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Journal of Artificial Organs : the... Jun 2024Excessive albumin losses during HC (haemocatharsis) are considered a potential cause of hypoalbuminemia-a key risk factor for mortality. This review on total albumin... (Review)
Review
Excessive albumin losses during HC (haemocatharsis) are considered a potential cause of hypoalbuminemia-a key risk factor for mortality. This review on total albumin losses considers albumin "leaking" into the dialysate and losses due to protein/membrane interactions (i.e. adsorption, "secondary membrane formation" and denaturation). The former are fairly easy to determine, usually varying at the level of ~ 2 g to ~ 7 g albumin loss per session. Such values, commonly accepted as representative of the total albumin losses, are often quoted as limits/standards of permissible albumin loss per session. On albumin mass lost due to adsorption/deposition, which is the result of complicated interactions and rather difficult to determine, scant in vivo data exist and there is great uncertainty and confusion regarding their magnitude; this is possibly responsible for neglecting their contribution to the total losses at present. Yet, many relevant in vitro studies suggest that losses of albumin due to protein/membrane interactions are likely comparable to (or even greater than) those due to leaking, particularly in the currently favoured high-convection HDF (haemodiafiltration) treatment. Therefore, it is emphasised that top research priority should be given to resolve these issues, primarily by developing appropriate/facile in vivo test-methods and related analytical techniques.
Topics: Humans; Dialysis Solutions; Hemodiafiltration; Hypoalbuminemia; Renal Dialysis; Serum Albumin
PubMed: 38238597
DOI: 10.1007/s10047-023-01430-y -
ClinicoEconomics and Outcomes Research... 2024Approximately 24% of hospitalized stage 2-3 acute kidney injury (AKI) patients will develop persistent severe AKI (PS-AKI), defined as KDIGO stage 3 AKI lasting ≥3...
BACKGROUND
Approximately 24% of hospitalized stage 2-3 acute kidney injury (AKI) patients will develop persistent severe AKI (PS-AKI), defined as KDIGO stage 3 AKI lasting ≥3 days or with death in ≤3 days or stage 2 or 3 AKI with dialysis in ≤3 days, leading to worse outcomes and higher costs. There is currently no consensus on an intervention that effectively reverts the course of AKI and prevents PS-AKI in the population with stage 2-3 AKI. This study explores the cost-utility of biomarkers predicting PS-AKI, under the assumption that such intervention exists by comparing C-C motif chemokine ligand 14 (CCL14) to hospital standard of care (SOC) alone.
METHODS
The analysis combined a 90-day decision tree using CCL14 operating characteristics to predict PS-AKI and clinical outcomes in 66-year-old patients, and a Markov cohort estimating lifetime costs and quality-adjusted life years (QALYs). Cost and QALYs from admission, 30-day readmission, intensive care, dialysis, and death were compared. Clinical and cost inputs were informed by a large retrospective cohort of US hospitals in the PINC AI Healthcare Database. Inputs and assumptions were challenged in deterministic and probabilistic sensitivity analyses. Two-way analyses were used to explore the efficacy and costs of an intervention preventing PS-AKI.
RESULTS
Depending on selected costs and early intervention efficacy, CCL14-directed care led to lower costs and more QALYs (dominating) or was cost-effective at the $50,000/QALY threshold. Assuming the intervention would avoid 10% of PS-AKI complications in AKI stage 2-3 patients identified as true positive resulted in 0.066 additional QALYs and $486 reduced costs. Results were robust to substantial parameter variation.
CONCLUSION
The analysis suggests that in the presence of an efficacious intervention preventing PS-AKI, identifying people at risk using CCL14 in addition to SOC is likely to represent a cost-effective use of resources.
PubMed: 38235419
DOI: 10.2147/CEOR.S434971 -
Clinical Kidney Journal Jan 2024We require a clinicopathological risk stratification method for immunoglobulin A nephropathy (IgAN) to predict kidney outcomes. We examined a renal failure risk group...
BACKGROUND
We require a clinicopathological risk stratification method for immunoglobulin A nephropathy (IgAN) to predict kidney outcomes. We examined a renal failure risk group (RF-RG) classification system created following a prior multicentre, retrospective study to determine if RF-RG could predict kidney outcomes.
METHODS
We collected data from Japanese patients with IgAN registered between 1 April 2005 and 31 August 2015. The primary outcome was a composite 50% increase in serum creatinine from baseline or dialysis induction. The secondary outcomes were times to proteinuria remission (ProR) and haematuria remission (HemR).
