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The Cochrane Database of Systematic... Jul 2019Intradialytic hypotension (IDH) is a common complication of haemodialysis (HD), and a risk factor of cardiovascular morbidity and death. Several clinical studies...
BACKGROUND
Intradialytic hypotension (IDH) is a common complication of haemodialysis (HD), and a risk factor of cardiovascular morbidity and death. Several clinical studies suggested that reduction of dialysate temperature, such as fixed reduction of dialysate temperature or isothermal dialysate using a biofeedback system, might improve the IDH rate.
OBJECTIVES
This review aimed to evaluate the benefits and harms of dialysate temperature reduction for IDH among patients with chronic kidney disease requiring HD, compared with standard dialysate temperature.
SEARCH METHODS
We searched Cochrane Kidney and Transplant's Specialised Register up to 14 May 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.
SELECTION CRITERIA
All randomised controlled trials (RCTs), cross-over RCTs, cluster RCTs and quasi-RCTs were included in the review.
DATA COLLECTION AND ANALYSIS
Two authors independently extracted information including participants, interventions, outcomes, methods of the study, and risks of bias. We used a random-effects model to perform quantitative synthesis of the evidence. We assessed the risks of bias for each study using the Cochrane 'Risk of bias' tool. We assessed the certainty of evidence using Grades of Recommendation, Assessment, Development and Evaluation (GRADE).
MAIN RESULTS
We included 25 studies (712 participants). Three studies were parallel RCTs and the others were cross-over RCTs. Nineteen studies compared fixed reduction of dialysate temperature (below 36°C) and standard dialysate temperature (37°C to 37.5°C). Most studies were of unclear or high risk of bias. Compared with standard dialysate, it is uncertain whether fixed reduction of dialysate temperature improves IDH rate (8 studies, 153 participants: rate ratio 0.52, 95% CI 0.34 to 0.80; very low certainty evidence); however, it might increase the discomfort rate compared with standard dialysate (4 studies, 161 participants: rate ratio 8.31, 95% CI 1.86 to 37.12; very low certainty evidence). There were no reported dropouts due to adverse events. No study reported death, acute coronary syndrome or stroke.Three studies compared isothermal dialysate and thermoneutral dialysate. Isothermal dialysate might improve the IDH rate compared with thermoneutral dialysate (2 studies, 133 participants: rate ratio 0.68, 95% CI 0.60 to 0.76; I = 0%; very low certainty evidence). There were no reports of discomfort rate (1 study) or dropouts due to adverse events (2 studies). No study reported death, acute coronary syndrome or stroke.
AUTHORS' CONCLUSIONS
Reduction of dialysate temperature may prevent IDH, but the conclusion is uncertain. Larger studies that measure important outcomes for HD patients are required to assess the effect of reduction of dialysate temperature. Six ongoing studies may provide much-needed high quality evidence in the future.
Topics: Dialysis Solutions; Humans; Hypotension; Randomized Controlled Trials as Topic; Renal Dialysis; Renal Insufficiency, Chronic; Temperature
PubMed: 31273758
DOI: 10.1002/14651858.CD012598.pub2 -
International Urology and Nephrology Jun 2019To provide updated evidence, we conducted a systematic review and meta-analysis to compare citrate lock with heparin in the prevention of hemodialysis catheter-related... (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVE
To provide updated evidence, we conducted a systematic review and meta-analysis to compare citrate lock with heparin in the prevention of hemodialysis catheter-related complications.
METHODS
A systematic review and meta-analysis of randomized controlled trials were obtained by searching PubMed, EMBASE, Ovid, Cochrane library, and the Web of Science databases. Primary outcomes were catheter-related bloodstream infections (CRBI), exit-site infections, bleeding events, catheter removal for poor flow, and thrombolytic treatment. Secondary outcomes were thrombocytopenia, access-related admission, and all-cause mortality.
