Management Of End-stage Renal Failure Research Articles

Supporting the transition from pre-dialysis to end-stage renal failure

Renal replacement therapy (RRT) is a life-saving therapy for those with chronic kidney disease (CKD) stage 5 or end-stage renal failure (ESRF)—defined as an estimated Glomerular Filtration Rate of less than 15 ml/min/1.73 m2. RRT has a profound impact on quality of life (QoL), dependent on the preparation for and timing of therapy initiation; the mode of RRT selected; and the individual's age, health, and priorities. This article explores the transition to RRT, directed by the research question, ‘How does the evidence base inform clinical decision-making when supporting CKD patients’ transition from pre-dialysis to management of ESRF?'. The discussion of these critical decisions, including timing, modality and potential of dialysis to benefit the individual, is framed by their effect on QoL as dialysis is established. There are many other aspects concerning the transition to RRT, which are not discussed, but the reader is signposted to additional information sources.

A Cost Analysis of Haemodialysis and Peritoneal Dialysis for the Management of End-Stage Renal Failure At an Academic Hospital in Pretoria, South Africa.

BackgroundHaemodialysis (HD) and peritoneal dialysis (PD) are commonly used treatments for the management of patients with end-stage renal disease (ESRD). The costs of managing these patients have grown in recent years with increasing rates of non-communicable diseases, which will adversely impact on national health budgets unless addressed. Currently, there is limited knowledge of the costs of ESRD within the public healthcare system in South Africa.ObjectiveThe aim of this study was to examine the direct costs of HD and PD in South Africa from a healthcare provider’s perspective.MethodsA prospective, observational study was undertaken at a leading public hospital in South Africa. A micro-costing approach was applied to estimate healthcare costs using 46 adult patients with ESRD who had been receiving HD and PD for at least 3 months.ResultsThe highest proportion of patients (35%) were aged 40–50 years. Patients aged 29–39 years were mostly on HD (28% vs. 21% on PD) while those aged 51–59 years mostly used PD (29% vs. 16% on HD). The average age of patients on HD and PD were 41 and 42 years, respectively. Fixed costs were the principal cost driver for HD ($16,231.45) while variable costs were the principal cost driver for PD (US$20,488.79). The annual cost of HD per patient (US$31,993.12) was higher than PD (US$25,282.00 per patient), even though the difference was not statistically significant (p = 0.816).ConclusionHD costs more than PD from the provider’s perspective. These cost estimates may be useful for carrying out future cost-effectiveness and cost-utility analyses in South Africa.

022 Hospice-based multi-disciplinary clinic for end-stage renal failure improves quality of care and reduces hospital admission

Background/contextPatients opting for conservative management of end-stage renal failure in South Worcestershire frequently died in hospital and struggled to attend acute hospital outpatient appointments.AimsTo improve quality of life through a...

Heparin/heparan sulphate interactions with complement--a possible target for reduction of renal function loss?

Current management of end-stage renal failure is based on renal replacement therapy by dialysis or transplantation. Increased occurrence of renal failure in both native and transplanted kidneys indicates a need for novel therapies to stop or limit the progression of the disease. Acute kidney injury and proteinuria are major risk factors in the development of renal failure. In this regard, innate immunity plays an important role in the pathogenesis of renal diseases in both native and transplanted kidneys. The complement system is a major humoral part of innate defense. Next to the well-known complement activators, quite a number of the complement factors react with proteoglycans (PGs) both on cellular membranes and in the extracellular compartment. Therefore, these interactions might serve as targets for intervention. In this review, the current knowledge of interactions between PGs and complement is reviewed, and additionally the options for interference in the progression of renal disease are discussed.

Prospective management of end-stage renal failure within a conservative care programme.