RESULTS
The enrolled 991 patients from 44 facilities were followed for a median of 5.5 years (interquartile range 2.5-7.5), during which 87 composite events (8.8%) occurred. RF-RG was significantly associated with the primary outcome {hazard ratio [HR] II 2.78 [95% confidence interval (CI) 1.12-6.93], III 7.15 (2.90-17.6), IV 33.4 (14.1-79.0), I as a reference, < .001}.The discrimination performance was good [C-statistic 0.81 (95% CI 0.76-0.86)] and the time-dependent C-statistics exceeded 0.8 over 10 years. Among the 764 patients with proteinuria and 879 patients with haematuria at baseline, 515 and 645 patients showed ProR and HemR, respectively. ProR was significantly less frequent in patients with advanced disease [subdistribution HR: II 0.79 (95% CI 0.67-0.94), III 0.53 (0.41-0.66), IV 0.15 (0.09-0.23), I as a reference, < .001]. We also observed an association between HemR and RF-RG.
CONCLUSIONS
RF-RG demonstrated good predictive ability for kidney outcomes.
PubMed: 38213485
DOI: 10.1093/ckj/sfad294 -
Nefrologia 2023
Topics: Humans; Renal Dialysis; Hemodiafiltration; Albumins; Dialysis Solutions
PubMed: 38212172
DOI: 10.1016/j.nefroe.2024.01.003 -
Renal Failure Dec 2024Citrate dialysate (CD) has been successfully used in conventional hemodialysis and continuous renal replacement therapy; however, no study has compared pre- and...
BACKGROUND
Citrate dialysate (CD) has been successfully used in conventional hemodialysis and continuous renal replacement therapy; however, no study has compared pre- and post-dilution online hemodiafiltration (oL-HDF). Therefore, we aimed to investigate the efficacy of citrate anticoagulation for oL-HDF and the metabolic changes and quality of life of patients on hemodialysis treated using both modes.
METHOD
Eight dialysis patients were treated with CD containing 0.8 mmol of citric acid for 4 weeks in each phase. Visual clotting scores were investigated as the primary endpoints. Adequacy of dialysis, laboratory parameters, and quality of life were measured as secondary objectives.
RESULTS
The mean clotting scores in the pre-dilution mode were significantly lower than those in the post-dilution mode and in all phases except the heparin-free phase ( < 0.001 in the baseline phase, = 0.001 in phase 1, and = 0.023 in phase 2). The values of Kt/V in both modalities were comparable except during the baseline phase, in which the values of pre-dilution were significantly greater than post-dilution (2.36 ± 0.52/week vs. 1.87 ± 0.33/week;95% CI -0.81 to -0.19, = 0.002). The patient's quality of life regarding their physical activity level was significantly higher in the post-dilution mode than in the pre-dilution mode at baseline and in phase 1 ( = 0.014 and 0.004 at baseline and in phase 1, respectively). Metabolic changes did not differ between the two modes.
CONCLUSION
Citrate dialysate decreased or prevented anticoagulation in both pre- and post-dilution modes of oL-HDF without significant side effects and had comparable adequacy of dialysis.
Topics: Humans; Hemodiafiltration; Renal Dialysis; Citric Acid; Dialysis Solutions; Quality of Life; Citrates; Anticoagulants
PubMed: 38189095
DOI: 10.1080/0886022X.2024.2302109 -
JAMA Network Open Jan 2024The decision of when to start maintenance hemodialysis may be affected by health system-level support for high-intensity care as manifested by area dialysis facility...
IMPORTANCE
The decision of when to start maintenance hemodialysis may be affected by health system-level support for high-intensity care as manifested by area dialysis facility density. Yet an association between early hemodialysis initiation and higher area density of dialysis facilities has not been shown.
OBJECTIVE
To examine whether there is an association between area dialysis facility density and earlier dialysis initiation.
DESIGN, SETTING, AND PARTICIPANTS
Cross-sectional analysis was conducted of publicly reported claims and geographic-based population data collected in the Medical Evidence files of the US Renal Data System (USRDS), a comprehensive registry of all patients initiating hemodialysis in the US, from calendar years 2011 through 2019. Data were linked to the American Community Survey, using residential zip codes, and then to health service area (HSA) primary care and hospitalization benchmarks, using the Dartmouth Atlas crosswalk. Data were analyzed from November 1, 2021, to August 31, 2023.
EXPOSURE
Dialysis facility density at the level of HSA (number of dialysis facilities per 100 000 HSA residents) split into 5 categories.
MAIN OUTCOMES AND MEASURES
The odds of hemodialysis initiation at an estimated glomerular filtration rate (eGFR) greater than 10 mL/min/1.73 m2 vs less than or equal to 10 mL/min/1.73 m2.