RESULTS
The meta-analysis showed that the citrate lock containing antimicrobials can reduce the risk of CRBI when compared with heparin lock (RR: 0.34, 95% CI 0.24-0.49; I = 0%; P < 0.00001), and a tunneled cuffed catheter (TCC) was more beneficial for the prevention of CRBI (RR: 0.42, 95% CI 0.25-0.69; I = 40%; P = 0.0007) when compared with non-tunneled cuffed catheters (NTCC). The microbiological correlation analysis suggests that the occurrence of CRBI is closely related to S. aureus in catheters locked by citrate (P = 0.015) rather than by heparin (P = 0.868). In the analysis of exit-site infection, citrate lock with NTCC was more effective in preventing exit-site infection than heparin (RR: 0.48, 95% CI 0.31-0.75; I = 0%; P = 0.001). In addition, the risk of bleeding episodes was reduced in hemodialysis patients using citrate lock with TCC (RR: 0.53, 95% CI 0.32-0.86; I = 0%; P = 0.01) and patients with citrate alone (RR: 0.51, 95% CI 0.30-0.85; I = 12%; P = 0.010). The risk of catheter removal for poor flow (P = 0.91), thrombolytic treatment (P = 0.76), thrombocytopenia (P = 0.37), access-related admission (P = 0.10), and all-cause mortality (P = 0.62) was not significantly different.
CONCLUSIONS
Antimicrobial-containing citrate lock solutions could reduce the risk of CRBI in hemodialysis patients. The occurrence of CRBI is closely related to S. aureus in catheters locked by citrate rather than by heparin. Citrate lock was effective in reducing exit-site infection in NTCC and bleeding events in TCC.
Topics: Anticoagulants; Catheter-Related Infections; Catheters; Central Venous Catheters; Citrates; Heparin; Humans; Randomized Controlled Trials as Topic; Renal Dialysis
PubMed: 31012037
DOI: 10.1007/s11255-019-02150-0 -
Seminars in Dialysis Jul 2019Dialysis adequacy is an independent predictor of high mortality rates in hemodialysis patients. Intradialytic exercise is a potential strategy to increase uremic solute...
Dialysis adequacy is an independent predictor of high mortality rates in hemodialysis patients. Intradialytic exercise is a potential strategy to increase uremic solute removal by increasing blood flow to low perfusion tissue beds. The purpose of this review is to establish the efficacy of intradialytic exercise for hemodialysis adequacy. Additionally, this review aims to provide practical information to aid health care professionals implement intradialytic exercise for dialysis adequacy. Database and hand searches identified 15 published interventional studies that implemented intradialytic exercise for dialysis adequacy as a primary outcome measure in adult maintenance hemodialysis patients. Data pertaining to dialytic solute clearance of urea, creatinine, beta microglobulin, phosphate, and potassium were extracted. Mean differences, normalized to percentages, and effect sizes were calculated and reported. The current data pertaining to the use of intradialytic exercise for improving dialysis adequacy in terms of Kt/V or small molecule uremic toxin clearance are equivocal. Limited data showed that intradialytic exercise has no effect middle molecule toxin (beta - microglobulin) clearance. Intradialytic exercise favored increased phosphate removal showing medium to large effects for reduced serum concentrations, reduced rebound and increased clearance. In summary, supervised light to moderate intradialytic aerobic cycling appears to be beneficial for increasing phosphate removal and may be an adjunct therapy for patients failing to meet clinical phosphate targets. Further work is required to establish the effect of intradialytic exercise on Kt/V and other middle molecule and protein bound solutes. Research aimed at establishing the most effective exercise prescription for improved solute clearance is warranted.
Topics: Aged; Combined Modality Therapy; Creatinine; Dialysis Solutions; Exercise Therapy; Female; Glomerular Filtration Rate; Humans; Kidney Failure, Chronic; Kidney Function Tests; Male; Middle Aged; Prognosis; Quality of Life; Renal Dialysis; Risk Assessment; Treatment Outcome; Urea; Uremia
PubMed: 30968465
DOI: 10.1111/sdi.12785 -
The Cochrane Database of Systematic... Jan 2019Cardiovascular (CV) disease is the leading cause of death in dialysis patients, and strongly associated with fluid overload and hypertension. It is plausible that low... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cardiovascular (CV) disease is the leading cause of death in dialysis patients, and strongly associated with fluid overload and hypertension. It is plausible that low dialysate [Na+] may decrease total body sodium content, thereby reducing fluid overload and hypertension, and ultimately reducing CV morbidity and mortality.
OBJECTIVES
This review evaluated harms and benefits of using a low (< 138 mM) dialysate [Na+] for maintenance haemodialysis (HD) patients.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Register of Studies up to 7 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.
SELECTION CRITERIA
Randomised controlled trials (RCTs), both parallel and cross-over, of low (< 138 mM) versus neutral (138 to 140 mM) or high (> 140 mM) dialysate [Na+] for maintenance HD patients were included.
