Maintenance Of Residual Renal Function Research Articles

Experience of humanistic nursing in hemodialysis nursing for patients with diabetic kidney disease.

Diabetic kidney disease (DKD) is a prevalent complication of diabetes that often requires hemodialysis for treatment. In the field of nursing, there is a growing recognition of the importance of humanistic care, which focuses on the holistic needs of patients, including their emotional, psychological, and social well-being. However, the application of humanistic nursing in the context of hemodialysis for DKD patients remains relatively unexplored. To explore the experience of humanistic nursing in hemodialysis nursing for DKD patients. Ninety-six DKD patients treated with hemodialysis from March 2020 to June 2022 were included in the study and divided into the control cluster (48 cases) and the study cluster (48 cases) according to different nursing methods; the control cluster was given routine nursing and the study cluster was given humanized nursing. The variances of negative emotion mark, blood glucose, renal function, the incidence of complications, life mark and nursing satisfaction before and after nur-sing were contrasted between the two clusters. No significant difference in negative emotion markers between the two clusters were observed before nursing (P > 0.05), and the negative emotion markers of the two clusters decreased after nursing. The Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale markers were lower in the study cluster than the control cluster. The healing rate of patients in the study cluster was significantly higher than the control cluster (97.92% vs 85.42%, P < 0.05). Blood glucose parameters were not significantly different between the groups prior to nursing (P > 0.05). However, after nursing, blood urea nitrogen and serum creatinine (SCr) levels in the study cluster were lower than those in the control cluster (P < 0.05). The incidence rate of complications was significantly lower in the study group compared to the control cluster (6.25% vs 20.83%, P < 0.05). There was no significant difference in the life markers between the two clusters before nursing. While the life markers increased after nursing for both groups, the 36-item health scale markers in the study cluster were higher than those within the control cluster (P < 0.05). Finally, the nursing satisfaction rate was 93.75% in the study cluster, compared to 75% in the control cluster (P < 0.05). In hemodialysis for DKD patients, the implementation of humanistic nursing achieved ideal results, effectively reducing patients' psychological negative emotion markers so that they can actively cooperate with the diagnosis and nursing, facilitate the control of blood glucose and the maintenance of residual renal function, reduce the occurrence of complications, and finally enhance the life quality and nursing satisfaction of patients. It is worthy of being widely popularized and applied.

Emodiafiltrazione e sopravvivenza: cosa abbiamo imparato dai più recenti studi clinici controllati?

Oggigiorno, è opinione comune che, rispetto all'emodialisi standard (HD), l'emodiafiltrazione on-line (HDF) possa consentire migliori risultati in termini di tolleranza intradialitica, stato nutrizionale, mantenimento della funzione renale residua, responsività all'eritropoietina e controllo della fosforemia. Tuttavia, finora, gli studi controllati non sono stati in grado di dimostrare la superiorità dell'HDF nel ridurre la morbilità e la mortalità. Due recenti studi prospettici, randomizzati e controllati, il “Convective Transport Study” (CONTRAST) e il “Comparison of Post-dilution Online Haemodiafiltration and Haemodialysis” (TURKISH OL-HDF STUDY), hanno confrontato la sopravvivenza e gli eventi cardiovascolari in HDF e in HD. Benché fossero studi ampi e appositamente disegnati per valutare questo importante outcome, non è stato possibile trovare differenze significative tra i due trattamenti (HDF vs HD low-flux nel CONTRAST e HDF vs HD high-flux nel TURKISH STUDY). In analisi post-hoc, entrambi gli studi hanno mostrato come alti volumi convettivi fossero associati a una migliore prognosi, anche se questi risultati devono essere considerati solo “generatori di ipotesi” e necessitano di essere testati in adeguati trial. I risultati derivanti dallo studio spagnolo e francese, non ancora pubblicati, ci aiuteranno a comprendere meglio l'importanza dell'HDF nella pratica clinica quotidiana.

