irrespective of baseline GFR, in conservatively managed CKD. As this...
BACKGROUND
Sodium-glucose cotransporter 2 (SGLT2) inhibitors attenuate incident cardiovascular outcomes, irrespective of baseline GFR, in conservatively managed CKD. As this condition inexorably progresses to demanding KRT, drug withdrawal is supported by the current lack of evidence of safety of SGLT2 inhibitors in dialysis.
METHODS
This study was a prospective, single-center, open-label trial ( ClinicalTrials.gov identifier: NCT05343078 ) aimed at assessing the pharmacokinetic properties and safety of dapagliflozin in patients with kidney failure on regular dialysis regimens compared with those with type 2 diabetes and age- and sex-matched controls with normal kidney function. Peripheral blood samples were collected from both groups every 30 minutes for 4 hours and again after 48 hours after ingestion of dapagliflozin 10 mg, which occurred immediately before dialysis session initiation in the kidney failure group. This protocol occurred in drug-naïve patients and again after six daily doses of dapagliflozin to assess whether the drug had accumulated. The plasma and dialysate levels of dapagliflozin at each time point were determined by liquid chromatography and used to calculate pharmacokinetics parameters (peak concentration [C max ] and area under the plasma concentration-versus-time curve) for each participant.
RESULTS
Dapagliflozin C max was 117 and 97.6 ng/ml in the kidney failure and control groups, respectively, whereas the corresponding accumulation ratios were 26.7% and 9.5%. No serious adverse events were reported for either group. Dapagliflozin recovered from dialysate corresponded to 0.10% of the administered dose.
CONCLUSIONS
In patients with kidney failure on dialysis, dapagliflozin was well tolerated, was slightly dialyzable, and had nonaccumulating pharmacokinetic properties.
CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER
Pharmacokinetics and Dialyzability of Dapagliflozin in Dialysis Patients (DARE-ESKD 1), NCT05343078.
Topics: Humans; Hypoglycemic Agents; Diabetes Mellitus, Type 2; Prospective Studies; Peritoneal Dialysis; Renal Dialysis; Renal Insufficiency; Dialysis Solutions
PubMed: 37227937
DOI: 10.2215/CJN.0000000000000196 -
BMC Nephrology Oct 2019This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version...
This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.
Topics: Ambulatory Care Facilities; Anticoagulants; Dialysis Solutions; Humans; Membranes, Artificial; Renal Dialysis; Renal Insufficiency; United Kingdom
PubMed: 31623578
DOI: 10.1186/s12882-019-1527-3 -
Blood Purification 2004The fluid quality description 'ultrapure' means practically free from bacteria and endotoxin. In quantitative terms it is defined as <0.1 CFU/ml and <0.03 EU/ml. The... (Review)
Review
The fluid quality description 'ultrapure' means practically free from bacteria and endotoxin. In quantitative terms it is defined as <0.1 CFU/ml and <0.03 EU/ml. The requirements on endotoxin as well as bacteria should be fulfilled, because these two entities are not strictly correlated. Ultrapure dialysis fluid can be prepared from standard quality fluid by a single step of controlled ultrafiltration. Recent clinical studies demonstrate that the use of ultrapure dialysis fluid in hemodialysis is associated with patient benefits indicating a less inflammatory state compared to hemodialysis with standard fluid. By applying one additional step of controlled ultrafiltration, ultrapure dialysis fluid can be further purified to such high microbiological quality that it can be used for infusion. This opens up the possibility for convective therapies, hemodiafiltration and hemofiltration, for which large volumes of sterile infusion solution are needed. With optimal application of these therapies, solute removal is enhanced, qualitatively as well as quantitatively, and fluid management is facilitated through improved hemodynamic stability.
