Days Of Renal Replacement Therapy Research Articles

Peritoneal Dialysis in Croatia

To present the state of renal replacement therapy (RRT) in Croatia, assess the quality of dialytic treatment, verify the value of peritoneal dialysis (PD), and promote expansion of PD in Croatia based on results attained locally. According to the integrative care concept, PD is the best way to start life-long RRT. Croatian nephrologists have adopted the policy of increasing the use of PD. However, evidence for recommendations were obtained in specific circumstances and might not be relevant elsewhere. The aim of this observational study is to compare the outcome of PD with that of hemodialysis (HD), as practiced in Croatia. Since 2000, the Croatian Registry for Renal Replacement Therapy has been collecting individual patient data for all patients on RRT, with complete coverage. As of 31 December 2004, there were 251 prevalent patients on PD (continuous ambulatory PD and automated PD) in Croatia, accounting for 7% of all patients on RRT and giving a prevalence of 57 patients per million population. From 1 January 2000 to 31 December 2004, 377 patients started PD and were followed from the first day of RRT. For 80% of them, PD was the first mode of RRT. The probability of staying on PD for 5 years was 31% [95% confidence interval (CI) 29-32]. Five-year technique survival (excluding transplanted, recovered, and deceased patients) was 68% (95%CI 65-70). For survival analysis and comparison between PD and HD, only patients on the same method from the start of their RRT were included. Patients changing treatment were censored after 60 days (intention-to-treat analysis). Unadjusted 5-year survival in the PD-first group (301 patients) was 60% (95%CI 54-65), which is significantly better than in the 2789 HD-first patients (42%, 95%CI 40-44; log-rank p < 0.0001). When data were stratified for age and diabetes, 5-year mortality rates on HD were higher in all strata. Only in patients >/=70 years old was the advantage of PD less impressive. Standardized mortality ratio was 1.85 (p < 0.01) in favor of PD. Hazard ratio of HD versus PD was 2.1 (95%CI 1.6-2.8). After adjustments for age, gender, diabetes, and nephroangiosclerosis, the hazard ratio settled at 1.5 (95%CI 1.1-1.9). In Croatia, PD is used mostly as the first RRT. Almost one third of patients continue PD for 5 years due to good patient and technique survival. Starting RRT with PD offers 50% superior 5-year survival in comparison to HD. Dialysis patients in Croatia would benefit from an expanded PD program.

Continuous venovenous hemodiafiltration versus hemodialysis as renal replacement therapy in patients with acute renal failure in the intensive care unit

Hemodialysis (HD) and continuous venovenous hemodiafiltration (CVVHDF) have been adopted as forms of renal replacement therapy (RRT) in patients with acute renal failure (ARF). Although CVVHDF has many advantages, previous studies reported no definite improvement in survival rate compared to HD. In this retrospective study, 148 intensive care unit patients underwent HD (70 males, 25 females; mean age 45 +/- 17 years) or CVVHDF (42 males, 11 females; mean age 52 +/- 18 years). The severity of illness was estimated at the initiation of RRT and on the third day of RRT and presented using the APACHE III scoring system. The number of organ failures was checked at the initiation of RRT. The survival rate was 46% in the HD group and 21% in the CVVHDF group (p = 0.002). CVVHDF was applied to the more severely ill patients, who had longer periods using a ventilator (p = 0.002) and/or vasopressor (p < 0.001), higher numbers of organ failures (p < 0.001) and higher initial APACHE III scores (p < 0.001). Among patients with APACHE III scores > 103, the survival rate was 13% in the CVVHDF group and 0% in the HD group. In patients with kidney failure and failure of two other organs, the survival rate was 9% in the HD group and 36% in the CVVHDF group (p = 0.035). The mortality rate in the CVVHDF group was higher than that in the HD group, which may have been because CVVHDF was applied to the more severely ill patients. In contrast, CVVHDF may give a chance of survival to patients with APACHE III scores > 103 and may be more useful than HD in patients with failure of three or more organs.

Pathophysiologic effects of uremic retention solutes.