RESULTS
Hemodialysis was initiated in a total of 844 466 individuals at 3397 HSAs at a mean (SD) eGFR of 8.9 (3.8) mL/min/1.73 m2. Their mean (SD) age was 63.5 (14.7) years, and 484 346 participants (57.4%) were men. In the HSA category with the highest facility density, individuals were younger (63.3 vs 65.2 years in least-dense HSAs), poorer (mean percent of households living in poverty, 10.4% vs 8.4%), and more commonly had a higher percentage of Black individuals (40.6% vs 11.3%). More individuals in the dialysis-dense HSAs than least-dense HSAs had diabetes (60.1% vs 58.5%) and fewer had access to predialysis nephrology care (60.8% vs 64.1%); the rates of heart failure and immobility varied, but not in a consistent pattern, by HSA dialysis density. The mean (SD) facility density was 4.1 (1.89) centers per 100 000 population in the most dialysis-dense HSAs. Compared with patients in HSAs with a mean of 1.0 per 100 000 population, the odds of hemodialysis initiation at eGFR greater than 10 mL/min/1.73 m2 were 1.07 (95% CI, 1.03-1.11) for patients in the densest HSAs, and compared with HSAs with 0 facilities, the odds of early hemodialysis initiation were 1.06 (95% CI, 1.02-1.10) for patients in the densest HSAs.
CONCLUSIONS AND RELEVANCE
In this cross-sectional study of USRDS- and HSA-level data, HSA dialysis density was associated with early hemodialysis initiation.
Topics: Male; Humans; Middle Aged; Female; Renal Dialysis; Cross-Sectional Studies; Kidney Failure, Chronic; Kidney; Catchment Area, Health
PubMed: 38170525
DOI: 10.1001/jamanetworkopen.2023.50009 -
Antioxidants (Basel, Switzerland) Nov 2023In this study, bile acid-based vesicles and nanoparticles (i.e., bilosomes and biloparticles) are studied to improve the water solubility of lipophilic drugs....
In this study, bile acid-based vesicles and nanoparticles (i.e., bilosomes and biloparticles) are studied to improve the water solubility of lipophilic drugs. Ursodeoxycholic acid, sodium cholate, sodium taurocholate and budesonide were used as bile acids and model drugs, respectively. Bilosomes and biloparticles were prepared following standard protocols with minor changes, after a preformulation study. The obtained systems showed good encapsulation efficiency and dimensional stability. Particularly, for biloparticles, the increase in encapsulation efficiency followed the order ursodeoxycholic acid < sodium cholate < sodium taurocholate. The in vitro release of budesonide from both bilosytems was performed by means of dialysis using either a nylon membrane or a portion of Wistar rat small intestine and two receiving solutions (i.e., simulated gastric and intestinal fluids). Both in gastric and intestinal fluid, budesonide was released from bilosystems more slowly than the reference solution, while biloparticles showed a significant improvement in the passage of budesonide into aqueous solution. Immunofluorescence experiments indicated that ursodeoxycholic acid bilosomes containing budesonide are effective in reducing the inflammatory response induced by glucose oxidase stimuli and counteract ox-inflammatory damage within intestinal cells.
PubMed: 38136145
DOI: 10.3390/antiox12122025 -
BMC Nephrology Dec 2023Peritoneal dialysis (PD) is an essential lifesaving treatment for end-stage renal disease. However, PD therapy is limited by peritoneal inflammation, which leads to...
BACKGROUND
Peritoneal dialysis (PD) is an essential lifesaving treatment for end-stage renal disease. However, PD therapy is limited by peritoneal inflammation, which leads to peritoneal membrane failure because of progressive peritoneal deterioration. Peritonitis is the most common complication in patients undergoing PD. Thus, elucidating the mechanism of chronic peritoneal inflammation after PD-associated peritonitis is an urgent issue for patients undergoing PD. This first case report suggests that an increased interleukin-1β (IL-1β) expression in the peritoneal dialysate after healing of peritonitis can contribute to peritoneal deterioration.
CASE PRESENTATION
A 64-year-old woman was diagnosed with diabetes mellitus 10 years ago and had been started on PD for end-stage renal disease. One day, the patient developed PD-associated acute peritonitis and was admitted to our hospital for treatment. Thus, treatment with antimicrobial agents was initiated for PD-associated peritonitis. Dialysate turbidity gradually disappeared after treatment with antimicrobial agents, and the number of cells in the PD fluid decreased. After 2 weeks of antimicrobial therapy, peritonitis was clinically cured, and the patient was discharged. Thereafter, the patient did not develop peritonitis; however, residual renal function tended to decline, and peritoneal function also decreased in a relatively short period. We evaluated pro-inflammatory cytokine levels before and after PD-associated peritonitis; interestingly, the levels of IL-1β remained high in the PD fluid, even after remission of bacterial peritonitis. In addition, it correlated with decreased peritoneal function.
CONCLUSIONS
This case suggests that inflammasome-derived pro-inflammatory cytokines may contribute to chronic inflammation-induced peritoneal deterioration after PD-related peritonitis is cured.
