Choice Of Renal Replacement Therapy Research Articles

Markers of Bone Metabolism in Hemodialyses and Hemodiafiltration

Renal osteodystrophy is a common complication of chronic renal failure and renal replacement therapy. The purpose of the study was to assess whether hemodialysis (HD) or hemodiafiltration (HDF) affects bone turnover. In all, 45 HD and 17 HDF patients were evaluated with respect to bone metabolism markers. We assessed PTH; markers of bone formation-alkaline phosphatase and its bone isoform, osteocalcin; markers of bone resorption- PICP, ICTP; Ctx; β2-microglobulin; and urinary DPD. BMD were determined for femoral neck and lumbar spine (L2–L4) using DEXA.Hemodialyzed patients had lower calcidiol, calcitriol, and BMD in the femur neck, and higher phosphate, Kt/V, residual renal function, venous pH, osteocalcin, ALP, bALP, DPD, β2-microglobulin, ICTP, Ctx, osteoprotegerin, and RANKL than patients on HDF. HDF seems to ameliorate bone metabolism in comparison with HD. Bone turnover in end-stage renal failure might be affected to some extent by the choice of renal replacement therapy.

The “French Hemodiafe Trial”: This Study is Neither Decisive nor Definitive in Resolving the Controversy on Renal Replacement Therapy in ICU

This short review paper addresses a recently published study on the controversy concerning the type of renal replacement therapy (RRT) used in ICU. It proposes a somewhat different point of view regarding this study, based on the numerous problems that have been identified with it. Indeed, given these shortcomings, the study conclusions are somewhat misleading and are not effectively supported by the trial data. If the treatment doses were comparable and kept constant in the OIHDO group, then the results may well have been strikingly different. In keeping with all drugs used in medicine, dose is crucial and should have remained unchanged by the investigators during the study in order to be able to draw valid conclusions based on the evidence. There is a need for a further study comparing CRRT and IHD. This should be better designed in terms of the exclusion criteria, delivered dose of CVVH (35 ml/kg/h) and IHD, timing of treatment and should also examine more secondary endpoints. This may answer many of the outstanding issues and provide a balanced opinion about this study and its real importance in ICU practice. Finally, this study does not have the scientific power (as explained by the accompanying editorial by Kellum) to put an end to the ICU controversy regarding the choice of RRT in acute renal failure while in ICU. Therefore, there is an urgent need for a better designed study regarding this controversy.

Satisfaction with care in peritoneal dialysis patients

Patient satisfaction is an important aspect of dialysis care, only recently evaluated in clinical studies. We developed a tool to assess peritoneal dialysis (PD) customer satisfaction, and sought to evaluate and validate the Customer Satisfaction Questionnaire (CSQ), quantifying PD patient satisfaction. The CSQ included questions regarding administrative issues, Delivery Service, PD Training, Handling Requests, and transportation. The study was performed using interviews in all Hungarian Fresenius Medical Care dialysis centers offering PD. CSQ results were compared with psychosocial measures to identify if patient satisfaction was associated with perception of social support and illness burden, or depression. We assessed CSQ internal consistency and validity. Factor analysis explored potential underlying dimensions of the CSQ. One hundred and thirty-three patients treated with PD for end-stage renal disease for more than 3 months were interviewed. The CSQ had high internal consistency. There was high patient satisfaction with customer service. PD patient satisfaction scores correlated with quality of life (QOL) and social support measures, but not with medical or demographic factors, or depressive affect. The CSQ is a reliable tool to assess PD customer satisfaction. PD patient satisfaction is associated with perception of QOL. Efforts to improve customer satisfaction may improve PD patients' quantity as well as QOL.

Estimating the impact of renal replacement therapy choice on outcome in severe acute renal failure

Mortality in severe acute renal failure (ARF) requiring renal replacement therapy (RRT) approximates 50% and varies with clinical severity. Continuous RRT (CRRT) has theoretical advantages over intermittent hemodialysis (IHD) for critical patients, but a survival advantage with CRRT is yet to be clearly demonstrated. To date, no prospective controlled trial has sufficiently answered this question, and the present prospective outcome study attempts to compare survival with CRRT versus that with IHD. Multivariable Cox-proportional hazards regression was used to analyze the impact of RRT modality choice (CRRT vs. IHD) on in-hospital and 100-day mortality among ARF patients receiving RRT during 2000 and 2001 at University of Michigan, using an "intent-to-treat" analysis adjusted for multiple comorbidity and severity factors. Overall in-hospital mortality before adjustment was 52%. Triage to CRRT (vs IHD) was associated with higher severity and unadjusted relative rate (RR) of in-hospital death (RR = 1.62, p = 0.001, n = 383). Adjustment for comorbidity and severity of illness reduced the RR of death for patients triaged to CRRT and suggested a possible survival advantage (RR = 0.81, p = 0.32). Analysis restricted to patients in intensive care for more than five days who received at least 48 hours of total RRT, showed the RR of in-hospital mortality with CRRT to be nearly 45% lower than IHD (RR = 0.56, n = 222), a difference in RR that indicates a strong trend for in-hospital mortality with borderline statistical significance (p = 0.069). Analysis of 100-day mortality also suggested a potential survival advantage for CRRT in all cohorts, particularly among patients in intensive care for more than five days who received at least 48 h of RRT (RR = 0.60, p = 0.062, n = 222). Applying the present methodology to outcomes at a single tertiary medical center, CRRT may appear to afford a survival advantage for patients with severe ARF treated in the ICU. Unless and until a prospective controlled trial is realized, the present data suggest potential survival advantages of CRRT and support broader application of CRRT among such critically ill patients.