Topics: Bacteria; Dialysis Solutions; Endotoxins; Humans; Quality Control; Renal Dialysis; Sterilization; Ultrafiltration
PubMed: 15655318
DOI: 10.1159/000081869 -
Advances in Chronic Kidney Disease Mar 2021Home hemodialysis (HHD), performed more frequently than in-center hemodialysis, is underutilized in the United States but has had a recent resurgence driven... (Review)
Review
Home hemodialysis (HHD), performed more frequently than in-center hemodialysis, is underutilized in the United States but has had a recent resurgence driven predominantly by innovative dialysis equipment that is easy to use, less intrusive to the home, and requires less storage space. There are 3 different hemodialysis machines approved for use in the home but currently NxStage™ accounts for the overwhelming majority of HHD patients. Therefore, it is the focus of this article. To minimize storage space in the home, the NxStage platform minimizes the volume of dialysate that is used per treatment. We refer to this method as the Frequent Low Dialysate Volume Approach (FLDVA). The approach to urea removal with the NxStage platform is much different compared to traditional in-center HD. To minimize the volume of dialysate per treatment, and still achieve target urea removal, the dialysate must be highly saturated. In this article, we explain how to increase the saturation of dialysate fluid. We also draw a parallel between urea removal in peritoneal dialysis and NxStage therapy and use that model to estimate an initial HHD prescription and to alter prescriptions when necessary.
Topics: Dialysis Solutions; Hemodialysis, Home; Humans; Kidney Failure, Chronic; Peritoneal Dialysis; Renal Dialysis; United States; Urea
PubMed: 34717862
DOI: 10.1053/j.ackd.2020.09.002 -
Journal of Artificial Organs : the... Mar 2023Hemodialysis is a blood purification method based on solute removal by diffusion and incorporates filtration to improve the efficiency of water removal and removal of... (Review)
Review
Hemodialysis is a blood purification method based on solute removal by diffusion and incorporates filtration to improve the efficiency of water removal and removal of high molecular weight substances. It is now a well-established treatment, due to the improved performance of dialyzers. This review outlines the development process of dialyzers, focusing on the application based on the mathematical analysis. First, phenomena occurring in the vicinity of the dialysis membrane are explained using a film model for diffusion and a gel polarization model for filtration. Then, currently established dialyzer designs are introduced using mathematical analysis. Furthermore, the design of dialyzers to promote internal filtration, the designs of hemodiafilters suitable for online hemodiafiltration (HDF), and the design of compact dialyzer for are also presented.
Topics: Humans; Renal Dialysis; Kidney Failure, Chronic; Hemodiafiltration; Filtration; Dialysis Solutions; Membranes, Artificial
PubMed: 36087159
DOI: 10.1007/s10047-022-01359-8 -
Contributions To Nephrology 2007Sustained low-efficiency dialysis (SLED) is an increasingly popular form of renal replacement therapy for patients with renal failure in the intensive care unit.... (Review)
Review
Sustained low-efficiency dialysis (SLED) is an increasingly popular form of renal replacement therapy for patients with renal failure in the intensive care unit. Advantages of SLED are efficient clearance of small solutes, good hemodynamic tolerability, flexible treatment schedules, and reduced costs. Studies comparing outcomes of SLED with those of other dialysis modalities are being performed.