DATA COLLECTION AND ANALYSIS
Two investigators independently screened studies for inclusion and extracted data. Statistical analyses were performed using random effects models, and results expressed as risk ratios (RR) for dichotomous outcomes, and mean differences (MD) or standardised MD (SMD) for continuous outcomes, with 95% confidence intervals (CI). Confidence in the evidence was assessed using GRADE.
MAIN RESULTS
We included 12 studies randomising 310 patients, with data available for 266 patients after dropout. All but one study evaluated a fixed concentration of low dialysate [Na+], and one profiled dialysate [Na+]. Three studies were parallel group, and the remaining nine cross-over. Of the latter, only two used a washout between intervention and control periods. Most studies were short-term with a median (interquartile range) follow-up of 3 (3, 8.5) weeks. Two were of a single HD session, and two of a single week's HD. Half of the studies were conducted prior to 2000, and five reported use of obsolete HD practices. Risks of bias in the included studies were often high or unclear, lowering confidence in the results.Compared to neutral or high dialysate [Na+], low dialysate [Na+] had the following effects on "efficacy" endpoints: reduced interdialytic weight gain (10 studies: MD -0.35 kg, 95% CI -0.18 to -0.51; high certainty evidence); probably reduced predialysis mean arterial blood pressure (BP) (4 studies: MD -3.58 mmHg, 95% CI -5.46 to -1.69; moderate certainty evidence); probably reduced postdialysis mean arterial BP (MAP) (4 studies: MD -3.26 mmHg, 95% CI -1.70 to -4.82; moderate certainty evidence); probably reduced predialysis serum [Na+] (7 studies: MD -1.69 mM, 95% CI -2.36 to -1.02; moderate certainty evidence); may have reduced antihypertensive medication (2 studies: SMD -0.67 SD, 95% CI -1.07 to -0.28; low certainty evidence). Compared to neutral or high dialysate [Na+], low dialysate [Na+] had the following effects on "safety" endpoints: probably increased intradialytic hypotension events (9 studies: RR 1.56, 95% 1.17 to 2.07; moderate certainty evidence); probably increased intradialytic cramps (6 studies: RR 1.77, 95% 1.15 to 2.73; moderate certainty evidence).Compared to neutral or high dialysate [Na+], low dialysate [Na+] may make little or no difference to: intradialytic BP (2 studies: MD for systolic BP -3.99 mmHg, 95% CI -17.96 to 9.99; diastolic BP 1.33 mmHg, 95% CI -6.29 to 8.95; low certainty evidence); interdialytic BP (2 studies:, MD for systolic BP 0.17 mmHg, 95% CI -5.42 to 5.08; diastolic BP -2.00 mmHg, 95% CI -4.84 to 0.84; low certainty evidence); dietary salt intake (2 studies: MD -0.21g/d, 95% CI -0.48 to 0.06; low certainty evidence).Due to very low quality of evidence, it is uncertain whether low dialysate [Na+] changed extracellular fluid status, venous tone, arterial vascular resistance, left ventricular mass or volumes, thirst or fatigue. Studies did not examine cardiovascular or all-cause mortality, cardiovascular events, or hospitalisation.
AUTHORS' CONCLUSIONS
It is likely that low dialysate [Na+] reduces intradialytic weight gain and BP, which are effects directionally associated with improved outcomes. However, the intervention probably also increases intradialytic hypotension and reduces serum [Na+], effects that are associated with increased mortality risk. The effect of the intervention on overall patient health and well-being is unknown. Further evidence is needed in the form of longer-term studies in contemporary settings, evaluating end-organ effects in small-scale mechanistic studies using optimal methods, and clinical outcomes in large-scale multicentre RCTs.
Topics: Antihypertensive Agents; Blood Pressure; Dialysis Solutions; Humans; Hypertension; Hypotension; Muscle Cramp; Randomized Controlled Trials as Topic; Renal Dialysis; Sodium; Weight Gain
PubMed: 30646428
DOI: 10.1002/14651858.CD011204.pub2 -
The Cochrane Database of Systematic... Oct 2018Biocompatible peritoneal dialysis (PD) solutions, including neutral pH, low glucose degradation product (GDP) solutions and icodextrin, have previously been shown to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Biocompatible peritoneal dialysis (PD) solutions, including neutral pH, low glucose degradation product (GDP) solutions and icodextrin, have previously been shown to favourably influence some patient-level outcomes, albeit based on generally sub-optimal quality studies. Several additional randomised controlled trials (RCT) evaluating biocompatible solutions in PD patients have been published recently. This is an update of a review first published in 2014.