Renal replacement therapy and acute renal failure

Acute renal failure (ARF) is a syndrome that occurs when there is a sudden decline in the glomerular filtration rate. The purpose of this review is to examine new developments and clinical applications of renal replacement therapies including hemodialysis, continuous renal replacement therapy, the bioartificial kidney, and peritoneal dialysis in the management of this complicated syndrome. New developments in hemodialysis include in-line hematocrit monitoring and improved biocompatible dialyzer membranes. While recent studies indicate that increased delivery of dialysis improves the outcome of patients with ARF, the optimal regimen of intermittent dialysis or continuous renal replacement therapy remains to be determined. The bioartificial kidney, combining hemofiltration with a device containing human tubular cells, is currently in clinical trials and represents another alternative in the management of ARF. In peritoneal dialysis, new solutions using icodextrin may improve fluid removal and blood pressure. The optimal choice of renal replacement therapy depends on many factors. Use of new options in renal replacement therapy and early initiation of dialysis may help to improve survival and outcome of patients with ARF.

To have and have not: Health and health care disparities in chronic kidney disease

A 50-year-old African American man came to the emergency room complaining of substernal chest discomfort over the past 2 months, as well as anorexia, general malaise, and decreased urinary frequency over the past 2 weeks. The patient stated that his chest pain lasted 2 to 3 minutes; did not radiate to the neck, jaw, or shoulder; was precipitated by lifting heavy objects; and did not occur at rest. He admitted to mild shortness of breath when walking up the stairs at home. He noted that for 2 weeks, he had been feeling exhausted and had had poor appetite, weight loss, and less frequent urination than usual. The patient had last seen a physician 4 years ago at an urgent care facility for a pilonidal cyst abscess. Five years prior to that, he had been told by a primary care physician that he had hypertension. He was treated with an unknown medication and, after a follow-up visit, was told that his blood pressure was normal. He has no other known history of cardiovascular or renal disease. He takes no medications. He lost his job as a cook and the health insurance that the job provided; he now says that he is unable to continue seeing the physician. He completed high school, is married, and works as a taxi driver as well as at a local farmers market on weekends. His father had hypertension and died suddenly at age 55. His mother is 71 and has diabetes. He has one older brother who

Special issues in the management of patients with ESRD and HIV infection

During 1985 to 1999, the percentage of hemodialysis centers providing care to patients with human immunodeficiency virus (HIV) in the United States increased from 11% to 39%, and the percentage of dialysis patients with HIV infection increased from 0.3% to 1.4%. Therefore, nephrologists are going to be confronted not only with providing dialysis care, but also with primary care issues of these patients. In this review, we discuss issues related to HIV infection and end-stage renal disease, such as choice of renal replacement therapy, vascular access, anemia, vaccination, prevention of opportunistic infections, and antiretroviral therapy, that will help nephrologists not only provide optimal care, but also improve outcomes in these patients. Am J Kidney Dis 41:279-291.

Patients’ Descriptions of Specific Factors Leading to Modality Selection of Chronic Peritoneal Dialysis Or Hemodialysis

