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American Journal of Kidney Diseases :... Dec 2019Patients with chronic kidney disease (CKD) are at substantially higher risk for developing cognitive impairment compared with the general population, and both lower... (Review)
Review
Patients with chronic kidney disease (CKD) are at substantially higher risk for developing cognitive impairment compared with the general population, and both lower glomerular filtration rate and the presence of albuminuria are associated with the development of cognitive impairment and poorer cognitive function. Given the excess of vascular disease seen in individuals with CKD, cerebrovascular disease is likely the predominant pathology underlying these associations, though impaired clearance of uremic metabolites, depression, sleep disturbance, anemia, and polypharmacy may also contribute. Modification of vascular disease risk factors may be helpful in limiting decline, though definite data are lacking. Specific to CKD, targeting a low blood pressure and reduction in albuminuria with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may slow cognitive decline, albeit modestly. Initiation of dialysis can improve severe impairment associated with uremia but does not appear to affect more subtle chronic cognitive impairment. In contrast, kidney transplantation appears to lead to improved cognitive function in many transplant recipients, suggesting that dialysis methods do not provide the same cognitive benefits as having a functioning kidney. Management of patients with both CKD and cognitive impairment should include a comprehensive plan including more frequent follow-up visits; involvement of family in shared decision making; measures to improve compliance, such as written instruction and pill counts; and a focus on advance directives in conjunction with an emphasis on understanding an individual patient's life goals. Further research is needed on novel therapies, including innovative dialysis methods, that aim to limit the development of cognitive impairment, slow decline in those with prevalent impairment, and improve cognitive function.
Topics: Age Factors; Aged; Cognitive Dysfunction; Combined Modality Therapy; Disease Management; Disease Progression; Female; Humans; Incidence; Male; Middle Aged; Neuropsychological Tests; Prognosis; Renal Dialysis; Renal Insufficiency, Chronic; Severity of Illness Index; Sex Factors
PubMed: 31378643
DOI: 10.1053/j.ajkd.2019.05.017 -
Kidney360 Feb 2023Incremental peritoneal dialysis (IPD) is a strategy of RRT that is based on the prescription of a lower dose rather than the standard full dose of peritoneal dialysis... (Review)
Review
Incremental peritoneal dialysis (IPD) is a strategy of RRT that is based on the prescription of a lower dose rather than the standard full dose of peritoneal dialysis (PD). The clearance goals are achieved through the combination of residual kidney function (RKF) and peritoneal clearance. The dialysis prescription should be increased as the RKF declines. IPD has been associated with clinical, economic, and environmental advantages. We emphasize possible better quality of life, fewer mechanical symptoms, lower costs, slight adverse metabolic effects, and less plastic waste and water consumption. The potential benefits for RKF preservation and the lower risk of peritonitis have also been discussed. There are some concerns regarding this strategy, such as inadequate clearance of uremic toxins and/or severe electrolyte disturbances due to undetected loss of RKF, lower clearance of medium-sized molecules (such as β-2-microglobulin) which mostly depends on the total PD dwell time, and patients' reluctance to dose adjustments. Current clinical evidence is based on moderate-quality to low-quality studies and suggests that the outcomes of IPD will be at least identical to those of full dose. This review aims to define IDP, discuss strategies for prescription, and review its advantages and disadvantages according to the current evidence.
Topics: Humans; Peritoneal Dialysis; Peritoneum; Prescriptions; Quality of Life; Renal Dialysis
PubMed: 36821618
DOI: 10.34067/KID.0006902022 -
American Journal of Nephrology 2019Residual kidney function (RKF) conveys a survival benefit among dialysis patients, but the mechanism remains unclear. Improved volume control, clearance of protein-bound... (Review)
Review
BACKGROUND
Residual kidney function (RKF) conveys a survival benefit among dialysis patients, but the mechanism remains unclear. Improved volume control, clearance of protein-bound and middle molecules, reduced inflammation and preserved erythropoietin and vitamin D production are among the proposed mechanisms. Preservation of RKF requires techniques to measure it accurately to be able to uncover factors that accelerate its loss and interventions that preserve it and ultimately to individualize therapy. The average of renal creatinine and urea clearance provides a superior estimate of RKF in dialysis patients, when compared with daily urine volume. However, both involve the difficult task of obtaining an accurate 24-h urine sample.