OBJECTIVES
This review aimed to look at the benefits and harms of biocompatible PD solutions in comparison to standard PD solutions in patients receiving PD.
SEARCH METHODS
The Cochrane Kidney and Transplant Specialised Register was searched up to 12 February 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register Search Portal and ClinicalTrials.gov.
SELECTION CRITERIA
All RCTs and quasi-RCTs in adults and children comparing the effects of biocompatible PD solutions (neutral pH, lactate-buffered, low GDP; neutral pH, bicarbonate(± lactate)-buffered, low GDP; glucose polymer (icodextrin)) in PD were included. Studies of amino acid-based solutions were excluded.
DATA COLLECTION AND ANALYSIS
Two authors extracted data on study quality and outcomes. Summary effect estimates were obtained using a random-effects model, and results were expressed as risk ratios and 95% confidence intervals (CI) for categorical variables, and mean differences (MD) or standardised mean differences (SMD) and 95% CI for continuous variables.
MAIN RESULTS
This review update included 42 eligible studies (3262 participants), including six new studies (543 participants). Overall, 29 studies (1971 participants) compared neutral pH, low GDP PD solution with conventional PD solution, and 13 studies (1291 participants) compared icodextrin with conventional PD solution. Risk of bias was assessed as high for sequence generation in three studies, allocation concealment in three studies, attrition bias in 21 studies, and selective outcome reporting bias in 16 studies.Neutral pH, low GDP versus conventional glucose PD solutionUse of neutral pH, low GDP PD solutions improved residual renal function (RRF) preservation (15 studies, 835 participants: SMD 0.19, 95% CI 0.05 to 0.33; high certainty evidence). This approximated to a mean difference in glomerular filtration rate of 0.54 mL/min/1.73 m (95% CI 0.14 to 0.93). Better preservation of RRF was evident at all follow-up durations with progressively greater preservation observed with increasing follow up duration. Neutral pH, low GDP PD solution use also improved residual urine volume preservation (11 studies, 791 participants: MD 114.37 mL/day, 95% CI 47.09 to 181.65; high certainty evidence). In low certainty evidence, neutral pH, low GDP solutions may make little or no difference to 4-hour peritoneal ultrafiltration (9 studies, 414 participants: SMD -0.42, 95% CI -0.74 to -0.10) which approximated to a mean difference in peritoneal ultrafiltration of 69.72 mL (16.60 to 122.00 mL) lower, and may increase dialysate:plasma creatinine ratio (10 studies, 746 participants: MD 0.01, 95% CI 0.00 to 0.03), technique failure or death compared with conventional PD solutions. It is uncertain whether neutral pH, low GDP PD solution use led to any differences in peritonitis occurrence, hospitalisation, adverse events (6 studies, 519 participants) or inflow pain (1 study, 58 participants: RR 0.51, 95% CI 0.24 to 1.08).Glucose polymer (icodextrin) versus conventional glucose PD solutionIn moderate certainty evidence, icodextrin probably reduced episodes of uncontrolled fluid overload (2 studies, 100 participants: RR 0.30, 95% CI 0.15 to 0.59) and augmented peritoneal ultrafiltration (4 studies, 102 participants: MD 448.54 mL/d, 95% CI 289.28 to 607.80) without compromising RRF (4 studies, 114 participants: SMD 0.12, 95% CI -0.26 to 0.49; low certainty evidence) which approximated to a mean creatinine clearance of 0.30 mL/min/1.73m higher (0.65 lower to 1.23 higher) or urine output (3 studies, 69 participants: MD -88.88 mL/d, 95% CI -356.88 to 179.12; low certainty evidence). It is uncertain whether icodextrin use led to any differences in adverse events (5 studies, 816 participants) technique failure or death.
AUTHORS' CONCLUSIONS
This updated review strengthens evidence that neutral pH, low GDP PD solution improves RRF and urine volume preservation with high certainty. These effects may be related to increased peritoneal solute transport and reduced peritoneal ultrafiltration, although the evidence for these outcomes is of low certainty due to significant heterogeneity and suboptimal methodological quality. Icodextrin prescription increased peritoneal ultrafiltration and mitigated uncontrolled fluid overload with moderate certainty. The effects of either neutral pH, low GDP solution or icodextrin on peritonitis, technique survival and patient survival remain uncertain and require further high quality, adequately powered RCTs.
