Dialysis Management Research Articles

Comparison of outcomes of different modalities of renal replacement therapy in patients of acute kidney injury: a single centre prospective observational study.

Acute Kidney Injury (AKI) is one of the most important causes of in-hospital mortality. The global burden of AKI continues to rise without a marked reduction in mortality. As such, the use of renal replacement therapy (RRT) forms an integral part of AKI management, especially in critically ill patients. There has been much debate over the preferred modality of RRT between continuous, intermittent and intermediate modes. While there is abundant data from Europe and North America, data from tropical countries especially the Indian subcontinent is sparse. Our study aims to provide an Indian perspective on the dialytic management of tropical AKI in a tertiary care hospital setup. 90 patients of AKI, 30 each undergoing Continuous Renal Replacement Therapy (CRRT), Intermittent Hemodialysis (IHD) and SLED (Sustained Low-Efficiency Dialysis) were included in this prospective cohort study. At the end of 28 days of hospital stay, discharge or death, outcome measures were ascertained which included mortality, duration of hospital stay, recovery of renal function and requirement of RRT after discharge. In addition median of the net change of renal parameters was also computed across the three groups. Lastly, Kaplan Meier analysis was performed to assess the probability of survival with the use of each modality of RRT. There was no significant difference in the primary outcome of mortality between the three cohorts (p=0.27). However, CRRT was associated with greater renal recovery (p= 0.015) than IHD or SLED. On the other hand, SLED and IHD were associated with a greater net reduction in blood urea (p=0.004) and serum creatinine (p=0.053). CRRT, IHD and SLED are all complementary to each other and are viable options in the treatment of AKI patients.

Peritoneal dialysis and acute kidney injury in acute brain injury patients.

Acute kidney injury (AKI) is a heterogeneous syndrome with multiple etiologies. It occurs frequently in the neurocritical intensive care unit and is associated with greater morbidity and mortality. In this scenario, AKI alters the kidney-brain axis, exposing patients who receive habitual dialytic management to greater injury. Various therapies have been designed to mitigate this risk. Priority has been placed by KDIGO guidelines on the use of continuous over intermittent acute kidney replacement therapies (AKRT). On this background, continuous therapies have a pathophysiological rationale in patients with acute brain injury. A low-efficiency therapy such as PD and CRRT could achieve optimal clearance control and potentially reduce the risk of secondary brain injury. Therefore, this work will review the evidence on peritoneal dialysis as a continuous AKRT in neurocritical patients, describing its benefits and risks so it may be considered as an option when deciding among available therapeutic options.

Intermittent Inotrope Infusion Associated with Peritoneal Dialysis for Management of Advanced Heart Failure Secondary to Cardiac Amyloidosis

Intermittent Inotrope Infusion Associated with Peritoneal Dialysis for Management of Advanced Heart Failure Secondary to Cardiac Amyloidosis

A case report of peritoneal dialysis for management of acute kidney injury caused by Russell’s viper envenomation in a dog

This report describes a five-year-old dog who had been bitten by a Russell’s viper. The patient presented clinical signs of anorexia, vomiting, lethargy, and anuria. Collectively with the laboratory test results of azotemia and hyperkalemia, acute kidney injury was diagnosed. Peritoneal dialysis (PD) was instigated when the azotemia became worse and anuria persisted, despite aggressive medical and fluid therapy. After 14 days of PD, the anuria was resolved, and the patient was discharged 7 days later. At the end of the last dialysis cycle, there was a significant reduction in the severity of the azotemia, and the serum hyperkalemia had returned to normal. One month after PD, the patient no longer had any abnormal clinical signs. Both the patient’s serum blood urea nitrogen level and creatinine levels returned to within the normal limit. PD proved to be an effective management of acute kidney injury in Russell’s viper envenomation in the reported dog. This report also describes a detailed procedure of PD which can be instigated in any veterinary practice