Residual renal function in peritoneal dialysis with failed allograft and minimum immunosuppression

Immunosuppression (IS) is often withdrawn in patients with end stage renal disease secondary to a failed renal allograft, and this can lead to an accelerated loss of residual renal function (RRF). As maintenance of RRF appears to provide a survival benefit to peritoneal dialysis (PD) patients, it is not clear whether this benefit of maintaining RRF in failed allograft patients returning to PD outweigh the risks of maintaining IS. A 49 year-old Caucasian male developed progressive allograft failure nine years after living-donor renal transplantation. Hemodialysis was initiated via tunneled dialysis catheter (TDC) and IS was gradually withdrawn. Two weeks after IS withdrawal he developed a febrile illness, which necessitate removal of the TDC and conversion to PD. He was maintained on small dose of tacrolimus (1 mg/d) and prednisone (5 mg/d). Currently (1 year later) he is doing exceedingly well on cycler-assisted PD. Residual urine output ranges between 600-1200 mL/d. Total weekly Kt/V achieved 1.82. RRF remained well preserved in this patient with failed renal allograft with minimal immunosuppressive therapy. This strategy will need further study in well-defined cohorts of PD patients with failed allografts and residual RRF to determine efficacy and safety.

Influence of blood pressure control on maintenance of residual function in patients treated by haemodialysis

Residual renal function (RRF) in the patients treated by haemodialysis (HD) is associated not only with better volume and blood pressure control but also with better metabolic control.The condition of the cardiovascular system significantly affects RRF. The aim of the study was to find if there was any association between blood pressure regulation and the achieved HD ultrafiltration in the first year of haemodialysis treatment and the maintenance of RRF. In this retrospective study, 53 patients were analyzed in the period 1994-2002. Residual clearance of urea (RCU) was measured for the first time at the beginning of HD treatment, and for the second time one year later. Laboratory data and values of blood pressure as well as the achieved HD ultrafiltration were taken from the electronic database of the Nephrology Hospital. The value of RCU less than 1 ml/min was considered as the loss of RRF and, at the beginning of HD treatment, 14 patients (26.4%) had that result. The rise of mean arterial pressure (MAP) was associated in linear regression analysis with a drop of residual diuresis volume (beta = -0.28; p = 0.04), but there was no association with RCU. The patients with MAP > 105 mm Hg had RKU less than the patients with MAP < 105 mm Hg (t = 2.23; p = 0.03). The rise of the HD ultrafiiltration significantly affected the loss of RRF obtained by the linear regression analysis (beta = -0.44; p = 0.0001). The greater HD ultrafiltration is related to a drop of RCU values. Only prospective randomised trials with the use of multiple regression analysis could define a more precise association between hypertension and RKU.

Treatment Time, Chronic Inflammation, and Hemodynamic Stability: The Overlooked Parameters in Hemodialysis Quantification

Decades after the introduction of chronic maintenance hemodialysis, the optimal means of quantifying dialysis dose remains controversial. Differences of opinion in the international dialysis community lead to substantial diversity in everyday clinical practice. Several studies suggest that the well-recognized international mortality differences in hemodialysis populations may result from these divergent approaches to dialysis care. One of the main areas of divergence is the different degree of reliance on dialysis clearance when prescribing dialysis. The "clearance approach" implies that treatment quality is primarily dependent on efficient removal of uremic toxins as estimated by dialytic urea clearance. Urea can be rapidly removed by high efficiency dialysis in a relatively short time. The main alternative to this strategy is the "time approach" based on the recognition that longer or more frequent dialysis provides benefits beyond increasing urea removal. Some of the putative benefits are more effective volume and blood pressure control, better maintenance of hemodynamic stability because of slower ultrafiltration and removal of uremic toxins that do not behave like urea. Recently, chronic inflammation has been proposed to be an important predictor of outcome in dialysis patients. Inflammatory markers are commonly elevated in chronic renal failure and levels of these seem to correlate with malnutrition, maintenance of residual renal function, and volume control. The relationships between dialysis clearance, treatment time, chronic inflammation, volume control, and hemodynamic stability are explored in this review. We propose that a better understanding of these complex relationships may provide opportunities for improving outcomes of maintenance hemodialysis patients.