The uremic syndrome can be defined as a deterioration of biochemical and physiologic functions, in parallel with the progression of renal failure, resulting in complex and variable symptomatology (1-3). The compounds that accumulate in the uremic blood and tissues during the development of end-stage renal disease (ESRD), directly or indirectly due to a deficient renal clearance, are called uremic retention solutes. These retention solutes may modify biochemical or physiologic func- tions; if they do so, they contribute to the uremic syndrome. Only a few solutes have an established role as uremic toxins. According to Bergstrom, apart from inorganic compounds, urea, oxalic acid, parathyroid hormone (PTH), and b2-micro- globulin conform to the most strict definition of uremic toxins (4). However, this does not preclude a potential toxic role for various other retention solutes (5). The following factors, which are not always considered, might affect uremic solute concentration and their impact on biologic functions. (1) In addition to classical sources of ure- mic solutes such as dietary protein breakdown, alternative sources such as environment, herbal medicines, or psychedelic drugs may play a role in uremic toxicity. (2) Many solutes with toxic capacity enter the body through the intestine. Changes in the composition of intestinal flora, or changes in intestinal production and absorption, might alter their serum concentra- tion. (3) Some uremic solutes interfere with functions that directly affect the biochemical action of other solutes: the expression of PTH receptors, the response to 1,25(OH)2 vita- min D3, as well as the protein binding and breakdown of several other solutes. (4) Most uremic patients are prescribed a host of drugs. Interference of drugs with protein binding and/or tubular secretion of uremic solutes will influence their biologic effect. (5) Lipophilic compounds may be responsible at least in part for functional alterations in uremia. ( 6) The impact of residual renal function on uremic solute retention should not be neglected. (7) The main strategy that has been used up to now to decrease uremic solute concentration is dialysis, but dialysis is nonspecific and removes essential compounds as well. (8) Uremic solutes accumulate not only in the plasma but also in the cells, where most of the biologic activity is exerted. Re- moval of intracellular compounds during dialysis through the cell membrane may be hampered, resulting in multicompart- mental kinetics and inadequate detoxification. It is of note that lower morbidity and mortality are observed in patients submit- ted to long dialysis sessions (6,7). Compounds may be cleared more efficiently with continuous or long-lasting low efficiency strategies, because removal is more gradual. Our views on the uremic syndrome and several uremic solutes have changed substantially during the last decade. Therefore, it was thought timely to summarize the present state of knowledge about the biochemical, physiologic, and/or clin- ical impact of those compounds that have been subjected to relatively thorough evaluation during these last 10 years. Spe- cific attention was also paid to generation and removal pat- terns.

Death during the first 90 days of dialysis: A case control study

Comparison of survival data among centers may be used to assess performance, but may be influenced by the number of patients who die during the first 90 days of renal replacement therapy (RRT). Data published by registries in Europe do not detail these deaths, and US data generally exclude them from analysis for financial reasons. To study factors influencing such deaths we compared 42 patients who died within 90 days of first commencing RRT in one Scottish renal unit (group A) between 1971 and 1992 with 42 age- and sex-matched controls who started RRT over the same period and survived longer (group B). Patients who died within 90 days of RRT ranged in age from 25.3 to 83.7 years and had a mean age of 65.2 (SEM, 1.6; 95% confidence interval, 61.9 to 68.4). The proportion of patients who died during the first 90 days of RRT increased from 2% of all patients treated before 1981 to 12% in subsequent years. Thirty-three patients in group A received emergency dialysis via temporary venous access compared with only nine in group B ( P < 0.055). There were more patients in group A with a diagnosis of arteriosclerotic renal artery stenosis (14 v 1) and with a history of smoking (15 v 2) than in group B ( P < 0.0005). Median renal or nonrenal follow-up before RRT was 1.1 month in group A and 10.6 months in group B ( P < 0.0001). Fewer patients in group A had no coexisting disease (1 v 17; P < 0.0001). Group A patients had a significantly lower mean serum albumin concentration at the time of commencing RRT than group B patients (31.4 g/ L v 37.1 g/ L) ( P = 0.0006). Blood pressure and serum concentrations of creatinine and potassium were comparable in both groups. We conclude that 90-day mortality in our center was associated with the presence of coexisting disease, renal artery stenosis, smoking, hypoalbuminaemia, and presentation with advanced renal failure. Furthermore, since such heterogeneous patients are difficult to classify, valid survival data can be obtained from different centers only when such early mortality is excluded from analysis.