P1071WITHIN-PATIENT RELATIONSHIPS BETWEEN ULTRAFILTRATION AND FLUID GAINS IN HAEMODIALYSIS PATIENTS

Abstract Background and Aims Despite the now-widespread use of haemodialysis treatment, optimal fluid management in long-term dialysis patients remains challenging. Whilst the between-patient factors affecting target weight and ultrafiltration have been well studied, little is known regarding the within-patient factors affecting these relationships. Method Dialysis data for a group of stable haemodialysis patients, from 4 dialysis units, were analysed over a period of one year. All weights and volumes are expressed as percentage of target weight. Results From 100 patients (aged 28–89, mean 65.4, 54% male) observed over a year, complete data were available for 15530 dialysis sessions, and 13027 combinations of dialysis session plus the following inter-dialytic interval. Mean arterial pressure dropped by 3.5(+/-14.6)mmHg during dialysis, with a significant correlation (p<0.05) between pressure drop and ultrafiltration volume in 26 patients (mean R=0.09, mean regression gradient 3.2). In 87 patients, inter-dialytic fluid gain correlated strongly (p<0.05) with the previous dialysis session’s ultrafiltration volume (mean R=0.37, mean regression gradient 0.20) suggesting a significant role of ultrafiltration volume in driving subsequent fluid intake behaviour (thirst). Unsurprisingly, more fluid was gained over longer inter-dialytic intervals: mean(sd) weight at the start of dialysis was 103.2(1.0)% after a 3-day gap and 102.5(1.0)% after a 2-day gap, with this difference being significant (p<0.05) in 87 patients. However, fluid gain was non-linear, diminishing during longer inter-dialytic intervals: mean(sd) daily inter-dialytic fluid gain was 1.13(0.38)% during the 3-day gap vs 1.21(0.53)% during the 2-day gap (p<0.05 in 36 patients), implying that at least a third of patients consume less fluid during the 3rd post-dialysis day. Conclusion Inter-dialytic fluid gain is strongly dependent on ultrafiltration during the previous dialysis session, and diminishes during the inter-dialytic interval. Large ultrafiltration volumes, which have historically been perceived as the inevitable result of large fluid intakes, are actually a cause of thirst and large fluid intakes in haemodialysis patients. These data, derived from within-patient analyses, strongly challenge our conventional understanding of dialytic fluid management.

Effectiveness of Peritoneal Dialysis in Management of Acute Hyperthermia after On-Pump Heart Surgery in Infants

Introduction: Acute hyperthermia is a common complication in the first 24 hours after open heart surgery with the incidence of 12% to 73%. The aim of this study was to evaluate the efficiency of postoperative peritoneal dialysis for controlling acute hyperthermia in pediatrics undergoing on-pump heart surgery. Methods: We reviewed clinical outcomes of 40 infants who underwent congenital surgery from August 2016 to August 2017. Patients were divided into two groups in terms of peritoneal dialysis requirement as group A and B. Demographic data, intraoperative and postoperative variables were compared between the patients. Results: Among the 40 high risk infants who underwent cardiac surgery, 20 patients were treated with peritoneal dialysis (group A). Mean rectal temperature and incidence of acute hyperthermia in 24h after surgery were higher in group A compared to group B (p ˂ 0.05). Infants in group A were younger, lighter and showed lower BSA compare to group B (p Conclusion: Peritoneal dialysis performance was effective in treatment of induced hyperthermia in the first 24 h after operation. Indeed, younger age and lighter weight children are more prone to postoperative complication related to cardiopulmonary bypass surgery.

Remote Patient Management in Peritoneal Dialysis: Impact on Clinician's Practice and Behavior.

Peritoneal dialysis (PD) is a self-administered chronic renal replacement therapy. It is a home-based therapy, and thus subject to the risk of discrepancy between prescribed dose and effective dialysis delivery. Till now automated peritoneal dialysis (APD) cyclers have recorded the dialysis treatments on a card that patients bring to the hospital for consultation in the PD unit. This card contains the operative parameters of each APD session. Recently, Baxter Healthcare developed a cloud-based tool for remote patient and treatment management. The new platform named Sharesource® embedded into the cycler HOMECHOICE CLARIA® allows to overcome the problems related to poor compliance and feeling of uncertainty by the patient, reducing the number of hospital visits and the workload for physician and nurses of the PD Unit. This new system uploads all treatment information to a secure cloud-based software. The 2-way communication platform gives remote visibility to patient's treatment and allows for feedback and correction of inadequate treatment program. Remote patient management (RPM) allows to visualize the course of home PD day after day, evaluating adherence to prescription, possible alarms during treatment, drainage times, and ultrafiltration amount. The evaluation of all the data can be done by the physician at his desk in the Hospital in front of the computer. RPM allows a patient's dialytic management in real time and enables the nephrologist to remotely modify treatment operative parameters, leaving the patient at home saving kilometers, money and time. In this chapter, we describe a simple algorithm used in our unit to define alarm thresholds and to describe actions to be instituted to correct any possible problem occurring during APD.