Actualités en dialyse péritonéale

Peritoneal dialysis, like hemodialysis, is a first-line therapy for patients with end-stage renal disease. Progress in medical devices and materials has reduced infectious complications such as peritonitis and catheter exit-site infections and thus decreased morbidity. Peritoneal dialysis fluids are increasingly biocompatible, result in fewer glucose degradation products, protect the peritoneal membrane better and thus improve tolerance. The maintenance of residual renal function, together with better comfort and no pain, help control the fluid and sodium balance. Automated peritoneal dialysis can be performed each night, either autonomously or assisted by a visiting nurse twice a day (to prepare, connect, and disconnect the machine). This treatment can thus be provided to most patients, regardless of their age. Peritoneal dialysis is indicated principally for young people waiting for a kidney transplantation (to preserve their vascular network), elderly patients who wish to remain either at home or in an institution, and patients with cardiac insufficiency, because of the better hemodynamic tolerance. Numerous obstacles, mainly nonmedical, still impede the development of peritoneal dialysis. Patients seen in emergencies start hemodialysis without necessarily receiving any information about peritoneal dialysis. Indeed, neither physicians nor patients receive adequate information.

Residual renal function and dialysis modality: Is it really beneficial to preserve residual renal function in dialysis patients? (Review Article)

Residual renal function (RRF) contributes to the achievement of treatment adequacy in stage 5 chronic kidney disease (CKD-5) patients. It may facilitate patients' acceptance of renal replacement therapy (RRT) in allowing reduction of treatment time duration and minimising dietary and fluid restriction. It has been confirmed to improve dialysis patient outcomes. Attempts to preserve RRF in incident Stage 5 chronic kidney disease patients are still subject to intense controversies in the nephrology community. The aim of this review is to analyse the role of renal replacement modalities in the maintenance of RRF in dialysis patients. Under the scope of this manuscript, four questions are explored: Is the preservation of residual renal function an objective for dialysis adequacy? Does dialysis modality affect the decline of RRF? What are the factors implicated by this loss of RRF? At what expense can the maintenance of RRF be achieved in dialysis patients? Preservation of RRF is undoubtedly an interesting means to enhance the efficacy of renal replacement therapy and reduce dietary fluid restriction but it should not be considered as a goal of dialysis adequacy in dialysis patients. Further, preservation of RRF must be considered as a permanent trade-off between patient comfort and chronic fluid volume overload.

Automated Peritoneal Dialysis Has Significant Effects on Systemic Hemodynamics

Maintenance of residual renal function (RRF) is an important determinant of outcome in peritoneal dialysis patients. It remains contentious as to whether automated peritoneal dialysis (APD) leads to an increased rate of decline of RRF compared with continuous ambulatory peritoneal dialysis (CAPD). We studied whether APD was associated with significant systemic hemodynamic changes that may play a role in the accelerated loss of RRF. As a follow-on from a previous study, 8 well-established CAPD patients underwent a 4-hour APD treatment consisting of 3 drain/fill cycles using 2 x 2.5 L 1.36% glucose and 1 x 3.86% glucose dialysate. Each dwell phase lasted 76 minutes. Blood pressure (BP) and a full range of hemodynamic variables, including pulse (HR), stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR), were measured noninvasively using continuous arterial pulse wave analysis. BP fell during 2 of the 3 drain/fill periods when dialysate was drained from the peritoneal cavity, but then rose upon instillation of dialysate fluid. The fall in BP was associated with a fall in TPR, matched by an inadequate rise in SV and CO. Over the entire study period, TPR progressively rose to +53.4% above baseline (p = 0.032). Both SV and CO fell over the same period, to -21.1% (p = 0.060) and -22.4% from baseline (p = 0.037) respectively. This did not result in any significant difference between start and end BP. This study demonstrates that APD is associated with significant systemic hemodynamic effects. The increased number of drain/fill cycles compared to CAPD, or the progressive rise in TPR and reduction in CO (possibly due to a cooling effect), may potentially be factors that adversely affect RRF in APD patients.

