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Annals of Biomedical Engineering Mar 2024Inadequate clearance of protein-bound uremic toxins (PBUTs) during dialysis is associated with morbidities in chronic kidney disease patients. The development of...
Inadequate clearance of protein-bound uremic toxins (PBUTs) during dialysis is associated with morbidities in chronic kidney disease patients. The development of high-permeance membranes made from materials such as graphene raises the question whether they could enable the design of dialyzers with improved PBUT clearance. Here, we develop device-level and multi-compartment (body) system-level models that account for PBUT-albumin binding (specifically indoxyl sulfate and p-cresyl sulfate) and diffusive and convective transport of toxins to investigate how the overall membrane permeance (or area) and system parameters including flow rates and ultrafiltration affect PBUT clearance in hemodialysis. Our simulation results indicate that, in contrast to urea clearance, PBUT clearance in current dialyzers is mass-transfer limited: Assuming that the membrane resistance is dominant, raising PBUT permeance from 3 × 10 to 10 m s (or equivalently, 3.3 × increase in membrane area from ~ 2 to ~ 6 m) increases PBUT removal by 48% (from 22 to 33%, i.e., ~ 0.15 to ~ 0.22 g per session), whereas increasing dialysate flow rates or adding adsorptive species have no substantial impact on PBUT removal unless permeance is above ~ 10 m s. Our results guide the future development of membranes, dialyzers, and operational parameters that could enhance PBUT clearance and improve patient outcomes.
Topics: Humans; Uremic Toxins; Uremia; Protein Binding; Renal Dialysis; Toxins, Biological
PubMed: 37993752
DOI: 10.1007/s10439-023-03397-6 -
Frontiers in Nephrology 2023The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including... (Review)
Review
The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including dialysis machines, became scarce, leading to the undertaking of value-based cost-effectiveness analyses and the rationing of resources to deliver patient care of the highest quality. A high proportion of COVID-19 patients admitted to the ICU required dialysis, resulting in a major burden on resources such as dialysis machines, nursing staff, technicians, and consumables such as dialysis filters and solutions and anticoagulation medications. Artificial intelligence (AI)-based big data analytics are now being utilized in multiple data-driven healthcare services, including the optimization of healthcare system utilization. Numerous factors can impact dialysis resource allocation to critically ill patients, especially during public health emergencies, but currently, resource allocation is determined using a small number of traditional factors. Smart analytics that take into account all the relevant healthcare information in the hospital system and patient outcomes can lead to improved resource allocation, cost-effectiveness, and quality of care. In this review, we discuss dialysis resource utilization in critical care, the impact of the COVID-19 pandemic, and how AI can improve resource utilization in future public health emergencies. Research in this area should be an important priority.
PubMed: 37965069
DOI: 10.3389/fneph.2023.1266967 -
JAMA Internal Medicine Dec 2023Patients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers...
IMPORTANCE
Patients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers prevent patients from receiving a transplant.
OBJECTIVES
To evaluate the effect of a multicomponent intervention designed to target several barriers that prevent eligible patients from completing key steps toward receiving a kidney transplant.
DESIGN, SETTING, AND PARTICIPANTS
This pragmatic, 2-arm, parallel-group, open-label, registry-based, superiority, cluster randomized clinical trial included all 26 CKD programs in Ontario, Canada, from November 1, 2017, to December 31, 2021. These programs provide care for patients with advanced CKD (patients approaching the need for dialysis or receiving maintenance dialysis).
INTERVENTIONS
Using stratified, covariate-constrained randomization, allocation of the CKD programs at a 1:1 ratio was used to compare the multicomponent intervention vs usual care for 4.2 years. The intervention had 4 main components, (1) administrative support to establish local quality improvement teams; (2) transplant educational resources; (3) an initiative for transplant recipients and living donors to share stories and experiences; and (4) program-level performance reports and oversight by administrative leaders.