Non- dialytic management of acute life threatening hyperkalaemia in an elderly patient with chronic kidney disease -Case report

Non- dialytic management of acute life threatening hyperkalaemia in an elderly patient with chronic kidney disease -Case report

Renal replacement therapy practices for patients with acute kidney injury in China.

Recent data indicate AKI is very common among hospitalized Chinese patients and continuous renal replacement therapy (CRRT) is increasingly offered for treatment. However, only anecdotal information regarding CRRT’s use in relation to other modalities and the specific manner in which it is prescribed exists currently. This report summarizes the results of a comprehensive physician survey designed to characterize contemporary dialytic management of AKI patients in China, especially with respect to the utilization of CRRT. The survey queried both nephrologists and critical care physicians across a wide spectrum of hospitals about factors influencing initial RRT modality selection, especially patient clinical characteristics and willingness to receive RRT, treatment location, and institutional capabilities. For patients initially treated with CRRT, data related to indication, timing of treatment initiation, dose, anticoagulation technique, and duration of therapy were also collected. Among AKI patients considered RRT candidates, the survey indicated 15.1% (95% CI, 12.3%-17.9%) did not actually receive dialysis at Chinese hospitals. The finding was largely attributed to prohibitively high therapy costs in the view of patients or their families. The survey confirmed the dichotomy in RRT delivery in China, occurring both in the nephrology department (with nephrologists responsible) and the intensive care unit (with critical care physicians responsible). For all patients who were offered and received RRT, the survey participants reported 63.9% (56.4%-71.3%) were treated initially with CRRT and 24.8% (19.2%-30.3%) with intermittent hemodialysis (HD) (P<0.001). The mean percentage of patients considered hemodynamically unstable at RRT initiation was 36.2% (31.3%-41.1%), although this figure was two-fold higher in patients treated initially with CRRT (43.1%; 35.8%-50.4%) in comparison to those initially treated with HD (22.4%; 16.4%-28.4%)(P<0.001). An overwhelming majority of intensive care patients were treated initially with CRRT (86.6%; 79.8–93.4%) while it was the initial modality in only 44.6% (33.5–55.7%) of patients treated in a nephrology department (P<0.001). Approximately 70% of respondents overall reported prescribing a CRRT dose in the range of 20–30 mL/kg/hr while approximately 20% of prescriptions fell above this range. Daily prescribed therapy duration demonstrated a marked divergence from values reported in the literature and standard clinical practice. Overall, the most common average prescribed value (50% of respondents) fell in the 10–20 hr range, with only 18% in the 20–24 hr range. Moreover, 32% of respondents reported an average prescribed value of less than 10 hrs per day. While the percentages for the 10–20 hrs range were essentially the same for nephrology and ICU programs, a daily duration of less than 10 hrs was much more common in nephrology programs (48.0%; 38.3%-57.9%) versus ICU programs (16%; 10.0%-24.6%)(P<0.001). Our analysis demonstrates both similarities and differences between RRT practices for AKI in China and those in the developed world. While some differences are driven by non-medical factors, future studies should explore these issues further as Chinese RRT practices are harmonized with those in the rest of the world.

Interplay of volume, blood pressure, organ ischemia, residual renal function, and diet: certainties and uncertainties with dialytic management.

Extracellular fluid volume overload and its inevitable consequence, hypertension, increases cardiovascular mortality in the long term by leading to left ventricular hypertrophy, heart failure, and ischemic heart disease in dialysis patients. Unlike antihypertensive medications, a strict volume control strategy provides optimal blood pressure control without need for antihypertensive drugs. However, utilization of this strategy has remained limited because of several factors, including the absence of a gold standard method to assess volume status, difficulties in reducing extracellular fluid volume, and safety concerns associated with reduction of extracellular volume. These include intradialytic hypotension; ischemia of heart, brain, and gut; loss of residual renal function; and vascular access thrombosis. Comprehensibly, physicians are hesitant to follow strict volume control policy because of these safety concerns. Current data, however, suggest that a high ultrafiltration rate rather than the reduction in excess volume is related to these complications. Restriction of dietary salt intake, increased frequency, and/or duration of hemodialysis sessions or addition of temporary extra sessions during the process of gradually reducing postdialysis body weight in conventional hemodialysis and discontinuation of antihypertensive medications may prevent these complications. We believe that even if an unwanted effect occurs while gradually reaching euvolemia, this is likely to be counterbalanced by favorable cardiovascular outcomes such as regression of left ventricular hypertrophy, prevention of heart failure, and, ultimately, cardiovascular mortality as a result of the eventual achievement of normal extracellular fluid volume and blood pressure over the long term.