Tailored dialysis start may allow persistence of residual renal function after graft failure: A case report

Background Restarting dialysis after kidney transplantation is a critical step with psychological and clinical implications. Maintenance of residual renal function a known factor affecting survival in chronic kidney disease, has so far not been investigated after a kidney transplantation. The case A 54-year-old woman who started dialysis in 1974 (first graft, 1975–1999) received a second “marginal” kidney graft in February 2001 (donor age, 65 years). Her chronic therapy was tacrolimus and steroids. She had a clinical history as follows: nadir creatinine level of 1.5 mg/dL, moderate-severe hypertension, progressive graft dysfunction, nonresponsiveness to addition of mycophenolate, tapering FK levels, and a rescue switch from tacrolimus to rapamycin. From October to December 2003, the creatinine level increased from 2–2.8 to 7 mg/dL. Biopsy specimen showed malignant and “benign” nephrosclerosis, posttransplantation glomerulopathy, and tacrolimus toxicity. Chronic dialysis was started (GFR <3 mL/min). Rapamycin was discontinued. Dialysis was tailored to reach an equivalent renal clearance of >15 mL/min (2 sessions/wk). Blood pressure control improved, nephrotoxic drugs were avoided, and fluid loss was minimized (maximum 500 mL/hr). By this policy, renal function progressively increased to GFR >10 mL/min in May 2004, allowing a once or twice weekly dialysis schedule, with good clinical balance, and obvious advantages for the quality of life. Conclusion This long-term patient, who restarted dialysis with severely reduced renal function, regained sufficient renal function to allow once weekly dialysis. Thus, careful tailoring of dialysis sessions at the restart of dialysis may allow preservation of residual kidney function, at least in individuals for whom a subsequent graft is unlikely.

The Decline in Residual Renal Function in Hemodialysis Is Slow and Age Dependent

Persons on peritoneal dialysis and hemodialysis with preserved residual renal function experience lower mortality rates than those without. Previous studies have shown slower rates of decline of residual renal function for peritoneal dialysis (PD)(2 to 3% decrease/month), compared with hemodialysis (HD)(6 to 7% decrease/month). However, our clinical observations suggested a lower rate of decline in hemodialysis patients. We evaluated data in 174 hemodialysis patients cared for from January 2000 through October 2001. Eighty-seven (50%) patients had at least two timed quarterly urine collections to estimate the rate of change of residual renal function over time (urea clearance, or KrU). All patients underwent thrice-weekly hemodialysis using polysulfone dialyzers with formaldehyde reprocessing. The rate of decline of residual renal function and the effect of KrU on laboratory variables were estimated using a random effects (MIXED) model, adjusting for the effects of age, sex, race, diabetes, and dialysis vintage. The mean KrU at baseline was 3.5 mL/min. Men (P < 0.001) and persons of shorter vintage (P < 0.0001) had more residual renal function at baseline. The estimated rate of decline of residual renal function was - 0.07 mL/min/month (- 1.9% decrease/month). The rate of decline in residual renal function was unaffected by sex, race, diabetes, or vintage, although the rate of decline was significantly attenuated among older individuals (age x time interaction, P = 0.01). Serum phosphorus (P = 0.03) and the calcium x phosphorus product (P = 0.009) increased over time and were influenced by the level of residual renal function (P = 0.06 and P = 0.006, respectively). Residual renal function did not influence the rate of change of other laboratory variables. In an ethnically diverse cohort of hemodialysis patients, the rate of decline of residual renal function was relatively slow and age dependent, as well as consistent with values others have reported for patients on peritoneal dialysis. Universal use of biocompatible dialyzers and bicarbonate dialysate may have contributed to differences discussed in prior reports. Residual renal function attenuated the increase in calcium-phosphorus product over time. A better understanding of the determinants of the rate of decline in residual renal function, and the specific benefits afforded to patients via maintenance of residual renal function, would help to inform the debates on timing of initiation and various dosing strategies in hemodialysis.