SUMMARY
In this article, we first review the definition and measurement of RKF, including newly proposed markers such as serum levels of beta2-microglobulin, cystatin C and beta-trace protein. We then discuss the predictors of RKF loss in new dialysis patients. We review several strategies to preserve RKF such as renin-angiotensin-aldosterone system blockade, incremental dialysis, use of biocompatible membranes and ultrapure dialysate in hemodialysis (HD) patients, and use of biocompatible solutions in peritoneal dialysis (PD) patients. Despite their generally adverse effects on renal function, aminoglycoside antibiotics have not been shown to have adverse effects on RKF in well-hydrated patients with end-stage renal disease (ESRD). Presently, the roles of better blood pressure control, diuretic usage, diet, and dialysis modality on RKF remain to be clearly established. Key Messages: RKF is an important and favorable prognostic indicator of reduced morbidity, mortality, and higher quality of life in both PD an HD patients. Further investigation is warranted to uncover factors that protect or impair RKF. This should lead to improved quality of life and prolonged lifespan in patients with ESRD and cost-reduction through patient centeredness, individualized therapy, and precision medicine approaches.
Topics: Angiotensin-Converting Enzyme Inhibitors; Dialysis Solutions; Glomerular Filtration Rate; Humans; Kidney; Kidney Failure, Chronic; Kidney Function Tests; Quality of Life; Renal Dialysis; Renin-Angiotensin System; Treatment Outcome
PubMed: 31630148
DOI: 10.1159/000503805 -
Critical Care (London, England) Oct 2016This article reports the conclusions of a consensus expert conference on the basic principles and nomenclature of renal replacement therapy (RRT) currently utilized to... (Review)
Review
This article reports the conclusions of a consensus expert conference on the basic principles and nomenclature of renal replacement therapy (RRT) currently utilized to manage acute kidney injury (AKI). This multidisciplinary consensus conference discusses common definitions, components, techniques, and operations of the machines and platforms used to deliver extracorporeal therapies, utilizing a "machine-centric" rather than a "patient-centric" approach. We provide a detailed description of the performance characteristics of membranes, filters, transmembrane transport of solutes and fluid, flows, and methods of measurement of delivered treatment, focusing on continuous renal replacement therapies (CRRT) which are utilized in the management of critically ill patients with AKI. This is a consensus report on nomenclature harmonization for principles of extracorporeal renal replacement therapies. Devices and operations are classified and defined in detail to serve as guidelines for future use of terminology in papers and research.
Topics: Acute Kidney Injury; Critical Illness; Humans; Renal Dialysis; Renal Replacement Therapy; Terminology as Topic; Ultrafiltration
PubMed: 27719682
DOI: 10.1186/s13054-016-1489-9 -
Toxins Jun 2018Uremic solutes contribute to cardiovascular disease in renal insufficiency. In this review we describe the clearance of selected uremic solutes, which have been... (Review)
Review
Uremic solutes contribute to cardiovascular disease in renal insufficiency. In this review we describe the clearance of selected uremic solutes, which have been associated with cardiovascular disease. These solutes-indoxyl sulfate (IS), p-cresol sulfate (PCS), phenylacetylglutamine (PAG), trimethylamine-n-oxide (TMAO), and kynurenine-exemplify different mechanisms of clearance. IS and PCS are protein-bound solutes efficiently cleared by the native kidney through tubular secretion. PAG and TMAO are not protein-bound but are also cleared by the native kidney through tubular secretion, while kynurenine is not normally cleared by the kidney. Increases in the plasma levels of the normally secreted solutes IS, PCS, TMAO, and PAG in chronic kidney disease (CKD) are attributable to a reduction in their renal clearances. Levels of each of these potential toxins are even higher in patients on dialysis than in those with advanced chronic kidney disease, which can be accounted for in part by a low ratio of dialytic to native kidney clearance. The rise in plasma kynurenine in CKD and dialysis patients, by contrast, remains to be explained. Our ability to detect lower levels of the potential uremic cardiovascular toxins with renal replacement therapy may be limited by the intermittency of treatment, by increases in solute production, and by the presence of non-renal clearance. Reduction in the levels of uremic cardiovascular toxins may in the future be achieved more effectively by inhibiting their production.