MAIN OUTCOMES AND MEASURES
The primary outcome was the rate of steps completed toward receiving a kidney transplant. Each patient could complete up to 4 steps: step 1, referred to a transplant center for evaluation; step 2, had a potential living donor contact a transplant center for evaluation; step 3, added to the deceased donor waitlist; and step 4, received a transplant from a living or deceased donor.
RESULTS
The 26 CKD programs (13 intervention, 13 usual care) during the trial period included 20 375 potentially transplant-eligible patients with advanced CKD (intervention group [n = 9780 patients], usual-care group [n = 10 595 patients]). Despite evidence of intervention uptake, the step completion rate did not significantly differ between the intervention vs usual-care groups: 5334 vs 5638 steps; 24.8 vs 24.1 steps per 100 patient-years; adjusted hazard ratio, 1.00 (95% CI, 0.87-1.15).
CONCLUSIONS AND RELEVANCE
This novel multicomponent intervention did not significantly increase the rate of completed steps toward receiving a kidney transplant. Improving access to transplantation remains a global priority that requires substantial effort.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03329521.
Topics: Humans; Kidney Transplantation; Renal Dialysis; Renal Insufficiency, Chronic; Ontario; Kidney; Systems Analysis
PubMed: 37922156
DOI: 10.1001/jamainternmed.2023.5802 -
Clinical Kidney Journal Nov 2023People living with chronic kidney disease (CKD) need to be able to live well with their condition. The provision of psychosocial interventions (psychological,...
BACKGROUND
People living with chronic kidney disease (CKD) need to be able to live well with their condition. The provision of psychosocial interventions (psychological, psychiatric and social care) and physical rehabilitation management is variable across England, as well as the rest of the UK. There is a need for clear recommendations for standards of psychosocial and physical rehabilitation care for people living with CKD, and guidance for the commissioning and measurement of these services. The National Health Service (NHS) England Renal Services Transformation Programme (RSTP) supported a programme of work and modified Delphi process to address the management of psychosocial and physical rehabilitation care as part of a larger body of work to formulate a comprehensive commissioning toolkit for renal care services across England. We sought to achieve expert consensus regarding the psychosocial and physical rehabilitation management of people living with CKD in England and the rest of the UK.
METHODS
A Delphi consensus method was used to gather and refine expert opinions of senior members of the kidney multi-disciplinary team (MDT) and other key stakeholders in the UK. An agreement was sought on 16 statements reflecting aspects of psychosocial and physical rehabilitation management for people living with CKD.
RESULTS
Twenty-six expert practitioners and other key stakeholders, including lived experience representatives, participated in the process. The consensus (>80% affirmative votes) amongst the respondents for all 16 statements was high. Nine recommendation statements were discussed and refined further to be included in the final iteration of the 'Systems' section of the NHS England RSTP commissioning toolkit. These priority recommendations reflect pragmatic solutions that can be implemented in renal care and include recommendations for a holistic wellbeing assessment for all people living with CKD who are approaching dialysis, or who are at listing for kidney transplantation, which includes the use of validated measurement tools to assess the need for further intervention in psychosocial and physical rehabilitation management. It is recommended that the scores from these measurement tools be included in the NHS England Renal Data Dashboard. There was also a recommendation for referral as appropriate to NHS Talking Therapies, psychology, counselling or psychotherapy, social work or liaison psychiatry for those with identified psychosocial needs. The use of digital resources was recommended to be used in addition to face-to-face care to provide physical rehabilitation, and all healthcare professionals should be educated to recognize psychosocial and physical rehabilitation needs and refer/sign-post people with CKD to appropriate services.
CONCLUSION
There was high consensus amongst senior members of the kidney MDT and other key stakeholders, including those with lived experience, in the UK on all aspects of the psychosocial and physical rehabilitation management of people living with CKD. The results of this process will be used by NHS England to inform the 'Systems' section of the commissioning toolkit and data dashboard and to inform the National Standards of Care for people living with CKD.