Topics: Adult; Bicarbonates; Child; Dialysis Solutions; Glucose; Humans; Hydrogen-Ion Concentration; Icodextrin; Kidney; Peritoneal Dialysis; Peritoneum; Pharmaceutical Solutions; Randomized Controlled Trials as Topic; Urine
PubMed: 30362116
DOI: 10.1002/14651858.CD007554.pub3 -
American Journal of Therapeutics 2020Intradialytic hypotension (IDH) is one of the most common complications of the hemodialysis procedure. Although there are no clear-cut answers as to the best strategy on...
BACKGROUND, AREAS OF UNCERTAINTY
Intradialytic hypotension (IDH) is one of the most common complications of the hemodialysis procedure. Although there are no clear-cut answers as to the best strategy on the management of IDH, data suggest that the administration of osmotically active drugs may decrease the occurrence of blood pressure decline during dialysis. The use of mannitol for IDH management in hemodialysis patients is scarce. This article highlights the use and benefits of mannitol and to assess the role of mannitol role in the management of IDH.
DATA SOURCES
Primary literature identified through MEDLINE/PubMed database and Google Scholar with no restrictions. Relevant and current literatures related to mannitol and IDH were used.
RESULTS AND DATA SYNTHESIS
Multiple studies have shown the benefits of mannitol for the management of IDH. Because of its oncotic effect, mannitol increases plasma osmolality to maintain adequate blood pressure and prevent the occurrence of IDH. Two observational studies and several reports were identified as being the most recent and applicable to clinical practice. Studies and data on the use of mannitol in IDH are scarce or outdated. The 2 studies used in this article conclude that mannitol carries benefits for both the adult and pediatric population. However, additional research in the future will be needed to confirm the evidence for various age groups. These 2 observational trials were also very small in number, and any future studies conducted should have a longer duration and larger population size. Although lacking data, these studies will suffice in introducing the benefits of mannitol in IDH.
CONCLUSIONS
Mannitol may be considered for the management of IDH; however, additional studies are required to evaluate the long-term risk and benefits associated with mannitol, as it carries a risk of accumulation in the body.
Topics: Blood Pressure; Humans; Hypertonic Solutions; Hypotension; Kidney Failure, Chronic; Mannitol; Observational Studies as Topic; Osmolar Concentration; Practice Guidelines as Topic; Renal Dialysis; Treatment Outcome
PubMed: 30272595
DOI: 10.1097/MJT.0000000000000855 -
The Cochrane Database of Systematic... Apr 2018Patients undergoing haemodialysis (HD) through a central venous catheter (CVC) are exposed to several risks, being a catheter-related infection (CRI) and a CVC lumen... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Patients undergoing haemodialysis (HD) through a central venous catheter (CVC) are exposed to several risks, being a catheter-related infection (CRI) and a CVC lumen thrombosis among the most serious. Standard of care regarding CVCs includes their sealing with heparin lock solutions to prevent catheter lumen thrombosis. Other lock solutions to prevent CRI, such as antimicrobial lock solutions, have proven useful with antibiotics solutions, but not as yet for non-antibiotic antimicrobial solutions. Furthermore, it is uncertain if these solutions have a negative effect on thrombosis incidence.
OBJECTIVES
To assess the efficacy and safety of antimicrobial (antibiotic, non-antibiotic, or both) catheter lock solutions for preventing CRI in participants undergoing HD with a CVC.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Specialised Register up to 18 December 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.
SELECTION CRITERIA
We included all randomised or quasi-randomised control trials (RCTs) comparing antimicrobial (antibiotic and non-antibiotic) lock solutions to standard lock solutions, in participants using a CVC for HD, without language restriction.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed studies for eligibility, and two additional authors assessed for risk of bias and extracted data. We expressed results as rate ratios (RR) per 1000 catheter-days or 1000 dialysis sessions with 95% confidence intervals (CI). Statistical analyses were performed using the random-effects model.