Topics: Female; Humans; Middle Aged; Interleukin-1beta; Peritoneal Dialysis; Peritonitis; Cytokines; Dialysis Solutions; Kidney Failure, Chronic; Inflammation; Anti-Infective Agents
PubMed: 38114999
DOI: 10.1186/s12882-023-03431-8 -
Kidney International Reports Dec 2023Needle-related distress is common among people receiving hemodialysis and affects quality of life and treatment decisions, yet little evidence exists to guide...
INTRODUCTION
Needle-related distress is common among people receiving hemodialysis and affects quality of life and treatment decisions, yet little evidence exists to guide management. This study explored patients' experiences of needle-related distress to inform the development of prevention, identification, and management strategies.
METHODS
Semistructured interviews concerning dialysis cannulation, needle-related distress, and potential solutions were conducted with people with current or recent experience of hemodialysis ( = 15) from a tertiary hospital-based service. Interviews ceased at thematic saturation. Transcripts were analyzed thematically.
RESULTS
There were 4 themes and 11 subthemes generated: (i) uncovering a hidden source of distress (dismissal and minimization by others; suffering in silence to stay alive; preparation, assessment, and education); (ii) coping with cannulation pain and trauma (interaction between physical damage, pain, and distress; operator dependency-the importance of nurse skill and technique); (iii) the environment created by dialysis nurses (emotional transference; communication during cannulation; valuing empathy and person-centered care; a psychosocially supportive dialysis unit); and (iv) supporting patient self-management of distress (accessing tools to help themselves; distraction to reduce distress).
CONCLUSION
Needle-related distress is an often-hidden element of the hemodialysis experience. Patients learn to tolerate it as an inevitable part of dialysis for survival. Nurses' technical skills and the dialysis environment they create are key determinants of the patient cannulation experience. Proposed solutions include psychological screening, education for patients to self-manage distress, and training for nurses in communication and providing relevant psychological support.
PubMed: 38106606
DOI: 10.1016/j.ekir.2023.09.011 -
Journal of General Internal Medicine May 2024The sodium-glucose cotransporter type 2 inhibitor dapagliflozin reduces the risk of progressive kidney disease and cardiovascular events in patients with chronic kidney... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The sodium-glucose cotransporter type 2 inhibitor dapagliflozin reduces the risk of progressive kidney disease and cardiovascular events in patients with chronic kidney disease, with and without type 2 diabetes. Whether its effects are uniform across the spectrum of age and among men and women is unknown.
OBJECTIVE
We performed a pre-specified analysis in DAPA-CKD to evaluate efficacy and safety of dapagliflozin according to baseline age and sex.
DESIGN
Prospective randomized placebo-controlled trial.
PARTICIPANTS
A total of 4304 adults with chronic kidney disease (estimated glomerular filtration rate (eGFR) 25-75 mL/min/1.73 m; urinary albumin-to-creatinine ratio 200-5000 mg/g) with and without type 2 diabetes.
INTERVENTION
Dapagliflozin 10 mg versus placebo once daily.
MAIN MEASURES
Primary endpoint was a composite of ≥ 50% sustained eGFR decline, end-stage kidney disease, and kidney or cardiovascular death. Secondary endpoints included kidney composite endpoint (same as primary composite endpoint but without cardiovascular death), cardiovascular composite endpoint (hospitalized heart failure or cardiovascular death), and all-cause mortality.
KEY RESULTS
Median follow-up was 2.4 years. Absolute risks of cardiovascular composite endpoint and all-cause mortality were higher in older patients. Absolute risk of kidney composite endpoint was highest in patients < 50 years (10.7 and 6.2 per 100 patient-years in the placebo and dapagliflozin groups, respectively) and lowest in patients ≥ 80 years (3.0 and 1.2 per 100 patient-years in the placebo and dapagliflozin groups, respectively). There was no evidence of heterogeneity of the effects of dapagliflozin on the primary or secondary endpoints based on age or sex. Neither age nor sex modified the effects of dapagliflozin on total or chronic eGFR slope.
CONCLUSIONS
Dapagliflozin reduced the risks of mortality, cardiovascular events, and CKD progression in older patients, including in septuagenarians and octogenarians who comprised 25% of participants. Ageism and/or therapeutic nihilism should not discourage the use of dapagliflozin in older women and men who are likely to experience considerable benefit.
TRIAL REGISTRY
clinicaltrials.gov NIH TRIAL REGISTRY NUMBER: NCT03036150.
Topics: Humans; Glucosides; Benzhydryl Compounds; Male; Female; Renal Insufficiency, Chronic; Middle Aged; Aged; Prospective Studies; Diabetes Mellitus, Type 2; Sodium-Glucose Transporter 2 Inhibitors; Age Factors; Sex Factors; Glomerular Filtration Rate; Adult; Double-Blind Method; Treatment Outcome; Follow-Up Studies; Aged, 80 and over
PubMed: 38097862
DOI: 10.1007/s11606-023-08397-9