Topics: Animals; Cardiovascular Diseases; Humans; Renal Dialysis; Toxins, Biological; Uremia
PubMed: 29865226
DOI: 10.3390/toxins10060226 -
Nephrology, Dialysis, Transplantation :... Jun 2016Mortality rates remain high for haemodialysis (HD) patients and simply increasing the HD dose to remove more small solutes does not improve survival. Online... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Mortality rates remain high for haemodialysis (HD) patients and simply increasing the HD dose to remove more small solutes does not improve survival. Online haemodiafiltration (HDF) provides additional clearance of larger toxins compared with standard HD. Randomized controlled trials (RCTs) comparing HDF with conventional HD on all-cause and cause-specific mortality in end-stage kidney disease (ESKD) patients reported inconsistent results and were at high risk of bias. We conducted a pooled individual participant data analysis of RCTs to provide the most reliable evidence to date on the effects of HDF on mortality outcomes in ESKD patients.
METHODS
Individual participant data were used from four trials that compared online HDF with HD and were designed to examine the effects of HDF on mortality endpoints. Bias by informative censoring of patients was resolved. Hazard ratios (HRs) and 95% confidence intervals (95% CI) comparing the effect of online HDF versus HD on all-cause and cause-specific mortality were calculated using the Cox proportional hazard regression models. The relationship between convection volume and the study outcomes was examined by delivered convection volume standardized to body surface area.
RESULTS
After a median follow-up of 2.5 years (Q1-Q3: 1.9-3.0), 769 of the 2793 participants had died (292 cardiovascular deaths). Online HDF reduced the risk of all-cause mortality by 14% (95% CI: 1%; 25%) and cardiovascular mortality by 23% (95% CI: 3%; 39%). There was no evidence for a differential effect in subgroups. The largest survival benefit was for patients receiving the highest delivered convection volume [>23 L per 1.73 m(2) body surface area (BSA) per session], with a multivariable-adjusted HR of 0.78 (95% CI: 0.62; 0.98) for all-cause mortality and 0.69 (95% CI: 0.47; 1.00) for cardiovascular disease mortality.
CONCLUSIONS
This pooled individual participant analysis on the effects of online HDF compared with conventional HD indicates that online HDF reduces the risk of mortality in ESKD patients. This effect holds across a variety of important clinical subgroups of patients and is most pronounced for those receiving a higher convection volume normalized to BSA.
Topics: Aged; Cause of Death; Europe; Female; Hemodiafiltration; Humans; Kidney Failure, Chronic; Male; Middle Aged; Proportional Hazards Models; Renal Dialysis; Risk Factors; Survival Rate
PubMed: 26492924
DOI: 10.1093/ndt/gfv349 -
Panminerva Medica Jun 2017Registry or national dialysis data show that a sizeable proportion of contemporary dialysis patients have substantial levels of residual kidney function especially upon... (Review)
Review
Registry or national dialysis data show that a sizeable proportion of contemporary dialysis patients have substantial levels of residual kidney function especially upon transitioning to dialysis therapy. However, among incident hemodialysis patients, the prevailing paradigm has been to initiate "full-dose" triweekly treatment schedules irrespective of native kidney function in most developed countries. Recognizing the benefits of residual kidney function upon the health and survival of dialysis patients, there has been growing interest in incremental hemodialysis, in which dialysis frequency and dose are tailored according to the degree of patients' residual kidney function. Infrequent hemodialysis can also be used for those who prefer a more conservative approach in managing uremia. Clinical practice guidelines support the use of twice-weekly hemodialysis among patients with adequate residual kidney function (renal urea clearance >3 mL/min/1.73 m2), and a growing body of evidence indicates that incremental hemodialysis is associated with better preservation of residual kidney function without adversely impacting survival. Nonetheless, incremental hemodialysis remains an underutilized approach in this population. In this review, we will discuss the history of the twice- versus triweekly hemodialysis schedules; current clinical practice guidelines regarding infrequent hemodialysis; emerging data on incremental treatment regimens and outcomes; and guidelines for the practical implementation of incremental and infrequent hemodialysis in the clinical setting.
Topics: Animals; Conservative Treatment; Creatinine; Humans; Kidney; Kidney Failure, Chronic; Phenotype; Quality of Life; Renal Dialysis; Time Factors; Treatment Outcome; Urea
PubMed: 28090764
DOI: 10.23736/S0031-0808.17.03299-2 -
Blood Purification 2017The low water permeability feature of original cellulosic membranes was considered an advantage in the absence of dialysis equipment that are capable of controlling...