There has been increasing interest in understanding how patients with chronic renal failure choose between chronic peritoneal dialysis (CPD) and hemodialysis (HD) for renal replacement therapy. The purpose of the present study was to examine the influences and specific factors that patients identify as significant in choosing a specific dialysis modality for treatment of their end-stage renal disease (ESRD). 40 patients (20 CPD, 20 HD) who had started dialysis within the preceding 6 months were randomly selected to participate in the study. A structured interview was conducted with the patients, discussing and exploring what factors patients thought were important in helping them decide their treatment modality. The format of the interview was open-ended. Based on patients' comments, a taxonomy of the specific factors that influenced the patients' decisions was developed. The study was conducted in a freestanding CPD unit and two freestanding HD units. All 20 CPD patients reported choosing their treatment modality; only 8 of the 20 HD patients reported having a choice of treatment modality. 18 of the 22 patients who participated in predialysis educational programs opted for CPD. 83% of the patients reported that their physician was important in influencing their treatment choice; however, the CPD patients relied more on written material and the opinions of their spouse/significant other or other family members in making their decisions. Issues of autonomy and control were important for 95% of patients choosing CPD. Both CPD and HD patients cited a variety of treatment-specific factors. The three most frequently cited reasons for choosing CPD were (1) flexibility of schedule (19 patients), (2) convenience of performing CPD in their own home (19 patients), and (3) the option of doing dialysis at night while sleeping (8 patients). The 8 HD patients who selected their treatment modality cited the desirability of having a planned schedule (7 patients) and letting nurses or other take care of them (5 patients). The present study explored factors perceived by patients as being important in determining their choice of renal replacement therapy. A taxonomy of patient influences and concerns has been developed to provide caregivers with a framework to structure their educational strategies and assist patients with progressive renal failure in making an informed choice of therapeutic modality for their ESRD treatment.

Pre‐emptive renal transplantation in children

Renal transplantation is a definitive therapeutic modality in end-stage renal disease (ESRD). Most ESRD patients in Japan experience dialysis prior to renal transplantation. The present study was undertaken to examine the usefulness of pre-emptive renal transplantation (PET). Between 1987 and 1998, 255 renal transplantations were carried out by the authors. Among those consecutive cases, 10 were cases of PET. In nine pediatric cases, demographics, graft and patient survival, height growth and benefits from successful transplantation were studied and compared with age-matched dialyzed transplantation controls. All transplantation was living-related. There was a disparity of causes of ESRD between the two groups. In PET, acquired renal deterioration due to a congenital lower urinary tract disorder was the major cause. Graft and patient prognosis was favorable in both groups. Growth retardation in PET patients under 15 years of age was significantly less apparent at the time of transplantation and after 3 years compared to the control. The benefits from transplantation were different in the two groups. Most PET patients felt an improvement of their physical condition; however, all of the control patients felt that the major boon was the freedom from the restriction of the daily diet and time for dialysis. In pediatric renal transplantation, short-term preceding dialysis does not have a detrimental effect, but PET could benefit ESRD patients by maintaining their quality of life. Moreover, PET minimizes the production of renal dwarfism in prepubertal children. Thus, PET should be taken into consideration in the choice of renal replacement therapy.

Comparison of Hemostatic Disturbances between Patients on Capd and Patients on Hemodialysis

Disturbances in hemostasis are common findings in uremic patients. Both bleeding diathesis and thrombosis are observed. The purpose of this study was to assess whether renal replacement therapy in the form of hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD) affects coagulation and fibrinolysis in patients with end-stage renal failure. Comparison of hemostatic measures in patients on CAPD, HD, and matched healthy controls. Department of Nephrology and Internal Medicine, Bialystok University School of Medicine. Twenty-four HD patients and 23 CAPD patients were evaluated with respect to platelet aggregation, hemostatic parameters, serum lipids, lipoprotein(a), and cytokines [tumor necrosis factor alpha (TNFalpha) and interleukin-1 (IL-1)]. Four exchanges of CAPD per day, using 2.0 L dialysate over a period of 25 +/- 31 months; or 4-5 hours of HD 3 times per week for a period of 31 +/- 22 months. Platelet aggregation in whole blood and platelet-rich plasma was significantly impaired in both groups of dialyzed patients compared to healthy volunteers. Markers of endothelial cell injury (thrombomodulin and von Willebrand factor) were significantly higher in HD and CAPD patients compared to the control group. A similar pattern of changes was observed for lipoprotein(a), fibrinogen, tissue factor pathway activity, and factor VII activity. Activity of factor X was significantly enhanced in CAPD compared to HD patients and controls. Euglobulin clot lysis time was significantly prolonged in HD and CAPD patients over controls, being more prolonged in CAPD patients. Markers of ongoing coagulation (thrombin-antithrombin complexes and prothrombin fragments 1+2) were higher in uremic patients, significantly higher in CAPD than in HD. A marker of ongoing fibrinolysis (plasmin-antiplasmin complexes) was higher in uremic patients but was lower in CAPD than in HD patients. Concentrations of TNFalpha and IL-1 were higher in HD than in CAPD patients. Patients on CAPD showed evidence of a higher degree of hypercoagulation than HD patients.Thus, hemostatic abnormalities in end-stage renal failure may be affected to some extent by the choice of renal replacement therapy.