PubMed: 37915908
DOI: 10.1093/ckj/sfad116 -
BMC Nephrology Oct 2023Without effective intervention, primary hyperoxaluria type 1 (PH1) causes oxalate-induced kidney damage, leading to end-stage kidney disease and serious complications... (Observational Study)
Observational Study
BACKGROUND
Without effective intervention, primary hyperoxaluria type 1 (PH1) causes oxalate-induced kidney damage, leading to end-stage kidney disease and serious complications throughout the body. Although PH1 carries a heavy burden that impacts quality of life, literature on the experiences of those living with PH1 and caring for patients with PH1 is limited. This study aimed to describe the diagnostic journey in PH1 and characterize patients' and caregivers' self-reported experiences throughout the disease course.
METHODS
This was an observational study involving in-depth, semi-structured telephone interviews. Dominant trends were assessed using constant comparative analysis to identify themes in interviewees' descriptions of their experiences. Individuals aged ≥ 12 years and caregivers of children aged 6-17 years with genetically confirmed PH1 were eligible. Informed consent/assent and ability to read and speak English were required.
RESULTS
Interviewees (16 patients, 12 caregivers) reported a prolonged diagnostic journey due to low disease awareness, among other factors. Upon diagnosis, PH1 was frequently symptomatic, typically involving kidney stone-related symptoms but also potentially symptoms arising beyond the kidneys. PH1 most commonly led to worry and social impairment in adolescents, impaired physical function in adults, and a range of impacts on caregivers. In late-stage disease, dialysis was the most burdensome aspect of living with PH1 (due to time requirements, limitations from living with a catheter, etc.), and this burden was exacerbated by the COVID-19 pandemic. Benefits desired from PH1 management included reductions in laboratory measures of oxalate burden, kidney stone and urination frequency, and oxalate-related skin ulcers.
CONCLUSIONS
PH1 greatly impacts patients' and caregivers' lives, primarily due to burdensome disease manifestations and associated emotional, physical, and practical impacts, as well as disease management challenges - particularly those related to dialysis in late-stage disease.
Topics: Child; Adult; Adolescent; Humans; Pandemics; Quality of Life; Renal Dialysis; Hyperoxaluria, Primary; Oxalates; Kidney Calculi; Patient Outcome Assessment
PubMed: 37884879
DOI: 10.1186/s12882-023-03365-1 -
Diagnosis (Berlin, Germany) Nov 2023
PubMed: 37882744
DOI: 10.1515/dx-2023-0136 -
Cureus Sep 2023Tunnelled dialysis catheters continue to be a choice in several patients as hemodialysis access. According to Kidney Disease Outcomes Quality Initiative guidelines, its...
Tunnelled dialysis catheters continue to be a choice in several patients as hemodialysis access. According to Kidney Disease Outcomes Quality Initiative guidelines, its handling implies disinfection, that can be performed using chlorhexidine solutions. Theoretically, these solutions have bactericidal capacity at concentrations greater than 0.12%. We present a curious situation of failure of the antiseptic process due to contamination of the chlorhexidine solution 4% of aqueous base. In this hemodialysis clinic, three cases of infections by the bacteria were identified over 2 weeks - in two of the cases, identified in blood culture, and in the other case in the exudate from the exit site of the catheter. Considering the abnormal number of infections by this agent and the fact that these patients were on different shifts, were treated in different rooms, and handled by different nurses, the antiseptic solutions used in the different hemodialysis rooms were analyzed, as well as a closed package from the same batch. After microbiological tests were performed on the antiseptic solution, we identified the growth of . This result identified the culprit as being the contamination of the 4% chlorhexidine solution. The competent authorities were notified, and the disinfection method was changed to use a chlorhexidine alcohol-based solution.
PubMed: 37868447
DOI: 10.7759/cureus.45693 -
Journal of Nephrology Dec 2023Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation...
BACKGROUND
Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation to self-care drove assisted peritoneal dialysis to evolve from family-based care to institutional programs, with specialized care givers. Some European countries have mastered this, while others are still bound by the availability of a volunteer to become responsible for treatment.