Topics: Acute Kidney Injury; Blood Coagulation; Blood Pressure; Cost-Benefit Analysis; Critical Care; Dialysis Solutions; Humans; Intensive Care Units; Prognosis; Renal Dialysis
PubMed: 17464142
DOI: 10.1159/000102122 -
Kidney & Blood Pressure Research 2023Hemodialysis is one of the most resources consuming medical intervention. Due to its concept, the proper amount of dialysis fluid passed through dialyzer is crucial to... (Review)
Review
BACKGROUND
Hemodialysis is one of the most resources consuming medical intervention. Due to its concept, the proper amount of dialysis fluid passed through dialyzer is crucial to obtain the expected outcomes. The most frequent source of dialysis fluid is production from liquid concentrate (delivered in containers or plastic bags) in dialysis machine. Alternatively, concentrates for dialysis may be produced in dialysis center by dilution in mixing devices dry or semidry premixed compounds connected with system of central dialysis fluid delivery system. Dialysate consumption depends on various factors like type of hemodialysis machine, session duration, prescribed flow, etc. Summary: Modern hemodialysis machines are equipped with the modules which automatically reduce flow rate of dialysis fluid to the patient blood flow and minimize dialysate consumption during preparation and after reinfusion. Smart using of available options offered by manufacturers allows to save additional portion of acid concentrate and water. The weight of concentrates to be delivered to the dialysis center is the major factor influencing the cost (financial and environmental) of transportation from the manufacturer to the final consumer. The crisis on the energy carriers market and extremely high fuel prices made the transportation cost one of the significant costs of the treatment, which must be bear by supplier and finally influence on the price of goods.
KEY MESSAGES
The careful choice of the concentrate delivery system can improve cost-effectiveness of dialysis. Such solutions implemented in dialysis unit helps make significant savings and decrease the impact on natural environment by carbon footprint reduction.
Topics: Humans; Renal Dialysis; Dialysis Solutions
PubMed: 37166319
DOI: 10.1159/000530439 -
Contributions To Nephrology 2011The process of on-line generation of ultrapure dialysis fluid is a core prerequisite for the safe execution of modern renal replacement therapies such as on-line... (Review)
Review
The process of on-line generation of ultrapure dialysis fluid is a core prerequisite for the safe execution of modern renal replacement therapies such as on-line hemodiafiltration and high-flux hemodialysis. In these extracorporeal treatments with variable degrees of convection, significant volumes of plasma water are removed and replaced with dialysis fluid, which must occur without causing harm to the patient. Historically, on-line generation of sterile and pyrogen-free physiological substitution fluid by the process of membrane ultrafiltration of fresh dialysis fluid has its origin in hemofiltration, a purely convective therapy. Development of this and later therapies is described in the historical context of a successful effort over decades to overcome the above formidable challenge, which was provided jointly by pioneering clinical investigators and a resourceful dialysis industry.
Topics: Dialysis Solutions; Hemodiafiltration; Hemofiltration; History, 20th Century; History, 21st Century; Humans; Renal Dialysis; Renal Insufficiency; Ultrafiltration
PubMed: 22188687
DOI: 10.1159/000333288 -
Revue Medicale Suisse Feb 2016Peritoneal dialysis is a dialysis modality used worldwide. Despite offering several advantages, its prevalence in Switzerland in end stage renal disease population is... (Review)
Review
Peritoneal dialysis is a dialysis modality used worldwide. Despite offering several advantages, its prevalence in Switzerland in end stage renal disease population is dramatically lower than hemodialysis (7.3% vs 92.7% in 2014) although its incidence has recently progressed. Technically, a catheter is inserted into the Douglas' pouch, enabling dialysate to be infused into the peritoneal cavity. The peritoneum acts as a semi-permeable membrane allowing for the removal of toxic substances and excess water. In the following article we will give an overview of peritoneal dialysis including its technical modalities, indications and main advantages as well as its contraindications and complications.
Topics: Contraindications; Dialysis Solutions; Humans; Kidney; Kidney Failure, Chronic; Peritoneal Dialysis; Renal Insufficiency, Chronic; Switzerland
PubMed: 27039607
DOI: No ID Found -
Journal of Nephrology 2013
Review
Topics: Amino Acids; Bicarbonates; Body Weight; Buffers; Creatinine; Dialysis Solutions; Glucans; Glucose; Hemodiafiltration; Humans; Hydrogen-Ion Concentration; Icodextrin; Peritoneal Dialysis; Peritoneal Dialysis, Continuous Ambulatory; Phthalic Acids; Prescriptions; Renal Dialysis; Software
PubMed: 24307441
DOI: 10.5301/JN.2013.11635