MAIN RESULTS
Thirty-nine studies, enrolling 4216 participants, were included in this review, however only 30 studies, involving 3392 participants, contained enough data to be meta-analysed. Risk of bias was low or unclear for most domains in the majority of the included studies.Studies compared antimicrobial lock solutions (antibiotic and non-antibiotic) to standard sealing solutions (usually heparin) of the CVC for HD. Fifteen studies used antibiotic lock solutions, 21 used non-antibiotic antimicrobial lock solutions, and 4 used both (antibiotic and non-antibiotic) lock solutions. Studies reported the incidence of CRI, catheter thrombosis, or both.Antimicrobial lock solutions probably reduces CRI per 1000 catheter-days (27 studies: RR 0.38, 95% CI 0.27 to 0.53; I = 54%; low certainty evidence), however antimicrobial lock solutions probably makes little or no difference to the risk of thrombosis per 1000 catheter days (14 studies: RR 0.79, 95% CI 0.52 to 1.22; I = 83%; very low certainty evidence). Subgroup analysis of antibiotic and the combination of both lock solutions showed that both probably reduced CRI per 1000 catheter-days (13 studies: RR 0.30, 95% CI: 0.22 to 0.42; I = 47%) and risk of thrombosis per 1000 catheter-days (4 studies: RR 0.26, 95% CI: 0.14 to 0.49; I = 0%), respectively. Non-antibiotic antimicrobial lock solutions probably reduced CRI per 1000 catheter-days for tunnelled CVC (9 studies: RR 0.60, 95% CI 0.40 to 0.91) but probably made little or no difference with non-tunnelled CVC (4 studies: RR 0.93, 95% CI 0.48 to 1.81). Subgroup analyses showed that antibiotic (5 studies: RR 0.76, 95% CI 0.42 to 1.38), non-antibiotic (8 studies: RR 0.85, 95% CI 0.44 to 1.66), and the combination of both lock solutions (3 studies: RR 0.63, 95% CI 0.22 to 1.81) made little or no difference to thrombosis per 1000 catheter-days compared to control lock solutions.
AUTHORS' CONCLUSIONS
Antibiotic antimicrobial and combined (antibiotic-non antibiotic) lock solutions decreased the incidence of CRI compared to control lock solutions, whereas non-antibiotic lock solutions reduce CRI only for tunnelled CVC. The effect on thrombosis incidence is uncertain for all antimicrobial lock solutions. Our confidence in the evidence is low and very low; therefore, better-designed studies are needed to confirm the efficacy and safety of antimicrobial lock solutions.
Topics: Anti-Bacterial Agents; Anti-Infective Agents; Anticoagulants; Catheter-Related Infections; Catheterization, Central Venous; Heparin; Humans; Incidence; Randomized Controlled Trials as Topic; Renal Dialysis; Venous Thrombosis
PubMed: 29611180
DOI: 10.1002/14651858.CD010597.pub2 -
Scientific Reports Mar 2018Hypercalcemia and hyperparathyroidism in patients receiving maintenance hemodialysis (MHD) can cause the progression of cardiovascular diseases (CVD) and mineral bone... (Meta-Analysis)
Meta-Analysis
Hypercalcemia and hyperparathyroidism in patients receiving maintenance hemodialysis (MHD) can cause the progression of cardiovascular diseases (CVD) and mineral bone disorders (MBD). The KDIGO recommends the dialysates with a calcium (Ca) concentration of 1.25-1.5 mmol/L for MHD treatments, but the optimal concentration remains controversial. Here, we conducted a systematic review and a meta-analysis of seven randomized controlled trials examining a total of 622 patients to investigate the optimal concentration for MHD for 6 months or longer. The dialysates with a low Ca concentration (1.125 or 1.25 mmol/L) significantly lowered the serum Ca and raised the intact parathyroid hormone levels by 0.52 mg/dL (95% confidence interval, 0.20-0.85) and 39.59 pg/mL (14.80-64.38), respectively, compared with a high Ca concentration (1.50 or 1.75 mmol/L). Three studies showed that a low concentration was preferred for lowering arterial calcifications or atherosclerosis in different arteries, but one study showed that coronary arterial calcifications increased with a low concentration. Two studies showed contradictory outcomes in terms of MBD. Our meta-analysis showed that a dialysate with a low Ca concentration lowered the serum Ca levels in patients receiving long-term MHD, but further studies are needed to determine the optimal Ca concentration in terms of CVD and MBD.