Adrenal function in patients with chronic renal failure

Previous studies have reported divergent findings on the function of the hypothalamic-pituitary-adrenal axis in patients with chronic renal failure (CRF). The low-dose adrenocorticotropin (ACTH) test offers the possibility of unmasking adrenal dysfunction, which might remain undiscovered using the ACTH test with the standard 250-microg dose. Furthermore, the choice of renal replacement therapy (either hemodialysis or continuous ambulatory peritoneal dialysis [CAPD]) might have an impact on adrenal function. To investigate these possibilities, ACTH tests were performed with three different doses (ie, 1, 5, and 250 microg) in 14 CRF patients and in seven healthy controls. Seven of the CRF patients were receiving chronic hemodialysis and seven were receiving CAPD. Basal plasma concentrations of cortisol were comparable in the three groups tested (5.3+/-0.4 microg/dL in the controls, 6.6+/- 0.7 microg/dL in the hemodialysis patients, and 7.9+/-1.0 microg/dL in the CAPD patients), whereas basal ACTH concentrations were significantly elevated in the CRF patients (28.5+/-3.8 pg/mL in the hemodialysis patients and 33.0+/-6.0 pg/mL in the CAPD patients) when compared with normal controls (17.0+/-1.4 pg/mL; P < 0.05). All three doses of ACTH resulted in a rapid increase of plasma cortisol concentrations that was comparable in all three groups. In the hemodialysis patients, a trend toward a diminished response to the lowest dose of 1 microg was noticed. We conclude, therefore, that adrenal response to ACTH in various doses is unaffected in CRF independent of whether hemodialysis or CAPD is chosen for renal replacement therapy. (Am J Kidney Dis 1998 Jul;32(1):52-5)

PREDICTING OUTCOME IN THE ELDERLY RENAL TRANSPLANT RECIPIENT

23 The elderly are the fastest growing population of patients developing end stage renal disease. Transplantation has emerged as a viable therapeutic option for the elderly, yet some patients have a poor outcome. The purpose of this study was to identify risk factors for early graft loss and patient death. Between 1984 and 1997, 206 patients over the age of 60 (mean±SEM age 64±3; range: 60-76; 126 men, 80 women; 128 CAD, 78 LD) received their first renal transplant at our institution. The etiology of the renal disease was diabetes (25%), glomerulonephritis (20%), hypertension (17%) and polycystic kidney disease (16%). Graft survival at 1 and 5 years was 86% and 60%. Patient survival at 1 and 5 years was 90% and 68%. Regression analysis identified the following variables which predicted graft loss in the first year (seeTable): Thus, age, a history of a pre-transplant malignancy, delayed graft function, and a smoking history were significant predictors of graft loss in the first year. A similar regression analysis for overall graft loss showed a history of pre-transplant vascular disease, defined as symptomatic or surgically treated cerebral or peripheral arterial disease (risk ratio 1.9, p<0.05) and a history of pre-transplant malignancy (risk ratio 2.5, p=0.01) were predictors of overall graft loss. A history of pre-transplant malignancy was a significant predictor of patient death (risk ratio 2.9, p=0.005). Diabetes or prior cardiac, pulmonary or GI disease had no effect on graft or patient survival.In conclusion, renal transplantation is a safe and effective therapy for the elderly renal failure patient. In this subset of elderly patients, predictors of early graft loss or patient death were age(particularly>70), a history of a pre-transplant malignancy, smoking history and a history of vascular disease. Identification of the high risk elderly patient will facilitate the choice of renal replacement therapy.

Management of acute renal failure in the pediatric patient: Hemofiltration versus hemodialysis

Although outcome data for acute renal failure (ARF) in the adult population (analyzed by etiology of ARF, severity of illness, and modality of treatment) are readily available, few similar data exist for the pediatric population. Pediatric survival rate data vary widely, based upon era of analysis, age and size of child, and cause of ARF. Few comparative data are available that address impact by modality chosen to treat ARF. Comparison of 122 children who were treated by hemodialysis (HD; n = 58) versus hemofiltration (HF; n = 64) reveals a combined survival rate of 65%. Survival by modality was higher for HD (83%) than for HF (48%). The major diagnosis treated with HF was sepsis ( 29 64 ; 45%), with a survival rate of 31%, whereas the major diagnosis treated with HD ( 27 58 ; 46%) was primary renal failure, with a survival rate of 96%. Seventy-one percent of children undergoing HF required pressor support for hypotension, whereas only 24% of those receiving HD needed pressor support ( P < 0.01). We conclude that the choice of renal replacement therapy (RRT) modality needs to be determined by the best treatment available. To adequately evaluate therapy measures, further analyses of outcome need to consider those factors that determine choice of RRT and those that affect survival independent of ARF.