The low water permeability feature of original cellulosic membranes was considered an advantage in the absence of dialysis equipment that are capable of controlling water removal. The advent of ultrafiltration control systems led to the development and use of high-flux (HF) membranes that allowed improved middle molecule removal including β-2 microglobulin. Further advances in technology allowed better control over the structure and permeability of membranes. Different polymers and improved spinning modalities led to significant advances in solute removal and hemocompatibility. Inner surface modification produced a reduction in membrane thrombogenicity and protein-membrane interaction with a less tendency to fouling and permeability decay. Further evolution in technology led to the development of a new class of membranes referred to as protein-leaking membranes or super-flux or high cutoff (HCO). These membranes are more permeable than conventional HF membranes and allow some passage of proteins, including albumin. The rationale for these membranes is the need for increased clearance of low molecular weight proteins and protein-bound solutes. However, albumin loss in protein-leaking HCO membranes represents a limitation whose effect in patients is still controversial. The last evolution in the field of membranes is the development of a new class defined as "high retention onset" (HRO) due to the peculiar high sieving value in the middle to high molecular weight range. The introduction of HRO membranes in the clinical routine has enabled the development of a new concept therapy called "expanded hemodialysis." Its simple set up and application offer the possibility to use it even in patients with suboptimal vascular access or even with an indwelling catheter. The system does not require particular hardware or unusual nursing skill. The quality of dialysis fluid is, however, mandatory to ensure a safe conduction of the dialysis session. This new therapy is likely to modify the outcome of end-stage kidney disease patients, thanks to the enhanced removal of molecules traditionally retained by current dialysis techniques.
Topics: Equipment Design; Humans; Inventions; Membranes, Artificial; Permeability; Renal Dialysis; Uremia
PubMed: 28486230
DOI: 10.1159/000476012 -
Jornal Brasileiro de Nefrologia 2024The desperate attempt to improve mortality, morbidity, quality of life and patient-reported outcomes in patients on hemodialysis has led to multiple attempts to improve...
The desperate attempt to improve mortality, morbidity, quality of life and patient-reported outcomes in patients on hemodialysis has led to multiple attempts to improve the different modes, frequencies, and durations of dialysis sessions in the last few decades. Nothing has been more appealing than the combination of diffusion and convection in the form of hemodiafiltration. Despite the concrete evidence of better clearance of middle weight molecules and better hemodynamic stability, tangible evidence to support the universal adoption is still at a distance. Survival benefits seen in selected groups who are likely to tolerate hemodiafiltration with better vascular access and with lower comorbid burden, need to be extended to real life dialysis patients who are older than the population studied and have significantly higher comorbid burden. Technical demands of initiation hemodiafiltration, the associated costs, and the incremental benefits targeted, along with patient-reported outcomes, need to be explored further before recommending hemodiafiltration as the mode of choice.
Topics: Humans; Hemodiafiltration; Renal Dialysis; Quality of Life; Hemodynamics; Convection
PubMed: 38527156
DOI: 10.1590/2175-8239-JBN-2024-PO02en -
Nutrients Jul 2022Hyperammonaemia is a metabolic derangement that may cause severe neurological damage and even death due to cerebral oedema, further complicating the prognosis of its... (Review)
Review
Hyperammonaemia is a metabolic derangement that may cause severe neurological damage and even death due to cerebral oedema, further complicating the prognosis of its triggering disease. In small children it is a rare condition usually associated to inborn errors of the metabolism. As age rises, and especially in adults, it may be precipitated by heterogeneous causes such as liver disease, drugs, urinary infections, shock, or dehydration. In older patients, it is often overlooked, or its danger minimized. This protocol was drafted to provide an outline of the clinical measures required to normalise ammonia levels in patients of all ages, aiming to assist clinicians with no previous experience in its treatment. It is an updated protocol developed by a panel of experts after a review of recent publications. We point out the importance of frequent monitoring to assess the response to treatment, the nutritional measures that ensure not only protein restriction but adequate caloric intake and the need to avoid delays in the use of specific pharmacological therapies and, especially, extrarenal clearance measures. In this regard, we propose initiating haemodialysis when ammonia levels are >200−350 µmol/L in children up to 18 months of age and >150−200 µmol/L after that age.
Topics: Adult; Aged; Ammonia; Child; Humans; Hyperammonemia; Liver Diseases; Prognosis; Renal Dialysis
PubMed: 35807935
DOI: 10.3390/nu14132755