Progression to end-stage renal disease (ESRD) is a major issue for heath care systems both clinically and financially. Given dialysis may not prolong life, and may indeed impair quality of life, alternative options for these patients such as conservative care are urgently needed. We appointed a dialysis charge nurse who had many years of experience of working with patients on dialysis to spearhead the newly set up Conservative Care Programme (CCP) in the Edinburgh Renal Unit. The rationale was to work as part of the renal multidisciplinary team to support patients and their families to make an informed shared decision whether to opt for dialysis or to follow the CCP.From the perspective of the patients, their families and carers we have received positive feedback since starting the CCP - thank you cards; phone calls both to the CCP Nurse Specialist and the renal unit affirming the positive experience patients had during the conservative management of their renal failure. Whilst continuing to provide the best quality of care to renal patients in NHS Lothian and Borders, the number of prevalent dialysis patients in our catchment area has fallen significantly over the last few years as demonstrated by Scottish Renal Registry data. These benefits are potentially applicable to other renal units across the UK.

Une approche intégrée de la suppléance rénale

The integrated approach to the management of end-stage renal failure (ESRF) which emerged in the nineties favoured peritoneal dialysis as first-intention renal replacement therapy. Here we broaden this concept to include all potential options which can be proposed for patients with severe chronic renal disease. The discussion begins with an analysis of the advantages of peritoneal dialysis as first-line therapy, emphasizing the factors affecting decision-making and the necessary logistic support. Transplantation, which can also be proposed as the first-line treatment, requires specific information concerning the graft obtained from a living or deceased donor, proper evaluation, and inscription on a waiting list well before the kidney failure reaches the terminal stage. Optimal management of chronic renal disease is the final aspect of this integrated approach. The question of complications, cardiovascular risk factors, and co-morbid conditions must be taken into consideration together with appropriate preparation of the patients for implementation of a well-adapted well accepted replacement therapy.

'The use of acacia gum in end stage renal failure'

To describe a new model for the management of end-stage renal failure (ESRF) associated with longest period of dialysis freedom (4-year) achieved with this novel form of renal replacement therapy (RRT).The research was done in accordance with Helsinki declaration and approved the scientific committee in the hospital. Conservative management of chronic renal failure (CRF) can only be successful in nonterminal CRF, and patients with ESRF cannot sustain life in the absence of renal replacement therapy. A new regimen combining the traditional conservative management of CRF (dietary and pharmacologic) with addition of Acacia gum (AG) 1 g kg(-1) per day has been reported to provide patients with ESRF dialysis freedom. An 11-year-old girl with ESRF initially required four sessions of intermittent peritoneal dialysis to control uremic symptoms despite conservative measures. The parents refused further treatment by dialysis. Thereafter, she was managed with a new regimen combining the traditional conservative management of CRF with addition of AG. Four year dialysis and improved well-being was achieved. The chronicity of her illness was confirmed by the presence of small contracted kidneys, a finding that has not changed during the subsequent follow-up. During these 4 years she continued experiencing improved well-being and good participation in outdoor activities, had never been acidotic or experienced significant uremic symptoms. This is the longest period of dialysis freedom reported in children with ESRF.

Hypertonic glucose-based peritoneal dialysate is associated with higher blood pressure and adverse haemodynamics as compared with icodextrin

Little is known about the haemodynamic effects of continuous ambulatory peritoneal dialysis (CAPD) despite its widespread use in the management of end-stage renal failure. We undertook a study to delineate the haemodynamic effects of CAPD using glucose-containing fluids (1.36 and 3.86% glucose) and icodextrin. Eight CAPD patients were recruited for a prospective crossover study. Patients attended for two investigatory days (in random order). CAPD was carried out using 1.36% followed by 3.86% glucose (buffered with lactate/bicarbonate, Physioneal) on one study day and 1.36% glucose followed by 7.5% icodextrin (Extraneal) on the other day. Dwell times were 150 min. Blood pressure (BP) and a full range of haemodynamic variables including pulse (HR), stroke volume (SV), cardiac output (CO) and total peripheral resistance (TPR) were measured non-invasively using continuous arterial pulse wave analysis. BP was significantly higher during 3.86% glucose dwells as compared with 1.36% glucose or icodextrin dwells (P<0.0001). TPR during all three dwells was similar; the higher blood pressure was due to an increased HR, SV and, therefore, CO during 3.86% glucose dwells. The higher blood pressure during the 3.86% glucose dwells was present despite the highest ultrafiltration volume and sodium removal. This study demonstrates large magnitude haemodynamic changes in response to CAPD. In addition to the well-recognized adverse effects on blood glucose and long-term peritoneal membrane viability, CAPD fluids containing high glucose concentrations may also exert undesirable effects on systemic haemodynamics, with potential long-term consequences for patient outcomes.