Back to the Future: Middle Molecules, High Flux Membranes, and Optimal Dialysis

Middle molecules can be defined as compounds with a molecular weight (MW) above 500 Da. An even broader definition includes those molecules that do not cross the membranes of standard low-flux dialyzers, not only because of molecular weight, but also because of protein binding and/or multicompartmental behavior. Recently, several of these middle molecules have been linked to the increased tendency of uremic patients to develop inflammation, malnutrition, and atheromatosis. Other toxic actions can also be attributed to the middle molecules. In the present publication we will consider whether improved removal of middle molecules by large pore membranes has an impact on clinical conditions related to the uremic syndrome. The clinical benefits of large pore membranes are reduction of uremia-related amyloidosis; maintenance of residual renal function; and reduction of inflammation, malnutrition, anemia, dyslipidemia, and mortality. It is concluded that middle molecules play a role in uremic toxicity and especially in the processes related to inflammation, atherogenesis, and malnutrition. Their removal seems to be related to a better outcome, although better biocompatibility of membranes might be a confounding factor.

The Influence of Demographic Factors and Modality on Loss of Residual Renal Function in Incident Peritoneal Dialysis Patients

To determine whether gender, race, diabetes, peritoneal dialysis (PD) modality, and comorbid conditions influence loss of residual renal function (RRF). Retrospective study of incident PD patients, using database of prospectively collected demographic, laboratory, and clearance data. Peritoneal Dialysis Registry of the University of Pittsburgh Medical Center. The study included 184 continuous ambulatory PD and automated PD patients who had at least two 24-hour urine collections for glomerular filtration rate (GRF) between April 1991 and March 2000. 836 urine collections were analyzed. Loss of RRF was defined as the slope of the decline in GFR as measured by the average of creatinine and urea clearances in 24-hour urine collections. Stepwise forward regression was used to identify demographic and laboratory factors associated with loss of GFR. Spearman correlations were used to assess the significance of associations. The median rate of decline of renal function was -0.17 mL/minute/month. Gender, race, diabetes, automated PD, peritoneal equilibration test, protein equivalent of nonprotein nitrogen appearance normalized to body surface area, and serum albumin did not predict loss of RRF. Cardiac disease was the only variable affecting decline of RRF (p = 0.045). Modality of PD and patient demographic factors do not contribute to the rate at which RRF is lost in incident PD patients. Additional study of the factors contributing to the decline and maintenance of RRF is needed.

Clinical impact of residual renal function on patients starting dialysis treatment.

We describe our clinical experience of monitoring residual renal function of patients on regular dialysis treatment as residual renal function can play an important role in the management of patients undergoing regular dialysis. With active residual renal function it is possible to delay the start of haemodialytic programmes. In managing dialysis treatments, it is important to maintain residual renal function by preventing hypotensive events. It is known that in acute renal failure intradialytic hypotension is able to reduce the recovery of renal function. Out patient follow-up plays an important role for these patients. This paper will also discuss the use of biocompatible membranes during dialysis. The outcome is that they are not associated with better maintenance of residual renal function.

Effect of aminoglycoside use on residual renal function in peritoneal dialysis patients.