Pleuroperitoneal Communication and Ovarian Cancer Complicating Peritoneal Dialysis: A Case Report of a Patient with End-Stage Kidney Disease.

Peritoneal dialysis has been a widely accepted modality for treating end-stage kidney disease, but a regular dialysis schedule can be seriously disrupted by various comorbid conditions requiring surgical intervention. A 40-year-old woman who had been receiving peritoneal dialysis was sequentially but separately complicated by pleuroperitoneal communication and ovarian cancer. Despite the need for temporary interruption of her peritoneal dialysis schedule, it was successfully resumed after the relevant surgeries for each disease. Several concerns regarding overall postoperative dialytic management strategies, including how to deal with the peritoneal dialysis catheter during the postoperative period as well as how long peritoneal dialysis should be interrupted, which remain an unresolved issue in the field of nephrology, are also discussed.

Bowel Obstruction and Peritoneal Dialysis: A Case Report of a Patient with Complications from a Broad Ligament Hernia

Abdominal hernias are a common cause of bowel obstruction. The major types of abdominal hernias are external or abdominal wall hernias, which occur at areas of congenital or acquired weakness in the abdominal wall. An alternative entity is internal hernias, which are characterized by a protrusion of viscera through the peritoneum or mesentery. We herein present the case of a female peritoneal dialysis patient with bowel obstruction due to an internal hernia. Although an initial work-up did not lead to a correct diagnosis, an exploratory laparotomy revealed that she had intestinal herniation due to a defect in the broad ligament of the uterus, which was promptly corrected by surgery. The concerns about the perioperative dialytic management as well as the diagnostic problems regarding the disease that arose in our experience with the present patient are also discussed.

Peritoneal dialysis vs. haemodialysis in the management of paediatric acute kidney injury in Kano, Nigeria: a cost analysis

To determine the cost of the dialytic management of paediatric acute kidney injury in a low-income country. All children under the age of 15years, who had either peritoneal dialysis or haemodialysis for acute kidney injury in Aminu Kano Teaching Hospital over a 1-year period, were studied. The average cost of each dialysis modality was estimated. Of 20 children, who had dialysis for acute kidney injury, 12 (60%) had haemodialysis and 8 (40%) had peritoneal dialysis. The mean cost for haemodialysis exceeded that of peritoneal dialysis ($363.33 vs. $311.66, t=1.04, P=0.313) with the mean cost of consumables significantly accounting for most of the cost variation ($248.49 vs. $164.73, t=2.91, P=0.009). Mean costs of nephrologist visit and nursing were not found to be significant. Peritoneal dialysis is the less costly alternative for managing acute kidney injury in children in our environment.

KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury

In response to the recently released 2012 KDIGO (Kidney Disease: Improving Global Outcomes) clinical practice guideline for acute kidney injury (AKI), the National Kidney Foundation organized a group of US experts in adult and pediatric AKI and critical care nephrology to review the recommendations and comment on their relevancy in the context of current US clinical practice and concerns. The first portion of the KDIGO guideline attempts to harmonize earlier consensus definitions and staging criteria for AKI. While the expert panel thought that the KDIGO definition and staging criteria are appropriate for defining the epidemiology of AKI and in the design of clinical trials, the panel concluded that there is insufficient evidence to support their widespread application to clinical care in the United States. The panel generally concurred with the remainder of the KDIGO guidelines that are focused on the prevention and pharmacologic and dialytic management of AKI, although noting the dearth of clinical trial evidence to provide strong evidence-based recommendations and the continued absence of effective therapies beyond hemodynamic optimization and avoidance of nephrotoxins for the prevention and treatment of AKI.

Can we treat fluid overload with fluid? Role of peritoneal dialysis in management of heart failure

Can we treat fluid overload with fluid? Role of peritoneal dialysis in management of heart failure

Outcome Comparisons of Intermittent and Continuous Therapies in Acute Kidney Injury: What do They Mean?