The epidemiology of chronic kidney disease

The world's disease profile is changing, and chronic diseases now account for the majority of global morbidity and mortality, rather than infectious diseases. The causes of chronic kidney diseases reflect this change and diabetes, together with hypertension, is now the major cause of end-stage renal failure worldwide, not only within the developed world, but also increasingly within the emerging world. Diabetes is of epidemic proportions, and its prevalence will double in the next 25 years, particularly in the developing countries. This will place an enormous financial burden on countries, including the cost of the management of end-stage renal failure. Thus, it is medically and economically imperative for awareness, detection, and prevention programs to be introduced across the world, particularly in the developing countries. This will require concerted action from global institutions, governments, health service providers, and medical practitioners.

Utilization and Limitations of Various Modalities of Long-Term Peritoneal Dialysis in King Khalid University Hospital: Six-Year Experience

ABSTRACT In 1982, we started the first long-term peritoneal dialysis program in Saudi Arabia for the management of end-stage renal failure in adults. Over the next 6 years, we accepted 54 adult pat...

Neurologic Complications of Renal Failure

T HE ASSOCIATION between abnormal renal function and central nervous system disease was recognized nearly 40 years ago . Seizures and coma were frequent complications of acute uremia , whereas peripheral neuropathy and encephalopathy, observed in progressive uremia, were terminal events. Despite improvements in the medical management of end-stage renal failure, including dialysis and transplantation, patients manifest a variety of neurologic disorders . The acute cerebral changes associated with uremia may present as the dialysis disequilibrium syndrome or as subdural, intracerebral or intraspinal hemorrhage; these bleeding diatheses occur in up to 10% of hypertensive hemodialysis patients . Potential toxins accumulating in uremia are numerous (see article by Powell et aI, this issue). To be considered a uremic toxin , the concentration of any putative compound should correlate better with some measurement of nerve or cerebral function than with a reduction in glomerular filtration rate. To date , this has not been convincingly demonstrated. The neurologic complications of arterial hypertension in children include convulsions in over 90 % of children with severe hypertension and facial palsy, blindness, paraplegia, and alterations in the level of consciousness.' Children may present with seizures as the first sign of hypertension. The prognosis for children having had a single episode of hypertensive encephalopathy is good, with no demonstrative neurologic deficit or focal abnormality on brain scan by computerized tomography.'

Survey of Continuous Ambulatory Peritoneal Dialysis in the United Kingdom, 1982

Forty -one adult renal units undertaking continuous ambulatory peritoneal dialysis (CAPD) in the United Kingdom answered a questionnaire about available facilities and their own practices. The responses suggest that many units are struggling with unsatisfactory environmental facilities and inadequate staff. Working methods, diagnostic facilities and therapeutic policies varied considerably from unit to unit. We need more information about the influence of such variables on the results of CAPD and its complications, particularly peritonitis. The use of CAPO for the management of end-stage renal failure in the United Kingdom has increased dramatically since its introduction in 1978 (I, 2). Although statistics from the European Dialysis and Transplant Association (EDT A) revealed a high technique failure rate and considerable morbidity from catheter and peritonitis problems (2, 3), individual units have reported better results (4, 5, 6). Discussion with nephrologists in the United Kingdom suggested that there were marked differences between renal units in the techniques used and the facilities available for the practice of CAPD, and that these might be reflected in the results of treatment. Therefore, we circulated a questionnaire to the 59 dialysis units in the United Kingdom requesting information concerning their facilities, practices, and the ways in which they diagnosed and managed CAPD-related infection in 1982. Replies were received from 52 units; of these six were not using CAPD and five others were pediatric centres. The questionnaires from the remaining 41 adult renal units were analysed for this report.