Residual renal function (RRF) is a major contributor to total solute clearance in peritoneal dialysis (PD) patients, and maintenance of RRF has been linked to decreased morbidity and mortality in PD. There have been few clinical studies examining the impact of factors that potentially affect RRF in PD. This is a prospective observational study that examines the effects of parenteral aminoglycosides, a common nephrotoxin in the general population, on RRF in a cohort of PD patients. Seventy-two patients from two Rhode Island PD units were observed over 4 years. Twenty-four-hour renal creatinine clearances and urine volumes were measured every 4 to 6 months. The patients were divided into three groups, depending on exposure to peritonitis and aminoglycoside use. Group I included patients without peritonitis who received no intravenous (IV) or intraperitoneal (IP) antibiotics. Group II included patients with peritonitis who received IV or IP penicillins, cephalosporins, vancomycin, or quinolones, but no aminoglycosides. Group III included patients with peritonitis who received IV or IP aminoglycosides for at least 3 days. Patients in group III had a more rapid decline in renal creatinine clearance (-0.66 +/- 0.58 mL/min/mon) than groups I and II (P < 0.005) and had a more rapid decline in daily urine volume (-74 +/- 62 mL/d/mon) than groups I and II (P < 0.01). We conclude that IV or IP aminoglycosides seem to increase the rapidity of decline in RRF in PD patients. In patients with solute clearance dependent on RRF, it seems reasonable to withhold aminoglycosides, especially if other antibiotics are available and appropriate.

What is the place of peritoneal dialysis in the integrated treatment of renal failure?

The role of peritoneal dialysis (PD) in renal replacement therapy (RRT) remains unclear. There are no controlled trials to provide hard evidence of its efficacy. Comparative studies with haemodialysis from different centres and countries have given conflicting results even when allowing for case mix. Data from the United States on patients starting or receiving treatment in the late 1980s suggested a worse prognosis for older patients, particularly diabetics receiving PD as compared to HD. Analysis of the USRDS data base for patients starting in the early 1990s shows an improvement in outcome but with no difference in overall mortality. The Canadian registry has recently published data showing a better survival with PD than with HD in the first two years of RRT. Morbidity is similar with both therapies, although hospitalization is increased with PD. Unfortunately long-term technique survival is not as good with PD. However, PD has certain medical advantages, particularly the maintenance of residual renal function that contributes to solute and fluid removal. It may also postpone the onset of amyloidosis. Patients transplanted after previous PD have a decreased risk of early acute renal failure and equally good long-term results when compared to those patients who were on HD before transplantation. The quality of life is as good with PD as with center HD, and there are social advantages to PD including an increased chance of employment, more flexible holidays and avoidance of thrice weekly travel to a dialysis center. PD also has logistical advantages and can be utilized by the majority of new patients. We therefore conclude that PD has potential advantages early in the course of RRT, and should therefore be offered as a first option to all suitable new patients. Whether PD has a major or minor role in later years (> 5) remains unclear.

Biocompatible membranes preserve residual renal function in patients undergoing regular hemodialysis

Initiation of hemodialysis causes a further decrease of residual renal function (RRF). To assess the impact of the biocompatibility of the dialysis membrane, we performed a prospective randomized investigation in 20 normotensive patients with tubulointerstitial nephritis. The patients were randomly allocated to treatment with either a high-flux polysulfone or cellulose membrane over a period of 12 months. RRF, defined by creatinine clearance and daily urine volume, was found to decrease in both groups of patients after the initiation of hemodialysis. Of the two membranes used, however, the cellulose membrane caused an accelerated decrease of RRF (P < 0.05). The better maintenance of RRF in patients treated with polysulfone membranes was associated with higher Kt/V values and increased hematocrit values (P < 0.05). The pathophysiologic mechanism underlying the more rapid decline of RRF could not be explained by intradialytic hypotension, but may be related to the nephrotoxic effects of inflammatory mediators due to bioincompatibility. Therefore, the use of polysulfone membranes might be preferable in patients with relevant RRF.