Topics: Bone Diseases; Calcium; Cardiovascular Diseases; Dialysis Solutions; Hemodialysis Solutions; Humans; Hypercalcemia; Hyperparathyroidism; Parathyroid Hormone; Phosphates; Randomized Controlled Trials as Topic; Renal Dialysis
PubMed: 29593281
DOI: 10.1038/s41598-018-23658-y -
Critical Care (London, England) Feb 2018Hemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease... (Review)
Review
BACKGROUND
Hemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effectiveness of RRT-related interventions for reducing HIRRT in such patients across RRT modalities.
METHODS
A systematic review of publications was undertaken using MEDLINE, MEDLINE in Process, EMBASE, and Cochrane's Central Registry for Randomized Controlled Trials (RCTs). Studies that assessed any intervention's effect on HIRRT (the primary outcome) in critically ill patients with AKI were included. HIRRT was variably defined according to each study's definition. Two reviewers independently screened abstracts, identified articles for inclusion, extracted data, and evaluated study quality using validated assessment tools.
RESULTS
Five RCTs and four observational studies were included (n = 9; 623 patients in total). Studies were small, and the quality was mostly low. Interventions included dialysate sodium modeling (n = 3), ultrafiltration profiling (n = 2), blood volume (n = 2) and temperature control (n = 3), duration of RRT (n = 1), and slow blood flow rate at initiation (n = 1). Some studies applied more than one strategy simultaneously (n = 5). Interventions shown to reduce HIRRT from three studies (two RCTs and one observational study) included higher dialysate sodium concentration, lower dialysate temperature, variable ultrafiltration rates, or a combination of strategies. Interventions not found to have an effect included blood volume and temperature control, extended duration of intermittent RRT, and slower blood flow rates during continuous RRT initiation. How HIRRT was defined and its frequency of occurrence varied widely across studies, including those involving the same RRT modality. Pooled analysis was not possible due to study heterogeneity.
CONCLUSIONS
Small clinical studies suggest that higher dialysate sodium, lower temperature, individualized ultrafiltration rates, or a combination of these strategies may reduce the risk of HIRRT. Overall, for all RRT modalities, there is a paucity of high-quality data regarding interventions to reduce the occurrence of HIRRT in critically ill patients.
Topics: Acute Kidney Injury; Critical Illness; Dialysis Solutions; Hemodynamics; Humans; Renal Replacement Therapy
PubMed: 29467008
DOI: 10.1186/s13054-018-1965-5 -
Nutrients Dec 2017End-stage kidney disease is a strong risk factor for cardiovascular-specific mortality. Polyphenol-rich interventions may attenuate cardiovascular disease risk factors;... (Meta-Analysis)
Meta-Analysis Review
End-stage kidney disease is a strong risk factor for cardiovascular-specific mortality. Polyphenol-rich interventions may attenuate cardiovascular disease risk factors; however, this has not been systematically evaluated in the hemodialysis population. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the following databases were searched: Cochrane Library (http://www.cochranelibrary.com/), MEDLINE (https://health.ebsco.com/products/medline-with-full-text), Embase (https://www.elsevier.com/solutions/embase-biomedical-research), and CINAHL (https://www.ebscohost.com/nursing/products/cinahl-databases/cinahl-complete). Meta-analyses were conducted for measures of lipid profile, inflammation, oxidative stress, and blood pressure. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias tool and quality of the body of evidence was assessed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Twelve studies were included for review. Polyphenol-rich interventions included soy, cocoa, pomegranate, grape, and turmeric. Polyphenol-rich interventions significantly improved diastolic blood pressure (Mean Difference (MD) -5.62 mmHg (95% Confidence Interval (CI) -8.47, -2.78); ² = 2%; = 0.0001), triglyceride levels (MD -26.52 mg/dL (95% CI -47.22, -5.83); ² = 57%; = 0.01), and myeloperoxidase (MD -90.10 (95% CI -135.84, -44.36); ² = 0%; = 0.0001). Included studies generally had low or unclear risks of bias. The results of this review provide preliminary support for the use of polyphenol-rich interventions for improving cardiovascular risk markers in haemodialysis patients. Due to the limited number of studies for individual polyphenol interventions, further studies are required to provide recommendations regarding individual polyphenol intervention and dose.
Topics: Biomarkers; Blood Pressure; Cardiovascular Diseases; Combined Modality Therapy; Curcuma; Diet Therapy; Humans; Kidney Failure, Chronic; Lythraceae; Peroxidase; Polyphenols; Renal Dialysis; Risk Factors; Soy Foods; Triglycerides; Vitis
PubMed: 29232891
DOI: 10.3390/nu9121345