Despite the fact that no new clinical outcome studies comparing intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) have been published in the past year, two meta-analyses addressing the topic (Bagshaw et al, Crit Care Med 2008; 36: 610-7, and Pannu et al, JAMA 2008; 299: 793-805) have been published recently. With respect to randomized controlled trials (RCTs), there was a substantial overlap between the studies considered in the analysis by Bagshaw et al and those considered in the analysis by Pannu et al. Although neither metaanalysis showed a benefit for either modality with respect to mortality or renal recovery, the two publications offered vastly different conclusions. Bagshaw et al concluded it is impossible to make any definitive recommendations about dialysis modality choice in AKI because previous studies were not adequately powered and failed to standardize for treatment dose. On the other hand, because the metaanalysis of Pannu et al demonstrated equivalent patient outcomes, and in light of the lower costs of IHD, they suggested that alternate-day hemodialysis should become the preferred therapy in many critically ill patients. As the clinical practice recommendations made by Pannu and colleagues have very important implications, we believe their analysis should be critically assessed. In this review, the weaknesses of the RCTs considered in the meta-analysis by Pannu et al are presented. Furthermore, the assumption by Pannu et al that IHD is associated with lower costs than CRRT is challenged, as they did not consider adequately both the short-term and long-term costs associated with the dialytic management of AKI patients. Based on our critical analysis, we believe the AKI dialytic treatment approach recommended by the JAMA investigators (Pannu et al) is not supported by the aggregate of the available clinical outcome data and, therefore, remains highly controversial. We would like to join with others in the AKI field by strongly recommending that investigators and other clinicians stop trying to make conclusive determinations about dialysis modalities when robust supportive data simply are not available. Instead of additional intermodality comparisons, the focus of future clinical research should be toward generating high-quality data on intramodality interventions, such as treatment dose and timing of treatment initiation. In this regard, at least for CRRT, we anxiously await the results of the ongoing RCTs evaluating the effect of CRRT dose on patient outcome.

Cardiovascular disease in end stage renal failure

Preface Cardiovascular Risk factors in End-stage renal disease Mortality and cardiovascular risk factors influencing survival in ESRD Ischemic heart disease in ESRD Structural basis of cardiovascular dysfunction in uremia Arterial function in ESRD Endothelial function in ESRD Cardiac hypertrophy in ESRD Lipoprotein abnormalities and Lp9a) in ESRD Hyperhomocysteinemia in ESRD Microalbuminuria in artherosclerotic vascular disease Oxidative stress and cardiovascular disease in ESRD Hypertension in ESRD Congestive heart failure and its management in ESRD Diagnosis and management of ischemic heart disease in ESRD Hypotension,, Arrhythmias and hemodynamic instability in ESRD Dialytic management of ESRD patients undergoing open heart surgery Manegement and Diagnosis of peripheral arterial disease among ESRD patients Prevention of Cardiovascular complications

Convective renal replacement therapies for acute renal failure and end‐stage renal disease

Although hemodialysis remains the primary treatment modality for the management of patients with end-stage renal disease (ESRD), its clearance of relatively large-sized uremic toxins is limited due to its primarily diffusive nature. Moreover, recent studies suggesting conventional, diffusion-based therapies may be limited in their ability to influence outcome in ESRD patients indicate the need for alternative chronic dialysis approaches, an example of which is convective therapies. In an analogous manner, a reassessment of the dialytic management of critically ill patients with acute renal failure (ARF) has also occurred recently based on clinical evidence that high-dose continuous hemofiltration improves survival. These recent clinical results suggest the utilization of convective therapies in both ARF and ESRD will increase in the future. This article provides a review of convective therapies, with an initial discussion of the determinants of convective solute removal. This is followed by a comprehensive overview of the manner in which hemofiltration and hemodiafiltration are applied clinically.

Update on dialytic management of acute renal failure.

The potential impact of renal replacement therapy on clinical outcomes in acute renal failure (ARF) remains a subject of ongoing investigation and controversy. This article reviews in depth the clinical trials to date that have examined the effect of dialysis-related variables on outcomes of patients with hospital-acquired ARF. In particular, the role of the dialysis modality, dialyzer characteristics, and dosing strategies are discussed. Clinical trials comparing intermittent hemodialysis (HD) to continuous renal replacement therapies (CRRT) have failed to demonstrate a survival difference when adjusting for disease severity. Similarly, studies evaluating dialyzer membrane biocompatibility and flux properties had no impact on survival. Efforts aimed at measuring dialysis adequacy in patients with ARF receiving HD using urea kinetic modeling are hindered by a lack of understanding of solute kinetics in this setting. However, dosing strategies during CRRT are promising. Finally, the application of cell therapy to the successful substitution of renal function shows promise for the future.

Update on Dialytic Management of Acute Renal Failure

Update on Dialytic Management of Acute Renal Failure