METHODS
A group of leading nephrologists from 13 European countries integrated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. The objective of this work is to share and summarize several different approaches, with their intrinsic difficulties and solutions, which might helpperitoneal dialysis units to develop and offer assisted peritoneal dialysis.
RESULTS
Assisted peritoneal dialysis does not mean 4 continuous ambulatory peritoneal dialysis exchanges, 7 days/week, nor does it exclude cycler. Many different prescriptions might work for our patients. Tailoring PD prescription to residual kidney function, thereby maintaining small solute clearance, reduces dialysis burden and is associated with higher technique survival. Assisted peritoneal dialysis does not mean assistance will be needed permanently, it can be a transitional stage towards individual or caregiver autonomy. Private care agencies can be used to provide assistance; other options may involve implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods.
CONCLUSION
Assisted peritoneal dialysis is a valid technique, which should be expanded. In countries without structural models of assisted peritoneal dialysis, active involvement by the nephrologist is needed in order for it to become a reality.
Topics: Humans; Peritoneal Dialysis; Peritoneal Dialysis, Continuous Ambulatory; Renal Dialysis; Europe; Caregivers; Kidney Failure, Chronic
PubMed: 37856067
DOI: 10.1007/s40620-023-01765-y -
Cureus Sep 2023Central venous catheter (CVC)-based hemodialysis is a major contributor to bacteremia in immunocompromised hosts. Heparin-locking CVCs is a frequent therapeutic... (Review)
Review
Central venous catheter (CVC)-based hemodialysis is a major contributor to bacteremia in immunocompromised hosts. Heparin-locking CVCs is a frequent therapeutic procedure. However, it has not been shown to reduce catheter-related bloodstream infections (CRBSIs). For this systematic review, we searched PubMed, PubMed Central, ResearchGate, Science Direct, and Multidisciplinary Digital Publishing Institute (MDPI) for multiple articles published between January 2018 and January 2023 to determine how antimicrobial locking solutions affect CRBSIs, which could ultimately lower the risk of morbidity, mortality, and hospitalization costs. Antilocking products, catheter-related bacteremia, central-line associated bloodstream infections, tunneled dialysis catheter, hemodialysis, antibiotic, and antimicrobial catheter locks, and the Medical Subject Heading (MeSH) method for PubMed were used as the main keywords for searching publications. A pool of 13 studies with 46,139 individuals showed that the therapy group had a lower incidence of CRBSIs than the heparin-treated control group. Furthermore, it was discovered that bacteria were resistant to gentamicin, and the use of antibiotics had no discernible impact on catheter malfunction. In conclusion, the most effective locking solution to date is an antilocking solution made up of an antibiotic or antimicrobial agent combined with low-dose heparin (500-2,500 U/mL).
PubMed: 37829985
DOI: 10.7759/cureus.45000 -
Frontiers in Physiology 2023Peritoneal dialysis (PD) is an effective alternative treatment for patients with end-stage renal disease (ESRD) and is increasingly being adopted and promoted worldwide.... (Review)
Review
Peritoneal dialysis (PD) is an effective alternative treatment for patients with end-stage renal disease (ESRD) and is increasingly being adopted and promoted worldwide. However, as the duration of peritoneal dialysis extends, it can expose problems with dialysis inadequacy and ultrafiltration failure. The exact mechanism and aetiology of ultrafiltration failure have been of great concern, with triggers such as biological incompatibility of peritoneal dialysis solutions, uraemia toxins, and recurrent intraperitoneal inflammation initiating multiple pathways that regulate the release of various cytokines, promote the transcription of fibrosis-related genes, and deposit extracellular matrix. As a result, peritoneal fibrosis occurs. Exploring the pathogenic factors and molecular mechanisms can help us prevent peritoneal fibrosis and prolong the duration of Peritoneal dialysis.
PubMed: 37817984
DOI: 10.3389/fphys.2023.1220450